Ulcer steroid

GI Age > 65 Previous ulcer Steroid treatment Treatment with more than one NSAID Scrutinize the indication, inform about the risks and choose another analgesic. Consider ulcer prophylaxis with proton pump inhihitors or misoprostol, or alternatively choose a COX-2 inhihitor... 

Unfortunately steroids merely suppress the inflammation while the underlying cause of the disease remains. Another serious concern about steroids is that of toxicity. The abmpt withdrawal of glucocorticoid steroids results in acute adrenal insufficiency. Long term use may induce osteoporosis, peptidic ulcers, the retention of fluid, or an increased susceptibiUty to infections. Because of these problems, steroids are rarely the first line of treatment for any inflammatory condition, and their use in rheumatoid arthritis begins after more conservative therapies have failed. 

In severe cases, or those refractory to treatment, truncal and limb weakness may be accompanied by involvement of masticatory, bulbar, and respiratory muscles. However the most life-threatening clinical manifestations are those affecting the gastrointestinal tract, since stomach ulceration can occur and death from perforation and peritonitis are not unknown. Medication with steroidal antiinflammatory agents is necessary but weakens the childrens resistance to infection, so that systemic spread of usually self-limiting disorders, such as candidiasis, may occasionally occur. 

O Patients with peptic ulcer disease should avoid exposure to factors known to worsen the disease, exacerbate symptoms, or lead to ulcer recurrence [e.g., non-steroidal anti-inflammatory drug (NSAID) use or cigarette smoking]. 

Gionchetti P, Rizzello F, Ferrieri A, Venturi A, Brignola C, Ferretti M, Peruzzo S, Miglioli M, Campieri M Rifaximin in patients with moderate or severe ulcerative colitis refractory to steroid-treatment A double-blind, placebo-controlled trial. Dig Dis Sci 1999 44 1220-1221. 

Immunosuppressive agents such as azathioprine and mercaptopurine (a metabohte of azathioprine) are sometimes used for the treatment of IBD. These agents are generally reserved for cases that are refractory to steroids and may be associated with serious adverse effects such as lymphomas, pancreatitis, or nephrotoxicity. Cyclosporine has been of short-term benefit in acute, severe ulcerative colitis when used in a continuous infusion. 

Steroids have a place in the treatment of moderate to severe ulcerative colitis that is unresponsive to maximal doses of oral and topical mesalamine. Prednisone up to 1 mg/kg/day or 40 to 60 mg daily may be used for patients who do not have an adequate response to sulfasalazine or mesalamine. 

Rectally administered steroids or mesalamine can be used as initial therapy for patients with ulcerative proctitis or distal colitis. 

Continuous IV infusion of cyclosporine (4 mg/kg/day) is recommended for patients with acute severe ulcerative colitis refractory to steroids. 

Steroids do not have a role in the maintenance of remission with ulcerative colitis because they are ineffective. Steroids should be gradually withdrawn after remission is induced (over 3 to 4 weeks). If they are continued, the patient will be exposed to steroid side effects without likelihood of benefits. 

Azathioprine is effective in preventing relapse of ulcerative colitis for periods exceeding 4 years. However, 3 to 6 months may be required for beneficial effect. For patients who initially respond to infliximab, continued administration of 5 mg/kg every 8 weeks as maintenance therapy is an alternative for steroid dependent patients. 

Aging is one of the major risk factors for developing gastric ulcers because of an increased incidence of Helicobacter pylori infections and a widely spread use of non-steroidal anti-inflammatory drugs (NSAID). Co-morbidity, with the need for prophylactic medication with antiplatelet therapy, warfarin and other anticoagulants, also increases the risk of gastrointestinal bleeding and ulcerations (Murakami et al. 1968). 

Arthrotec tablets contain the non-steroidal anti-inflammatory drug diclofenac and the prostaglandin misoprostol. The combination of the two active ingredients makes Arthrotec suitable in patients predisposed to gastrointestinal ulceration. Dulco-lax (bisacodyl) tablets act as a stimulant laxative. Voltarol Retard tablets contain the non-steroidal anti-inflammatory drug diclofenac. All... 

Wound healing Because of the inhibitory effect of corticosteroids on wound healing in patients who have experienced recent nasal septal ulcers, recurrent epistaxis, nasal surgery, or trauma, use nasal steroids with caution until healing has occurred. Vasoconstrictors In the presence of excessive nasal mucosa secretion or edema of the nasal mucosa, the drug may fail to reach the site of intended action. In such cases, use a nasal vasoconstrictor during the first 2 to 3 days of therapy. 

Non-steroidal anti-inflammatory associated ulcer can be managed in various ways. There are no significant differences in principal between management of non-steroidal and aspirin associated disease or for aspirin whether at low cardioprotective or full doses. Risks are dose related and greater for some drugs, notably piroxicam, than others notably ibuprofen at low dose. 

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. 

Steroid administration was once thought to lead to the formation of peptic ulcers, with hemorrhage or perforation or reactivation of a healed ulcer. It is now realized that this effect is principally observed in patients who have received concomitant nonsteroidal antiinflammatory treatment. Since there is a minimal increase in the incidence of ulcers in patients receiving glucocorticoid treatment alone, prophylactic antiulcer regimens are usually not necessary. 

Initial hematocrit and fecal occult blood test within 3 mo of starting regular chronic therapy repeat every 6-12 mo (more frequently in high-risk patients (>65 years, peptic ulcer disease, concurrent steroids or anticoagulants) electrolytes, creatinine, and BUN within 3 mo of starting regular chronictherapy repeat every 6-12 mo... 

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