Prednisone asthma

Aerosolized steroids clearly play an important role in the present-day management of asthma (87). They are reasonably safe and work best when taken prophylacticaHy. Patient compliance, however, remains a significant problem. In part this problem is typical of any aerosolized agent. But in the case of steroids, the problem is exacerbated because a patient needs to take the steroids (especially prednisone) are the antiasthmatic agents of last resort and are widely used to treat status asthmaticus. An agent that could mimic the actions of steroids but which would work faster and/or without side effects might be the ideal antiasthmatic agent. 

Systemic corticosteroids (Table 80-4) are indicated in all patients with acute severe asthma not responding completely to initial inhaled /J2-agonist administration (every 20 minutes for three to four doses). Prednisone, 1 to 2 mg/kg/day (up to 40 to 60 mg/day), is administered orally in two divided doses for 3 to 10 days. Because short-term (1 to 2 weeks), high-dose systemic steroids do not produce serious toxicities, the ideal method is to use a short burst and then maintain the patient on appropriate long-term control therapy with inhaled corticosteroids. 

Stabilize the patient s asthma before treatment is started. Initially, use aerosol concurrently with usual maintenance dose of systemic steroid. After approximately 1 week, start gradual withdrawal of the systemic steroid by reducing the daily or alternate daily dose. Make the next reduction after 1 to 2 weeks, depending on response. Generally, these decrements should not exceed 25% of the prednisone dose or its equivalent. A slow rate of withdrawal cannot be overemphasized. 

The corticosteroids are effective in most children and adults with asthma. They are beneficial for the treatment of both acute and chronic aspects of the disease. Inhaled corticosteroids, including triamcinolone ace-tonide (Azmflcort),beclomethasone dipropionate (Beclo-vent, Vancerit), flunisolide AeroBid), and fluticasone (Flovent), are indicated for maintenance treatment of asthma as prophylactic therapy. Inhaled corticosteroids are not effective for relief of acute episodes of severe bronchospasm. Systemic corticosteroids, including prednisone and prednisolone, are used for the short-term treatment of asthma exacerbations that do not respond to (32-adrenoceptor agonists and aerosol corticosteroids. Systemic corticosteroids, along with other treatments, are also used to control status asthmaticus. Because of the side effects produced by systemically administered corticosteroids, they should not be used for maintenance therapy unless all other treatment options have been exhausted. 

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. 

Of these agents, zileuton is the least prescribed because of reports of occasional liver toxicity. The receptor antagonists appear to have little toxicity. Reports of Churg-Strauss syndrome (a systemic vasculitis accompanied by worsening asthma, pulmonary infiltrates, and eosinophilia) appear to have been coincidental, with the syndrome unmasked by the reduction in prednisone dosage made possible by the addition of zafirlukast or montelukast. Of these two, montelukast is the most prescribed, probably because it can be taken without regard to meals and because of the convenience of once-daily treatment. 

Prednisone Like fluticasone Like fluticasone Asthma adjunct in COPD Oral duration 12-24 hours Toxicity Multiple t see Chapter 39... 

Glucocorticoids can cause neuropsychiatric adverse effects that dictate a reduction in dose and sometimes withdrawal of treatment. Of 32 patients with asthma (mean age 47 years) who took prednisone in a mean dosage of 42 mg/day for a mean duration of 5 days, those with past or current symptoms of depression had a significant reduction in depressive symptoms during... 

In a probable pharmacodynamic interaction, severe peripheral edema followed treatment with montelukast and prednisone for asthma (494). 

A 23-year-old man, with a history of asthma, house dust mite allergy, and rhinoconjunctivitis, presented with acute respiratory symptoms. He was given oral cetirizine, inhaled salmeterol, and fluticasone propionate, and oral prednisone 40 mg/day for 1 week and 20 mg/day for 1 week. His asthma recurred when prednisone was withdrawn and he took oral prednisone 60 mg/day for 1 week and 40 mg/day for 1 week. He also took montelukast 10 mg/day. He then developed severe peripheral edema with a gain in weight of 13 kg. Prednisone was withdrawn and his edema resolved. Montelukast was continued. 

Brown ES, Suppes T, Khan DA, Carmody TJ 3rd. Mood changes during prednisone bursts in outpatients with asthma. J Chn Psychopharmacol 2002 22(1) 55-61. 

The British Thoracic and Tuberculosis Association. Inhaled corticosteroids compared with oral prednisone in patients starting long-term corticosteroid therapy for asthma. Lancet 1975 2(7933) 469-73. 

The effect of supplementary inhaled budesonide in acute asthma has been evaluated in a randomized, double-blind comparison with standard treatment in 44 children aged 6 months to 18 years with a moderate to severe exacerbation of asthma (26). Prednisone 1 mg/kg orally and nebulized salbutamol (0.15 mg/kg) every 30 minutes for three doses and then every hour for 4 hours were given to all children. In addition, each child was given 2 mg of nebulized budesonide or nebulized isotonic saline. There was a more rapid discharge rate in the budesonide group. There were no adverse effects. The authors concluded that nebulized budesonide may be an effective adjunct to oral prednisone in the management of moderate to severe exacerbations of asthma. 

Sung L, Osmond MH, Klassen TP. Randomized, controlled trial of inhaled budesonide as an adjunct to oral prednisone in acute asthma. Acad Emerg Med 1998 5(3) 209-13. 

Flupenthixol and procyclidine Fluphenazine Prednisone and salbutamol Betal nut (Areca catechu) Rigidity, bradykinesia, jaw tremor Betal contains arecoline, a cholinergic alkaloid Tremor, stiffness, akithesia Inadequate control of asthma Arecoline challenge causes dose-related bronchoconstriction in patients with asthma... 

The recurrence of a similar situation was avoided in 1996. An 18-year-old American swimmer about to compete in the qualifying meet for the Olympic team realized that he had taken a dose of his asthma medication (prednisone) too close to the event. Knowing that it would be detected, he chose to withdraw from the meet, saying he would wait another 4 years. 

The correct answer is B. Due to the increased severity of this allergic reaction secondary to re-exposure, the next step in therapy is oral steroids. Prednisone, a glucocorticoid, is commonly used to treat conditions such as skin inflammation, asthma, and arthritis. Prednisone acts by decreasing the production of the mediators of inflammation, thereby resulting in its antiinflammatory action. A is incorrect. Hydrocortisone is a low potency glucocorticoid that is indicated for mild inflammation and irritation of the skin. The child s inflammation is severe enough to require systemic steroid therapy. 

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