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Rational+use+of+steroids (1) Rational+use+of+steroids (1) Presentation Transcript

  • 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 Gluco corticoid activity Dose for, in mg/ day Addisonian syndrome / HPA axis suppression Immuno suppression 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- Mine ralo- 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.