Corticosteroid continuance

The principal asthma therapies have all been in clinical practice since the early 1970s and before, yet their mechanisms and potential hazards in many cases remain obscure. The trend towards inhaled corticosteroids continues to raise concerns about their long-term side-effects. This has fuelled efforts to develop safer anti-inflammatory therapies, despite the advent of fluticasone, which is 100 per cent first-pass metabolized in the liver and has fewer systemic effects (Harding, 1990). Suggestions that the long-actingy 2-agonists (salmeterol, formoterol) may be anti-inflammatory appear to be unfounded, but the possibility of an antiinflammatory effect of theophylline (Ward et al., 1993) has accelerated development of selective phosphodiesterase (PDE IV) inhibitors, which may have reduced side-effects and a better therapeutic index than theophylline itself. The immunosuppressants, such as cyclosporin A which prevents expression of IL-2 and IL-2R in T cells, are limited by toxicity to a small minority of very severe corticosteroid-dependent asthmatics. 

SUMMARY DRUG TABLE ADRENOCORTICAL HORMONES CORTICOSTEROIDS AN D MIN ERALOCORTICOIDS (Continued)... 

Albuterol 2.5-5 mg nebulized every hour ° Ipratropium 500 meg nebulized every hour ° Continue therapy for 1-3 h, provided there is improvement ° Consider corticosteroid... 

Treatment of severe acute asthma includes the use of oxygen for the rapid reversal of hypoxemia, a short-acting P2-agonist to reverse airway constriction, and a systemic corticosteroid to attenuate the inflammatory response.1 Close monitoring of objective measures such as FEVi or PEF is important to quantify the response to therapy. Because recovery from exacerbations is often gradual, intensified therapy should be continued for several days. 

Continual symptoms High-dose inhaled corticosteroids High-dose inhaled corticosteroids... 

Although the optimal duration of systemic corticosteroids is unknown, therapy should be continued until PEF is greater than or equal to 80% of predicted or personal best. According to the NAEPP, the usual regimen is to continue frequent multiple doses until the patient s FEVi or PEF improves to 50% of predicted and then decrease the frequency to twice daily. In general, the duration of therapy ranges from 3 days for mild exacerbations to 14 days for severe exacerbations. It is not necessary to taper the systemic steroid dose in patients receiving short bursts of systemic corticosteroid therapy, as the adrenal suppression that occurs is transient and rapidly reversible.18... 

Reassess pulmonary function every 20 to 30 minutes. If there was not an immediate response to the inhaled short acting p2-agonist, initiate systemic corticosteroid therapy. If the patient is not improving, add ipratropium to the patient s therapy and continue with a high-dose inhaled short-acting P2-agonist. 

Disease x 7 days, or Infliximab 5 mg/kg IV at weeks 0, 2, and 6 If no response to IV corticosteroids or infliximab Cyclosporine 4 mg/kg per day IV possible Restart oral mesalamine or sulfasalazine May continue infliximab at maintenance doses of 5 mg/kg every 8 weeks... 

Infliximab 5 mg/kg is also an option for severe UC. Cyclosporine 2 to 4 mg/kg per day given as a continuous intravenous infusion should be reserved for patients unresponsive to 7 to 10 days of intravenous corticosteroid therapy. 

Corticosteroids can be initiated in septic shock when adrenal insufficiency is present or when weaning of vasopressor therapy proves futile. A daily dose equivalent to 200 to 300 mg hydrocortisone should be continued for 7 days. Adverse events are few because of the short duration of therapy. 

Hydrocortisone given parenterally is the corticosteroid of choice because of its combined glucocorticoid and mineralocorticoid activity. The starting dose is 100 mg IV by rapid infusion, followed by a continuous infusion or intermittent bolus of 100 to 200 mg every 24 hours. IV administration is continued for 24 to 48 hours. If the patient is stable at that time, oral hydrocortisone can be started at a dose of 50 mg every 8 hours for another 48 hours. A hydrocortisone taper is then initiated until the dosage is 30 to 50 mg/day in divided doses. 

Low-dose inhaled corticosteroids are the treatment of choice for women with mild persistent asthma. Budesonide is preferred, but other inhaled corticosteroids that were used effectively prior to pregnancy can be continued. 

Giant cell arteritis (cranial or temporal arteritis) is an inflammatory condition that may affect any of the large arteries, especially the temporal and occipital arteries. The thickened temporal arteries may be tender and non-pulsatile, with erythema and oedema of the overlying skin. Early treatment with high-dose corticosteroids such as prednisolone is essential and should be continued for a minimum of 2-3 years at a reduced dose. 

Concomitant therapy-Can be used concomitantly with short-acting 2-agonists, inhaled or systemic corticosteroids, and theophylline therapy. A satisfactory clinical response to formoterol does not eliminate the need for continued treatment with an anti-inflammatory. 

In patients unable to take the capsules, therapy may be initiated with the injection. Administer the initial dose no sooner than 6 hours after transplantation. The recommended starting dose is 0.03 to 0.05 mg/kg/day as a continuous IV infusion. Give adult patients doses at the lower end of the dosing range. Concomitant adrenal corticosteroid therapy is recommended early posttransplantation. Proceed with continuous IV infusion only until the patient can tolerate oral administration. 

NSAIDs and oral corticosteroids may be continued. Onset of action generally occurs between 4 and 8 weeks. If insufficient benefit is seen and tolerability is good (including serum creatinine less than 30% above baseline), the dose may be increased by 0.5 to 0.75 mg/kg/day after 8 weeks and again after 12 weeks to a maximum of 4 mg/kg/day. If no benefit is seen by 16 weeks of therapy, discontinue. There is limited P.1164... 

VIII.b.1.1. Proctitis. Disease limited to the rectum in the active phase can be treated with corticosteroids or aminosalicylates as suppositories or ene-mata (Table 3). Treatment has to be continued for one to two months until symptoms resolve. 

Severe persistent Continual symptoms Limited physical activity Frequent exacerbations <60% PEF variability > 30% Step 3 with high dose of inhaled corticosteroid and long-acting bronchodilator Oral corticosteroid long term (2 mg/kg/day, not to exceed 60 mg/day)... 

Clarke described a chromatographic system for the identification of corticosteroids including cortisone [2]. The method uses Whatman paper 1, impregnated with a 40% v/v solution of formamide in methanol, which must be prepared immediately before use. A saturated solution of formamide in chloroform was used as the solvent system [125]. The paper was equilibrated for 2 1/2 hours in a tank that had been saturated with the solvent for 24 hours. Development was continued in a descending manner until the solvent front had advanced about 35 cm. To locate the analytes,... 

After treatment, use topical corticosteroids to decrease contact dermatitis, antihistamines for pruritus pruritus may continue for 4-6 wk... 

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