Corticosteroids, oral contraindications

Systemic corticosteroids are a useful option in patients with contraindications to NSAIDs or colchicine (primarily renal impairment) or polyarticular attacks, especially in elderly patients. A single intramuscular injection of a long-acting corticosteroid such as triamcinolone hexacetonide may be used. Oral agents may be needed, especially for severe attacks. Prednisone 40 to 60 mg (or an equivalent dose of another agent) is given daily, with a gradual taper over 2 weeks. 

A single intramuscular injection of a long-acting corticosteroid (e.g., methylprednisolone acetate) can be used as an alternative to the oral route if patients are unable to take oral therapy. If not contraindicated, low-dose colchicine can be used as adjunctive therapy to injectable corticosteroids to prevent rebound flare-ups. 

Although oral corticosteroids have had an established use in herpes zoster treatment, their value has become controversial.They are clearly contraindicated in HIV and while the virus is still present in immunocompetent patients. Some authors report increased quality of life and decreased acute pain with oral steroid use in the elderly, but this value is offset by potential risk. Significant relief may be obtained with early antiviral therapy so that oral steroids are an unnecessary risk. Oral steroids are of no value in preventing PHN as was previously believed. The duration of PHN, however, is significantly shortened by early and aggressive use of oral antiviral agents in the acute phase of herpes zoster. Tricyclic antidepressants may also be useful when prescribed at the time of acute... 

Individuals with contraindications to NSAIDs (e.g., active peptic ulcer disease, renal impairment, heart failure, or history of hypersensitivity) or individuals who cannot ingest medications orally may be treated with intravenous corticosteroids or intra-articular corticosteroids. 

Corticosteroids may be used to treat acute attacks of gouty arthritis, but they are reserved primarily for resistant cases or for patients with a contraindication to colchicine and NSAID therapy. Doses of 40 to 80 USP units of adrenocorticotropic hormone gel are given intramuscularly every 6 to 8 hours for 2 to 3 days, and then the doses are reduced in stepwise fashion and discontinued. Intra-articular administration of triamcinolone hexacetonide in a dose of 20 to 40 mg may be useful in treating acute gout limited to one or two joints. Prednisone may be administered orally in doses of 30 to 60 mg for 3 to 5 days in patients with multiple-joint involvement. Because rebound attacks may occur on steroid withdrawal, the dose should be tapered gradually by 5-mg decreases over 10 to 14 days and discontinued. 

Mitotane (lysodren) is administered in initial daily oral doses of 2-6 g, usually given in 3 or 4 divided portions, but the maximal tolerated dose may vary from 2 to 16 g/day. Treatment should be continued for at least 3 months if beneficial effects are observed, therapy should be maintained indefinitely. Spironolactone should not be administered concomitantly, since it interferes with the adrenal suppression produced by mitotane. Treatment with mitotane is indicated for the palliation of inoperable adrenocortical carcinoma, producing symptomatic benefit in 30—50% of such patients. Although the administration of mitotane produces anorexia and nausea in 80% of patients, somnolence and lethargy in 34%, and dermatitis in 15—20%, these effects do not contraindicate the use of the drug at lower doses. Since this drug damages the adrenal cortex, administration of corticosteroids is indicated, particularly in patients with evidence of adrenal insufficiency, shock, or severe trauma. 

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