Rational use of Steroids

Sachin Kuchya, MD DNB

Steroids - Introduction

Three classes, • Glucocorticoids – The daily secretion of cortisol

is about 20 mg/ day with diurnal variation, peaks during early morning hrs, lowest during late evening hrs. Also exert feedback inhibition on HPA axis, maximal inhibition during late evening hours

• Mineralocorticoids – for salt & water balance

• Sex steroids – for reproductive function

IRRATIONAL USE ?

• Glucocorticoids – most common.

Example 1

• Methylprednisolone 4 mg / Prednisolone 4 mg / Dexamethasone 0.5 –1.0 – 2 mg three times daily for treating an episode of Asthma exacerbation / attack of Gouty arthritis.

Why Irrational – Inadequate Immunosupression & risk of HPA axis suppression

Example 2

• IV Hydrocortisone 100 – 200 mg every 6 hourly / IV Methyl prednisolone 40 – 125 mg every 8 hourly for status asthmaticus (even included in some guidelines)

Why Irrational –Risk of salt & water retention ( greater with hydrocortisone) & risk of HPA axis suppression

Steroids – Classification(on the basis of biological half lives)

Short acting

8-12 hrs

Cortisone

Hydrocortisone (Cortisol)

Intermediate acting

12-36 hrs

Fludrocortisone

Prednisone

Prednisolone

Methylprednisolone

Long acting

36-72 hrs

Triamcinolone

Dexamethasone

Betamethasone

Steroids – Classification

Glucocorticoid activity

Mineralocorticoid activity

Short acting Cortisol 1 1

Cortisone 0.8 0.8

Fludrocortisone 10 125

Intermediate Prednisone 4 0.8

Prednisolone 4 0.8

Methylprednisolone 5 0.5

Long acting Triamcinolone 5 0

Dexamethasone 25 0

Betamethasone 25 0

Glucocorticoids - Indications

• As hormone replacement therapy – in deficiency syndromes like Addisonian states ( physiological replacement doses)

• For HPA axis suppression, in Congenital Adrenal Hyperplasia (physiological doses are sufficient)

• Anti Inflammatory activity / Immunosuppressive action (5- 20 times of physiological doses)

Glucocorticoid - Doses

Glucocorticoid activity

Dose for, in mg/ day

Addisonian syndrome / HPA axis suppression

Immunosuppression

Cortisol 1 20 100- 400

Cortisone 0.8 25

Prednisone 4 5 20-100

Prednisolone 4 5 20-100

Methylprednisolone 5 4 16 - 1000

Triamcinolone 5 4

Dexamethasone 25 1.0 4- 16

Betamethasone 25 1.0 4- 16

Glucocorticoid – Preferred ones

Gluco- Mineralo-

Preferred indication

Short acting

Cortisol 1 1 For deficiency syndromes.

Cortisone 0.8 0.8

Inter-mediate

Prednisone 4 0.8 For immunosupression

Prednisolone 4 0.8

Methylprednisolone 5 0.5

Long acting

Dexamethasone 25 0 For HPA axis suppression, no risk of salt & water retention.

Betamethasone 25 0

Glucocorticoids – Dosing regimen

Preferred indication Dosing regimen

Cortisol For deficiency syndromes.

10 mg PO, at 8 AM & 2 PM

Cortisone

Prednisone For immunosupression, minimal risk of HPA axis suppression.

20 mg & upwards, at 8 AM daily/ on alternate days

Prednisolone

Methylprednisolone

Dexamethasone For HPA axis suppression, no risk of salt & water retention.

1-2 mg at bed time

Betamethasone

Rational use…. Example 1

Methylprednisolone 4 mg / Prednisolone 4 mg / Dexamethasone 0.5 – 2 mg three times daily for treating an episode of Asthma exacerbation / attack of Gouty arthritis.

The rational regimen for treating an episode of Asthma exacerbation / attack of Gouty arthritis - Methylprednisolone 16 - 32 mg / Prednisolone 20 - 60 mg once daily / on alternate days, repeated at 8 AM in the morning.

Rational use….. Example 2

IV Hydrocortisone 100 – 200 mg every 6 hourly / IV Methyl prednisolone 40 – 125 mg every 8 hourly for status asthmaticus (even included in some guidelines)

The rational regimen for status asthmaticus – IV Methylprednisolone 125 – 1000mg stat followed by oral regimen stated above (example 1), once the condition settles down.

Benefit of RUD - Glucocorticoids

Better immunosupression in patients with Br Asthma / RA / without any HPA axis inhibition

Adequate inhibition of HPA axis in patients with Congenital Adrenal Hyperplasia, without salt & water overloading.

Thank you, wish to have your views & comments.

Based on Goodman & Lawrence.