System glucocorticoids

All patients starting or receiving long-term systemic glucocorticoid therapy should receive at least 1,500 mg elemental calcium and 800 to 1,200 units of vitamin D daily and practice a bone-healthy lifestyle. 

Intraarticular injections of depot forms may be useful when only a few joints are involved. If effective, injections may be repeated every 3 months. No one joint should be injected more than two or three times per year. Adverse effects of systemic glucocorticoids limit their long-term use. Dosage tapering and eventual discontinuation should be considered at some point in patients receiving chronic therapy. 

Supportive care includes administration of systemic glucocorticoids until all symptoms of active disease disappear. 

Patients with seropositive rheumatoid arthritis taking long-term systemic glucocorticoids are at risk of accelerated cardiac rupture in the setting of transmural acute myocardial infarction treated with thrombolytic drugs (25). 

Transient hypertrophic cardiomyopathy has been attributed to systemic glucocorticoid administration for a craniofacial hemangioma (28). 

Children have more frequent, more severe, and more rapid ocular hypertensive responses to topical dexamethasone than adults. In one case a systemic glucocorticoid caused significant but asymptomatic ocular hypertension in a child (67). 

Systemic glucocorticoid treatment can cause severe exacerbation of bullous exudative retinal detachment and lasting visual loss in some patients with idiopathic central serous chorioretinopathy (SEDA-20, 374 68). The atypical presentation of this condition can include peripheral retinal capillary nonperfusion and retinal neovascularization. The treatment of choice in patients with idiopathic central serous chorioretinopathy is laser photocoagulation. 

A delayed hypersensitivity reaction, characterized by a skin rash, due to dexamethasone has been reported (171). These kinds of reactions to systemic glucocorticoids are rarely reported. 

Topical glucocorticoids are well-known contact sensitizers. Immediate allergic or allergic-like reactions to systemic glucocorticoids also occur, but less often. Two atopic patients developed urticaria, possibly IgE-mediated, from a hydrocortisone injection or infusion (176) and other reactions have been reported. 

A possible relation between systemic glucocorticoid use and a risk of esophageal cancer has been described in a population-based study in Denmark, in which the prescriptions database and the Danish cancer registry were linked (365). There was an increase in the number of cases observed (n = 36) compared with the number expected (n = 19), with a standardized incidence ratio of 1.92 (95% Cl = 1.34, 2.65). 

An 11-year-old boy with iridocyclitis developed Cushing s syndrome, a posterior subcapsular cataract, and increased intraocular pressure in both eyes after the topical administration of prednisolone acetate 1% eye-drops bilaterally for 6 months. The Cushing s syndrome was aggravated when periocular methylpredni-solone acetate was started while bilateral posterior subtenon injections of 80 mg of suspension were continued every 6 weeks for 6 months. He had not used systemic glucocorticoids before. 

Klein JF. Adverse psychiatric effects of systemic glucocorticoid therapy. Am Fam Physician 1992 46(5) 1469-74. 

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. 

When a patient switches from oral or parenteral therapy to inhalation therapy, the systemic effect is reduced, just as if the dose of systemic glucocorticoid is reduced, and precautions should be taken to avoid withdrawal symptoms. 

Beclomethasone dipropionate and several other glucocorticoids—primarily budesonide and flunisolide and mometasone furoate, administered as aerosols—have been found to be effective in the treatment of asthma (see Chapter 20 Drugs Used in Asthma). The switch from therapy with systemic glucocorticoids to aerosol therapy must be undertaken with caution, since manifestations of glucocorticoid deficiency will appear if adrenal function has been suppressed. In such patients, a slow, graded reduction of systemic therapy and monitoring of endogenous adrenal function should accompany the institution of aerosol administration. 

TCDD on the immune system." One potentially important indirect mechanism operates through effects on the endocrine system. Glucocorticoids, sex steroids, T4, growth hormone, and prolactin have been shown to regulate immune responses, and 2,3,7,8-TCDD has been shown to alter the activity of all of them (see also sections on endocrine and reproductive effects). 

Inhaled glucocorticoids are the drugs of first choice in patients with moderate to severe asthma who require inhalation of p2-adrener-gic agonists more than once daily (see Figure 22.2). Severe asthma may also require systemic glucocorticoids, usually for short term. Inhaled glucocorticoids often reduce (or eliminate) the need for oral glucocorticoids in patients with severe asthma. To be... 

The epimeric mixture of 16 ( K,S ),17-[butylidenebis(oxy) -11/7,21 -dill ydroxy-pregna-l,4-diene-3,20-dione was shown to have a local anti-inflammatory potency comparable to that of fluorocinolone acetonide. In contrast, its systemic glucocorticoid activity was found to be four to seven times lower than that of fluocinolone acetonide. 

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