Methylprednisolone asthma

Methylprednisolone Succinate and Acetate (Solu-Medrol, DepO Medrol) [Steroid] Uses Tx inflammation d/t anaphylaxis and asthma suspected SCI Action Adrenal corticost oid Dose Adul. Anaphylaxis/ status asthmaticus 125-250 mg IV/EM Suspected SCI Load w/ 30 mg/kg then inf... 

Synthetic glucocorticoids are prednisolone, prednisone, methylprednisolone, dexamethasone, betamethasone and triamcinolone (Table 13.2). Hydrocortisone is available as either succinate or phosphate salts for oral and intravenous administration. It is the drug of choice when a rapid effect is required, e.g. acute adrenal insufficiency, or as peri-operative replacement therapy. Prednisolone can also be given intravenously. It has about 0.8 of the mineralocorticoid activity of hydrocortisone. Prednisone is a prodrug that is converted to prednisolone in the body. For chronic therapy, synthetic steroids without mineralocorticoid activity are preferred, such as dexamethasone, betamethasone or triamcinalone. Beclo-metasone passes membranes poorly and is more active topically than when given orally. It is used as an aerosol for chronic rhinitis and asthma, and topically in severe eczema. Fludrocortisone is a synthetic halogenated derivate of cortisol that is used for its mineralocorticoid effect. 

Urgent treatment is often begun with an oral dose of 30-60 mg prednisone per day or an intravenous dose of 1 mg/kg methylprednisolone every 6 hours the daily dose is decreased after airway obstruction has improved. In most patients, systemic corticosteroid therapy can be discontinued in a week or 10 days, but in other patients symptoms may worsen as the dose is decreased to lower levels. Because adrenal suppression by corticosteroids is related to dose and because secretion of endogenous corticosteroids has a diurnal variation, it is customary to administer corticosteroids early in the morning after endogenous ACTH secretion has peaked. For prevention of nocturnal asthma, however, oral or inhaled corticosteroids are most effective when given in the late afternoon. 

An anaphylactoid reaction occurred in a 68-year-old woman after treatment with intravenous methylprednisolone for asthma. She had developed urticaria with methylprednisolone 1 year earlier, but the reaction had been thought to be related to the solvent in the formulation (302). 

Vanpee D, Gillet JB. Allergic reaction to intravenous methylprednisolone in a woman with asthma. Ann Emerg Med 1998 32(6) 754. 

An asthmatic patient using inhaled budesonide and salbutamol developed an acute asthma attack. Despite emergency treatment the patient deteriorated, requiring endotracheal intubation and assisted ventilation, and there was no improvement until the glucocorticoid was withdrawn, after which there was steady improvement. Skin prick tests with prednisolone, sodium hemisuccinate, and 6-methylprednisolone-sodium hemisuccinate were positive. Thirty minutes after intradermal 6-methylprednisolone-sodium hemisuccinate 4 mg, the patient developed a dry cough, dyspnea, and wheezing and a 17% fall in FEVi. 

Anaphylactic shock has been described after intranasal hydrocortisone acetate, intramuscular methylprednisolone (SEDA-21, 419) (251), intravenous methylprednisolone (SEDA-22, 448) (252), intramuscular dexamethasone (SEDA-22, 448) (253), and intra-articular methylprednisolone (SEDA-22, 449) (254). A life-threatening anaphylac-tic-like reaction to intravenous hydrocortisone has been described in patients with asthma (255). Acute laryngeal obstruction has been described for the first time after the intravenous administration of hydrocortisone (SEDA-22, 449) (256). There is some reason to believe that sodium succinate esters are more likely to cause hypersensitivity reactions (SEDA-17, 449), but unconjugated glucocorticoids can definitely produce allergy in some cases (SEDA-16, 452). 

A 17-year-old boy, with an 11-year history of asthma, had anaphylaxis with respiratory distress shortly after he received intravenous methylprednisolone for an exacerbation of asthma while taking a tapering course of oral prednisone 15 mg/day (259). He had been glucocorticoid-dependent for at least 1 year. He reported having received intravenous glucocorticoids previously. He was treated with inhaled salbutamol and then intravenous methylprednisolone 125 mg over 15-30 seconds, and 3-4 minutes later became flushed and dyspneic, and developed diffuse urticarial lesions on his trunk and face and an undetectable blood pressure. He was treated with adrenaline, but required intubation. Sinus bradycardia developed and then asystole. He was successfully resuscitated and a 10-15 seconds period of generalized tonic-clonic activity was treated with diazepam. He remained unresponsive to stimulation for... 

Some macrolides have a dose- and time-related effect on methylprednisolone elimination, resulting in a prolonged half-life and reduced clearance (157). These changes were considered advantageous (steroid sparing) in patients with asthma (158,159). However, a retrospective analysis of 3995 patients treated with azithromycin did not show any pharmacokinetic interaction in patients who were also taking methylprednisolone (127,128). 

In an open study in six adults with mild to moderate asthma, clarithromycin significantly reduced methylprednisolone clearance, thereby increasing the risk of steroid-induced adverse effects (160). In contrast, prednisolone clearance and mean prednisolone plasma concentrations were unaffected. Frank psychosis due to combined therapy with prednisone and clarithromycin has been reported (161). 

Steroids snch as beclamethasone dipropionate, budes-onide, triamcinolone acetonide, and flunisolide are active when given topically and can control asthma without causing systemic effects or adrenal suppression. However, orally administered steroids such as prednisone, prednisolone, or methylprednisolone are still needed by some patients. 

Troleandomydn. A pharmacokinetic study in 4 children and 6 adult corticosteroid-dependent asthmatics found that troleandomycin 14 mg/kg daily for one week increased the half-life of methylprednisolone by 88%, from 2.46 to 4.63 hours, and reduced the total body clearance by 64%. All 10 had Cushingoid symptoms (cushingoid facies and weight gain), which resolved when the methylprednisolone dosage was reduced, without any loss in the control of the asthma. Another study found that the dose of methylprednisolone could be reduced by 50% in the presence of troleandomycin, without loss of disease control. Other studies have found similar effects. However, a randomised, placebo-controlled 2-year study found that although troleandomycin modestly reduced the lequiied dose... 

Burgdorff T, Venemalm L, Vogt T, et al. IgE-mediated anaphylactic reaction induced by succinate ester of methylprednisolone. Arm Allergy Asthma Immunol. 2002 89 425-8. 

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