Therapies corticosteroid

The predominant clinical use of corticosteroids is a result of their associated antiinflammatory properties. These are commonly used as topicals for the suppression of symptoms, including inflammation, occurring in a particular disease state these compounds are rarely considered curative in their usage. Many other disease states do, however, respond well symptomatically to treatment with corticosteroid therapy. Some of these (11) are Hsted below. 

Corticosteroids may be given in high doses for some arthritic disorders. Many adverse reactions are associated with high-dose and long-term corticosteroid therapy. Chapter 50 discusses some of the adverse reactions associated with corticosteroid therapy. A comprehensive list of adverse reactions is provided in Display 50-2. Contraindications, precautions, and interactions of the corticosteroids are discussed in Chapter 50. 

The corticosteroids are administered with caution in older adults because they are more likely to have preexisting conditions such as congestive heart failure, hypertension, osteo-poros s and arthritis which may be worsened by the use of such agents The nurse monitors older adults for exacerbation of existing conditionsduring corticosteroid therapy. In addition, lower dosages may be needed because of the effects of aging, such as decreased muscle mass renal function, and plasma volume. 

MANAGING FLUID AND ELECTROLYTE IMBALANCES. Fluid and electrolyte imbalances, particularly excess fluid volume, are common with corticosteroid therapy. The nurse checks the patient for visible edema, keeps... 

High-dose corticosteroid therapy (e.g., hydrocortisone 200 mg/d or greater or its equivalent)... 

Corticosteroid therapy for patients with alcoholic hepatitis (steatonecrosis) with or without hepatic encephalopathy... 

Add standing treatment with one or more long-acting bronchodilators (i.e., tiotropium, salmeterol, and formoterol) ° Add inhaled corticosteroid therapy if repeat exacerbations... 

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. 

Risk factors for NSAID-induced peptic ulcers and complications are presented in Table 15-2. Several important principles should be considered when estimating the risk for developing PUD in a patient taking an NSAID (1) risk factors are generally additive (2) some risk factors (e.g., corticosteroid therapy) are not by themselves a risk factor for ulceration but increase PUD risk substantially when combined with NSAID therapy and (3) many of the risk factors postulated to increase PUD... 

Preexisting coagulopathy (elevated INR or thrombocytopenia) Concomitant corticosteroid therapy... 

Treatment of active mild to moderate Crohn s disease involves use of oral or topical aminosalicylate derivatives, whereas moderate to severe disease may require systemic corticosteroid therapy. 

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. 

Patients with moderate to severe active CD may be treated with oral corticosteroids, such as prednisone 40 to 60 mg daily.2 Budesonide 9 mg orally once daily may be used for moderate active CD involving the terminal ileum or ascending colon. Infliximab is an effective alternative to corticosteroid therapy for patients with moderate to severe CD, including patients with fistulizing or perianal disease.15,37-39 The recommended regimen for induction of remission is infliximab 5 mg/kg at weeks 0, 2, and 6 it is effective in inducing remission in... 

Limited evidence indicates that cyclosporine, or possibly tacrolimus, may be effective as salvage therapy for patients who fail intravenous corticosteroid therapy.2 Surgical intervention may ultimately be necessary for medically refractory disease. 

CD occurs in approximately 4.56 per 100,000 pediatric patients, and UC occurs in about 2.14 cases per 100,000.43 A major issue in children with IBD is the risk of growth failure secondary to inadequate nutritional intake. Failure to thrive may be an initial presentation of IBD in this population. Aggressive nutritional interventions may be required to facilitate adequate caloric intake. Chronic corticosteroid therapy may also be associated with reductions in growth. 

Evaluate patients receiving systemic corticosteroid therapy for improvement in symptoms and opportunities to taper or discontinue steroid therapy. For patients using more than 5 mg daily of prednisone for more than 2 months or for steroid-dependent patients consider the following ... 

Develop a plan to assess the effectiveness of the antihistamine and/or intranasal corticosteroid therapy after 3 months. 

Fluconazole 12 mg/kg/day PO for 6-12 weeks transitioned to itraconazole or fluconazole Corticosteroid therapy should be considered in hypoxic patients with acute pulmonary infection... 

Corticosteroids play a key role in the management of SVCS, particularly in cases of lymphoma, because these tumors inherently respond to corticosteroid therapy. They are also helpful in the setting of respiratory compromise. Corticosteroids benefit patients who are receiving radiation therapy by reducing local radiation-induced inflammation and increased intracranial pressure. Dexamethasone 4 mg intravenously or by mouth every 6 hours is a frequently used regimen. The dosage should be tapered on completion of radiation therapy or resolution of symptoms. 

Evaluate the patient for drug interactions, allergies, and adverse effects with chemotherapy and/or corticosteroid therapy. 

Factors that can predispose patients to developing metabolic bone disease include deficiencies of phosphorus, calcium, and vitamin D vitamin D and/or aluminum toxicity amino acids and hypertonic dextrose infusions chronic metabolic acidosis corticosteroid therapy and lack of mobility.35,39 Calcium deficiency (due to decreased intake or increased urinary excretion) is one of the major causes of metabolic bone disease in patients receiving PN. Provide adequate calcium and phosphate with PN to improve bone mineralization and help to prevent metabolic bone disease. Administration of amino acids and chronic metabolic acidosis also appear to play an important role. Provide adequate amounts of acetate in PN admixtures to maintain acid-base balance. 

A first open, uncontrolled study [46], performed in 12 patients with active IBD refractory to standard treatment who all had positive stool culture, suggested that adding rifaximin (800 mg daily) could be beneficial. A further small but controlled investigation performed in our unit [47] evaluated the efficacy and systemic absorption of rifaximin in patients with moderately to severely active UC refractory to steroid treatment. Patients were eligible if they had no response to intravenous corticosteroid therapy (methylprednisolone 1 mg/kg/day) after 7-10 days. Twenty-eight patients were randomized to receive rifaximin 400 mg b.i.d. or placebo for 10 days as an add-on... 

Systemic corticosteroid therapy is not recommended in OA, given the lack of proven benefit and the well-known adverse effects with long-term use. 

Low-dose, long-term corticosteroid therapy may be used to control symptoms in patients with difficult-to-control disease. Prednisone doses below 7.5 mg/day (or equivalent) are well tolerated but are not devoid of the long-term corticosteroid adverse effects. The lowest dose that controls... 

The addition of a second long-term control medication to inhaled corticosteroid therapy is one recommended treatment option in moderate to severe persistent asthma. 

The clinical benefits of systemic corticosteroid therapy in the chronic management of COPD are often not evident, and there is a high risk of toxicity. Consequently, chronic, systemic corticosteroids should be avoided if possible. 

Consensus guidelines indicate that inhaled corticosteroid therapy should be considered for symptomatic patients with stage III or IV disease (FEVj less than 50%) who experience repeated exacerbations despite bronchodilator therapy. 

---