Corticosteroids General Statement (Monograph)
Drug class: Adrenals
- Disease-modifying Antirheumatic Drugs
- DMARDs
- Immunosuppressive Agents
- Antiemetic Agents
ATC class: H02AB10
VA class: HS051
Introduction
Corticosteroids are hormones secreted by the adrenal cortex or synthetic analogs of these hormones. They exhibit glucocorticoid and/or mineralocorticoid activity and affect almost all body systems, but are used principally for their potent anti-inflammatory and immunosuppressant effects and for replacement.
Uses for Corticosteroids General Statement
In physiologic dosages, corticosteroids are used to replace deficient endogenous hormones. In pharmacologic dosages, the drugs have both therapeutic and diagnostic applications based on their ability to suppress secretion of normal adrenal hormones. Glucocorticoids are also used in pharmacologic dosages for their anti-inflammatory and immunosuppressant properties and their effects on blood and lymphatic systems in the palliative treatment of various diseases.
When glucocorticoids are used for their anti-inflammatory and immunosuppressant properties, synthetic glucocorticoids that have minimal mineralocorticoid activity are preferred to cortisone or hydrocortisone. Glucocorticoid therapy is not curative and is rarely indicated as the primary method of treatment, but rather as supportive therapy to be used adjunctively with other indicated therapies. If prolonged oral administration of glucocorticoids is required, alternate-day therapy should be used whenever possible to minimize adverse reactions, and continual attempts should be made to reduce the dosage or, preferably, to withdraw glucocorticoid therapy completely. (See General Dosage under Dosage and Administration: Dosage.)
Adrenocortical Insufficiency
Corticosteroids are administered in physiologic dosages to replace deficient endogenous hormones in patients with adrenocortical insufficiency. Because production of both mineralocorticoids and glucocorticoids is deficient in these patients, hydrocortisone or cortisone (in conjunction with liberal salt intake) is usually the corticosteroid of choice for replacement therapy. Concomitant administration of a more potent mineralocorticoid (fludrocortisone) may be required in some patients, particularly in infants. If synthetic glucocorticoids are used instead of hydrocortisone or cortisone, a mineralocorticoid must also be given. In suspected or known adrenal insufficiency, parenteral therapy may be used preoperatively or during serious trauma, illness, or shock unresponsive to conventional therapy. In shock caused by acute adrenocortical insufficiency, IV administration of hydrocortisone (or a synthetic glucocorticoid) in conjunction with other therapy for shock is essential.
Adrenogenital Syndrome
In salt-losing forms of congenital adrenogenital syndrome, cortisone or hydrocortisone is administered in conjunction with liberal salt intake. Because of the risk of growth retardation with excessive dosage (see Cautions: Pediatric Precautions), the minimum dosage of the corticosteroid required to suppress adrenocortical hyperfunction should be used. If sodium loss and hypotension are not adequately controlled by cortisone or hydrocortisone, an additional mineralocorticoid drug should be given. Mineralocorticoid replacement can usually be discontinued in children 5–7 years of age, but a glucocorticoid must be continued throughout life. Patients with the hypertensive form of congenital adrenogenital syndrome (who secrete excessive amounts of desoxycorticosterone) should be treated with a “short-acting” glucocorticoid with minimal mineralocorticoid activity (e.g., prednisone). Longer acting glucocorticoids (e.g., dexamethasone) should not be used in such patients because there is a tendency toward overdosage and growth may be retarded.
Hypercalcemia
Glucocorticoids promote a reduction in serum calcium concentrations and are effective as hypocalcemic agents in patients with steroid-sensitive malignancies (e.g., multiple myeloma, lymphoma) and in patients with hypercalcemia due to sarcoidosis or vitamin D intoxication. Glucocorticoids are not effective in hypercalcemia caused by hyperparathyroidism.
Thyroiditis
The anti-inflammatory action of glucocorticoids dramatically relieves symptoms such as fever and acute thyroid pain and swelling in granulomatous (subacute, nonsuppurative) thyroiditis. The drugs are indicated in moderate to high dosages for palliative therapy in severely ill patients unresponsive to salicylates and thyroid hormones. Glucocorticoids may also be effective in reducing orbital edema in endocrine exophthalmos (thyroid ophthalmopathy). Changes in thyroid status may necessitate adjustment of glucocorticoid dosage.
Rheumatic Disorders and Collagen Diseases
In rheumatic disorders and collagen diseases, glucocorticoids relieve inflammation and suppress symptoms, but do not affect progression of the disease. The drugs are rarely indicated except for palliative, short-term treatment of acute exacerbations and systemic complications in patients refractory to more conservative therapy. Dosage in life-threatening situations is often high and is reduced rapidly after the crisis is past. Maintenance therapy with glucocorticoids is rarely indicated in rheumatoid arthritis, acute gouty arthritis, or systemic lupus erythematosus, but may be used as part of a total treatment program in selected patients when more conservative therapies have proven ineffective. Glucocorticoid withdrawal is extremely difficult in patients with these conditions, as relapses or rebounds usually occur upon discontinuance of the drugs.
In the symptomatic treatment of rheumatoid arthritis that involves only a few persistently inflamed joints or in the treatment of inflammation of tendons or bursae, local injections of slightly soluble glucocorticoids may be beneficial. Patients usually experience dramatic relief initially. Although inflammation tends to recur and sometimes it is more intense after cessation of therapy, the drugs can prevent invalidism by facilitating movement of joints that might otherwise become immobile.
Systemically administered glucocorticoids control acute manifestations of rheumatic carditis more rapidly than salicylates and may be life-saving in certain conditions, but glucocorticoids, like salicylates, cannot prevent valvular damage and are no better than salicylates for long-term treatment. Salicylates used concomitantly with glucocorticoids may decrease inflammatory rebound when the steroids are withdrawn. (See Drug Interactions: Nonsteroidal Anti-Inflammatory Agents.) Cytotoxic therapy is the treatment of choice in Wegener’s granulomatosis, but glucocorticoids may be used adjunctively for severe systemic complications.
Glucocorticoids remain the primary treatment to control symptoms and prevent severe, often life-threatening complications in patients with dermatomyositis and polymyositis, polyarteritis nodosa, relapsing polychondritis, polymyalgia rheumatica and giant-cell (temporal) arteritis, or mixed connective tissue disease syndrome. High dosage may be required for acute situations; after a response has been obtained, glucocorticoids must often be continued for long periods at low dosage. Polymyositis associated with malignancy and childhood dermatomyositis may not respond well to glucocorticoids.
Systemic glucocorticoids are rarely indicated in psoriatic arthritis, diffuse scleroderma (progressive systemic sclerosis), acute and subacute bursitis, and osteoarthritis. Risks outweigh benefits received, and more conservative therapy should be used. In osteoarthritis, intra-articular injections of glucocorticoids may be beneficial but should be limited in number as joint damage may occur.
Dermatologic Diseases
In dermatologic diseases such as pemphigus and pemphigoid, exfoliative dermatitis, bullous dermatitis herpetiformis, severe erythema multiforme (Stevens-Johnson syndrome), uncontrollable eczema, cutaneous sarcoidosis, mycosis fungoides, and lichen planus, systemic glucocorticoids should generally be reserved for acute exacerbations unresponsive to conservative therapy. In all these dermatologic diseases, high dosage of glucocorticoids may be required. Early initiation of systemic glucocorticoid therapy may be life-saving in pemphigus vulgaris and pemphigoid, and high or massive doses may be required. Dosage should be reduced gradually to the lowest effective level, but discontinuance may not be possible; alternate-day therapy may often be used beneficially.
Although chronic skin disorders are seldom an indication for systemic glucocorticoids, intralesional or sublesional injections may occasionally be indicated for localized chronic disorders (including keloids, psoriatic plaques, alopecia areata, discoid lupus erythematosus, and granuloma annulare) unresponsive to topical therapy. Systemic glucocorticoids are rarely indicated for psoriasis or alopecia (areata, totalis, or universalis). When systemic corticosteroids are used in the treatment of psoriasis, exacerbation of the disease may occur when the drugs are withdrawn or dosage is decreased. Although glucocorticoids may stimulate hair growth in patients with alopecia, hair loss returns when the drugs are discontinued.
Allergic Conditions
Systemic glucocorticoids are used for control of severe or incapacitating allergic conditions that do not respond to adequate trials of conventional therapy in patients with bronchial asthma, seasonal or perennial allergic rhinitis, atopic dermatitis, urticaria associated with transfusion, or acute noninfectious laryngeal edema (although epinephrine is the drug of choice). Systemic glucocorticoids also may be used in acute manifestations of angioedema, serum sickness, contact dermatitis, drug hypersensitivity, and allergic symptoms of trichinosis. In acute conditions, the drugs may be used for short periods in high dosage with other therapy such as antihistamines and sympathomimetics.
In the symptomatic treatment of chronic allergic conditions, systemic glucocorticoids generally should be reserved for acute conditions and severe exacerbations. Prolonged treatment of chronic allergic conditions should be reserved for patients with disabling conditions unresponsive to more conservative therapy and for whom the risks of long-term glucocorticoid therapy are justified.
Ocular Disorders
Optic Neuritis
Systemic glucocorticoids have been used for the treatment of acute optic neuritis† [off-label]. Interest in the use of IV methylprednisolone in the management of acute relapses of multiple sclerosis has been heightened as a result of the Optic Neuritis Treatment Trial. In this trial in which short-term glucocorticoid therapy (IV methylprednisolone 1 g daily for 3 days followed by oral prednisone 1 mg/kg daily for 11 days versus oral prednisone alone at this dosage for 14 days) was compared with placebo for the treatment of initial episodes of acute optic neuritis, the rate of vision recovery was faster with the methylprednisolone regimen, with the greatest benefit being observed in patients with visual acuity of 20/50 or worse at entry; however, there were no substantial differences in visual outcomes between the groups at 6 months. Use of oral prednisone alone did not improve the rate of vision recovery compared with placebo and was associated with an increased risk of new episodes of optic neuritis in either eye.
At 2-year follow-up, patients who had received the methylprednisolone regimen had a lower rate of progression to clinically definite multiple sclerosis than those who received placebo. This beneficial effect was most evident in patients at the highest risk for multiple sclerosis (i.e., those with multicentric brain lesions on magnetic resonance imaging [MRI] at study entry). However, after 3 years, differences between the treatment groups were no longer significant, suggesting that IV methylprednisolone delayed but did not arrest the development of multiple sclerosis after optic neuritis. At 5-year follow-up, most patients who had received the methylprednisolone regimen retained good to excellent vision, even if there had been single or multiple recurrences of optic neuritis during the 5-year period. The cumulative probability of having a new episode of optic neuritis over the 5-year follow-up period was 19% for affected eyes, 17% for fellow eyes, and 30% for either eye.
Patients who developed clinically diagnosed multiple sclerosis over the follow-up period were more likely to have recurrences of optic neuritis in the affected or fellow eye and also were more likely to have slight worsening of vision between the 6-month and 5-year follow-up examinations than patients without clinically diagnosed multiple sclerosis.
Other Ocular Disorders
Systemic glucocorticoids may be used to suppress a variety of allergic and nonpyogenic ocular inflammations and to reduce scarring in ocular injuries. Glucocorticoids have been used for the treatment of severe acute and chronic allergic and inflammatory processes involving the eye that are intractable to adequate trials of conventional treatment (e.g., allergic conjunctivitis, keratitis, allergic corneal marginal ulcers, herpes zoster ophthalmicus, iritis and iridocyclitis, chorioretinitis, diffuse posterior uveitis and choroiditis, anterior segment inflammation, temporal arteritis, sympathetic ophthalmia). Moderate dosage is used initially and is quickly discontinued after the acute condition is controlled. Some disorders may relapse upon discontinuance of therapy and low-dose maintenance therapy may be required. Glucocorticoids are of no value in the treatment of degenerative ocular diseases such as cataracts.
Topically applied glucocorticoids appear to be as effective as systemic steroids for the treatment of most anterior ocular inflammations. Systemic glucocorticoid therapy may be required, however, in stubborn cases of anterior segment eye disease and is necessary when deeper ocular structures are involved.
Respiratory Diseases
Asthma
Corticosteroids are used as adjunctive treatment of asthma. The Global Initiative for Asthma (GINA) guidelines provide evidence-based recommendations for the management of asthma in adults, adolescents, and children ≥6 years of age. The guideline states that all patients with asthma should be evaluated for symptom control, risk of future exacerbations, treatment issues (e.g., inhaler technique and adherence), and comorbidities. A stepwise approach to treatment is recommended where specific drugs are added or adjusted up or down through a series of steps (1 through 5) to achieve symptom control while keeping the patient on the lowest effective treatment. Drugs used in the management of asthma include inhaled corticosteroids (ICS)-formoterol, long-acting beta agonists (LABA), short-acting β2-adrenergic agonists (SABA), long-acting muscarinic agonists (LAMA), leukotriene receptor antagonists, theophylline, oral corticosteroids, and biologic agents.
Chronic Obstructive Pulmonary Disease
Oral and inhaled corticosteroids have been used in the management of chronic obstructive pulmonary disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline states that oral glucocorticoids play a role in the acute management of COPD exacerbations, but have no role in the chronic daily treatment of COPD because of the lack of benefit and high rate of systemic complications.
Sarcoidosis
In the management of sarcoidosis, systemic glucocorticoids are indicated for ocular, CNS, glandular, myocardial, or severe pulmonary involvement or for hypercalcemia or severe skin lesions unresponsive to intralesional or sublesional injections of glucocorticoids. Long-term therapy may be required.
Advanced Pulmonary and Extrapulmonary Tuberculosis
Systemic glucocorticoids have been used as adjunctive therapy in some patients with severe pulmonary or extrapulmonary tuberculosis in an attempt to suppress manifestations related to the host’s inflammatory response to the Mycobacterium tuberculosis bacillus and ameliorate complications of the disease. While evidence from studies of M. tuberculosis infection in both animals and humans indicates that glucocorticoids can have deleterious effects (e.g., increased virulence of the organism) in the absence of adequate antituberculosis therapy, such effects generally appear to be prevented by coadministration of effective antimycobacterial agents (e.g., streptomycin, isoniazid). Data from randomized, controlled trials are limited and principally consist of studies conducted before the use of current 4-drug, short-course antituberculosis regimens; however, an analysis of available evidence suggests that adjunctive glucocorticoid therapy may enhance short-term resolution of disease manifestations (e.g., clinical and radiographic abnormalities) in patients with advanced pulmonary tuberculosis and also may reduce mortality associated with certain forms of extrapulmonary disease (e.g., meningitis, pericarditis). Additional randomized, controlled studies in patients receiving current short-course antituberculosis regimens are needed to fully elucidate the potential benefits and risks of adjunctive glucocorticoid therapy in pulmonary or extrapulmonary tuberculosis. Dosage of adjunctive corticosteroids may need to be adjusted upward in patients receiving rifampin-containing antituberculosis regimens as a result of rifampin-induced increases in corticosteroid metabolism.
Advanced Pulmonary Tuberculosis
Adjunctive systemic glucocorticoid therapy has been used to treat severe systemic and respiratory manifestations in patients with advanced pulmonary tuberculosis. Although benefit to the patient is unclear, radiographically evident abnormalities (other than cavities) usually resolve more rapidly with glucocorticoid therapy. No improvement in long-term outcomes (chronic respiratory disease or death) has been observed. In patients receiving adequate antituberculosis therapy (2 or more effective agents), glucocorticoid use does not appear to delay the time to conversion of sputum culture to negative or affect long-term cure rates.
Tuberculous Meningitis
Use of systemic adjunctive glucocorticoids (e.g., dexamethasone, prednisone) in patients with moderate to severe tuberculous meningitis appears to reduce sequelae (e.g., intellectual impairment) and/or improve survival. In a randomized, controlled study in young children (mean age younger than 36 months) with tuberculous meningitis, therapy with prednisone (2–4 mg/kg daily) reduced mortality in patients with stage III disease from 17% to 4% but did not reduce the incidence of permanent motor deficits (hemiparesis and quadriparesis). Results from a prospective, randomized, placebo-controlled study in adults and adolescents older than 14 years of age with tuberculous meningitis (with or without HIV infection) also showed reduced mortality (relative risk of death of 0.69; 95% confidence interval of 0.52–0.92) in patients receiving dexamethasone (IV therapy tapered over 2–4 weeks, depending on disease severity, followed by oral therapy tapered over 4 weeks), but dexamethasone therapy was not associated with a substantial reduction in the proportion of severely disabled patients among survivors or in the proportion of patients who had either died or were severely disabled after 9 months. A faster resolution of abnormal CSF parameters (e.g., elevated intracranial pressure, basal exudate, CNS tuberculomas) occurs with glucocorticoids use, which may aid in patient management. Available data suggest that response is most favorable in patients with disease of intermediate severity (as opposed to early or late disease) and that continuation of glucocorticoid therapy for at least 4 weeks may be associated with better outcomes than with shorter regimens.
Tuberculous Pericarditis
Limited data suggest that adjunctive systemic glucocorticoid therapy is effective in the management of acute tuberculous pericarditis, rapidly reducing the size of pericardial effusions and the need for drainage procedures and decreasing mortality (probably through control of hemodynamically threatening effusion). However, glucocorticoid therapy does not appear to alter the incidence of progression to constrictive disease when used for treatment of either the acute or intermediate stage of pericarditis.
Tuberculous Pleurisy
While most studies of adjunctive systemic glucocorticoid therapy in patients with tuberculous pleurisy have not been randomized or controlled, limited evidence suggests that such therapy hastens the resolution of pain, dyspnea, and fever associated with this form of the disease. However, glucocorticoids appear to have little efficacy in preventing fibrotic changes and resultant constrictive lung disease, and some clinicians advise against their routine use.
Other Tuberculosis Complications
Limited data suggest that intrathoracic adenopathy associated with primary tuberculosis may resolve more rapidly with the use of adjunctive systemic glucocorticoids. While a few studies have reported a reduced frequency of complications (e.g., recurrent abdominal pain, intestinal obstruction) with adjunctive glucocorticoid therapy in patients with peritoneal tuberculosis, data from randomized trials are lacking, and rapid improvement in symptoms occurred in these patients with antituberculosis therapy alone. Although it has been suggested that atelectasis associated with endobronchial tuberculosis may benefit from glucocorticoid therapy, results of a randomized, controlled trial in a limited number of patients with this form of the disease suggested no important benefit of glucocorticoid therapy over antituberculosis therapy alone with regard to healing rates and changes in pulmonary function. Inadequate data are available regarding the safety and efficacy of adjunctive glucocorticoid therapy in patients with tuberculous lymphadenitis, miliary or laryngeal tuberculosis, or HIV-associated tuberculosis.
Lipid Pneumonitis
In lipid pneumonitis, glucocorticoids appear to promote the breakdown or dissolution of pulmonary lesions and eliminate lipids in the sputum. Although high doses of glucocorticoids are commonly used in hydrocarbon pneumonitis to prevent pulmonary edema and fibrosis, there is no evidence that they prevent any complications or improve the recovery rate.
Pneumocystis jirovecii Pneumonia
The use of systemic glucocorticoids as an adjunct to anti-infective therapy for the treatment of moderate to severe pneumonia caused by Pneumocystis jirovecii † [off-label] (formerly Pneumocystis carinii) in patients with human immunodeficiency virus (HIV) infection, including acquired immunodeficiency syndrome (AIDS), can decrease the likelihood of deterioration of oxygenation, respiratory failure, and/or death in those with moderate to severe pneumonia. Based on the results of controlled, randomized studies, experts recommend that adults and adolescents older than 13 years of age with documented or suspected HIV infection and documented or suspected pneumocystis pneumonia be given systemic glucocorticoid therapy in addition to anti-infective treatment if they have moderate to severe pulmonary dysfunction, defined as an arterial oxygen pressure of less than 70 mm Hg or an arterial-alveolar gradient of 35 mm Hg or greater on room air. It is not known whether patients with mild pneumocystis pneumonia (arterial oxygen pressure exceeding 70 mm Hg or arterial-alveolar gradient less than 35 mm Hg on room air) might have clinically important benefit with adjunctive glucocorticoid therapy, and such benefit may be difficult to demonstrate in clinical studies because of the generally good clinical outcome of this group.
It is recommended that adjunctive glucocorticoid therapy be initiated as early as possible, preferably within the first 24–72 hours after initiation of specific anti-infective therapy. Benefit in controlled studies has not been demonstrated with initiation of glucocorticoid therapy more than 72 hours after initiation of specific antipneumocystis therapy; however, most clinicians would initiate such therapy in those with moderate to severe pneumocystis pneumonia even if it has been more than 72 hours after initiation of anti-infective therapy. Glucocorticoid therapy can be started in patients with presumed AIDS-associated pneumocystis pneumonia if these patients meet the recommended oxygenation criteria. The diagnosis of HIV infection and pneumocystis pneumonia should be confirmed promptly to minimize the likelihood of masking and/or exacerbating other treatable diseases (e.g., tuberculosis) and to avoid adverse effects of unnecessary drugs. Pending the availability of specific efficacy or safety data, it may be reasonable to consider adjunctive systemic glucocorticoid therapy for pneumocystis pneumonia in immunosuppressed patients without HIV infection or in pregnant women with HIV infection according to the same criteria as for nonpregnant adults with HIV infection.
When glucocorticoid therapy is used as an adjunct to anti-infective therapy in HIV-infected patients with moderate to severe pneumocystis pneumonia, experts recommend specific regimens of prednisone or, if parenteral therapy is required, methylprednisolone. Higher dosages for patients whose condition is not improving on glucocorticoids, or newly initiated glucocorticoid therapy for those patients in whom standard treatment alone is failing, may or may not be beneficial; available evidence is inadequate to provide specific recommendations.
Coronavirus Disease 2019 (COVID-19)
Corticosteroid therapy (e.g., dexamethasone, hydrocortisone, methylprednisolone, prednisone) has been used as adjunctive therapy in the treatment of serious complications from coronavirus disease 2019 (COVID-19)† [off-label]. Patients with severe COVID-19 may develop a systemic inflammatory response that can result in lung injury and multisystem organ dysfunction. The potent anti-inflammatory effects of corticosteroids may prevent or mitigate these deleterious effects.
The National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel issued guidelines for the treatment of COVID-19, including recommendations for use of corticosteroids in patients with COVID-19. For the treatment of COVID-19 in nonhospitalized adults and hospitalized adults who do not require supplemental oxygen, the NIH guidelines panel recommends against the use of dexamethasone or other corticosteroids. However, the NIH panel recommends use of dexamethasone (6 mg daily orally or IV for up to 10 days or until hospital discharge, whichever comes first) in hospitalized adults with COVID-19 who require supplemental oxygen or are receiving mechanical ventilation or extracorporeal membrane oxygenation (ECMO). The NIH panel states that it is not known at this time whether other corticosteroids will have a similar benefit as dexamethasone. However, if dexamethasone is not available, the panel recommends using alternative corticosteroids (e.g., hydrocortisone, methylprednisolone, prednisone).
Data regarding potential adverse effects of dexamethasone in patients with COVID-19, efficacy in combination with other treatments (e.g., remdesivir, tocilizumab, baricitinib), and efficacy in other patient populations (e.g., pediatric patients, pregnant women) are insufficient to date. Although efficacy of concomitant use of dexamethasone and remdesivir has not been rigorously studied, the NIH panel states there is a theoretical rationale for using dexamethasone plus remdesivir in some patients with severe COVID-19 and clinically important drug interactions are not expected. Specifically, the NIH guideline panel recommends concomitant use of dexamethasone and remdesivir in hospitalized patients requiring increasing amounts of supplemental oxygen or use of dexamethasone alone when combined therapy with remdesivir cannot be used or is unavailable in such patients. Similarly, the NIH panel recommends the use of dexamethasone alone or in combination with remdesivir in hospitalized patients requiring high-flow oxygen or noninvasive ventilation. For such patients who were recently hospitalized with rapidly increasing oxygen needs and systemic inflammation, the panel also recommends the addition of baricitinib or tocilizumab to either monotherapy with dexamethasone or combination therapy with dexamethasone and remdesivir. For hospitalized COVID-19 patients requiring invasive mechanical ventilation or ECMO, the NIH panel recommends therapy with dexamethasone alone, although dexamethasone in combination with remdesivir may be considered in patients who were recently intubated. For those receiving invasive mechanical ventilation or ECMO who are within 24 hours of ICU admission with rapid respiratory decompensation, the NIH panel recommends dexamethasone in combination with tocilizumab. Clinicians should consult the most recent NIH COVID-19 treatment guidelines for additional information on use of corticosteroids in patients with COVID-19.
The World Health Organization (WHO) Guideline Development Group also issued guidelines for the use of systemic corticosteroids in patients with COVID-19. For the treatment of patients with nonsevere COVID-19, the WHO Guideline Development Group suggests not using systemic corticosteroids, regardless of hospitalization status; however, if the clinical condition of such patients worsens (e.g., increased respiratory rate, signs of respiratory distress, or hypoxemia), systemic corticosteroids are recommended for treatment. The WHO Guideline Development Group strongly recommends the use of systemic corticosteroids (e.g., dexamethasone 6 mg orally or IV once daily or hydrocortisone 50 mg IV every 8 hours for 7-10 days) over no systemic corticosteroid therapy for the treatment of patients with severe and/or critical COVID-19, regardless of hospitalization status. This treatment recommendation includes critically ill patients with COVID-19 who could not be hospitalized or receive oxygen supplementation because of resource limitations. The WHO Guideline Development Group also recommends the concomitant use of systemic corticosteroids with an interleukin (IL-6) inhibitor (e.g., sarilumab, tocilizumab) for patients with severe or critical COVID-19. These experts recommend against discontinuing systemic corticosteroids in patients with nonsevere COVID-19 who are receiving systemic corticosteroids for chronic conditions (e.g., COPD, autoimmune diseases). Clinicians should consult the most recent WHO COVID-19 treatment guidelines for additional information.
In one randomized, controlled, open-label study (NCT04381936; RECOVERY), the effect of potential treatments (including low-dose dexamethasone) on all-cause mortality in hospitalized patients with COVID-19 was evaluated. Patients were randomized to receive dexamethasone (6 mg once daily orally or IV for up to 10 days) plus standard care or standard care alone. Preliminary data analysis indicated that overall 28-day mortality was reduced in patients who received dexamethasone compared with those who received standard care alone, and the greatest benefit was observed in patients receiving invasive mechanical ventilation or those receiving supplemental oxygen without mechanical ventilation. However, no survival benefit was observed with dexamethasone and there was a possibility of harm in patients who did not require respiratory support at study enrollment.
In another randomized, controlled, open-label, multicenter study (NCT04327401; CoDEX), the effect of dexamethasone on the number of ventilator-free days was evaluated in patients with COVID-19-associated moderate or severe acute respiratory distress syndrome (ARDS) who were receiving mechanical ventilation. Patients were randomized to receive dexamethasone (20 mg IV once daily for 5 days followed by 10 mg IV once daily for another 5 days or until ICU discharge) plus standard care or standard care alone. Preliminary data analysis indicated that use of dexamethasone plus standard care was associated with a higher mean number of ventilator-free days (6.6 days) compared with those receiving standard care alone (4 days). This trial was terminated early after results of the RECOVERY trial became available and, therefore, was likely underpowered to determine secondary outcomes such as mortality.
In one randomized, double-blind sequential trial (NCT02517489; CAPE COVID), the effect of low-dose hydrocortisone on treatment failure was evaluated in critically ill patients with COVID-19-related acute respiratory failure compared with placebo. In the hydrocortisone treatment group, 76 patients received a continuous IV infusion of hydrocortisone at an initial dosage of 200 mg daily for 7 days followed by 100 mg daily for 4 days, and then 50 mg daily for 3 days (total of 14 days; some patients received a shorter regimen); 73 patients received placebo. The primary study end point was treatment failure (defined as death or persistent dependency on mechanical ventilation or high-flow oxygen therapy) on day 21. Treatment failure on day 21 occurred in 42.1% of patients receiving hydrocortisone compared with 50.7% of patients receiving placebo. No substantial difference was observed between the treatment groups; however, the study was discontinued early after results of the RECOVERY trial became available and, therefore, was likely underpowered to determine a statistically and clinically important difference in the primary outcome.
In another randomized, open-label, multicenter study (NCT02735707; REMAP-CAP), an embedded multifactorial adaptive platform was used to evaluate patients receiving multiple interventions within multiple domains. In the COVID-19 corticosteroid domain, adults with suspected or confirmed COVID-19 following ICU admission for respiratory or cardiovascular organ support were randomized to receive a fixed 7-day regimen of IV hydrocortisone (50 or 100 mg every 6 hours), a shock-dependent regimen of IV hydrocortisone (50 mg every 6 hours when shock was clinically evident), or no hydrocortisone or other corticosteroid. The primary study end point was organ support-free days (defined as days alive and free of ICU-based respiratory or cardiovascular support) within 21 days. The 7-day fixed regimen and the shock-dependent regimen of hydrocortisone were associated with a 93 and 80% probability of benefit in terms of organ support-free days compared with no hydrocortisone. However, the trial was discontinued early after results of the RECOVERY trial were available and no treatment strategy met the prespecified criteria for statistical superiority, precluding definitive conclusions. In addition, serious adverse effects were reported in 2.6% of patients in the study (4 patients receiving the fixed-dosage regimen and 5 patients receiving the shock-dependent regimen compared with 1 patient receiving no hydrocortisone).
In one randomized, parallel, double-blind, placebo-controlled, phase 2b trial (NCT04343729; Metcovid), the effect of a short course of IV methylprednisolone was evaluated compared with placebo in hospitalized adults with suspected COVID-19 from a single center in Brazil. Patients were enrolled prior to laboratory confirmation of COVID-19 to avoid treatment delays and the presence of COVID-19 was later confirmed based on RT-PCR testing in 81.3% of these patients. At time of enrollment, 34% of patients in each treatment group required invasive mechanical ventilation. Supplemental oxygen was required in 51% of patients receiving methylprednisolone and in 45% of those receiving placebo. In the methylprednisolone treatment group, 194 patients received IV methylprednisolone at a dosage of 0.5 mg/kg twice daily for 5 days; 199 patients received placebo. A modified intent-to-treat analysis was conducted; the primary study end point was 28-day mortality. Overall, the 28-day mortality rate was 37.1 or 38.2% in patients who received methylprednisolone or placebo, respectively, showing no substantial difference in overall mortality between the treatment groups. However, a subgroup analysis found a lower mortality rate in patients older than 60 years of age who received methylprednisolone compared with placebo (46.6 vs 61.9%, respectively). Patients older than 60 years of age reportedly had a higher degree of systemic inflammatory disease as manifested by increased median concentrations of C-reactive protein (CRP) compared with patients 60 years of age or younger. In those 60 years of age or younger, there was a higher incidence of fatal outcomes in the methylprednisolone group. The authors concluded that caution is needed when using systemic corticosteroids in patients with less severe COVID-19 since a trend toward more harm was noted in the younger age group.
In another multicenter, observational, longitudinal study (NCT04323592), the association between use of prolonged, low-dose methylprednisolone treatment and ICU admission, intubation, or all-cause death within 28 days (composite primary end point) was evaluated in patients with severe COVID-19 pneumonia admitted to 14 respiratory high-dependency units in Italy. A total of 173 patients were enrolled in the study with 83 patients receiving methylprednisolone plus standard care and 90 patients receiving standard care alone. In the methylprednisolone treatment group, patients received a loading dose of IV methylprednisolone 80 mg at study entry followed by IV infusion of the drug at a dosage of 80 mg daily at a rate of 10 mL/hr for at least 8 days until achievement of either a PaO2/FiO2 (P/F ratio) greater than 350 mm Hg or CRP concentrations less than 20 mg/L. Subsequently, twice-daily administration of either oral methylprednisolone 16 mg or IV methylprednisolone 20 mg was given until achievement of a P/F ratio greater than 400 mm Hg or CRP concentrations reached less than 20% of the normal range. The composite primary end point was reached by 22.9 or 44.4% of patients in the group receiving methylprednisolone or standard care alone, respectively. Therefore, use of methylprednisolone was associated with a reduction in the risk of ICU admission, invasive mechanical ventilation, or death within 28 days (adjusted hazard ratio: 0.41). Specifically, 18.1 or 30% of patients required ICU admission and 16.9 or 28.9% of patients required invasive mechanical ventilation in those receiving methylprednisolone or standard care alone, respectively. In addition, use of methylprednisolone was associated with a 28-day lower risk of all-cause mortality than use of standard care alone (7.2 vs 23.3%, respectively) with an adjusted hazard ratio of 0.29. Overall, there was no difference in adverse effects between treatment groups with the exception of increased reports of hyperglycemia and mild agitation in the methylprednisolone-treated patients; no adverse effects resulted in drug discontinuation. The authors concluded that early, low-dose, prolonged therapy with methylprednisolone resulted in decreased ICU burden, reduced need for invasive mechanical ventilation, and lower mortality along with improvement in systemic inflammation and oxygenation markers in hospitalized patients with severe COVID-19 pneumonia at high risk of progression to acute respiratory failure.
In one multicenter quasi-experimental study with single pretest and posttest (NCT04374071), the efficacy of early, short-term therapy with systemic methylprednisolone was evaluated in hospitalized adults with confirmed moderate to severe COVID-19 from a multicenter health system in Michigan. A total of 213 patients were enrolled with 132 patients receiving early therapy with IV methylprednisolone at dosages of 0.5–1 mg/kg daily in 2 divided doses for 3 days plus standard care and 81 patients receiving early therapy with standard care alone. The primary end point was a composite based on the need for ICU transfer, progression to respiratory failure requiring mechanical ventilation, or in-hospital all-cause mortality. The primary composite end point occurred at a substantially lower rate in the group receiving early corticosteroid therapy (34.9%) compared with the group receiving early therapy with standard care alone (54.3%). The early corticosteroid group had a median time to initiation of methylprednisolone of 2 days compared with 5 days for the standard care group. The median hospital length of stay was substantially reduced from 8 to 5 days in patients receiving early corticosteroid therapy compared with those receiving early therapy with standard care alone. ARDS occurred in 26.6% of patients receiving early corticosteroid therapy compared with 38.3% of those in the standard care group. The authors concluded that early, short-term therapy with methylprednisolone in patients with moderate to severe COVID-19 may prevent disease progression and improve clinical outcomes.
In a prospective meta-analysis of studies using systemic corticosteroids (i.e., dexamethasone, hydrocortisone, or methylprednisolone) from the WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, data were pooled from 7 randomized clinical trials in 12 countries that evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The primary outcome was all-cause mortality up to 30 days after randomization to treatment. Administration of systemic corticosteroids was associated with lower all-cause mortality at 28 days compared with usual care or placebo (222 deaths among 678 patients who received corticosteroids and 425 deaths among 1025 patients who received usual care or placebo). The effect of corticosteroids on reduced mortality was observed in critically ill patients who were and were not receiving mechanical ventilation at randomization and also in patients from the RECOVERY trial who required supplemental oxygen with or without noninvasive ventilation, but who were not receiving invasive mechanical ventilation at the time of randomization. The odds ratios for the association between corticosteroids and mortality were similar for dexamethasone and hydrocortisone. The optimal dosage and duration of corticosteroid treatment could not be determined from this analysis; however, there was no evidence suggesting that a higher dosage of corticosteroids was associated with greater benefit than a lower dosage. The authors also concluded that there was no suggestion of an increased risk of serious adverse effects associated with corticosteroid use.
In a retrospective, case-control study, the efficacy of early, low-dose, short-term therapy with systemic methylprednisolone or prednisone was evaluated in hospitalized adults with nonsevere COVID-19 pneumonia from a single center in China. A total of 475 patients were enrolled with 55 of these patients receiving early, low-dose corticosteroids. Methylprednisolone 20 or 40 mg IV daily was administered to 50 of these patients for 3–5 days, and oral prednisone 20 mg daily (equivalent dosage to methylprednisolone) was administered to 5 such patients for 3 days. Systemic corticosteroid therapy was initiated within a median of 2 days following hospital admission. A total of 420 patients received standard therapy (no corticosteroids); using propensity score matching, 55 of these patients were selected as matched controls. The primary outcome was the rate of patients who developed severe disease and mortality. In the corticosteroid treatment group, 12.7% of patients developed severe disease compared with 1.8% of patients in the control group. There was one death in the group receiving methylprednisolone and none in the control group. Regarding secondary outcomes, duration of fever, virus clearance time, and length of hospital stay were all substantially longer in patients receiving corticosteroids compared with no corticosteroid therapy. Because of the finding that early, low-dose, short-term systemic corticosteroid therapy was associated with worse clinical outcomes in hospitalized adult patients with nonsevere COVID-19 pneumonia, the authors concluded that the study results do not support the use of corticosteroids in this population. However, it is difficult to interpret these results because of potential confounding factors inherent in the nonrandomized study design. It is unclear if the results of this study apply to corticosteroids other than methylprednisolone or prednisone.
Other Respiratory Diseases
Systemic glucocorticoids may be used for symptomatic relief of acute manifestations of respiratory diseases including symptomatic idiopathic eosinophilic pneumonias (e.g., Löffler’s syndrome) not manageable by other means, idiopathic pulmonary fibrosis, allergic bronchopulmonary aspergillosis, idiopathic bronchiolitis obliterans with organizing pneumonia, aspiration pneumonitis, hypersensitivity pneumonitis, and berylliosis. Glucocorticoids also are used in fulminating or disseminated tuberculosis (see Advanced Pulmonary and Extrapulmonary Tuberculosis under Uses: Respiratory Diseases) in conjunction with appropriate antituberculosis therapy. High dosage may be required for several days. Glucocorticoids are not indicated for uncomplicated chronic respiratory diseases.
Complications of Prematurity
Antenatal Use in Preterm Labor
Short-course IM therapy with glucocorticoids (e.g., dexamethasone, betamethasone) is used in selected women with preterm labor to hasten fetal maturation (e.g., lungs, cerebral blood vessels), including women with preterm premature rupture of membranes, preeclampsia, or third-trimester hemorrhage. Antenatal administration of glucocorticoids generally appears to reduce the incidence and/or severity of neonatal respiratory distress syndrome (RDS) as indicated by a reduction in requirements for neonatal ventilatory support or surfactant therapy, and the beneficial effects are additive with those of surfactant.
Antenatal glucocorticoid therapy also can improve neonatal circulatory stability and reduce the incidence or severity of intraventricular hemorrhage. The incidence of necrotizing enterocolitis also is reduced by the use of antenatal glucocorticoids. The combined effects on multiple organ maturation during glucocorticoid therapy reduces the incidence of neonatal mortality, and the beneficial effects extend to a broad range of gestational ages (i.e., 24–34 weeks) and are not limited by gender or race.
Data are conflicting concerning the effects of antenatal glucocorticoids on the incidence of bronchopulmonary dysplasia, and patent ductus arteriosus in neonates, and the efficacy and safety of antenatal therapy with the drugs before 24 weeks or after 34 weeks of gestation have not been established. Short-term adverse effects of antenatal glucocorticoid administration include transient neonatal and maternal adrenal suppression and increased risk of infection. No long-term sequelae were noted in children up to 12 years of age who had been exposed to short-term antenatal glucocorticoids.
Antenatal use of glucocorticoids to reduce infant morbidity and mortality in women with preterm premature rupture of membranes is somewhat controversial, since the magnitude of neonatal benefit on RDS appears to be less and the risk of neonatal infection is greater than those in women with intact membranes. However, even in the presence of preterm premature rupture of membranes, the incidence of neonatal mortality and intraventricular hemorrhage is reduced with antenatal glucocorticoid therapy. In addition, the magnitude of increased risk of neonatal infection associated with such therapy appears to be small. Therefore, because of the benefit on mortality and hemorrhage in fetuses younger than 30–32 weeks’ gestation and the apparently small risk, antenatal maternal glucocorticoid therapy is considered appropriate in the absence of clinically important chorioamnionitis.
Antenatal therapy with IM dexamethasone phosphate (6 mg every 12 hours for 2 days) or IM betamethasone sodium phosphate in fixed combination with betamethasone acetate (12 mg once daily for 2 days) has been studied most extensively, and some experts state that these drugs generally have been preferred for use in preterm labor because of similarities in potency and efficacy and their ability to readily cross the placenta, as well as the relative absence of mineralocorticoid activity and relatively weak immunosuppressive effects. These glucocorticoids also have been preferred because of their longer duration of action compared with hydrocortisone or methylprednisone.
Beneficial effects of IM glucocorticoids on fetal maturation are greatest more than 24 hours after initiating therapy and extend up to at least 7 days; however, clinically important improvement in neonatal outcomes also has been observed in women receiving an incomplete course of glucocorticoid therapy (i.e., less than 24 hours), and antenatal administration of even a partial course of glucocorticoids should be attempted unless immediate delivery is anticipated. Some experts recommend a single course of treatment for all pregnant women between 24–34 weeks’ gestation who are at risk of preterm delivery within 7 days and state that repeat courses of antenatal glucocorticoids should not be used routinely because data evaluating the risks and benefits of such therapy are insufficient. A recent clinical study evaluated the overall effect on neonatal morbidity of repeated weekly courses of antenatal glucocorticoid therapy compared with a single course of treatment in pregnant women at risk of preterm delivery. The incidence of neonatal morbidity (defined as the presence of severe RDS, bronchopulmonary dysplasia, severe intraventricular hemorrhage [IVH], periventricular leukomalacia, necrotizing enterocolitis, proven sepsis, or death between randomization and nursery discharge) observed with weekly treatment courses (22.5%) was similar to that observed with single courses of therapy (28%). Other clinical studies are in progress to determine if a specific number of exposures to antenatal corticosteroids or an increased interval between treatment courses will improve neonatal outcomes in women at risk of preterm delivery.
Maternal use of tocolytic agents in conjunction with glucocorticoids may delay delivery in patients with preterm labor long enough for the fetus to derive benefit from glucocorticoid-induced accelerated fetal maturation. Combined use of the drugs has been shown to reduce the risk of neonatal RDS, and women between 24–34 weeks’ gestation at risk of preterm delivery are candidates for antenatal glucocorticoid therapy regardless of fetal race, gender, or availability of surfactant. Because β-adrenergic tocolytic monotherapy may be associated with an increased risk of intraventricular hemorrhage, the addition of antenatal glucocorticoid therapy could have a secondary benefit of reducing this risk.
Antenatal glucocorticoid therapy appears to have an additive effect with postnatal prophylactic lung surfactant therapy in reducing the incidence of RDS and neonatal mortality. In addition, antenatal glucocorticoids can reduce the incidence and/or severity of intraventricular hemorrhage, which surfactant therapy alone does not appear to benefit. However, data are limited concerning the prophylactic use of combination therapy for respiratory distress syndrome in women less than 28 weeks’ gestation.
Postnatal Use for Bronchopulmonary Dysplasia
Although some evidence indicates that postnatal IV glucocorticoids (e.g., dexamethasone) may be useful in preventing or treating bronchopulmonary dysplasia in preterm neonates with very low birth weight (i.e., less than 1.5 kg) who require mechanical ventilation, other evidence suggests that such therapy may be associated with an increased risk of serious adverse effects. Glucocorticoid therapy may provide short-term pulmonary benefits (e.g., reduced incidence of bronchopulmonary dysplasia, facilitation of weaning from mechanical ventilation) but does not reduce overall mortality and may be associated with both short-term adverse effects (e.g., hyperglycemia, hypertension, GI bleeding or intestinal perforation, hypertrophic obstructive cardiomyopathy, poor weight gain, poor growth of head circumference) and long-term sequelae. Long-term follow-up of preterm infants receiving IV glucocorticoids within 12 hours after birth indicates that postnatal glucocorticoid therapy is associated with an increased incidence of neurodevelopmental delay, cerebral palsy, impaired cognitive function, and stunted growth at or before school age. Therefore, the American Academy of Pediatrics (AAP) currently states that routine use of systemic glucocorticoids for prevention or treatment of bronchopulmonary dysplasia in very low birth weight infants is not recommended.
Hematologic Disorders
Glucocorticoids are used in the management of acquired (autoimmune) hemolytic anemia, idiopathic thrombocytopenic purpura (ITP), secondary thrombocytopenia, erythroblastopenia, congenital (erythroid) hypoplastic anemia (Diamond-Blackfan syndrome), and pure red cell aplasia.
Although there is no evidence that glucocorticoids affect the course or duration of hematologic disorders, high or even massive dosage of the drugs is often used to decrease bleeding tendencies and normalize blood counts. When treatment is indicated in adults or children with moderate to severe idiopathic thrombocytopenic purpura (ITP), glucocorticoids, immune globulin IV (IGIV), or splenectomy are considered first-line therapies depending on the extent of bleeding involved. Other methods of treatment, such as splenectomy, should be considered if glucocorticoids must be continued for prolonged periods (exceeding several months), especially in patients with idiopathic or secondary thrombocytopenia, acquired (autoimmune) hemolytic anemia, erythroblastopenia (RBC anemia), or congenital (erythroid) hypoplastic anemia. Cytotoxic drugs produce better results in erythroblastopenia, but glucocorticoids may enhance response.
Glucocorticoids may not affect or prevent renal complications in Henoch-Schoenlein purpura. Glucocorticoids have been widely used in aplastic anemia in children, but there is no evidence to prove their effectiveness.
GI Diseases
In ulcerative colitis, regional enteritis, and celiac disease, moderate to high dosage glucocorticoids may be useful as short-term palliative therapy for acute exacerbations and systemic complications of these chronic conditions. Glucocorticoids should not be used if there is a probability of impending perforation, abscess, or other pyogenic infection. Systemic and topical (rectal enema) glucocorticoids may be useful in acute ulcerative colitis. Sulfasalazine is the drug of choice for chronic ulcerative colitis, and a gluten-free diet is the primary method of therapy for celiac disease.
Glucocorticoids are rarely indicated for maintenance therapy in chronic GI diseases (ulcerative colitis, celiac disease) as they do not prevent relapses and may produce severe adverse reactions with long-term administration. Gastric hemorrhage and malignant hypertension are especially frequent. Occasionally, however, low dosages of glucocorticoids, in conjunction with other supportive therapy, may be useful for patients unresponsive to the usual therapy indicated for chronic conditions.
Crohn’s Disease
Conventional systemic glucocorticoids (e.g., prednisone, prednisolone, methylprednisolone) have been used for the management of mildly to moderately active and moderately to severely active Crohn’s disease† [off-label], while budesonide (a more recently approved glucocorticoid) is used orally as delayed-release capsules for the management of mildly-to-moderately active Crohn’s disease involving the ileum and/or ascending colon. Conventional glucocorticoids are at least as effective as sulfasalazine, mesalamine, budesonide, or azathioprine in patients with Crohn’s disease; however, many clinicians and experts state that conventional glucocorticoids should not be used for the management of mildly to moderately active disease, because of their high incidence of adverse effects and, therefore, their use should be reserved for patients with moderately to severely active disease.
Although no appropriate dose-ranging studies have been performed to evaluate conventional glucocorticoid dosing or dosage schedules for Crohn’s disease, comparable clinical effects have been reported in placebo-controlled and active comparator clinical trials in which 50–70% of patients received glucocorticoid dosages equivalent to prednisone (40 mg daily; tapered after clinical response). In these patients, resolution of certain symptoms and resumption of weight gain usually occurred after 1–4 weeks of therapy, while clinical remission was achieved over 8–12 weeks. Parenteral glucocorticoids (dosages equivalent to prednisone 40–60 mg, given as divided doses or as a continuous infusion) are recommended for patients with severe fulminant Crohn’s disease† [off-label]; individuals with inflammatory abdominal mass should receive broad-spectrum anti-infective agents in conjunction with glucocorticoids. Once patients respond to parenteral therapy, they should gradually be switched to an equivalent regimen of an oral glucocorticoid. About 50% of patients with active Crohn’s disease, who are receiving systemic glucocorticoids, become glucocorticoid-dependent or glucocorticoid-resistant; such patients should receive drugs with steroid-sparing effects (e.g., azathioprine, mercaptopurine) or, alternatively, infliximab. Glucocorticoids should not be used for maintenance therapy of Crohn’s disease, because both conventional glucocorticoids and budesonide usually do not prevent relapses and the drugs (especially conventional glucocorticoids) may produce severe adverse reactions with long-term administration.
Systemic conventional glucocorticoids (e.g., prednisone 1–2 mg/kg daily up to 60 mg daily) have been used in pediatric patients with mild esophageal or gastroduodenal Crohn’s disease†. In addition, glucocorticoids (e.g., prednisone or methylprednisolone 1–2 mg/kg daily up to 60 mg daily) are recommended for the management of moderately to severely active Crohn’s disease, in children. Results of a 12-week comparator-drug (prednisone versus budesonide) controlled study in pediatric patients 8–18 years of age (weighing more than 20 kg) with mildly to moderately active Crohn’s disease (Pediatric Crohn’s Disease Activity Index [PCDI] score of 12.5–40) indicate that remission rates in children receiving prednisone (40 mg daily for 2 weeks and then tapered until discontinuance) were similar (50% for prednisone versus 47% for budesonide) to those receiving budesonide (9 mg daily for 8 weeks, tapered until discontinuance). Incidence of adverse effects was substantially lower (about 32% for budesonide versus 71% for prednisone) and less severe in pediatric patients receiving budesonide than in those receiving prednisone.
Trichinosis
Glucocorticoids are used in the treatment of trichinosis with neurologic or myocardial involvement.
Neoplastic Diseases
Glucocorticoids in high dosage are used alone or as a component of various chemotherapeutic regimens in the palliative treatment of neoplastic diseases of the lymphatic system (e.g., leukemias and lymphomas in adults and acute leukemias in children). Massive dosage of glucocorticoids has occasionally been used in the treatment of neoplastic diseases but rarely offers any additional benefit and greatly increases adverse effects. Beneficial results are enhanced, however, when glucocorticoids are used as part of a total treatment regimen in combination with cytotoxic and immunosuppressive drugs; such a regimen should be administered only by an experienced oncologist.
In adults, acute lymphocytic (lymphoblastic) leukemia, chronic lymphocytic leukemia, and Hodgkin’s disease respond well to combination regimens that include a glucocorticoid (usually prednisone or prednisolone). Acute myeloblastic leukemia, lymphosarcoma, and the blast crisis of chronic myelocytic leukemia may fail to respond or may relapse upon discontinuance of therapy.
In moderate dosage, glucocorticoids induce tumor remission in approximately 15% of patients with breast cancer. Because glucocorticoids used alone are not as effective as other agents (e.g., cytotoxic agents, hormones, antiestrogens) in the treatment of breast cancer, their use should be reserved for patients unresponsive to other therapy.
Glucocorticoids (e.g., prednisone) also have been used alone or as a component of various combination chemotherapeutic regimens in the treatment of advanced, symptomatic (i.e., painful) hormone-refractory prostate cancer. Use of glucocorticoids and/or chemotherapeutic agents in the treatment of advanced, hormone-resistant prostate cancer is palliative, with patients having median survival durations of less than 1 year; no therapy has been shown to improve survival to date, and therefore the principal goal of therapy in such cancer currently is improvement in quality of life, particularly pain. Randomized studies have shown that the addition of an antineoplastic agent (e.g., mitoxantrone) to glucocorticoid therapy results in a greater proportion of patients achieving a palliative response (i.e., pain reduction) and a longer duration of such response compared with glucocorticoid treatment alone. Improvement in certain quality-of-life measures, including indicators related to pain, physical activity or function, constipation, and mood, also may favor combination therapy.
Glucocorticoids (e.g., dexamethasone, prednisone) also have been used as a component of various combination chemotherapeutic regimens in the treatment of multiple myeloma. Dexamethasone has been used in combination chemotherapeutic regimens in various doses (20–40 mg) and schedules. Although high-dose dexamethasone has been associated with increased adverse effects (e.g., hyperglycemia, psychiatric effects, insomnia, hyperactivity, infectious complications), high-dose dexamethasone is an effective component of combination chemotherapeutic regimens for the treatment of multiple myeloma.
Cancer Chemotherapy-induced Nausea and Vomiting
Corticosteroids (e.g., dexamethasone, methylprednisolone) have been used for the prevention of nausea and vomiting associated with emetogenic cancer chemotherapy† including that associated with cisplatin. Most clinical experience to date has been with dexamethasone.
Liver Diseases
Glucocorticoids may be beneficial or harmful in patients with liver disease. Although evidence is conflicting, the drugs probably are of no value in patients with acute hepatitis and massive necrosis. In patients with subacute hepatic necrosis and chronic active hepatitis, administration of glucocorticoids in high dosage can decrease serum bilirubin, ascites, and mortality rate. Prolonged low-dosage maintenance therapy may be necessary. In nonalcoholic cirrhosis in women, glucocorticoids increase survival rate in the absence of ascites, but not when ascites is present. The drugs are ineffective in men with nonalcoholic cirrhosis. Glucocorticoids may decrease mortality rate in patients with alcoholic cirrhosis with hepatic encephalopathy, but they should not be used in less seriously ill patients. Acute viral hepatitis is usually benign and self-limited, and glucocorticoids are rarely indicated.
Cerebral Edema
Glucocorticoids administered parenterally, in high dosage, may be useful to decrease cerebral edema associated with brain tumors and neurosurgery. Some patients with cerebral edema associated with pseudotumor cerebri may also benefit from use of glucocorticoids, but the efficacy of the drugs is controversial and remains to be established. Edema resulting from brain abscesses is less responsive than that resulting from brain tumors.
The use of glucocorticoids in the management of cerebral edema is not a substitute for careful neurosurgical evaluation and definitive management such as neurosurgery or other specific therapy. Effects of glucocorticoids are not apparent for several hours and in acute situations the drugs should only be used adjunctively with other indicated therapy. Although any glucocorticoid may be effective, those having minimal mineralocorticoid activity are preferable. Glucocorticoids do not appear to be beneficial in cerebral edema associated with cerebral infarction.
Head Injury
Pooled analyses of small controlled studies of glucocorticoids in patients with head injury have failed to clearly establish the efficacy of glucocorticoid therapy in this patient population. Because of a lack of evidence of efficacy, some experts have recommended against the use of glucocorticoids for improving outcomes or reducing intracranial pressure in patients with head injury. More recent evidence from a large, international, randomized, placebo-controlled study (Corticosteroid Randomization after Significant Head Injury [CRASH]) indicates that use of glucocorticoids in patients with head injuries may be detrimental. Results from this study in more than 10,000 patients with head injury and a Glasgow coma score not exceeding 14 within 8 hours of injury indicate that glucocorticoid therapy (e.g., methylprednisolone 2 g administered by IV infusion over 1 hour, followed by methylprednisolone 0.4 g/hour by IV infusion for 48 hours) is associated with a substantial increase in risk of death (21.1% with methylprednisolone versus 17.9% with placebo) within 2 weeks after head injury; the relative risk of death from all causes within 2 weeks in patients receiving methylprednisolone compared with placebo in this study was 1.18 (95% confidence interval of 1.09–1.27). The cause of the observed increase in mortality in patients receiving glucocorticoids is unclear because cause of death was not documented. Recruitment of patients for this study was halted after results from interim analyses were reported. Results regarding effects of glucocorticoid therapy on disability 6 months after head injury are pending.
Acute Spinal Cord Injury
Some evidence indicates that therapy with large IV doses of glucocorticoids (i.e., methylprednisolone) can improve motor and sensory function in patients with acute spinal cord injury† when treatment is initiated promptly following injury. However, benefit in controlled studies in humans has been demonstrated to date only in patients receiving high-dose IV methylprednisolone within 8 hours after spinal cord injury, and whether improvement in neurologic function with such therapy will routinely lead to specific improvements in disability has not been established.
In a multicenter, comparative study, patients with acute spinal cord injuries† who received an initial 30-mg/kg dose of methylprednisolone (as the sodium succinate salt) by rapid IV injection (over 15 minutes) within 8 hours of injury, followed by infusion of the drug at 5.4 mg/kg per hour for an additional 23 hours, had substantial improvement in motor function and pinprick and touch sensation at 6 weeks and 6 months compared with those who received IV naloxone hydrochloride (5.4 mg/kg by rapid IV injection followed by 4 mg/kg per hour for an additional 23 hours) or placebo. The benefits of methylprednisolone therapy were observed in patients with complete as well as incomplete loss of motor and sensory function, and neurologic improvement observed at 6 weeks in methylprednisolone-treated patients was still evident at 6 months. Patients receiving naloxone or placebo and those in whom therapy with high-dose methylprednisolone was initiated later than 8 hours (but usually within 14 hours) after injury did not have substantial improvement in motor function or touch sensation. Mortality at 6 months was similar among treatment groups, and overall mortality was low (6%) compared with that of previous studies. Although the use of glucocorticoids in patients with spinal cord injuries has been associated with increased morbidity in some studies, clinically important differences in the incidence of wound infections, GI bleeding, and other complications among treatment groups in this study were not observed.
Limited evidence in animals suggests that the ameliorative effects of glucocorticoids in spinal cord injury† are related to dose and time of initiation of therapy; these effects appear to be characterized by a biphasic, bell-shaped response curve. In one study in animals with experimentally induced spinal cord injury, posttraumatic spinal cord ischemia was effectively minimized by a 30-mg/kg dose of methylprednisolone administered 30 minutes but not several hours after injury; at 30 minutes, a 15-mg/kg dose produced little benefit, while a dose of 60 mg/kg was ineffective or deleterious. Such studies suggest that the lack of appreciable benefit observed in an earlier controlled study of patients with acute spinal cord injury who were treated up to 48 hours after injury using a methylprednisolone dose of 100 mg or 1 g (approximately 15 mg/kg) daily for 10 days may have been related in part to delayed administration of the drug or administration of an insufficient dose. Additional studies are needed to determine the optimal timing, dosage, and duration of therapy with methylprednisolone or other glucocorticoids in patients with acute spinal cord injury and to elucidate further the potential benefits of glucocorticoid therapy on functional status in such patients.
Low Back Pain
Glucocorticoids (alone or combined with a local anesthetic and/or an opiate analgesic) have been used epidurally† for symptomatic relief of low back pain†. Although this use remains controversial and convincing evidence of efficacy remains to be established, most experts state that this invasive form of therapy is an option for short-term relief of acute, subacute, or chronic radicular pain in patients with low back pain and radiculopathy associated with disk disease or herniation or spinal stenosis when more conservative therapies (e.g., rest, analgesics, physical therapy) fail and as a means of potentially avoiding surgery. The effect of epidural glucocorticoid injections on long-term outcomes of unremitting low back pain remains unclear. Epidural therapy for low back pain and radiculopathy involves injection of the drug(s) into the epidural space near the site where the nerve roots pass before entering the intervertebral foramen. Such therapy theoretically allows a concentrated amount of drug(s) to be deposited and retained locally, exposing nerves to the drug(s) for prolonged periods in an attempt to reduce inflammation, swelling, and pain. Epidural injections may be performed by caudal, interlaminar, or transforaminal approaches; the transforaminal approach requires the smallest injection volume and appears to be the most specific and possibly most effective route.
Because of the potential for complications related to improper needle placement or drug administration, many experts state that epidural injections should be performed by an experienced clinician using fluoroscopic guidance and contrast control to ensure that the needle is correctly positioned and that the injection is not performed intravascularly, intrathecally, or into tissues other than the epidural space. While some clinicians suggest that fluoroscopic guidance may not be necessary in patients who have not undergone previous surgery and whose spinal anatomy is normal, and for whom there are no other factors making the procedure technically difficult (e.g., obesity), serious adverse neurologic effects have been reported following epidural glucocorticoid injection both with and without fluoroscopic guidance. (See Cautions: Nervous System Effects.) Long-acting injectable suspension formulations of methylprednisolone, triamcinolone, and betamethasone are the most commonly used preparations for epidural injections. Optimal technique, dosage, timing of initial injection, and injection frequency, as well as maximum number of epidural glucocorticoid injections, remain to be established.
Water-soluble glucocorticoid preparations typically have not been used for epidural injection because they are cleared rapidly from the spinal canal and have been associated with adverse neurologic effects (e.g., seizures, segmental hyperalgesia) when injected intrathecally in animals. Limited evidence suggests that large particles (e.g., exceeding 50 μm) in glucocorticoid suspension preparations potentially may cause embolic vascular occlusion during inadvertent intra-arterial injection; it appears that some particulate suspensions (e.g., methylprednisolone acetate, triamcinolone hexacetonide) may contain substantial amounts of these large particles, and some clinicians have suggested that a glucocorticoid solution preparation (e.g., dexamethasone sodium phosphate) or a suspension with an overall smaller size of particulate matter (e.g., fixed combination of betamethasone sodium phosphate and betamethasone acetate) may be preferred for epidural injections. Long-acting injectable suspension preparations of glucocorticoids (e.g., Aristospan, Celestone Soluspan, Depo-Medrol, Kenalog) also contain preservatives and/or suspending agents (e.g., benzalkonium chloride, benzyl alcohol, myristyl-γ-picolinium chloride, polyethylene glycol) that have been associated with neurotoxic effects in animals or humans. While most reports of neurotoxicity with intraspinal glucocorticoid therapy in humans have involved intrathecal administration, the safety of epidural injections using preserved glucocorticoid formulations is controversial, and epidural administration of these formulations is not recommended by the manufacturers. Currently there are no studies supporting the use of any one formulation over any other in terms of safety.
The principal risk of epidural injection therapy for low back pain and radiculopathy is rare epidural abscess. However, other serious adverse effects, including infectious complications (e.g., meningitis), neurologic effects (e.g., arachnoiditis, spinal cord trauma, increased intracranial pressure, nerve injury, seizures, bladder or bowel dysfunction, paraparesis or paralysis, brain damage), ocular effects, embolic vascular complications, and death may occur following attempted epidural injection (see Cautions). Systemic glucocorticoid effects (e.g., hypothalamic-pituitary-adrenal [HPA] axis suppression, hypercorticism, Cushing’s syndrome, osteoporosis, fluid retention, hyperglycemia) also may occur after epidural glucocorticoid administration.
Data from the American Society of Anesthesiologists (ASA) Closed Claims Project database, which includes closed anesthesia malpractice claims arising from chronic pain management, suggest that serious injuries (e.g., brain damage, death) can occur when glucocorticoids are combined with local anesthetics and/or opiate analgesics for epidural injection and that patient safety may be improved by excluding typical epidural doses (volumes in excess of intrathecal test doses) of local anesthetics and/or opiate analgesics from epidural glucocorticoid injections.
Limited evidence suggests that therapeutic facet joint† and intradiscal glucocorticoid injections† are minimally effective or ineffective in the treatment of low back pain, although some clinicians report that facet joint injections may be useful in some patients with facet arthropathy. Inclusion of a glucocorticoid in trigger point injections also does not appear to be beneficial. Sacroiliac joint injections performed using fluoroscopic guidance may provide temporary pain relief in some patients when the principal source of spinal pain is the sacroiliac joint.
Although oral glucocorticoids have been used by some clinicians in the treatment of low back pain†, they do not appear to be effective and evidence supporting such use is lacking.
Bacterial Meningitis
Glucocorticosteroids have been used as adjunctive therapy in patients with bacterial meningitis†; however, results of many studies evaluating this use have been inconclusive or conflicting. Most trials were conducted with dexamethasone. In a Cochrane review which included 25 randomized controlled studies of corticosteroid use in acute bacterial meningitis, corticosteroids were found to reduce hearing loss and neurological sequelae, but did not improve overall mortality. Subgroup analysis showed that the benefits were limited to high-income countries; there was no beneficial effect of corticosteroid therapy in low-income countries. In most of the studies, the corticosteroid used was dexamethasone; hydrocortisone or prednisone were used in a few studies.
Multiple Sclerosis
Glucocorticoids currently are considered the drugs of choice for the management of acute relapses of multiple sclerosis. The anti-inflammatory and immunomodulating effects of the drugs can accelerate neurologic recovery by restoring the blood-brain barrier, reducing edema, and possibly improving axonal conduction.
For moderate to severe relapses, methylprednisolone has been administered IV in a dosage of 1 g daily for 3–5 days, followed by 60 mg of oral prednisone daily, tapering the dosage over 12 days. Alternative regimens have included 1 g or 15 mg/kg of IV methylprednisolone tapered over 15 days to 1 mg/kg and followed by oral prednisone or prednisolone in gradually decreasing dosages over several weeks to months.
Interest in the use of IV methylprednisolone in the management of acute relapses of multiple sclerosis heightened as a result of the Optic Neuritis Treatment Trial in which the rate of recovery in vision was faster in those receiving the drug and the risk of development of clinically definite multiple sclerosis was reduced during the first 2 years of follow-up. (See Uses: Ocular Disorders.) The beneficial effect of the methylprednisolone regimen on disease progression was transient since results at 3- and 5-year follow-up indicate that there were not clinically important differences among treatment groups in the rate of development of clinically definite multiple sclerosis or the degree of neurologic disability among those who developed the disease during the 5-year follow-up period. Additional study is needed and under way to determine whether pulsed doses of glucocorticoids given every other month can slow progression of the disease in patients with moderate disability and secondary progressive multiple sclerosis.
Myasthenia Gravis
Glucocorticoids (e.g., prednisone) are used in the management of myasthenia gravis, usually in patients who have had an inadequate response to anticholinesterase therapy. Glucocorticoids also have been administered parenterally in the treatment of myasthenic crisis.
Organ Transplants
In massive dosage, glucocorticoids may be used concomitantly with other immunosuppressive drugs to prevent rejection of transplanted organs. Because the incidence of secondary infections is high in patients receiving these drugs, such therapy should be administered by physicians experienced in its use.
Nephrotic Syndrome
Glucocorticoids can induce diuresis and remission of proteinuria in children and adults with nephrotic syndrome secondary to primary renal disease, especially when there is minimal renal histologic change. Lupus nephritis may also respond to glucocorticoids. High dosage may be required for prolonged periods, and alternate-day therapy should be used to decrease adverse effects. Nephrotic syndrome secondary to diabetes mellitus, renal amyloidosis, glomerulonephritis, or other diseases is generally refractory to glucocorticoids.
Diagnostic Uses
Dexamethasone inhibits pituitary adrenocorticotropic hormone (ACTH) release and decreases output of endogenous corticosteroids when given in an amount which does not itself appreciably affect concentrations of urinary 17-hydroxycorticosteroids. This effect is utilized in the dexamethasone suppression test for the diagnosis of Cushing’s syndrome and the differential diagnosis of adrenocortical tumors.
The dexamethasone suppression test (DST) has been used for the detection, diagnosis, and management of mental depression; however, considerable controversy currently exists regarding the clinical utility of the test. The sensitivity of the DST in patients with major depression is relatively modest (about 40–50%), and a positive test result (nonsuppression) does not appear to reliably predict response to antidepressant therapy and a negative test result (suppression) is not an indication for withholding antidepressant therapy. Therefore, the American Psychiatric Association, American College of Physicians, and other experts currently state that, pending further studies and evaluation, the DST should not be used routinely for the diagnosis and management of depression, although judicious use of the DST may be a useful adjunct in clinical decision making in selected situations and as a research tool.
Duchenne Muscular Dystrophy
The current standard of care for patients with Duchenne muscular dystrophy includes the use of corticosteroids (e.g., prednisone, deflazacort) for improving muscle function and strength. The American Academy of Neurology recommends the use of prednisone or deflazacort to improve muscle strength, pulmonary function, and possibly also slow the development of scoliosis and need for surgery in patients with Duchenne muscular dystrophy. Results of direct comparative studies suggest that prednisone and deflazacort are similarly effective in improving motor function, but differ in their adverse effect profiles (e.g., prednisone may be associated with more weight gain while deflazacort may be associated with a greater risk of cataracts).
Cardiovascular Disorders
Shock
Use of corticosteroids in the treatment of septic shock has been controversial. Although some controlled studies have shown beneficial effects of high-dose regimens on morbidity and mortality in septic shock, many studies have not. Results of one prospective, controlled study suggest that glucocorticoids do not improve overall survival in patients with severe, late septic shock but may be beneficial early in the course of septic shock and in certain subgroups of patients. However, 2 subsequent, prospective, controlled studies failed to show a benefit of high-dose glucocorticoid therapy that was initiated early (i.e., within 2.8 hours of diagnosis) in patients with presumed sepsis or septic shock. In addition, there was some evidence that such therapy may be associated with an increased risk of mortality in certain patients (i.e., those with serum creatinine concentrations exceeding 2 mg/dL at diagnosis and those who developed secondary infection). More recent meta-analyses found that systemic corticosteroid use accelerated the resolution of shock and increased vasopressor-free days; however, corticosteroids increased neuromuscular weakness without a clear effect on short- or long-term mortality. The Surviving Sepsis Campaign guidelines suggest the use of IV corticosteroids for adults with septic shock and an ongoing requirement for vasopressor therapy; this recommendation is based on a moderate quality of evidence. The optimal dose, timing of initiation, and duration of corticosteroids remain uncertain. The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg daily given as 50 mg IV every 6 hours or as a continuous infusion. The guidelines suggest that this is commenced at a dose of norepinephrine or epinephrine ≥0.25 mcg/kg/min at least 4 hours after initiation.
Pericarditis
Systemic corticosteroids (e.g. prednisone) have been used in the treatment of pericarditis†, but is generally considered a second- or third-line treatment. Corticosteroid use (mostly with high dosages) in this setting has been associated with recurrence and a prolonged disease course. In a nonrandomized observational study, use of higher doses of corticosteroids (i.e., prednisone 1 mg/kg/day) for recurrent pericarditis was associated with increased risk of adverse effects, recurrence, and hospitalizations compared with low-dose corticosteroid therapy (i.e., prednisone 0.2 to 0.5 mg/kg).
Chronic Fatigue Syndrome
Because of evidence that chronic fatigue syndrome† is associated with subnormal cortisol secretion secondary to impaired activation of the hypothalamic-pituitary-adrenal (HPA) axis, glucocorticoid supplementation has been studied in patients with this condition. In a study in patients 18–55 years of age who met the US Centers for Disease Control and Prevention (CDC) case criteria for chronic fatigue syndrome, low-dose oral glucocorticoid therapy (approximately 13 mg/m2 [20–30 mg] of hydrocortisone every morning and 3 mg/m2 [5 mg] every afternoon for about 12 weeks) produced some symptomatic improvement as determined by a global self-rating wellness scale; however, there was no evidence of improvement in several other self-rating scales, including mood, depression, and activity scales. Because the modest symptomatic improvement with glucocorticoid therapy was associated with clinically important adrenal suppression, such therapy is not practical nor advisable for the chronic management of chronic fatigue syndrome.
Other Uses
In miscellaneous inflammatory reactions, such as those resulting from dental procedures, short-term glucocorticoid therapy can decrease edema and may alleviate pain associated with such inflammations.
Local injection of glucocorticoids (e.g., methylprednisolone, betamethasone) into the tissue near the carpal tunnel has been used in a limited number of patients to relieve symptoms (e.g., pain, edema, sensory deficit) of carpal tunnel syndrome. In clinical studies, short-term response was noted in most patients, but the improvement in symptoms waned during the following 11–24 months. Limited evidence suggests that injection technique may influence the duration of effect.
Glucocorticoids (e.g., betamethasone, dexamethasone, methylprednisolone) have been used by local injection for the management of cystic tumors of an aponeurosis or tendon (ganglia).
For EENT and topical uses of the corticosteroids, see 52:08.08 and 84:06.08.
Corticosteroids General Statement Dosage and Administration
Administration
Glucocorticoids, in appropriate forms, may be administered orally, by oral inhalation, and by IV, IM, subcutaneous, intra-articular, intrabursal, intradermal, intrasynovial, intralesional, or soft tissue injection. Long-acting injectable suspension formulations of some glucocorticoids (e.g., betamethasone, methylprednisolone, triamcinolone) have been administered by epidural injection, although the safety of epidural injections using preserved glucocorticoid formulations is controversial and epidural administration of these formulations is not recommended by the manufacturers. (See Uses: Low Back Pain and see Cautions: Nervous System Effects.) The manufacturer of Depo-Medrol (sterile methylprednisolone acetate suspension) states that this formulation of methylprednisolone acetate contains benzyl alcohol, which is potentially toxic when administered locally to neural tissue, and that this formulation should not be administered intrathecally because of reports of severe adverse events with such use. (See Cautions: Nervous System Effects.) Whenever possible, topical corticosteroid therapy (see 52:08.08 and 84:06.08) is preferable to systemic therapy.
Because injections of slightly soluble glucocorticoids may produce atrophy at the site of injection, IM injections of these products should be made deeply into gluteal muscle; repeated IM injections at the same site should be avoided, and these products should not be administered subcutaneously. Knee, ankle, wrist, elbow, shoulder, phalangeal, and hip joints are suitable sites for intra-articular injections of glucocorticoids; spinal joints and joints without synovial spaces are not suitable for intra-articular injection. For intra-articular injections, a 20- to 24-gauge needle should be used; needle placement should be verified by aspirating a few drops of synovial fluid prior to drug administration with a second syringe. Joints should be injected where the synovial cavity is most superficial and free from large vessels and nerves. Joint fluid should be examined to exclude sepsis, and injection into an infected site should be avoided; if joint sepsis is evident, appropriate antibacterial therapy should be instituted. Symptoms of septic arthritis include local swelling, further restriction of joint motion, fever, or malaise. Glucocorticoids should not be injected into unstable joints and patients should be cautioned not to overuse joints in which the inflammatory process is still active despite symptomatic improvement.
For management of tenosynovitis and tendinitis, glucocorticoids should be injected into affected tendon sheaths rather than into tendons.
For disorders of the foot (bursitis, tenosynovitis, acute gouty arthritis), a tuberculin syringe with a 25-gauge, ¾-inch needle should be used for intra-articular or soft-tissue administration.
For dermatologic conditions, a tuberculin syringe with a 25-gauge, ½-inch needle should be used for intralesional administration.
In treatment of intercostal neuritis or neuralgia, local injections of glucocorticoids should be made cautiously to avoid penetration of the pleura, which may be indicated by appearance of sudden sharp pain during the injection.
Dosage
General Dosage
In the management of acute disorders, glucocorticoid dosage should be sufficient to ensure that symptoms are controlled quickly, and treatment should be discontinued as soon as possible. Acute disorders respond most rapidly to divided daily doses. In life-threatening situations where adrenal insufficiency may be the precipitating cause, glucocorticoids can be administered in any dosage required without serious complications, even before a definite diagnosis has been made.
Dosage ranges for glucocorticoids are extremely wide, and patient responses are quite variable. The amount of drug each patient receives should be individualized according to the diagnosis, severity, prognosis and probable duration of the disease, and patient response and tolerance. Occasionally, patients may respond better to one glucocorticoid than another but this is unpredictable.
Types of dosages generally used in various disease states are: physiologic or replacement (amount of glucocorticoid normally secreted by the adrenal cortex each day—approximately 20 mg of hydrocortisone), pharmacologic (any dosage greater than a physiologic dosage) which includes maintenance or low (dosage slightly in excess of physiologic amounts—e.g., 5–15 mg of prednisone daily), moderate (approximately 0.5 mg of prednisone/kg daily), high (approximately 1–3 mg of prednisone/kg daily), and massive (approximately 15–30 mg of prednisolone/kg daily). The approximate equivalent oral glucocorticoid dosages established by various laboratory assays are as follows:
|
Drug |
Equivalent Dosage |
|---|---|
|
Cortisone |
25 mg |
|
Hydrocortisone |
20 mg |
|
Prednisolone |
5 mg |
|
Prednisone |
5 mg |
|
Methylprednisolone |
4 mg |
|
Triamcinolone |
4 mg |
|
Dexamethasone |
0.75 mg |
|
Betamethasone |
0.6 mg |
“Equivalent dosages” are general approximations and may not apply to all diseases or routes of administration (especially oral inhalation, IM or intrasynovial injections). In addition, duration of HPA-axis suppression and degree of mineralocorticoid activities must be considered separately. (See Pharmacology.)
Estimated equivalent daily dosages of inhaled glucocorticoids for the treatment of asthma for adults and adolescents 12 years of age or older are as follows:
|
Drug |
Low Daily Dosage (mcg) |
Medium Daily Dosage (mcg) |
High Daily Dosage (mcg) |
|---|---|---|---|
|
Beclomethasone with Fluoroethane Propellant |
80–240 |
>240–480 |
>480 |
|
Budesonide Powder for Oral Inhalation |
180–600 |
>600–1200 |
>1200 |
|
Flunisolide with Hydrofluoroalkane (HFA) Propellant |
320 |
>320–640 |
>640 |
|
Fluticasone with Fluoroethane Propellant |
88–264 |
>264–440 |
>440 |
|
Fluticasone Powder for Oral Inhalation |
100–300 |
>300–500 |
>500 |
|
Mometasone Powder for Oral Inhalation |
200 |
400 |
>400 |
|
Triamcinolone Acetonide with Dichlorodifluoromethane Propellant |
300–750 |
>750–1500 |
>1500 |
Estimated equivalent daily dosages of inhaled glucocorticoids for the treatment of asthma for infants and children are as follows (Table 3):
Safety and efficacy of inhaled corticosteroids in children younger than 1 year of age have not been established.
NA: not applicable.
Safety and efficacy of flunisolide inhalation aerosol in children younger than 6 years of age have not been established.
|
Low Daily Dosage |
Medium Daily Dosage |
High Daily Dosage |
||||
|---|---|---|---|---|---|---|
|
Drug |
Infants and Children 0–4 years of age |
Children 5–11 years of age |
Infants and Children 0–4 years of age |
Children 5–11 years of age |
Infants and Children 0–4 years of age |
Children 5–11 years of age |
|
Beclomethasone with Fluoroethane Propellant |
NA |
80–160 mcg |
NA |
>160–320 mcg |
NA |
>320 mcg |
|
Budesonide Powder for Oral Inhalation |
NA |
180–400 mcg |
NA |
>400–800 mcg |
NA |
>800 mcg |
|
Budesonide Suspension for Nebulization |
0.25–0.5 mg |
0.5 mg |
>0.5–1 mg |
1 mg |
>1 mg |
2 mg |
|
Flunisolide with Hydrofluoroalkane (HFA) Propellant |
NA |
160 mcg |
NA |
320 mcg |
NA |
≥640 mcg |
|
Fluticasone with Fluoroethane Propellant |
176 mcg |
88–176 mcg |
>176–352 mcg |
>176–352 mcg |
>352 mcg |
>352 mcg |
|
Fluticasone Powder for Oral Inhalation |
NA |
100–200 mcg |
NA |
>200–400 mcg |
NA |
>400 mcg |
|
Triamcinolone Acetonide with Dichlorodifluoromethane Propellant |
NA |
300–600 mcg |
NA |
>600–900 mcg |
NA |
>900 mcg |
Long-term glucocorticoid therapy should not be initiated without due consideration of its risks. Other less dangerous drugs should be used if possible. If glucocorticoids are clearly necessary, the drugs should be administered in the smallest dosage possible and should generally be used only as adjuncts to other treatments. Patients should be continually monitored for signs that indicate dosage adjustment is necessary, such as remission or exacerbations of the disease and stress (surgery, infection, trauma). Periodic attempts should be made to decrease dosage or, preferably, to withdraw the drugs completely. Prescription refills should always be limited so that periodic evaluations can be made of the patient’s condition.
Coronavirus Disease 2019 (COVID-19)
When used for adjunctive treatment in adults with coronavirus disease 2019 (COVID-19)†, dexamethasone has been used IV or orally in a dosage of 6 mg daily for up to 10 days or until hospital discharge, whichever comes first. If dexamethasone is not available, use of other systemic corticosteroids is recommended. It is not known at this time whether other corticosteroids (e.g., hydrocortisone, methylprednisolone, prednisone) will have a similar benefit as dexamethasone. For equivalent daily dosages of these alternative corticosteroids to dexamethasone, see Table 4.
Dosages recommended by the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel.
|
Drug |
Equivalent Daily Dosage |
Frequency of Administration |
|---|---|---|
|
Dexamethasone |
6 mg |
Once daily |
|
Methylprednisolone |
32 mg |
Once daily or in 2 divided doses daily |
|
Prednisone |
40 mg |
Once daily or in 2 divided doses daily |
|
Hydrocortisone |
160 mg |
2–4 divided doses daily |
When used for adjunctive treatment in pediatric patients with COVID-19†, the NIH COVID-19 Treatment Guidelines Panel recommends dexamethasone 0.15 mg/kg (maximum dosage 6 mg) given IV or orally for up to 10 days. If dexamethasone is not available, equivalent dosages of alternative corticosteroids may be considered.
Clinicians should consult the most recent NIH COVID-19 treatment guidelines for additional information on use of corticosteroids in patients with COVID-19.
Alternate-Day Therapy
Alternate-day therapy is the dosage regimen of choice for long-term oral glucocorticoid treatment of most conditions. In alternate-day therapy, a single dose is administered every other morning. The drug is administered in the morning to simulate the natural circadian rhythm of corticosteroid secretion which is high in the morning and low in the evening. This regimen provides relief of symptoms while minimizing adrenal suppression, protein catabolism, and other adverse effects. However, some patients, especially those with rheumatoid arthritis or ulcerative colitis, require daily glucocorticoid therapy because symptoms of the underlying disease cannot be controlled by alternate-day therapy. Only “short-acting” steroids (e.g., prednisone, prednisolone, methylprednisolone) that suppress the HPA axis for less than 1.5 days after a single oral dose should be used for alternate-day therapy.
Several methods of transferring patients from initial divided-dose oral therapy to alternate-day therapy have been described. Twice the total daily dose that has been found to be effective may be administered as a single dose every other morning; this dose may then be gradually decreased to maintenance levels. Alternatively, the daily dose may be decreased to maintenance levels prior to initiation of alternate-day therapy; then twice the daily dose is given every other day. A third method is to establish a maintenance dose that is administered every morning as a single dose; alternate-day therapy is then introduced by gradual increases of this dose on alternate mornings with corresponding decreases in the dose administered on intervening mornings until twice the daily dose is being taken on alternate mornings.
Because an intact HPA axis is necessary for alternate-day therapy to be effective, it may be difficult to transfer a patient who has been maintained on divided-dose therapy for prolonged periods to alternate-day therapy, but continual attempts should be made to do so. Symptomatic treatment with other drugs on the “off day” or a trial of more than double the daily dose every other day may be helpful. When alternate-day therapy is not possible, the entire daily dose of glucocorticoid can usually be administered as a single morning dose; however, some patients will require divided daily doses of glucocorticoids.
Discontinuance of Therapy
Although high-dose glucocorticoid therapy used for only brief periods in emergency situations may be reduced and discontinued quite rapidly, withdrawal following long-term therapy with pharmacologic dosages of systemic glucocorticoids should be very gradual until recovery of HPA-axis function occurs. (See Cautions: Adrenocortical Insufficiency.) These precautions also apply when a patient is transferred from a systemic glucocorticoid to oral or nasal inhalation therapy with beclomethasone dipropionate, budesonide, fluticasone propionate, or flunisolide.
For certain acute allergic conditions (e.g., contact dermatitis such as poison ivy), glucocorticoids may be administered short term (e.g., for 6 days), giving an initially high dose (e.g., 30 mg of prednisone in divided doses) on the first day of therapy, and then withdrawing therapy by tapering the dose over several days (e.g., by 5 mg of prednisone daily).
Many methods of slow withdrawal or “tapering” have been described. In one suggested regimen, glucocorticoid dosage is decreased by the equivalent of 2.5–5 mg of prednisone every 3–7 days until the physiologic dose (e.g., 5 mg of prednisone or prednisolone, 0.75 mg of dexamethasone, or 20 mg of hydrocortisone) is reached. Other recommendations state that decrements usually should not exceed 2.5 mg of prednisone (or its equivalent) every 1–2 weeks except in patients on alternate-day therapy in whom it may be possible to decrease dosage in decrements of 5 mg of prednisone (or its equivalent) at 1- to 2-week intervals. If the disease flares up during withdrawal, dosage may need to be increased and followed by a more gradual withdrawal. In addition, increased dosage will be required during periods of stress. When a physiologic dosage has been reached, it has been suggested that single 20-mg oral morning doses of hydrocortisone be substituted for whatever glucocorticoid the patient has been receiving. After 2–4 weeks, the dosage of hydrocortisone may be decreased by 2.5 mg every week until a single morning dosage of 10 mg daily is reached.
The time required for complete HPA function recovery following discontinuance of glucocorticoid therapy is variable. Tests of adrenal function may be used to measure recovery of adrenocortical function. Normal morning plasma cortisol concentrations (exceeding 10 mcg/dL) indicate that basal pituitary-adrenal function is adequate and that maintenance therapy can be discontinued. However, this does not assure that adrenal function has recovered sufficiently to adequately increase cortisol production in response to stress and, therefore, supplemental glucocorticoids may still be required during stress. Complete recovery of HPA function generally can be assumed and supplementary therapy during stress can usually be discontinued when response to a corticotropin or cosyntropin test is normal.
Cautions for Corticosteroids General Statement
Short-term administration of glucocorticoids, even in massive dosages, is unlikely to produce harmful effects. When the drugs are used for longer than brief periods, however, they can produce a variety of devastating effects, including adrenocortical atrophy and generalized protein depletion.
Adrenocortical Insufficiency
When given in supraphysiologic doses for prolonged periods, glucocorticoids may cause decreased secretion of endogenous corticosteroids by suppressing pituitary release of corticotropin (secondary adrenocortical insufficiency). The degree and duration of adrenocortical insufficiency produced by the drugs is highly variable among patients and depends on the dose, frequency and time of administration, and duration of glucocorticoid therapy. This effect may be minimized by use of alternate-day therapy. (See Alternate-Day Therapy under Dosage and Administration: Dosage.)
As in patients with primary adrenocortical insufficiency maintained on corticosteroids, patients who develop secondary adrenocortical insufficiency require higher corticosteroid dosage when they are subjected to stress (e.g., infection, surgery, trauma). In addition, acute adrenal insufficiency (even death) may occur if the drugs are withdrawn abruptly or if patients are transferred from systemic glucocorticoid therapy to oral inhalation therapy. Therefore, the drugs should be withdrawn very gradually following long-term therapy with pharmacologic dosages. (See Discontinuance of Therapy under Dosage and Administration: Dosage.) Adrenal suppression may persist up to 12 months in patients who receive large dosages for prolonged periods. Until recovery occurs, patients may show signs and symptoms of adrenal insufficiency when they are subjected to stress and replacement therapy may be required. Since mineralocorticoid secretion may be impaired, sodium chloride and/or a mineralocorticoid should also be administered.
Musculoskeletal Effects
Muscle wasting, muscle pain or weakness, delayed wound healing, and atrophy of the protein matrix of the bone resulting in osteoporosis, vertebral compression fractures, aseptic necrosis of femoral or humeral heads, or pathologic fractures of long bones are manifestations of protein catabolism which may occur during prolonged therapy with glucocorticoids. These adverse effects may be especially serious in geriatric or debilitated patients. Before initiating glucocorticoid therapy in postmenopausal women, the fact that they are especially prone to osteoporosis should be considered. Glucocorticoids should be withdrawn if osteoporosis develops, unless their use is life-saving. A high-protein diet may help to prevent adverse effects associated with protein catabolism.
An acute myopathy has been observed with the use of high doses of glucocorticoids, particularly in patients with disorders of neuromuscular transmission (e.g., myasthenia gravis) or in patients receiving concomitant therapy with neuromuscular blocking agents (e.g., pancuronium). This acute myopathy is generalized, may involve ocular and respiratory muscles, and may result in quadriparesis. Myopathy may be accompanied by elevated serum creatine kinase [CK, creatine phosphokinase, CPK] concentrations. Resolution or clinical improvement of the myopathy may occur weeks to years after discontinuance of glucocorticoid therapy.
Tendon rupture, particularly of the Achilles tendon, has occurred in patients receiving glucocorticoids.
Osteoporosis
Osteoporosis and related fractures are some of the most serious adverse effects of long-term glucocorticoid therapy. More than 10% of patients are diagnosed with a fracture and 30–40% have radiographic evidence of vertebral fractures during long-term glucocorticoid use. Glucocorticoid-induced bone loss and osteoporosis result from increased osteoclast-mediated bone resorption and decreased osteoblast-mediated bone formation. Contributing mechanisms include: 1) effects on calcium homeostasis (e.g., decreased intestinal absorption of calcium and phosphate, increased urinary calcium excretion possibly secondary to a direct effect on tubular reabsorption, resultant secondary hyperparathyroidism leading to increased bone resorption if persistent), 2) effects on sex hormones (e.g., decreased sex hormone production both indirectly by reducing endogenous pituitary hormone concentrations and adrenal androgen production and directly through effects on gonadal hormone release, decreased pituitary secretion of luteinizing hormone with resultant decreased ovarian estrogen and testicular androgen production), 3) inhibition of bone formation (e.g., inhibition of osteoblast proliferation and attachment to matrix, inhibition of the synthesis of type I collagen and noncollagenous proteins by osteoblasts, and dose-related decreases in circulating osteocalcin, possibly mediated by effects on oncogene expression, prostaglandin E production, and the production of insulin-like growth factors and transforming growth factor), and 4) other effects (e.g., effects on the normal forces of muscle contraction on bone resulting from glucocorticoid-induced myopathy and muscle weakness, contribution of the underlying inflammatory condition being treated). Bone loss is most rapid during the first 3–6 months following initiation of glucocorticoid therapy and continues at a slower, steadier rate with prolonged use.
Patients with such bone loss are predisposed to fractures (particularly vertebral fractures because of greater effects of glucocorticoids on trabecular than cortical bone). The risk of fractures is both dose and duration dependent, with higher daily or cumulative doses of glucocorticoids and longer durations of use associated with greater risk. A high glucocorticoid dosage generally is considered a daily dosage equivalent to more than 7.5 mg of prednisone. However, some studies have reported an increased risk of fracture with daily dosages as low as 2.5–7.5 mg of prednisolone or equivalent, while others have found no appreciable decline in bone density with prednisone dosages averaging 8 mg daily or dosages of less than 5 mg daily. Alternate-day regimens have not been shown to be associated with less risk of bone loss than daily regimens. Bone loss has even been associated with oral inhalation of glucocorticoids. However, risk of osteoporosis is uncertain in patients receiving recommended doses of inhaled glucocorticoids.
Glucocorticoid-induced bone loss can be both prevented and treated; however, many patients receiving long-term glucocorticoid therapy do not receive appropriate therapies to prevent bone loss or are treated only after a fracture has occurred. The American College of Rheumatology (ACR) recommends that preventive therapy be considered for patients in whom the benefits of such therapy outweigh the potential harms. ACR recommendations are based on a risk-stratification approach in which an individual’s risk level for developing a fracture (low, moderate, or high) is determined based on predisposing factors including the individual's preexisting or anticipated glucocorticoid dosage. An initial clinical fracture risk assessment is recommended as soon as possible, but at least within 6 months of initiating long-term glucocorticoid therapy and reassessments are recommended every 12 months during continued treatment. ACR states that the available data on fracture risk and risk reduction are more limited in children and adults younger than 40 years of age; nevertheless such patients also should be assessed for their fracture risk and managed accordingly.
To minimize the risk of glucocorticoid-induced bone loss, the smallest possible effective dosage and duration should be used. Topical and inhaled preparations should be used whenever possible. Lifestyle modifications to reduce the risk of osteoporosis (e.g., cigarette smoking cessation, limitation of alcohol consumption, participation in a weight-bearing exercise for 30–60 minutes daily) should be encouraged in all patients. In addition, patients should receive adequate calcium and vitamin D supplementation to preserve bone mass and limit the extent of glucocorticoid-induced bone loss. Patients who are considered to be at moderate-to-high risk of fracture generally should receive additional pharmacologic therapy. Bisphosphonates generally are preferred and have been shown to reduce the incidence of radiographic vertebral fractures in patients with glucocorticoid-induced osteoporosis.
The ACR guideline for the prevention and treatment of glucocorticoid-induced osteoporosis recommends calcium and vitamin D supplementation in addition to lifestyle modification in any patient receiving long-term (at least 3 months) glucocorticoid therapy at a daily dosage equivalent to at least 2.5 mg of prednisone. No further preventive measure is generally recommended in patients who are considered to be at low risk of fracture; however, such patients should be monitored closely during continued glucocorticoid therapy, with fracture risk assessments and bone mineral density (BMD) measurements performed at regular intervals. ACR recommends an additional pharmacologic agent in patients who are considered to be at moderate-to-high risk of fracture. Oral bisphosphonates generally are preferred in most situations because of their demonstrated benefits in reducing fracture risk as well as their safety and low cost; other suggested options include IV bisphosphonates, teriparatide, denosumab, and raloxifene (for postmenopausal women if no other therapy is appropriate). Because of some uncertainty regarding the relative benefits versus harms of these interventions, ACR states that most of their recommendations are conditional and that treatment decisions should be individualized based on patient preferences, values, and comorbidities.
Increased Susceptibility to Infection
Glucocorticoids, especially in large doses, increase susceptibility to and mask symptoms of infection. Infections with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic infections in any organ system, may be associated with glucocorticoids alone or in combination with other immunosuppressive agents. These infections may be mild, but they can be severe or fatal, and localized infections may disseminate.
Patients who become immunosuppressed while receiving glucocorticoids have increased susceptibility to infections compared with healthy individuals. Some infections such as varicella (chickenpox) and measles can have a more serious or even fatal outcome in such patients, particularly in children.
Immunosuppression is most likely to occur in patients receiving high-dose (e.g., equivalent to at least 1 mg/kg of prednisone daily), systemic glucocorticoid therapy for any period of time, particularly in conjunction with glucocorticoid-sparing drugs (e.g., troleandomycin) and/or concomitant immunosuppressant agents; however, patients receiving moderate dosages of systemic glucocorticoids for short periods or low dosages for prolonged periods also may be at risk.
FDA states that the possibility of orally inhaled glucocorticoid therapy causing sufficient immunosuppression to place a patient at risk of infection also should be considered. However, the risk of such therapy, including any possible contribution of local pulmonary immunosuppressant effects of inhaled drug to the development of serious pulmonary infections (e.g., varicella pneumonia), remains to be more fully elucidated.
Glucocorticoid-dependent children should undergo anti-varicella-zoster virus antibody testing. Vaccination should be considered for those who have absent or inadequate antibody concentrations. In addition, such children and any adult who are not likely to have been exposed to varicella or measles should avoid exposure to these infections while receiving glucocorticoids. If exposure to varicella or measles occurs in such individuals, administration of varicella zoster immune globulin (VZIG) or immune globulin, respectively, may be indicated. If varicella develops, treatment with an antiviral agent (e.g., acyclovir) may be considered, although fatal outcome (e.g., in those developing hemorrhagic varicella) may not always be avoided even if such therapy is initiated aggressively.
The immunosuppressive effects of glucocorticoids may result in activation of latent infection or exacerbation of intercurrent infections, including those caused by Candida, Mycobacterium, Toxoplasma, Strongyloides, Pneumocystis, Cryptococcus, Nocardia, or Ameba. Glucocorticoids should be used with great care in patients with known or suspected Strongyloides (threadworm) infection. In such patients, glucocorticoid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia.
The National Institutes of Health (NIH) COVID-19 Treatment Guidelines panel states that prolonged use of systemic corticosteroids in patients with COVID-19† may increase the risk of reactivation of latent infections (e.g., hepatitis B virus [HBV], herpesvirus, strongyloidiasis, tuberculosis). The risk of reactivation of latent infections following a 10-day course of dexamethasone (6 mg once daily) is not well established. When initiating dexamethasone in patients with COVID-19, appropriate screening and treatment to reduce the risk of Strongyloides hyperinfection in those at high risk of strongyloidiasis (e.g., patients from tropical, subtropical, or warm, temperate regions or those engaged in agricultural activities) and reduce the risk of fulminant reactivation of HBV should be considered.
Some experts advise that the need to continue at least physiologic replacement dosages of glucocorticoids in glucocorticoid-dependent patients developing serious infection should be considered since discontinuance of the drugs before or after the development of varicella may have contributed to fatal outcome in some reported cases. Additional insight is needed regarding the dosages, routes, and types of glucocorticoids as well as immunologic characteristics likely to place patients at substantial risk of immunosuppression and serious infection.
The most common adverse effect of oral inhalation therapy with glucocorticoids is Candida albicans or Aspergillus niger infections of the mouth, pharynx, and occasionally the larynx. Oral candidiasis also is one of the most frequent adverse effects of therapy with long-term oral glucocorticoids. The occurrence of these fungal infections appears to be dose dependent; they also occur more frequently in women than in men. Some clinicians recommend that patients rinse their mouths with water and swallow after each oral inhalation dose to prevent Candida infection. Usually, Candida or Aspergillus infections are of little clinical importance, but occasionally they may require antifungal therapy or discontinuance of the oral inhalation.
The principal risk of epidural injection therapy for low back pain and radiculopathy is rare epidural abscess. Infectious complications (including bacterial meningitis) have been reported following epidural injection. Fungal and bacterial infections (including meningitis) have been reported in patients who received epidural or intra-articular therapy with contaminated glucocorticoid injections prepared by compounding pharmacies.
Fluid and Electrolyte Disturbances
Sodium retention with resultant edema, potassium loss, hypokalemic alkalosis, and hypertension may occur in patients receiving glucocorticoids. Congestive heart failure may occur in susceptible patients. These mineralocorticoid effects are less frequent with synthetic glucocorticoids (except fludrocortisone) than with hydrocortisone or cortisone, but may occur, especially when synthetic glucocorticoids are given in high dosage for prolonged periods. Dietary salt restriction is advisable and potassium supplementation may be necessary in patients receiving glucocorticoids for anti-inflammatory or immunosuppressant effects. When glucocorticoids with substantial mineralocorticoid activity are administered, patients should be instructed to notify their physicians if edema develops. All glucocorticoids increase calcium excretion and may cause hypocalcemia.
Ocular Effects
Prolonged use of glucocorticoids may result in posterior subcapsular and nuclear cataracts (particularly in children), exophthalmos, or increased intraocular pressure which may result in glaucoma or may occasionally damage the optic nerve. However, data from several studies indicate that the risk of subcapsular and nuclear cataracts associated with inhaled glucocorticoid use is negligible in young asthmatic patients, but the risk of such cataracts may be elevated in older patients. Data from a case-control study indicate that the risk of ocular hypertension or open-angle glaucoma was increased in patients receiving high dosages of orally inhaled glucocorticoids (at least 1600 mcg of beclomethasone dipropionate, budesonide, or triamcinolone acetonide) daily for at least 3 months. Patients receiving lower dosages of orally inhaled or intranasal glucocorticoids were not at increased risk for these adverse ocular effects. Results from a population-based study indicate that use of orally inhaled corticosteroids is associated with development of posterior subcapsular and nuclear cataracts. Establishment of secondary fungal and viral infections of the eye may also be enhanced in patients receiving glucocorticoids. Blindness has occurred rarely following intralesional injection of glucocorticoids around the face and head. Ocular effects (e.g., transient blindness, amblyopia, acute retinal necrosis syndrome, intraocular hemorrhage, cortical blindness) also have occurred following epidural injection. Eye irritation and eyelid edema have been reported in patients receiving glucocorticoids in clinical trials.
Endocrine Effects
When glucocorticoids are administered over a prolonged period, they may produce various endocrine disorders including hypercorticism (cushingoid state) and amenorrhea or other menstrual difficulties. Corticosteroids may decrease glucose tolerance, produce hyperglycemia, and aggravate or precipitate diabetes mellitus especially in patients predisposed to diabetes mellitus. If steroid therapy is required in patients with diabetes mellitus, changes in insulin or oral antidiabetic agent dosage or diet may be necessary. Corticosteroids have also been reported to increase or decrease motility and number of sperm in some men.
GI Effects
Adverse GI effects of corticosteroids include nausea, vomiting, anorexia which may result in weight loss, increased appetite which may result in weight gain, diarrhea or constipation, abdominal distention, pancreatitis, gastric irritation, and ulcerative esophagitis. Indigestion is one of the most frequently occurring adverse effects in patients receiving long-term therapy with oral corticosteroids. Blood in the stool has been reported in patients receiving prednisolone orally disintegrating tablets in clinical trials. Corticosteroids have been implicated in the development, reactivation, perforation, hemorrhage, and delayed healing of peptic ulcers. Although concomitant administration of antacids or other antiulcer agents (e.g., cimetidine) has been suggested to prevent peptic ulcer formation in patients receiving high dosages of corticosteroids, routine concomitant use of these agents does not appear to be warranted since corticosteroid-induced ulcers occur infrequently (in 2% or less of patients receiving corticosteroids) and the efficacy of antiulcer therapy in preventing these ulcers has not been established. However, selective use of preventive antiulcer therapy may be considered in patients receiving corticosteroids who are at increased risk of peptic ulcer formation (e.g., those receiving other ulcerogenic drugs). Gastric irritation may be reduced if oral corticosteroids are taken immediately before, during, or immediately after meals, or with food or milk.
Nervous System Effects
Adverse neurologic effects of glucocorticoids have included headache, vertigo, insomnia, restlessness and increased motor activity, ischemic neuropathy, electroencephalogram (EEG) abnormalities, and seizures. Glucocorticoids may precipitate mental disturbances ranging from euphoria, mood swings, depression and anxiety, and personality changes to frank psychoses. Emotional instability or psychotic tendencies may be aggravated by the drugs. Increased intracranial pressure with papilledema (i.e., pseudotumor cerebri) has been reported, generally in association with withdrawal of glucocorticoid therapy.
Aseptic meningitis, arachnoiditis, exacerbation of pain, spinal cord trauma, subdural injection, intracranial air injection, increased intracranial pressure, nerve injury, seizures, bladder or bowel dysfunction, paraparesis or paralysis, sensory disturbances, and brain damage have been reported following epidural injection and/or intrathecal administration. It is unclear whether reports of neurologic effects associated with epidural glucocorticoid administration involved improper needle placement or were related to administration of the drug and/or preservatives.
Serious, potentially permanent, adverse neurologic events (e.g., spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, brain edema), including death, have been reported rarely following epidural glucocorticoid injection both with and without fluoroscopic guidance. In addition to potential direct needle trauma to the spinal cord, such adverse events also may be the result of inadvertent intra-arterial injection of the particulate glucocorticoid suspension with subsequent embolization. Many of the events occurred within minutes to 48 hours after epidural injection of the glucocorticoid. In some cases, diagnoses of adverse neurologic events were confirmed by magnetic resonance imagining or computed tomography. Patients should be advised to immediately seek emergency medical attention for unusual symptoms (e.g., loss of or changes in vision, tingling in extremities, sudden weakness or numbness affecting the face or occurring unilaterally or bilaterally in the arms or legs, dizziness, severe headache, seizures) occurring after epidural glucocorticoid injection.
Dermatologic Effects
Various adverse dermatologic effects are associated with systemic glucocorticoid administration and include impaired wound healing, skin atrophy and thinning, acne, increased sweating, hirsutism, facial erythema, striae, petechiae, ecchymoses, and easy bruising. Long-term therapy with high dosages of inhaled corticosteroids is associated with skin thinning and easy bruising, particularly among women. Dermatologic manifestations of hypersensitivity to the corticosteroids include hives and/or allergic dermatitis, urticaria, and angioedema. Burning or tingling of the perineal area may occur after IV injection of the drugs. Parenteral corticosteroid therapy has also produced hypopigmentation or hyperpigmentation, scarring, induration, delayed pain or soreness, subcutaneous and cutaneous atrophy, and sterile abscesses. Kaposi’s sarcoma has been reported to occur in patients receiving glucocorticoid therapy; discontinuance of such therapy may result in remission of the disease.
Dermal and/or subdermal changes forming depressions in the skin at the injection site have been reported with use of methylprednisolone acetate injectable suspension (Depo-Medrol). Caution should be used to minimize the incidence of dermal and subdermal atrophy.
Other Adverse Effects
A steroid withdrawal syndrome seemingly unrelated to adrenocortical insufficiency and consisting of anorexia, nausea and vomiting, lethargy, headache, fever, joint pain, desquamation, easy bruising, myalgia, weight loss, and/or hypotension has been reported following abrupt withdrawal of glucocorticoids. Symptoms often occurred while plasma glucocorticoid concentrations were still high but were falling rapidly; apparently the abrupt change in glucocorticoid concentration rather than a low concentration per se was responsible for the phenomenon. Bradycardia has occurred during or after IV administration of large doses of methylprednisolone sodium succinate but did not appear to be related to the rate or duration of infusion.
A few patients have experienced hoarseness, dry mouth, and sore throat during oral inhalation therapy with glucocorticoids; these adverse effects have also occurred in patients receiving only the aerosol vehicle and may be minimized by rinsing the mouth and swallowing after using the aerosol. Pharyngolaryngeal pain has been reported in patients receiving glucocorticoids in clinical trials. Dysphonia also has been reported following epidural glucocorticoid injection.
Injections of slightly soluble glucocorticoids may produce atrophy at the site of injection. (See Dosage and Administration: Administration.) Intra-articularly administered corticosteroids have caused postinjection flare and Charcot-like arthropathy. Epidural lipomatosis has been reported with repeated epidural glucocorticoid injections but appears to resolve following discontinuance of such therapy. Cerebral or pulmonary embolism, hematoma formation, pneumothorax, intravascular injection, and vascular injury also have been reported following epidural injection therapy.
Minor transient complications of epidural glucocorticoid therapy include headache, nausea, facial flushing, fever, and inadvertent spinal tap. Headache appears to occur commonly with epidural injection of glucocorticoids presumably secondary to pressure changes in the epidural space or accidental puncture of the dura.
Intranasal administration of these drugs has been associated with allergic reactions and rhinitis. Temporary or permanent visual impairment, including blindness, has been reported with glucocorticoid administration by intranasal, ophthalmic, and other routes of administration. Increased intraocular pressure, infection, residue or slough at the injection site, and ocular and periocular inflammation, including allergic reactions, have been reported with ophthalmic administration of glucocorticoids.
Hypercholesterolemia, atherosclerosis, thrombosis, thromboembolism, fat embolism, and thrombophlebitis have also been associated with corticosteroid therapy, particularly with cortisone. Hypertrophic cardiomyopathy has been reported in premature infants receiving glucocorticoids (e.g., prednisolone). Thrombocytopenia has been observed in a few patients following prolonged, high-dose glucocorticoid therapy. Palpitation, tachycardia, swelling of mouth and tongue, frequency and urgency of urination, and enuresis have been reported rarely. Anaphylactic reactions also have been reported rarely with parenteral glucocorticoid therapy. Glucocorticoids may decrease serum concentrations of ascorbic acid (vitamin C) and vitamin A; symptoms of vitamin A or C deficiency may occur rarely.
Transient, mild, asymptomatic elevations in ALT (SGPT), AST (SGOT), and alkaline phosphatase concentrations have been reported in patients receiving glucocorticoids; these effects are not associated with any clinical syndrome and generally resolve upon discontinuance of glucocorticoid therapy.
Precautions and Contraindications
Prior to initiation of long-term glucocorticoid therapy, baseline ECGs, blood pressures, chest and spinal radiographs, glucose tolerance tests, and evaluations of HPA-axis function should be performed on all patients. Upper GI radiographs should be performed in patients predisposed to GI disorders, including those with known or suspected peptic ulcer disease. During long-term therapy, periodic height, weight, chest and spinal radiographs, hematopoietic, electrolyte, glucose tolerance, and ocular and blood pressure evaluations should be performed.
Patients receiving glucocorticoids should be instructed to notify their physicians of any infections, signs of infections (e.g., fever, sore throat, pain during urination, muscle aches), or injuries that develop during therapy or within 12 months after therapy is discontinued, so that adjustments in dosage can be made or glucocorticoid therapy reintroduced if necessary. In addition, when surgery is required, patients should be advised to inform the attending physician, dentist, or anesthesiologist that they are receiving or have recently (within 12 months) received glucocorticoids. Patients should carry identification cards listing the diseases for which they are being treated, the glucocorticoid they are receiving and its dosage, and the name and telephone number of their physician. Patients being transferred from systemic corticosteroid to oral inhalation therapy should carry special identification (e.g., card, bracelet) indicating the need for supplementary systemic corticosteroids during periods of stress. Patients receiving orally inhaled glucocorticoid therapy who are currently being withdrawn or who have been withdrawn from systemic corticosteroids should be advised to immediately resume full therapeutic dosages of systemic corticosteroids and to contact their clinician for further instructions during stressful periods (e.g., severe infection, severe asthmatic attack).
Because anaphylactoid reactions have occurred in patients receiving glucocorticoids parenterally, precautionary measures should be taken prior to parenteral administration of the drugs, particularly in patients with history of a drug allergy. Some patients who appear to be hypersensitive to parenteral glucocorticoids may actually be hypersensitive to the paraben preservatives present in some injectable formulations.
Because an apparent association has been suggested between use of corticosteroids and left ventricular free-wall rupture after a recent myocardial infarction, corticosteroids should be used with extreme caution in these patients.
Some commercially available oral preparations of prednisolone, and triamcinolone contain the dye tartrazine (FD&C yellow No. 5), which may cause allergic reactions including bronchial asthma in susceptible individuals. Although the incidence of tartrazine sensitivity is low, it frequently occurs in patients who are sensitive to aspirin.
Some commercially available formulations of dexamethasone, hydrocortisone, and prednisolone contain sulfites that may cause allergic-type reactions, including anaphylaxis and life-threatening or less severe asthmatic episodes, in certain susceptible individuals. The overall prevalence of sulfite sensitivity in the general population is unknown but probably low; such sensitivity appears to occur more frequently in asthmatic than in nonasthmatic individuals.
Glucocorticoids should be used with caution in patients with hypothyroidism or cirrhosis, because such patients often show exaggerated response to the drugs. Glucocorticoids should be used with caution in psychotic patients or patients with hypertension or congestive heart failure.
Corticosteroids should be used with caution in patients with active or latent peptic ulcer, diverticulitis, nonspecific ulcerative colitis (if there is a probability of impending perforation, abscess, or other pyogenic infection), and in those with recent intestinal anastomoses. Manifestations of peritoneal irritation following GI perforation may be minimal or absent in patients receiving glucocorticoids.
Glucocorticoids should be used cautiously in patients with myasthenia gravis, particularly in those receiving anticholinesterase therapy. If possible, anticholinesterase agents should be withdrawn at least 24 hours prior to initiating glucocorticoid therapy. Because cortisone has been reported rarely to increase blood coagulability and to precipitate intravascular thrombosis, thromboembolism, and thrombophlebitis, corticosteroids should be used with caution in patients with thromboembolic disorders. Glucocorticoids should be used with caution in patients with seizure disorders, renal insufficiency, osteoporosis, or herpes simplex infections of the eye; some manufacturers state that glucocorticoids should not be used in patients with active ocular herpes simplex infections. Corneal perforation may occur in patients with ocular herpes simplex infections who are receiving glucocorticoids. Glucocorticoids are not recommended for use in the treatment of optic neuritis as such use may increase the risk of new episodes.
Because glucocorticoids increase susceptibility to and mask symptoms of infection, the drugs should not be used, except in life-threatening situations, in patients with viral infections or bacterial infections not controlled by anti-infectives. Manufacturers state that glucocorticoid oral inhalation therapy should be used with caution, if at all, in patients with untreated systemic fungal, bacterial, viral, or parasitic infections. Patients whose susceptibility to infection is high, such as those receiving glucocorticoids as immunosuppressive therapy, are especially likely to develop secondary infections. Patients receiving glucocorticoids who are potentially immunosuppressed should be warned of the risk of exposure to certain infections (e.g., chickenpox, measles) and of the importance of obtaining medical advice if such exposure occurs. Since glucocorticoid therapy can reactivate tuberculosis, treatment of latent tuberculosis infection should be included in the regimen of patients with a history of active tuberculosis undergoing prolonged glucocorticoid therapy. If glucocorticoids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary. Use of glucocorticoids in patients with active tuberculosis should be restricted to those with fulminating or disseminated tuberculosis in which glucocorticoids are used in conjunction with appropriate antimycobacterial chemotherapy. Manufacturers state that glucocorticoid oral inhalation therapy should be used with caution, if at all, in patients with clinical or asymptomatic Mycobacterium tuberculosis infections of the respiratory tract. Since glucocorticoids can reactivate latent amebiasis, any patient who has been in the tropics or who has unexplained diarrhea should be evaluated for amebiasis to exclude these patients prior to initiating therapy. In the treatment of acute or disseminated tuberculosis, glucocorticoids should only be used as part of a total antituberculosis regimen. Corticosteroids should not be used in patients with cerebral malaria. The manufacturers of methylprednisolone warn that the efficacy of glucocorticoids in the treatment of sepsis syndrome and septic shock has not been established, and that at least one study suggested that such use in certain patients (e.g., those with serum creatinine concentrations exceeding 2 mg/dL at diagnosis and those who develop secondary infections) may be associated with an increased risk of mortality.
Some clinicians state that glucocorticoid oral inhalation therapy probably should be avoided when the risk of activating bronchopulmonary mycoses appears high, as in patients with bronchiectasis or inadequate immunologic responses. Although manufacturers state that glucocorticoids are contraindicated in patients with systemic fungal infections, most authorities believe that glucocorticoid therapy may be initiated in patients with known infections (including those from fungi) if effective specific chemotherapy is administered concomitantly. The manufacturers of methylprednisolone acetate state that although the drug is contraindicated in patients with systemic fungal infections, it may be used as an intra-articular injection for localized joint conditions. In patients with acute infection, methylprednisolone acetate should not be administered intra-articularly, bursally, or into a tendon for local effects.
FDA states that the efficacy and safety of epidural administration of glucocorticoids have not been established, and glucocorticoids are not FDA-labeled for such use. Prior to initiating such therapy, healthcare providers should discuss with patients the potential benefits and risks of epidural glucocorticoid injections and alternative treatments. Epidural administration of glucocorticoids is contraindicated in patients with local or systemic infection; individuals with bleeding disorders or receiving concurrent anticoagulant therapy (e.g., warfarin, heparin, antiplatelet agents); patients with known hypersensitivity to local anesthetic agents, contrast agents, or glucocorticoids; and patients who experienced complications with prior glucocorticoid injections. Epidural glucocorticoid therapy should be used with caution in patients with congestive heart failure or diabetes mellitus. Fluoroscopy (recommended for ensuring proper needle placement) is contraindicated in pregnant women.
IM administration of corticosteroids is contraindicated in patients with idiopathic thrombocytopenic purpura.
Pediatric Precautions
The effects of glucocorticoids on the pathophysiology and course of diseases are considered to be similar in adults and children. Evidence of safety and efficacy for prednisolone in pediatric patients has been provided through studies using the drug in pediatric patients for the treatment of nephrotic syndrome (in patients older than 2 years of age) and aggressive leukemias and lymphomas (in patients older than 1 month of age). However, some of the conclusions of these studies, and evidence of safety and efficacy for other pediatric indications (e.g., severe asthma and wheezing), are based on controlled trials in adults.
The adverse effects of prednisolone in pediatric patients are similar to those in adults. As in adults, periodic evaluations of height, weight, ocular pressure, and blood pressure should be performed in children receiving glucocorticoids. Children, like adults, also should undergo clinical evaluation for the presence of infection, psychosocial disturbances, thromboembolism, peptic ulcers, cataracts, and osteoporosis.
Long-term administration of pharmacologic dosages of glucocorticoids to children should be avoided if possible, since the drugs may retard bone growth when administered by any route. If prolonged therapy is necessary, the growth and development of infants and children should be closely monitored, and the potential effects on growth should be weighed against clinical benefits and the availability of alternative therapy. Most children receiving recommended dosages of inhaled glucocorticoids achieved their predicted adult heights but at a later than normal age, and the potential but small risk of delayed growth is well balanced by the improved health outcomes associated with inhaled glucocorticoid therapy for mild or moderate persistent asthma in such children. Therapy with low-to-medium dose inhaled glucocorticoids is associated with a short-term (first year of treatment) decrease in growth rates (approximately 1 cm), but such effects appear to be temporary and do not predict final adult height. Effects on growth are not likely with inhaled glucocorticoid dosages of up to 200 mcg daily, and HPA-axis suppression is unlikely at dosages of less than 200 mcg daily of budesonide [or its equivalent] daily dosage. Results of controlled longitudinal studies and several cross-sectional studies in children with asthma receiving long-term inhaled glucocorticoid (2–5 years) therapy indicate that bone mineral density was not affected by use of inhaled glucocorticoids. High dosages of inhaled glucocorticoids for prolonged periods of time (e.g., exceeding 1 year), particularly in combination with frequent courses of systemic glucocorticoid therapy may be associated with adverse growth effects and/or reduced bone mineral density. Retardation of bone growth has been observed at low systemic doses of glucocorticoids and in the absence of hypothalamic-pituitary-adrenal (HPA) axis suppression (e.g., as determined by tests of HPA axis function such as cosyntropin stimulation and basal plasma cortisol concentrations). Growth velocity may therefore be a more sensitive indicator of systemic glucocorticoid exposure than some commonly used tests of HPA axis function. In order to minimize the potential effects of glucocorticoids on growth, dosage in children should be titrated to the lowest effective level. Alternate-day therapy minimizes growth suppression and should be instituted if growth suppression occurs.
Glucocorticoid-induced osteoporosis and associated fractures are common in children and adolescents receiving long-term systemic therapy with the drugs since bone turnover is high and the rates of bone formation required to maintain adequate mineralization of the rapidly growing skeleton also are high in this age group. In addition, glucocorticoids by inhibiting bone formation may prevent achievement of peak bone mass during adolescence. The underlying pediatric condition for which glucocorticoids are prescribed also may be associated independently with an increased risk of osteoporosis. Methods for monitoring bone mineralization (e.g., dual-energy x-ray absorptiometry [DXA]) in children and adolescents are similar to those in adults. However, the roles of various preventive or corrective therapies for glucocorticoid-induced bone loss in children currently are not well defined. At this time, the most prudent approach to minimizing the negative effects of glucocorticoids on BMD in children and adolescents is by ensuring that the patients consistently ingest adequate calcium and vitamin D, either through diet or supplementation.
High dosages of glucocorticoids in children may cause acute pancreatitis leading to pancreatic destruction. Children have developed increases in intracranial pressure (pseudotumor cerebri), causing papilledema, oculomotor or abducens nerve paralysis, visual loss, and headache. Pseudotumor cerebri has occurred most frequently following reduction of dosage or a change in the steroid administered.
Some commercially available injections of dexamethasone, hydrocortisone, methylprednisolone, and triamcinolone contain benzyl alcohol as a preservative. Although a causal relationship has not been established, administration of injections preserved with benzyl alcohol has been associated with toxicity in neonates. Toxicity appears to have resulted from administration of large amounts (i.e., 100–400 mg/kg daily) of benzyl alcohol in these neonates. Although manufacturers of some benzyl alcohol-containing injectable glucocorticoids state that these drugs are contraindicated in premature infants and use of drugs preserved with benzyl alcohol should be avoided in neonates whenever possible, the American Academy of Pediatrics states that the presence of small amounts of the preservative in a commercially available injection should not proscribe its use when the medication is indicated in neonates and comparable benzyl alcohol-free preparations are not available.
The safety and efficacy of dexamethasone or other corticosteroids for COVID-19† treatment have not been fully evaluated in pediatric patients. Therefore, caution should be used when extrapolating recommendations for adults with COVID-19 to patients younger than 18 years of age. The NIH COVID-19 Treatment Guidelines Panel recommends use of dexamethasone (see Coronavirus Disease 2019 [COVID-19] under Dosage and Administration: Dosage) for hospitalized pediatric patients with COVID-19 who are receiving high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO); dexamethasone is not routinely recommended for pediatric patients who require only low levels of oxygen support (i.e., nasal cannula only). If dexamethasone is not available, the NIH panel states that alternative corticosteroids such as hydrocortisone, methylprednisolone, or prednisone may be considered. Use of corticosteroids for treatment of severe COVID-19 in pediatric patients who are profoundly immunocompromised has not been evaluated to date and may be harmful; therefore, the NIH panel states that such use should be considered only on a case-by-case basis. IV corticosteroids have been used as first-line therapy in pediatric patients with multisystem inflammatory syndrome in children (MIS-C); however, the NIH panel recommends consultation with a multidisciplinary team when considering and managing immunomodulating therapy for children with this condition. The optimal choice and combination of immunomodulating therapies for children with MIS-C have not been definitely established. Clinicians should consult the most recent NIH COVID-19 treatment guidelines for additional information on the use of corticosteroids in pediatric patients with COVID-19.
Pregnancy and Lactation
Pregnancy
Glucocorticoids may cause fetal damage when administered to pregnant women. One retrospective study of 260 women who received pharmacologic dosages of glucocorticoids during pregnancy revealed 2 instances of cleft palate, 8 stillbirths, 1 spontaneous abortion, and 15 premature births. Another study reported 2 cases of cleft palate in 86 births. Occurrence of cleft palate in these studies is higher than in the general population but could have resulted from the underlying diseases as well as from the steroids. Other fetal abnormalities that have been reported following glucocorticoid administration in pregnant women include hydrocephalus and gastroschisis. Women should be instructed to inform their physicians if they become or wish to become pregnant while receiving glucocorticoids. If glucocorticoids must be used during pregnancy or if the patient becomes pregnant while taking one of these drugs, the potential risks should be carefully considered.
In a retrospective study of 260 women, administration of glucocorticoids throughout pregnancy has been reported to precipitate adrenal crisis in one neonate, but in other studies there was no evidence of this. Infants born to women who receive glucocorticoids during pregnancy should be carefully monitored for symptoms of adrenal insufficiency and appropriate therapy begun immediately if such symptoms appear.
Lactation
Corticosteroids may be distributed into milk and could suppress growth, interfere with endogenous glucocorticoid production, or cause other adverse effects in nursing infants. Since adequate reproductive studies have not been performed in humans with glucocorticoids, these drugs should be administered to nursing mothers only if the benefits of therapy are judged to outweigh the potential risks to the infant.
Drug Interactions
Drugs Affecting Hepatic Microsomal Enzymes
Metabolism of certain glucocorticoids is mediated by the cytochrome P-450 (CYP) isoenzyme 3A4, and the possibility exists that drugs that induce, inhibit, or compete for this isoenzyme may alter metabolism and clearance of glucocorticoids. Conversely, some glucocorticoids (e.g. betamethasone) inhibit the action of CYP3A4, and some glucocorticoids (e.g., dexamethasone) induce CYP3A4. These glucocorticoids may alter the metabolism of drugs metabolized by CYP3A4.
Cyclosporine
Concomitant administration of prednisolone and cyclosporine may result in decreased plasma clearance of prednisolone, and plasma concentrations of cyclosporine may be increased during concomitant therapy with methylprednisolone. In addition, seizures reportedly have occurred in adult and pediatric patients receiving high-dose glucocorticoid therapy concurrently with cyclosporine. The mechanism of this interaction may involve competitive inhibition of hepatic microsomal enzymes. The potential drug interaction between cyclosporine and prednisolone or methylprednisolone and the possibility of exacerbated toxicity, as well as the need for appropriate dosage adjustment, should be considered when these drugs are administered concomitantly.
Other Drugs
Drugs that induce cytochrome P-450 (CYP) isoenzyme 3A4 (e. g., barbiturates, phenytoin, rifampin, ephedrine, carbamazepine) may enhance metabolism of, and reduce, glucocorticoid concentrations. Dosage of glucocorticoids given in combination with such cytochrome P-450 inducers may need to be increased to achieve the desired response. Conversely, concomitant administration of certain glucocorticoids with drugs that inhibit CYP3A4 (e.g., macrolide antibiotics, ketoconazole) may decrease glucocorticoid clearance; dosage of glucocorticoids given in combination with cytochrome P-450 inhibitors may need to be decreased to avoid potential adverse effects.
Antidiabetic Therapy
Because glucocorticoids may increase blood glucose concentrations, patients with diabetes mellitus receiving concurrent insulin and/or oral hypoglycemic agents may require adjustments in the dosage of such therapy.
Estrogens
Estrogens may potentiate effects of hydrocortisone, possibly by increasing the concentration of transcortin and thus decreasing the amount of hydrocortisone available to be metabolized. Effects of other glucocorticoids that bind to transcortin could be similarly potentiated and dosage adjustments may be required if estrogens are added to or withdrawn from a stable dosage regimen.
Nonsteroidal Anti-inflammatory Agents
Concomitant administration of ulcerogenic drugs such as indomethacin during corticosteroid therapy may increase the risk of GI ulceration. Aspirin should be used cautiously in conjunction with glucocorticoids in patients with hypoprothrombinemia. Although concomitant therapy with salicylates and corticosteroids does not appear to increase the incidence or severity of GI ulceration, the possibility of this effect should be considered.
Serum salicylate concentrations may decrease when corticosteroids are administered concomitantly. Likewise, when corticosteroids are discontinued in patients receiving salicylates, serum salicylate concentration may increase; salicylate intoxication has been precipitated rarely. Several mechanisms may be involved in this interaction. In one study in healthy individuals and in patients with polyarthritis who received both drugs concomitantly, corticosteroids increased the renal clearance of salicylate, possibly by increasing glomerular filtration rate. Corticosteroids may also induce the metabolism of salicylate. Salicylates and corticosteroids should be used concurrently with caution. Patients receiving both drugs should be observed closely for adverse effects of either drug. It may be necessary to increase salicylate dosage when corticosteroids are administered concurrently or decrease salicylate dosage when corticosteroids are discontinued in patients receiving salicylates.
In one study in patients with rheumatoid arthritis, concomitant administration of indomethacin and prednisolone resulted in increased plasma concentrations of free prednisolone; total plasma prednisolone concentrations were unchanged. It was suggested that indomethacin may have a steroid-sparing effect.
Potassium-depleting Drugs
Potassium-depleting diuretics (e.g., thiazides, furosemide, ethacrynic acid) and other drugs that deplete potassium, such as amphotericin B, may enhance the potassium-wasting effect of glucocorticoids. Serum potassium should be closely monitored in patients receiving glucocorticoids and potassium-depleting drugs.
Vaccines and Toxoids
Because corticosteroids inhibit antibody response, the drugs may cause a diminished response to toxoids and live or inactivated vaccines. In addition, corticosteroids may potentiate replication of some organisms contained in live, attenuated vaccines and supraphysiologic dosages of the drugs can aggravate neurologic reactions to some vaccines. Routine administration of vaccines or toxoids should generally be deferred until corticosteroid therapy is discontinued. Administration of live virus or live, attenuated vaccines, including smallpox vaccine, is contraindicated in patients receiving immunosuppressive dosages of glucocorticoids. In addition, if inactivated vaccines are administered to such patients, expected serum antibody response may not be obtained. The Advisory Committee on Immunization Practices (ACIP) states that administration of live virus vaccines usually is not contraindicated in patients receiving corticosteroid therapy as short-term (less than 2 weeks) treatment, in low to moderate dosages, as long-term alternate-day treatment with short-acting preparations, in maintenance physiologic dosages (replacement therapy), or if corticosteroids are administered topically, ophthalmically, intra-articularly, bursally, or into a tendon. If immunization is necessary in a patient receiving corticosteroid therapy, serologic testing may be needed to ensure adequate antibody response and additional doses of the vaccine or toxoid may be necessary. Immunization procedures may be undertaken in patients receiving nonimmunosuppressive doses of glucocorticoids or in patients receiving glucocorticoids as replacement therapy (e.g., Addison’s disease). For specific information on administration of vaccines or toxoids in patients receiving corticosteroids, see the individual monographs in 80:00.
Oral Anticoagulants
The effect of glucocorticoids on oral anticoagulant therapy is variable, and the efficacy of oral anticoagulants has been reported to be enhanced or diminished with concomitant glucocorticoid administration. Patients receiving glucocorticoids and oral anticoagulants concomitantly should be monitored (e.g., using coagulation indices) in order to maintain desired anticoagulant effect.
Laboratory Test Interferences
Glucocorticoids may decrease iodine 131 uptake and protein-bound iodine concentrations, making it difficult to monitor the therapeutic response of patients receiving the drugs for thyroiditis. Glucocorticoids may produce false-negative results in the nitroblue tetrazolium test for systemic bacterial infection. Glucocorticoids may suppress reactions to skin tests. Phenytoin interferes with dexamethasone suppression tests.
Pharmacology
Pharmacology of the corticosteroids is complex and the drugs affect almost all body systems. Maximum pharmacologic activity lags behind peak blood concentrations, suggesting that most effects of the drugs result from modification of enzyme activity rather than from direct actions by the drugs.
Aldosterone is a naturally occurring mineralocorticoid, and it affects electrolyte and fluid balance by acting on the distal renal tubule to promote sodium reabsorption and potassium and hydrogen excretion. Although glomerular filtration rate is also increased which promotes sodium excretion, the net effect is almost always sodium retention with resultant edema and hypertension. The naturally occurring glucocorticoids, hydrocortisone (cortisol) and cortisone, have some mineralocorticoid activity in addition to their glucocorticoid activity. Synthetic glucocorticoids also exhibit some degree of mineralocorticoid activity, especially with prolonged, high-dose therapy. Fludrocortisone has extremely potent mineralocorticoid properties and is only used for this purpose; prednisone and prednisolone have approximately half the mineralocorticoid activity of hydrocortisone and cortisone; and betamethasone, dexamethasone, meprednisone (no longer commercially available in the US), methylprednisolone, and triamcinolone have relatively little mineralocorticoid activity.
In physiologic doses (see General Dosage under Dosage and Administration: Dosage), corticosteroids are administered to replace deficient endogenous hormones. In larger (pharmacologic) doses, glucocorticoids decrease inflammation by stabilizing leukocyte lysosomal membranes, preventing release of destructive acid hydrolases from leukocytes; inhibiting macrophage accumulation in inflamed areas; reducing leukocyte adhesion to capillary endothelium; reducing capillary wall permeability and edema formation; decreasing complement components; antagonizing histamine activity and release of kinin from substrates; reducing fibroblast proliferation, collagen deposition, and subsequent scar tissue formation; and possibly by other mechanisms as yet unknown. The drugs suppress the immune response by reducing activity and volume of the lymphatic system, producing lymphocytopenia, decreasing immunoglobulin and complement concentrations, decreasing passage of immune complexes through basement membranes, and possibly by depressing reactivity of tissue to antigen-antibody interactions. Glucocorticoids stimulate erythroid cells of bone marrow, prolong survival time of erythrocytes and platelets, and produce neutrophilia and eosinopenia. Glucocorticoids promote gluconeogenesis, redistribution of fat from peripheral to central areas of the body, and protein catabolism, which results in negative nitrogen balance. They reduce intestinal absorption and increase renal excretion of calcium.
In pharmacologic doses, systemically administered glucocorticoids suppress release of corticotropin (adrenocorticotropic hormone, ACTH) from the pituitary; thus the adrenal cortex ceases secretion of endogenous corticosteroids (secondary adrenocortical insufficiency). The degree and duration of hypothalamic-pituitary-adrenal (HPA) axis suppression produced by the drugs is highly variable among patients and depends on the dose, frequency and time of administration, and duration of glucocorticoid therapy. If suppressive doses of glucocorticoids are administered for prolonged periods, the adrenal cortex atrophies and patients develop cushingoid (hypercorticism) features and respond to stress like patients with primary adrenocortical insufficiency (Addison’s disease, hypocorticism). (See Cautions: Adrenocortical Insufficiency.)
The duration of anti-inflammatory activity of glucocorticoids approximately equals the duration of HPA-axis suppression. In one study, the duration of HPA-axis suppression after a single oral dose of glucocorticoids was as follows:
|
Drug |
Duration of Suppression |
|---|---|
|
Hydrocortisone 250 mg |
1.25–1.5 days |
|
Cortisone 250 mg |
1.25–1.5 days |
|
Methylprednisolone 40 mg |
1.25–1.5 days |
|
Prednisone 50 mg |
1.25–1.5 days |
|
Prednisolone 50 mg |
1.25–1.5 days |
|
Triamcinolone 40 mg |
2.25 days |
|
Dexamethasone 5 mg |
2.75 days |
|
Betamethasone 6 mg |
3.25 days |
Following IM administration of a single dose of 40–80 mg of triamcinolone acetonide, 50 mg of triamcinolone diacetate, 9 mg of betamethasone sodium phosphate and betamethasone acetate suspension, or 40–80 mg of methylprednisolone, the duration of HPA suppression is 2–4 weeks, 1 week, 1 week, and 4–8 days, respectively. Suppression of the HPA axis below the normal clinical range did not occur when beclomethasone dipropionate was administered by oral inhalation in dosages up to and including 640 mcg daily; however, a dose-dependent reduction of adrenal cortisol production was observed. Since inhaled beclomethasone dipropionate is absorbed into circulation and can be systemically active, HPA axis suppression could occur when recommended dosages are exceeded or in particularly sensitive individuals. With recommended dosages of triamcinolone acetonide administered by oral inhalation, suppression of the HPA axis has occurred within 6–12 weeks in some patients.
In a comparative pharmacodynamic study in healthy geriatric individuals (65–89 years of age) and in younger adults (23–34 years of age), geriatric individuals receiving a single dose of IV prednisolone (0.8 mg/kg, no longer commercially available in the US) or oral prednisone (0.8 mg/kg) exhibited a higher area under the concentration-time curve (AUC) for cortisol than that observed in younger adults. Increased cortisol concentrations in geriatric patients may be the result of attenuated suppression of endogenous cortisol or decreased hepatic clearance of cortisol compared with younger adults.
The mechanism of antiemetic action of corticosteroids remains to be established.
Corticosteroids General Statement Pharmacokinetics
Absorption
Most glucocorticoids appear to be readily absorbed when administered orally as free alcohols, ketones, cypionates, or acetates. Following IM administration, absorption of the water-soluble sodium phosphate and sodium succinate salts is rapid; the rate of absorption of the lipid-soluble acetate and acetonide esters is much slower. Following intra-articular administration of betamethasone sodium phosphate and betamethasone acetate injectable suspension, systemic absorption of the soluble portion (betamethasone sodium phosphate) is rapid. When the most rapid onset of action is desired, a water-soluble glucocorticoid ester should be administered IV. Systemic absorption occurs slowly following intra-articular, intrabursal, intrasynovial, intradermal, or soft tissue injection of most glucocorticoids.
Following oral inhalation, glucocorticoids are absorbed from the GI and respiratory tracts. After oral inhalation of beclomethasone dipropionate given via metered-dose aerosol with a tetrafluoroethane (non-CFC) propellant, most of the dose (e.g., 51–60% is deposited in the respiratory tract; approximately 27–33% of a dose is deposited in the oropharynx. Systemic bioavailability of fluticasone propionate is about 30 or 13.5% following oral inhalation of the aerosol (via metered spray) or of the powder (via the Diskhaler device, no longer commercially available in the US), respectively. Systemic bioavailability of budesonide is about 39% in healthy individuals following oral inhalation of the powder (via the Turbuhaler device) and about 6% in asthmatic children (4–6 years of age) following administration of the micronized suspension for nebulization (via jet nebulizer). Following oral inhalation of 320 mcg of flunisolide, the oral bioavailability is less than 7%. Absolute (compared with IV administration) bioavailability of orally inhaled mometasone furoate as a powder averaged less than 1%. Bioavailability following oral administration of fluticasone propionate is negligible (less than 1%), principally because of incomplete absorption and presystemic metabolism of the drug. Systemic bioavailability of a single orally ingested dose of budesonide is higher in patients with Crohn’s disease (21%) than in healthy individuals (about 9%); however, bioavailabilities approach those of healthy individuals following multiple dosing.
Prednisolone sodium phosphate orally disintegrating tablets and solution are bioequivalent based on comparison of area under the plasma concentration-time curves (AUCs) and peak plasma concentrations of the 2 formulations.
Results of a pharmacokinetic study in healthy geriatric adults and younger adults (23–34 years of age) receiving a single IV dose of prednisolone (0.8 mg/kg, no longer commercially available in the US) or oral dose of prednisone (0.8 mg/kg) indicate that the plasma prednisolone concentrations and AUCs of total and unbound prednisolone in geriatric adults are higher than that reported in younger adults. (See Pharmacokinetics: Elimination.)
Normal endogenous plasma concentrations of cortisol and cortisone are 4–30 mcg/dL and 1–2 mcg/dL, respectively.
Distribution
Animal studies indicate that most glucocorticoids are rapidly removed from the blood and distributed to muscles, liver, skin, intestines, and kidneys.
Glucocorticoids vary in the extent to which they are bound to plasma proteins. Cortisol (hydrocortisone) is extensively bound to corticosteroid-binding globulin (transcortin) and albumin, which are plasma proteins. With physiologic concentrations, cortisol is bound primarily to transcortin and only 5–10% of cortisol in plasma is unbound and is biologically active. Prednisolone (unlike other synthetic glucocorticoids such as betamethasone, dexamethasone, or triamcinolone) has a high affinity for transcortin and competes with cortisol for this binding protein. Results of a pharmacokinetic study in healthy geriatric adults and younger adults (23-34 years of age) receiving a single IV dose of prednisolone (0.8 mg/kg, no longer commercially available in the US) or oral dose of prednisone (0.8 mg/kg) indicate that the mean unbound fraction of prednisolone was higher, and the steady-state volume of distribution of unbound prednisolone was reduced in geriatric adults compared with younger adults. Because only unbound drug is pharmacologically active, patients with low serum albumin concentrations may be more susceptible to effects of glucocorticoids than patients with normal serum albumin concentrations.
Glucocorticoids cross the placenta and may be distributed into milk.
Elimination
Glucocorticoids having a ketone group at C-11 (e.g., cortisone, prednisone) must be reduced (primarily in the liver) to their corresponding 11-hydroxy analogs (hydrocortisone, prednisolone, and meprednisolone) in order to be pharmacologically active. Prednisone is rapidly converted to prednisolone, but much of cortisone is inactivated before it can be converted to hydrocortisone.
Pharmacologically active glucocorticoids are metabolized in most tissues, but primarily in the liver, to biologically inactive compounds. The metabolic clearance of hydrocortisone may be decreased in patients with hypothyroidism and increased in those with hyperthyroidism. Changes in thyroid status may necessitate adjustment of glucocorticoid dosage. The metabolic clearance of prednisolone is impaired in geriatric patients (as evidenced by a reduced fractional urinary clearance of 6β-hydroxyprednisolone) compared with younger adults. Inactive metabolites are excreted by the kidneys, primarily as glucuronides and sulfates, but also as unconjugated products. Small amounts of unmetabolized drugs are also excreted in urine. Negligible amounts of most of the drugs are excreted in bile; enterohepatic circulation does not occur.
Chemistry
Corticosteroids are hormones secreted by the adrenal cortex or synthetic analogs of these hormones. Traditionally, corticosteroids have been classified as mineralocorticoids or glucocorticoids based on their primary pharmacologic activity; however, separation of the drugs into these classes is not absolute. (See Pharmacology.) Of the corticosteroids that are used clinically, beclomethasone, betamethasone, budesonide, cortisone, dexamethasone, flunisolide, fluticasone, hydrocortisone, methylprednisolone, prednisolone, prednisone, and triamcinolone are classified as glucocorticoids. Although fludrocortisone is also a glucocorticoid, it has very potent mineralocorticoid properties and is used for its mineralocorticoid effects.
Related Monographs
For further information on chemistry and stability, uses, cautions, and dosage and administration of corticosteroids, see the individual monographs in 68:04.
AHFS DI Essentials™. © Copyright 2025, Selected Revisions February 27, 2023. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
† Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration.