Corticosteroids—glucocorticoids reactions

Editor s notes In this chapter adverse effects and reactions that arise from the oral or parenteral administration of corticosteroids (glucocorticoids and mineralocorti-coids) are covered in the section on systemic administration. Other routes of administration are dealt with in the sections after that inhalation and nasal administration are dealt with in Chapter 16, topical administration to the skin in Chapter 14, and ocular administration in Chapter 47. 

Prompt intensive treatment with corticosteroids may be lifesaving when an excessive inflammatory reaction has resulted in septic shock. A massive infusion of corticosteroids can restore cardiac output and reverse hypotension by sensitizing the response of adrenoceptors in the heart and blood vessels to the stimulating action of catecholamines. This protective role of steroids may be due to a direct effect on vascular smooth muscle. The combination of glucocorticoids and dopamine therapy preserves renal blood flow during shock. 

Hypersensitivity reactions to etoposide or teniposide usually occur within minutes after intravenous administration, and are probably related to release of vasoactive substances by basophils and/or mast cells. Several reports have suggested that premedication with an antihistamine and/or a corticosteroid may prevent further hypersensitivity reactions, even in patients with a history of previous reactions. However, this strategy should not be followed when patients have had severe hypersensitivity reactions, such as long-lasting bronchospasm or severe hjrpotension (130,131). Etoposide was successfully restarted in 78% of patients who had had a hypersensitivity reaction, especially when the drug was infused at a slower rate after premedication with an antihistamine and/or a glucocorticoid (132). 

Treatment of these problems is by substituting another insulin species which does not cross-react with the antibodies, by desensitization, or by local or systemic administration of glucocorticoids. If a severe allergic reaction occurs, the drug has to be discontinued and the patient treated with the usual agents (e.g. adrenaline, antihistamines or corticosteroids). Patients who have experienced severe systemic allergic symptoms should be skin-tested with another insulin preparation before its initiation. Desensitization procedures may permit resumption of insulin administration. 

Cells of the zona fasciculata have fewer receptors for Angll and express two enzymes, steroid 17a-hydroxylase (CYP17) and 11/3-hydroxylase (CYPllBl), which catalyze the production of glucocorticoids. In the zona reticularis, CYP17 carries out a second C17-20 lyase reaction that converts C21 corticosteroids to C19 androgen precursors. 

Landon J, Wynn V, Wood JB (1965) Adrenal response to infused corticotropin in subjects receiving glucocorticoids. J Clin Endocrinol 25 602 Mendelson LM, Meltzer EO, Hamburger RN (1974) Anaphylaxis like reactions to corticosteroid therapy. J Allergy Clin Immunol 54 125 Mohr PD (1975) Allergic reactions to tetracosactrin. Br Med J 4 162 Nagel JF, Fuscaldo JT, Fireman P (1977) Paraben allergy. JAMA 237 1594... 

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