Glucocorticoids adverse reaction

Because ACTH stimulates the release of glucocorticoids from the adrenal gland, adverse reactions seen with the administration of this hormone are similar to those seen with the glucocorticoids (see Display 50-2) and affect many body systems. The most common adverse reactions include ... 

DISPLAY 50-2 Adverse Reactions Associated With Glucocorticoids... 

Promoting an Optimai Response to Therapy Nursing management depends on the patient s diagnosis, physical status, and die reason for use of die drag. The nurse may need to assess vital signs every 4 hours and observe for die adverse reactions seen with glucocorticoid administration. 

Monitor for adverse reactions from hydrocortisone administration. Glucocorticoid therapy at physiologic replacement doses should not lead to the development of Cushing s syndrome. However, careful monitoring should still be performed. Use the smallest effective dose. 

Monitor the patient for adequacy of treatment, as well as adverse reactions from glucocorticoid and/or mineralocorticoid therapy. 

Most patients who are treated therapeutically with glucocorticoids do not have glucocorticoid deficiency. Adverse reactions to glucocorticoids depend very largely on the ways in which, and the purposes for which, they are used. There are four groups of uses. 

The incidence and severity of adverse reactions to glucocorticoids depend on the dose and duration of treatment. Even the very high single doses of glucocorticoids, such as methylprednisolone, which are sometimes used, do not cause serious adverse effects, whereas an equivalent dose given over a long period of time can cause many long-term effects. 

The benefit of glucocorticoid therapy is often limited by several adverse reactions, including cardiovascular disorders such as hypertension and atherosclerosis. Plasma volume expansion due to sodium retention plays a minor role, but increased peripheral vascular resistance, due in part to an increased pressor response to catecholamines and angiotensin II, plays a major role in the pathogenesis of hypertension induced by glucocorticoid excess. However, the molecular mechanism remains unclear. 

The eye can be involved in generalized adverse reactions to systemically administered glucocorticoids. For example, conjunctivitis can occur as part of an allergic reaction and infections of the eye can be masked as a result of antiinflammatory and analgesic effects. Ophthalmoplegia can occur as one of the consequences of glucocorticoid myopathy (SEDA-16, 450). Two complications that require special discussion are cataract and glaucoma. 

In the previous literature this adverse reaction was described in patients taking glucocorticoids for from 4 months to several years. 

Most knowledge of the adverse effects of glucocorticoids has been acquired in connection with their use as oral products. However, various other routes of administration have been developed, sometimes specifically in the hope of securing a local therapeutic effect while avoiding systemic adverse reactions. Although experience has shown that the latter cannot be eliminated in this way, they can be diminished in some cases. In other cases, new problems arise. Administration by inhalation is covered in the monograph on inhaled glucocorticoids. 

A 58-year-old woman, who had been involved in the manufacturing of glucocorticoid creams and ointments for over 10 years, developed occupational contact sensitization to topical glucocorticoids (472). Patch tests were positive to hydrocortisone, hydrocortisone butyrate, and tixocortol pivalate. Intradermal tests were positive to hydrocortisone succinate, methylpredniso-lone, and prednisolone. An oral challenge with betamethasone 0.75 mg, 2.5 mg, and 8 mg on three consecutive days resulted in no adverse reactions. 

Ventura MT, Calogiuri GF, Matino MG, Dagnello M, Buquicchio R, Foti C, Di Corato R. Alternative glucocorticoids for use in cases of adverse reaction to systemic glucocorticoids a study on 10 patients. Br J Dematol 2003 148 139-41. 

Although there is no direct evidence of potentiation of hematological toxicity, the concomitant use of drugs that are known to carry a risk of blood dyscrasias is unwise. Simultaneous use of glucocorticoids in small doses is not thought to detract from the beneficial effects of gold and can delay the onset of adverse reactions (39)... 

The clinical significance of antibodies to infliximab has also been explored in 125 patients with Crohn s disease who were given infliximab, of whom 61% had antibodies after the fifth infusion however, there was no further increase in incidence after subsequent treatment (21). The presence of antibodies was associated with a 2.4-fold increase in the risk of infusion reactions, lower serum infliximab concentrations, and a shorter duration of clinical response, compared with patients with no infliximab antibodies. Patients who received concomitant immunosuppressive therapy had a lower incidence of infliximab antibodies, higher infliximab serum concentrations, and a longer duration of clinical response. Pretreatment with glucocorticoids may reduce the risk of antibody formation, but it is not known whether a pretreatment test for human antichimeric antibodies has a predictive value for adverse reactions (22). However, there were technical issues relating to the antibody assay and definition of clinically relevant antibody titers in this study. 

Toxicity The principal adverse reactions to cyclosporine therapy are renal dysfunction, tremor, hirsutism, hypertension, hyperhpidemia, and gum hyperplasia. Hyperuricemia may lead to worsening of gout, increased P-glycoprotein activity, and hypercholesterolemia. Nephrotoxicity occurs in the majority of patients treated and is the major indication for cessation or modification of therapy. Hypertension occurs in -50% of renal transplant and almost all cardiac transplant patients. Combined use of calcineurin inhibitors and glucocorticoids is particularly diabetogenic, although this apparently is more problematic in patients treated with tacrohmus see below). Especially at risk are obese patients, African American or Hispanic recipients, or those with family history of type 2 diabetes or obesity. Cyclosporine, as opposed to tacrolimus, is more hkely to produce elevations in low-density lipoprotein (LDL) cholesterol. 

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