Corticosteroids, oral side effects

Improvements in asthma treatment include the development of more effective, safer formulations of known dmgs. The aerosol adrninistration of P2-agonists or corticosteroids results in a decrease in side effects. Also, the use of reUable sustained release formulations has revolutionized the use of oral xanthines which have a very narrow therapeutic index (see Controlled release technology). For many individuals, asthma symptoms tend to worsen at night and the inhaled bronchodilatots do not usually last through an entire night s sleep (26,27). 

Maintenance of remission of ulcerative colitis may be achieved with oral or topical aminosalicylates. Mesalamine suppositories 1 g daily may prevent relapse in up to 90% of patients with proctitis.1 Mesalamine enemas are appropriate for left-sided disease and may often be dosed three times weekly. Oral mesalamine at lower doses (e.g., 1.6 g per day) may be combined with topical therapies to maintain remission. Topical or oral corticosteroids are not effective for maintaining remission of distal UC and should be avoided. 

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Long-term use of oral corticosteroids may result in side-effects, such as peptic ulceration, adrenal suppression and subcapsular cataracts. 

Salbutamol is a selective beta2-receptor agonist indicated in the management of asthma as a bronchodilator relieving acute attacks. It may be used in combination with inhaled corticosteroids such as beclometasone. Salbutamol acts within a few minutes and tends to be short-acting, unlike salmeterol. Side-effects of salbutamol include tachycardia and palpitations. It does not cause drowsiness and does not precipitate oral candidiasis. Inhaled corticosteroids may precipitate oral candidiasis. 

Side-effects and disadvantages of inhaled corticosteroids include hoarseness and oral candidiasis. Patients on inhaled corticosteroids are advised to rinse their mouth with water after using the inhaler, to reduce the occurrence of such... 

Blepharitis is a topical inflammation of the eyelid margins that should be treated using topical antibacterial agents. Gentamicin eye ointment is preferred to the fusidic acid drops since the ointment is a better formulation to be used where the condition involves the eyelid margins. Chloramphenicol eye drops is the third option since it is an antibiotic with a wider spectrum of activity. A combination of corticosteroid and antibiotic is not recommended because of the side-effects associated with the steroid. The use of oral tablets is not usually recommended since blepharitis can easily be managed with topical drops. The use of dexamethasone eye drops, monotherapy steroid, could clear the inflammation but mask persistence of infection. 

A major breakthrough in asthma therapy was the introduction in the 1970s of aerosol corticosteroids These agents (Table 39.3) maintain much of the impressive therapeutic efficacy of parenteral and oral corticosteroids, but by virtue of their local administration and markedly reduced systemic absorption, they are associated with a greatly reduced incidence and severity of side effects. The success of inhaled steroids has led to a substantial reduction in the use of systemic corticosteroids. Inhaled corticosteroids, along with 2-(tdreno-ceptor agonists, are front-line therapy of chronic asthma. 

Theophylline improves long-term control of asthma when taken as the sole maintenance treatment or when added to inhaled corticosteroids. It is inexpensive, and it can be taken orally. Its use, however, also requires occasional measurement of plasma levels it often causes unpleasant minor side effects (especially insomnia) and accidental or intentional overdose can result in severe toxicity or death. For oral therapy with the prompt-release formulation, the typical dose is 3-4 mg/kg of theophylline every 6 hours. Changes in dosage result in a new steady-state concentration of theophylline in 1-2 days, so the dosage may be increased at intervals of 2-3 days until therapeutic plasma concentrations are achieved (10-20 mg/L) or until adverse effects develop. 

Treatment with a leukotriene-receptor antagonist, particularly montelukast, is widely prescribed, especially by primary care providers. Taken orally, leukotriene-receptor antagonists are easy to use and appear to be used more regularly than inhaled corticosteroids. They are rarely associated with troublesome side effects. Maintenance therapy with a leukotriene antagonist or with cromolyn or nedocromil appears to be roughly as effective as maintenance therapy with theophylline. Because of concerns over the possible long-term toxicity of systemic absorption of inhaled corticosteroids, this maintenance therapy is widely used for treating children in the USA. 

Inhaled corticosteroids are minimally absorbed and have a local effect. However, depending on the dose and potency of the inhaled corticosteroid, inhaled forms can produce systemic side-effects. Oral prednisolone is rapidly absorbed and is metabolised by the liver. Some corticosteroids may be administered intravenously. 

Inhaled corticosteroids should be prescribed for patients with an FEVi of 50% predicted or less, who have two or more exacerbations needing treatment with antibiotics or oral corticosteroids a year. Warn patients about the possible risk of osteoporosis and other side effects of high-dose inhaled corticosteroids. None of the inhaled corticosteroids currently available is licensed alone for use in COPD. 

Oral corticosteroids have no role in the chronic treatment of PTC, because there are significant side effects of high-dose oral steroid use, and patients may eventually gain weight. However, in the short term, steroid treatment may be effective in patients with severe or rapid visual deterioration. Corticosteroids must be used with caution because coming off the steroids can cause PTC exacerbation. 

The use of periocular steroids circumvents many of the side effects associated with systemic steroids however, complications may still arise. lOP response is a particular concern, because depot medications cannot be removed easily, as compared with tapering or discontinuing an oral preparation. Cataractogenesis may occur with any steroid preparation with intravitreal corticosteroid implants, the incidence of cataract formation requiring surgery over 2 years is nearly 90%. 

Orally administered corticosteroids are effective in the treatment of chronic bronchial asthma. The inhalation route has been widely used in attempts to avoid systemic side-effects, such as adrenal suppression, but evidence suggests that inhaled steroids are absorbed systemically to a significant extent. The respiratory tract epithelium has permeability characteristics similar to those of the classical biological membrane, so lipid-soluble compounds are absorbed more rapidly than lipid-insoluble molecules. Cortisone, hydrocortisone and dexamethasone are absorbed rapidly by a nonsaturable diffusion process from the lung, the half-time of absorption being of the order of 1-1.7 min. Quaternary ammonium compounds, hippurates and mannitol have absorption half-times, in contrast, of between 45 and 70 min. 

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