Oral
- Prednisolone
- Budesonide (e.g. entocort)
Rectal
- Predisolone (e.g. predfoam)
- Hydrocortisone
Parenteral
- Hydrocortisone
- Dexamethasone
- Methylprednisolone
Equivalent doses
Prednisolone 5mg is equal to:
- Dexamethasone 750 micrograms
- Hydrocortisone 20mg
- Methylprednisolone 4mg
Inflammatory bowel disease
- Inflammatory bowel disease
- Haemorrhoids
- Autoimmune Hepatitis
Corticosteroids have an anti-inflammatory effect in many tissues. Virtually all cells contain steroid receptors which then bind to DNA to prevent or induce gene expression.
In the context of inflammation, corticosteroids:
- Decrease neutrophil and macrophage recruitment and action
- Decrease fibroblast formation
- Decrease osteoblast and increase osteoclast activity
- Decrease production of prostanoids
- Decrease production of cytokines
- Decrease histamine release
- Decrease IgG production
Corticosteroids are used to reduce the inflammation in Ulcerative Colitis and Crohn's disease.
Corticosteroids can be administered by the following routes:
- Oral
- Rectal
- Subcutaneous
- Intravenous
- Topical
- Intra-nasal
- Inhalation
- Intra-articular
Beclometasone and budesonide have poor membrane penetration properties, making them useful for topical / local therapy with minimal systemic absorption. Dexamethasone is very potent and has no salt retaining action, making it useful for high dose therapy.
There are a wide range of adverse effects, which are associated with systemic absorption. These include:
-
Osteoporosis
- Ischaemic necrosis of femoral head
- Cataract
- Acute Glaucoma
- Cushingoid features including weight gain
- The cortisol-like effect of corticosteroids increase insulin resistance and the likelihood of hyperglycaemia leading to transient or permanent type 2 diabetes.
- Increased susceptibility to infection, particularly TB, varicella and
- candida
- Hyperglycaemia
- Hypertension
- Fluid retention and worsening of heart failure
- Hypokalaemia
- Mask inflammatory response
- Mental disturbance including psychosis
- Addisonian crisis in abrupt withdrawal
Patients admitted to hospital who are treated with long term oral steroids should be treated as if they have Addison's disease.
Pharmacokinetic interactions can occur between liver enzyme inducers and corticosteroids, reducing the effect of the steroids.
Pharmacodynamic interactions can occur where steroid effects increase or antagonise the effect of other drugs. For example:
- Steroids can mask the adverse effects of NSAIDs
- Hypokalaemia can be made worse if steroids are used in combination with other drugs which lower potassium
- Antihypertensive and hypoglycaemic agents are antagonised by corticosteroids
Patients prescribed long term corticosteroids should be provided with a "steroid card" and warned not to stop their medication suddenly. In instances where corticosteroids are used for more than 3 weeks, or in multiple short courses, or at very high doses, patients should be given a reducing regime. They should also be warned about the common adverse effects, particularly immunosuppression, adrenal suppression and psychiatric disturbances.
Oral steroids are best taken in the morning to match the body's normal diurnal variation, and taking with meals can help avoid dyspepsia.
In inflammatory bowel disease, rectal preparations may be used to reduce systemic effects and target particular parts of the bowel. Patients will need instruction in how to use these. Different types of enema (e.g. foam) may be easier for some patients to use.
Patients should also be alerted to symptoms of hyperglycaemia and type 2 diabetes as this is a risk with corticosteroid use.
There is no dosage adjustment required in hepatic or renal insufficiency.
