Steroidal therapy

Corticosteroids a chronic painless myopathy associated with the long-term use of corticosteroids is a particularly common example of drug-induced muscle disorder. It is almost certain that mild cases are overlooked because steroids are so frequently used to treat inflammatory myopathies such as polymyositis. Fluorinated steroids are particularly frequently implicated, and the incidence of drug-induced muscle disease is dose and time-related. The presence of muscle weakness can even complicate topical steroid therapy. Corticosteroid-induced myopathy is mediated via intramuscular cytosolic steroid receptors. The steroid-receptor complexes inhibit protein synthesis and interfere with oxidative phosphorylation. The myopathy is associated with vacuolar changes in muscle, and the accumulation of cytoplasmic glycogen and mitochondrial aggregations. 

Evaluate patients receiving systemic corticosteroid therapy for improvement in symptoms and opportunities to taper or discontinue steroid therapy. For patients using more than 5 mg daily of prednisone for more than 2 months or for steroid-dependent patients consider the following ... 

Although tacrolimus therapy is associated with increasing blood pressure, studies have found that tacrolimus has less dramatic effects on GFR and RBF than cyclosporine. In some clinical trials, tacrolimus caused less severe HTN and required significantly fewer antihypertensive medications at both 24 and 60 months after transplantation than cyclosporine.61-63 Thus conversion from cyclosporine-based immunosuppression to tacrolimus-based immunosuppression may be one way to minimize blood pressure increases in transplant recipients. Conversion to sirolimus also may be an alternative to the calcineurin inhibitors in patients with difficult-to-treat HTN because sirolimus therapy is less associated with increased blood pressure. Additionally, withdrawal or tapering of steroid therapy may be an effective strategy for lowering blood pressure. 

Systemic corticosteroids, administered orally or by depot injection, are considered last-resort options when all other treatments for SAR are inadequate. Systemic steroids may be used to control rhinitis symptoms in patients with severe PAR or nasal polyposis. Data comparing oral and parenteral steroid therapy are lacking however, oral therapy is preferred due to its low cost... 

Determine if adjunctive dexamethasone therapy is indicated if so, start steroid therapy 15 to 20 minutes before the first dose of antimicrobial therapy. 

L5. Lepore, M. J., Long-term or maintenance adrenal steroid therapy in non-tropical sprue. Am. J. Med. 25, 381-390 (1958). 

In the presence of infection, malignant diseases, and steroid therapy, haptoglobins may be demonstrable even if the rate of hemolysis is more than twice the normal rate (B12). 

Holm AF, Fokkens WJ, Godthelp T, Mulder PG, Vroom TM, Rijntjes E Effect of 3 months nasal steroid therapy on nasal T cells and Langerhans cells in patients suffering from allergic rhinitis. Allergy 1995 50 204-209. 

Shenoy S, Arnold S, Chatila T Response to steroid therapy in autoimmune lymphoproliferative syndrome secondary to ALPS. J Pediatr 2000 3 101-109. 

Steroids have mineralocorticoid and glucocorticoid effects. Betamethasone has little, if any, mineralocorticoid effect. However, it should be used with caution in patients predisposed to hypertension since mineralocorticoid effects may lead to sodium and water retention and an increase in blood pressure. When used systemically, especially at high doses, steroid therapy is associated with a risk of psychiatric reactions such as euphoria, irritability, mood lability and sleep disorders. Glucocorticoid side-effects include diabetes and osteoporosis. 

The clinicians noted that although the first patient responded well to steroid therapy, steroids may be less useful in more severe cases of bronchiolitis obliterans. Specifically, steroid treatment should be stopped if no improvement is seen during the first days because this treatment may increase the risk of lung infection in the presence of a denuded lung epithelium. 

In an extensive study (A4) of 88 Nigerian children with the nephrotic syndrome, 80% were observed with a nonselectivity proteinuria, and steroid therapy was ineffective in most of these ehildren. Unlike European and American children with the nephrotic syndrome, less than half of the Nigerian children who had highly selective type proteinuria showed... 

If a diagnosis of amiodarone-induced hypersensitivity pneumonitis is made, discontinue amiodarone and institute steroid treatment. If a diagnosis of amiodarone-induced interstitial/alveolar pneumonitis is made, institute steroid therapy and discontinue amiodarone or, at a minimum, reduce dosage. 

Bitolterol Prophylaxis and treatment of bronchial asthma and reversible bronchospasm. May be used with or without concurrent theophylline or steroid therapy. 

Replacement therapy Jranster from systemic steroid therapy may unmask allergic conditions previously suppressed. During withdrawal from oral steroids, some patients may experience withdrawal symptoms despite maintenance or improvement of respiratory function. 

Corticosteroids If systemic or inhaled steroid therapy is at all reduced, monitor patients carefully. 

Endocrine diseases and their treatment have a major impact on health throughout the world, particularly in terms of diabetes, thyroid disease, steroid therapy, and control of fertility. Most endocrine therapy is simple and relatively cheap, but a clear understanding of their actions and uses is essential for safe and cost-effective treatment. In this chapter we will focus mainly on well established and validated endocrine therapies that are widely used throughout the world, with briefer mention of drugs that have recently been introduced. In the sections that follow we outline the major issues in the current clinical pharmacology of endocrine disease, covering each of the major endocrine systems in turn. 

IV.a.1.10. Immunosuppression. An important effect of steroid therapy is immunosuppression and this may be an essential part of their anti-inflammatory action in some situations. However patients may therefore be at risk of serious illness as a result of normally minor infection. This is particularly important with diseases such as chickenpox and measles. In addition the usual clinical effects of such diseases may be masked, delaying their diagnosis. 

Pulmonary eosinophilic syndrome, characterized by extreme hypoxemia, eosinophilia, interstitial pneumonitis, hilar lymphadenopathy, and pleural effusions, can be severe and can occur with as little as 7 to 9 days of therapy with the tetracyclines. In severe cases steroid therapy is required, but the outcome following drug discontinuation is nearly always good. 

In about one-fourth to one-third of the patients receiving prolonged steroid therapy, the hyperglycemic effects... 

The normal subject may retain sodium and water during steroid therapy, although the synthetic steroid ana-... 

Steroids are important components in the treatment of hematopoietic malignancies. Their efficacy in chronic lymphocyfic leukemia and mulfiple myeloma sfems from fheir lympholyfic effecfs fo reduce cell prolifera-fion, promofe cell cycle arresf, and induce cell deafh by apopfosis. A complicafion of chronic lymphocyfic leukemia, fhaf is, aufoimmune hemolyfic anemia, also responds favorably fo steroids. However, the development of resistance may limit the effectiveness of steroid therapy. 

D) Patients should not require an increment in steroid therapy during increased stress (e.g., severe infection). 

L E. Recovery from prolonged steroid therapy is slow, and the withdrawal may be unpleasant. The patient may be reluctant to reduce the dose of steroid because of its salutary effects on the psyche. Tapering the dose of steroid is important in steroid withdrawal however, the patient may temporarily require a dose increase during periods of heightened stress. 

A transfer from systemic to local steroid therapy may unmask previously suppressed bronchial asthma condition. 

Patients on chronic steroid therapy should wear Medic Alert bracelet... 

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