Corticosteroid adverse effects

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... 

Information about the clarithromycin or erythromycin interactions with methylprednisolone is much more limited than with the interaction between troleandomycin and methylprednisolone, but they all appear to be established and of clinical importance. The effect should be taken into account during concurrent use and appropriate dosage reductions made to avoid the development of corticosteroid adverse effects. The authors of one study suggest that this reduction should be empirical, based primarily on clinical symptomatology. Another group found that a 68% reduction in methylprednisolone dosage was possible within 2 weeks. Troleandomycin appears to have a greater effect than erythromycin or clarithromycin. 

Nonspecific immunosuppressive therapy in an adult patient is usually through cyclosporin (35), started intravenously at the time of transplantation, and given orally once feeding is tolerated. Typically, methylprednisone is started also at the time of transplantation, then reduced to a maintenance dose. A athioprine (31) may also be used in conjunction with the prednisone to achieve adequate immunosuppression. Whereas the objective of immunosuppression is to protect the transplant, general or excessive immunosuppression may lead to undesirable compHcations, eg, opportunistic infections and potential malignancies. These adverse effects could be avoided if selective immunosuppression could be achieved. Suspected rejection episodes are treated with intravenous corticosteroids. Steroid-resistant rejection may be treated with monoclonal antibodies (78,79) such as Muromonab-CD3, specific for the T3-receptor on human T-ceUs. Alternatively, antithymocyte globulin (ATG) may be used against both B- and T-ceUs. 

One more serious medical task the determination of corticosteroids in plasma and cerebrospinal liquid of childi en with acute lymphoblastic leucosis. From the viewpoint of a number of physicians complications often take place from adverse effects of corticosteroids. 

Local adverse effects of inhaled corticosteroids include oral candidiasis and dysphonia. The incidence of local adverse... 

Systemic adverse effects are dose-dependent and are rare at low to medium doses however, high-dose inhaled corticosteroids have been associated with adrenal suppression, decreased bone mineral density, skin thinning, and easy bruising.3,29 Growth suppression in children may occur even with low-dose inhaled corticosteroids however, suppression appears to occur primarily in the first year of treatment and may be due to delayed growth with the potential of future catch-up growth.30... 

Assess the patient for adverse effects, particularly candidiasis and dysphonia associated with inhaled corticosteroids. 

The most common adverse effects from inhaled corticosteroids include oropharyngeal candidiasis and hoarse voice. These can be minimized by rinsing the mouth after use and by using a spacer device with metered-dose inhalers. Increased bruising and decreased bone density have also been reported the clinical importance of these effects remains uncertain.1,2,19... 

Agents targeting the excessive immune response or cytokines involved in IBD are potential treatment options (Table 16-3). Azathioprine and its active metabolite 6-mercaptopurine (6-MP) are inhibitors of purine biosynthesis and reduce IBD-associated GI inflammation. They are most useful for maintaining remission of IBD or reducing the need for long-term use of corticosteroids. Use in active disease is limited by their slow onset of action, which may be as long as 3 to 12 months. Adverse effects associated with azathioprine and 6-MP include hypersensitivity reactions resulting in pancreatitis, fever, rash, hepatitis, and leukopenia.25,26... 

Oral sulfasalazine or mesalamine is effective in maintaining remission in patients with more extensive disease.1,26 Lower daily doses (e.g., 2 to 4 g sulfasalazine or 1.6 to 2.4 g mesalamine) may be used for disease maintenance. As with distal UC, oral corticosteroids are not effective for maintaining remission and should be avoided due to the high incidence of adverse 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... 

Short-term use of corticosteroids is not associated with most of the adverse effects of chronic steroid use. The most common adverse effects encountered are gastrointestinal upset, insomnia, and mood swings.28... 

Educate the patient regarding possible adverse effects of acute use of corticosteroids and have her or him report any unexpected occurrences. 

One chronic adverse effect that is of concern is osteoporosis.32,33 Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, and valproate have all been shown to decrease bone mineral density, even after only 6 months of treatment. Data on the relationship between other AEDs and osteoporosis are not currently available. Multiple studies have shown the risk of osteoporosis due to chronic AED use to be similar to the risk with chronic use of corticosteroids. Patients taking carbamazepine, phenytoin, phenobarbital, or valproate for longer than 6 months should take supplemental calcium and vitamin D. Additionally routine monitoring for osteoporosis should be performed every 2 years, and patients should be instructed on ways to protect themselves from fractures. 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

Short-term adverse effects from corticosteroids include fluid retention, hyperglycemia, central nervous system stimulation, weight gain, and increased risk of infection. Patients with diabetes should have blood glucose levels monitored carefully during the corticosteroid course. 

Intranasal anticholinergic agents (e.g., ipratropium) reduce the severity and duration of rhinorrhea but have no effect on other nasal symptoms.11,12,21 Ipratropium reduces cholinergic hyperreactivity and cholinergically mediated histamine- and antigen-induced secretion. Intranasal ipratropium acts locally, with only minimal systemic absorption. Clinical trials demonstrated that ipratropium bromide 0.3% reduced rhinorrhea in adults and children with PAR.11,12 Intranasal ipratropium is an option for patients in whom rhinorrhea is refractory to topical intranasal corticosteroids and/or antihistamines.8,12 Intranasal ipratropium is available only by prescription, and the dose is two sprays nasally two to three times daily.15 Adverse effects are minimal, but dry nasal membranes have been reported.11,12... 

Intranasal corticosteroids are the most effective anti-inflammatory agents used in pediatric patients with allergic rhinitis. Although fewer studies have been conducted in children, results demonstrate that intranasal corticosteroids are effective and well tolerated, with an adverse-effect profile similar to placebo. Mometasone is indicated for children as young as 2 years of age, fluticasone is indicated for children 4 years of age and older, and beclomethasone, budesonide, flunisolide, and triamcinolone are indicated for children 6 years and older.15 Because concerns regarding effect of intranasal steroids on growth exist, the growth of pediatric patients prescribed intranasal steroids should be monitored routinely via stadiometry. 

Is the patient taking antihistamines and/or intranasal steroids Is the patient experiencing adverse effects (e.g., sedation from antihistamines or nasal itching, burning, or bleeding from intranasal corticosteroids) ... 

It is important to remember that adverse effects of topical corticosteroids may be systemic in nature and hypothalamic-pituitary-adrenal axis suppression can occur, especially when high-potency corticosteroids are used. Infants and small children may be more susceptible due to their increased skin sur-face body mass ratio.18 Topical corticosteroids may also cause striae, skin atrophy, acne, telangiectasias, and rosacea.2,10,18 Atrophy can result in thin, fragile, easily lacerated skin. Striae are caused by tearing of dermal connective tissue and are irreversible.18 Due to their significant adverse-effect profile, it has been recommended that no topical corticosteroid be used regularly for more than 4 weeks without review and reassessment.2... 

For patients receiving corticosteroids, monitor for adverse effects and drug interactions. Does the patient need Gl prophylaxis for long-term treatment Slowly taper once symptoms improve and/or radiation is completed. 

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

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