Corticosteroid systemic effects

Corticosteroids, while effective for rapidly inducing remission, are not effective for maintenance therapy and are associated with significant adverse effects with long-term use. Therefore, systemic or topical corticosteroids should not be used for maintaining remission in patients with IBD. Unfortunately up to 50% of patients treated acutely with corticosteroids become dependent on them to prevent symptoms.2... 

Pharmacotherapy has an important role in managing AR symptoms (Table 59-2). Intranasal corticosteroids, systemic and topical antihistamines and decongestants, mast cell stabilizers, and immunotherapy all are beneficial in treating symptoms of AR.9 Antihistamines and intranasal corticosteroids are considered first-line therapy for AR, whereas decongestants, mast cell stabilizers, leukotriene modifiers, and systemic corticosteroids are secondary treatment options10-12 (Fig. 59-2). Whenever exposure to allergens can be predicted (e.g., SAR or visiting homes with a pet), medications should be used pro-phylactically to maximize effectiveness.11... 

Intraarticular corticosteroid injections can provide relief, particularly when a joint effusion is present. Average doses for injection of large joints in adults are methylprednisolone acetate 20 to 40 mg or triamcinolone hexacetonide 10 to 20 mg. After aseptic aspiration of the effusion and corticosteroid injection, initial pain relief may occur within 24 to 72 hours, with peak relief occurring in about 1 week and lasting for 4 to 8 weeks. The patient should minimize joint activity and stress on the joint for several days after the injection. Therapy is generally limited to three or four injections per year because of the potential systemic effects of the drugs and because the need for more frequent injections indicates poor response to therapy. 

Corticosteroids and adrenocorticotropic hormone have been widely used for the treatment of ulcerative colitis and Crohn s disease and are used in moderate to severe disease. Prednisone is most commonly used. Budesonide is an oral controlled-release formulation that minimizes systemic effects. 

Systemic toxicity of inhaled corticosteroids is minimal with low to moderate inhaled doses, but the risk of systemic effects increases with high doses. Local adverse effects include dose-dependent oropharyngeal candidiasis and dys-phonia, which can be reduced by the use of a spacer device. The ability of spacer devices to enhance lung delivery is inconsistent and should not be relied on. 

Corticosteroids can produce a variety of devastating and systemic effects. Some of the ADRs associated with corticosteroids are listed in Table 28.4. 

Systemic effects Systemic absorption of topical corticosteroids has produced reversible HPA axis suppression, Cushing syndrome, hyperglycemia, and glycosuria. As a general rule, little effect on the HPA axis will occur with a potent topical corticosteroid in amounts of less than 50 g weekly for an adult and 15 g weekly for a... 

Nasal corticosteroids are effective in vasomotor rhinitis, but because of the duration of the disorder, certain caution is advised to avoid systemic effects and local adverse reactions after long-term use. Ipratropium bromide spray works well if the dominating problem is runny nose. 

Several inhaled corticosteroids are currently prescribed in asthma, although their availability varies between countries (Table 8). There are relatively few studies comparing efficacy of the different inhaled steroids. There appear to be some differences between inhaled corticosteroids in terms of their systemic effects at comparable anti-asthma doses. There is evidence, that all of the inhaled steroids are absorbed to some extent from the lung and hence will have some systemic activity. It is recommended, therefore, in all guidelines to give the lowest dose of inhaled steroid compatible with asthma control. 

The corticosteroids are effective in most children and adults with asthma. They are beneficial for the treatment of both acute and chronic aspects of the disease. Inhaled corticosteroids, including triamcinolone ace-tonide (Azmflcort),beclomethasone dipropionate (Beclo-vent, Vancerit), flunisolide AeroBid), and fluticasone (Flovent), are indicated for maintenance treatment of asthma as prophylactic therapy. Inhaled corticosteroids are not effective for relief of acute episodes of severe bronchospasm. Systemic corticosteroids, including prednisone and prednisolone, are used for the short-term treatment of asthma exacerbations that do not respond to (32-adrenoceptor agonists and aerosol corticosteroids. Systemic corticosteroids, along with other treatments, are also used to control status asthmaticus. Because of the side effects produced by systemically administered corticosteroids, they should not be used for maintenance therapy unless all other treatment options have been exhausted. 

The most commonly observed side effects associated with vidarabine are lacrimation, burning, irritation, pain, and photophobia. Vidarabine has oncogenic and mutagenic potential however, the risk of systemic effects is low because of its limited absorption. It should not be used in conjunction with ophthalmic corticosteroids, since these drugs increase the spread of HSV infection and may produce side effects such as increased intraocular pressure, glaucoma, and cataracts. 

Fabbri L, Melara R. Systemic effects of inhaled corticosteroids are milder in asthmatic patients than in normal subjects. Thorax 2001 56(3) 165-6. 

Martin RJ, Szefler SJ, Chinchilh VM, Kraft M, Dolovich M, Boushey HA, Cherniack RM, Craig TJ, Drazen JM, Fagan JK, Fahy JV, Fish JE, Ford JG, Israel E, Kunselman SJ, Lazarus SC, Lemanske RF Jr, Peters SP, Sorkness CA. Systemic effect comparisons of six inhaled corticosteroid preparations. Am J Respir Crit Care Med 2002 165(10) 1377-83. 

Lipworth BJ. Airway and systemic effects of inhaled corticosteroids in asthma dose response relationship. Pulm Pharmacol 1996 9(l) 19-27. 

Drugs are applied to the mucous membranes of the conjunctiva, nasopharynx, and vagina to achieve local effects. On the other hand, the antidiuretic hormone lypressin (Diapid) is given by nasal spray, but the intention is to produce systemic effects. For the treatment of meningeal leukemia, cytosine arabinoside is injected directly into the spinal subarachnoid space. In osteoarthritis, corticosteroids are given by intra-articular injection. 

Although systemic absorption of the prednisolone from the enema probably does occur, especially when the colon is particularly inflamed, corticosteroids usually have less systemic effects when given this way. Furthermore, by giving an enema, the drug is being delivered directly to its site of action - remember that in ulcerative colitis the disease is confined to the lower gastrointestinal tract. 

The tablets would be simple to use, but may have greater adverse effects. This is because they will enter the bloodstream in greater amounts by the oral route and have systemic effects. The higher the dose used the greater the potential for adverse effects. It is usually recommended that corticosteroids are used in the lowest possible dose for the shortest possible period of time. 

Intranasal corticosteroids are effective in reducing ocular symptoms as well as nasal symptoms. The mechanism of action is unclear it may partly be due to a systemic effect resulting from local absorption, although system-ically related adverse effects are uncommon. These are used once or twice daily depending on choice and should be used regularly during the hay fever season. 

Systemic effects caused by intranasal corticosteroids are rare. The MHRA... 

Benzene also affects the central nervous system. Effects noted include drowsiness, dizziness, headache, vertigo, tremor, delirium, and loss of consciousness (Flury 1928 Greenburg 1926 Kraut et al. 1988 Yin et al. 1987b). Since benzene may induce an increase in brain catecholamines, it may also have a secondary effect on the immune system via the hypothalamus-pituitary-adrenal axis (Hsieh et al. 1988b). Increased metabolism of catecholamines can result in increased adrenal corticosteroid levels, which are immunosuppressive (Hsieh et al. 1988b). Further studies to determine the molecular mechanism of these effects could lead to additional approaches for reducing the toxic effects of benzene. 

Intralesional injection of steroid can lead to adrenal suppression. Infents and small children are especially susceptible, because a given amoimt of steroid is distributed in a smaller volume of fluid and tissue compartments. Infents injected with mixtiu es of triamcinolone acetonide and betamethasone or dexamethasone fiar periocular hemangiomas exhibited depressed serum cortisol and adrenocorticotropic hormone levels. The adrenal suppression can last up to 5 months and can result in weight loss and growth retardation. It is not known whether other corticosteroid preparations would produce similar effects or which other fectors might influence these results. In general, topical and periocular use of steroids produces minimal systemic effects. Withdrawal of topical or periocular steroids does not generally cause adrenal crisis. 

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