Oral corticosteroid therapy

Eosinophilia Physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or neuropathy in their patients. In rare cases, patients on therapy with montelukast may present with systemic eosinophilia. These events usually, but not always, have been associated with the reduction of oral corticosteroid therapy. 

Zafirlukast and montelukast are well tolerated. Zafirlukast increases plasma concentrations of warfarin and decreases the concentrations of theophylline and erythromycin. In rare cases, treatment of patients with CysLT receptor antagonists is associated with the development of Churg-Strauss syndrome, a condition marked by acute vasculitis, eosinophilia, and a worsening of pulmonary symptoms. Because these symptoms often appear when patients are given the leukotriene receptor antagonists when they are being weaned from oral corticosteroid therapy, it is not clear whether they are related to the action of the antagonists or are due to a sudden reduction in corticosteroid therapy. 

Long-term control of bronchial asthma, assists in reducing or discontinuing oral corticosteroid therapy inhalafion 2 inhalafions fwice a day, morning and evening. Maximum 4 inhalafions fwice a day. 

An issue for inhaled corticosteroid treatment is patient compliance. Analysis of prescription renewals shows that corticosteroids are taken regularly by a minority of patients. This may be a function of a general "steroid phobia" fostered by emphasis in the lay press over the hazards of long-term oral corticosteroid therapy and by ignorance over the difference between corticosteroids and anabolic steroids, taken to enhance muscle strength by now-infamous athletes. This fear of corticosteroid toxicity makes it hard to persuade patients whose symptoms have improved after starting the treatment that they should continue it for protection against attacks. 

A patient developed bilateral visual loss after systemic administration of gallium nitrate (SEDA-22, 244) (18). The condition worsened after oral corticosteroid therapy and partial recovery of optic nerve function in both eyes was present only after 12 months of oral ferrous sulfate administration. 

Callahan CM, Dittos RS, Katz BP. Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease A meta-analysis. Ann Intern Med 1991 114 216-223. 

For chronic dermatitis, lubricants, emollients, or moisturizers should be applied after bathing. Soap-free (or mild) cleansers and products containing colloidal oatmeal also contribute to alleviating itch and soothing the skin. If the patient s reaction does not subside within a few days, or further spread occurs, the patient should be referred for specialist follow-up and for prescription therapy with stronger topical corticosteroids and possibly oral corticosteroid therapy. 

Budesonide is a corticosteroid/flucocorticoid/intranasal steroid. It exhibits a wide range of inhibitory activities against multiple cell types and mediators involved in aller-gic-mediated inflammation. Its indications are Intranasal management of seasonal and perennial allergic rhinitis symptoms in adults and children oral inhalation for the maintenance treatment of asthma as prophylactic therapy in adults and children and for patients requiring oral corticosteroid therapy for asthma inhalation suspension maintenance treatment of asthma and prophylactic therapy in children 12 months to 8 years of age oral capsule Crohn s disease. 

Fluticasone is a corticosteroid that exerts potent antiinflammatory effect on nasal passages for management of the nasal symptoms of seasonal and perennial allergic and non-allergic rhinitis in adults and pediatric patients 4 years and older (Flonaze) patients requiring oral corticosteroid therapy for asthma (Flovent, Flovent Rotadisk, Flovent Dis-kus) maintenance treatment of asthma as prophylactic therapy in patients 4 years and older (Flovent Diskus, Flovent Rotadisk) and 12 years and older (Flovent). 

POSTERIOR SUBCAPSULAR CATARACTS AND RAISED INTRAOCULAR PRESSURE ARE CAUSED BY PROLONGED ORAL CORTICOSTEROID THERAPY IN ADULT PATIENTS WITH INFLAMMATORY BOWEL DISEASE... 

Tam DTH, Ngoc TV, Tien NTH, Kieu NTT, Thuy ITT, Thanh LTC, et al. Effects of short-coiuse oral corticosteroid therapy in early dengue infection in Vietnamese patients a randomized placebo-controlled trial. Clin Inf Dis 2012 55(9) 1216-24. 

There are few definitive data to substantiate the efficacy of LTRA therapy in refractory asthma, except for patients with aspirin-sensitive asthma. This is a fairly uncommon form of asthma that occurs generally in adults who often have no prior (i.e., childhood) history of asthma or atopy, may have nasal polyposis, and who often are dependent upon oral corticosteroids for control of their asthma. This syndrome is not specific to aspirin but is provoked by any inhibitors of the cycloxygenase-1 (COX-1) pathway. These patients have been shown to have a genetic defect that causes... 

Systemic corticosteroids if no immediate response or incomplete response to aggressive inhaled P2-adrenergic agonist therapy, if patient recently received an oral corticosteroid, or if the episode is considered severe... 

Treatment depends on the symptoms and severity of the exacerbation. Mild exacerbations can often be treated at home with an increase in bronchodilator therapy with or without oral corticosteroids (Fig. 12-3). Antibiotics are indicated only if there are clinical signs of airway infection (e.g., increased volume and change in color of sputum and/or fever). Moderate to severe exacerbations require management in the... 

Treatment of active mild to moderate Crohn s disease involves use of oral or topical aminosalicylate derivatives, whereas moderate to severe disease may require systemic corticosteroid therapy. 

Patients with IBD, particularly those with CD, are also at risk for bone loss. This may be a function of malabsorption or an effect of repeated courses of corticosteroids. Patients with IBD should receive a baseline bone density measurement prior to receiving corticosteroids. Vitamin D and calcium supplementation should be used in all patients receiving long-term corticosteroids. Oral bisphosphonate therapy may also be considered in patients receiving prolonged courses of corticosteroids or in those with osteopenia or osteoporosis. 

Oral corticosteroids may be used for patients who are unresponsive to sulfasalazine or mesalamine. Prednisone doses of 40 to 60 mg per day (or equivalent) are recommended.1 Azathioprine or 6-MP is used for patients unresponsive to corticosteroids or those who become steroid-dependent. Over a 12-month period, these agents have been shown to reduce the relapse rate to 36% versus 59% seen with placebo.1 Infliximab 5 mg/kg may also be used for patients who are unresponsive to conventional oral therapies and may reduce the need for colectomy after 3 months of treatment.35... 

Patients with severe UC symptoms require hospitalization for management of their disease. If the patient is unresponsive to oral or topical mesalamine and oral corticosteroids, then a course of intravenous corticosteroids should be initiated.1 Hydrocortisone 300 mg/day given in three divided doses or methylprednisolone 60 mg daily for 7 to 10 days are the preferred therapies. 

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. 

Patients with moderate to severe active CD may be treated with oral corticosteroids, such as prednisone 40 to 60 mg daily.2 Budesonide 9 mg orally once daily may be used for moderate active CD involving the terminal ileum or ascending colon. Infliximab is an effective alternative to corticosteroid therapy for patients with moderate to severe CD, including patients with fistulizing or perianal disease.15,37-39 The recommended regimen for induction of remission is infliximab 5 mg/kg at weeks 0, 2, and 6 it is effective in inducing remission in... 

Oral corticosteroids (e.g., prednisone, methylprednisolone) can be used to control pain and synovitis while DMARDs are taking effect ( bridging therapy ). This is often used in patients with debilitating symptoms when DMARD therapy is initiated. 

In patients unable to take the capsules, therapy may be initiated with the injection. Administer the initial dose no sooner than 6 hours after transplantation. The recommended starting dose is 0.03 to 0.05 mg/kg/day as a continuous IV infusion. Give adult patients doses at the lower end of the dosing range. Concomitant adrenal corticosteroid therapy is recommended early posttransplantation. Proceed with continuous IV infusion only until the patient can tolerate oral administration. 

NSAIDs and oral corticosteroids may be continued. Onset of action generally occurs between 4 and 8 weeks. If insufficient benefit is seen and tolerability is good (including serum creatinine less than 30% above baseline), the dose may be increased by 0.5 to 0.75 mg/kg/day after 8 weeks and again after 12 weeks to a maximum of 4 mg/kg/day. If no benefit is seen by 16 weeks of therapy, discontinue. There is limited P.1164... 

IV.b.2.1. Prevention of non-steroidal associated ulcer. Risks of precipitating such ulcers by non-selective COX therapy are particularly large in the elderly, in those receiving concurrent cardiovascular prophylaxis with aspirin, and in those receiving concurrent oral corticosteroids or anticoagulants and in those with histories of prior ulcer. 

VIII.b.1.3. Extensive disease. Rectal therapies are insufficient, and patients should receive, if outpatients, oral corticosteroids, and if in-patients oral or parenteral corticosteroids with full supportive treatment including parenteral fluids and blood transfusion. The need for intensive in-patient treatment is indicated by the presence of severe diarrhoea, anaemia, fever and tachycardia with radiographic evidence of colonic mucosal oedema on plain X-ray, or of toxic megacolon. 

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. 

It is a cysteinyl leukotriene receptor antagonist indicated for the management of persistent asthma. It has been shown to have substantial blockade of airway leukotriene receptors 24 hours after oral dosing. Montelukast appears to be a useful alternative or adjunct to inhaled corticosteroid therapy in adults and an alternative to sodium cro-moglycate in children. 

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. 

If asthmatic symptoms occur frequently or if significant airflow obstruction persists despite bronchodilator therapy, inhaled corticosteroids should be started. For patients with severe symptoms or severe airflow obstruction (eg, FEVi < 50% predicted), initial treatment with a combination of inhaled and oral corticosteroid (eg, 30 mg/d of prednisone for 3 weeks) treatment is appropriate. Once clinical improvement is noted, usually after 7-10 days, the oral dose should be discontinued or reduced to the minimum necessary to control symptoms. 

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