How to master Steroid (glucocorticoids) prescription, different scenarios, case based approach Ahmed Yehia Ismaeel, MD Beni-Suef

1. How to master
Steroid prescription,
different scenarios,
case-based approach
Ahmed Yehia, MD, Internal Medicine
(Immunology, Allergy & Rheumatology)
Beni-Suef

2. ‫تعا‬
‫ر‬
‫ف‬

3. ‫تعارف؟‬
!
‫بتهزر؟‬ ‫أنت‬
‫الكورتيزون؟‬ ‫يعرف‬ ‫ال‬ ‫من‬ ‫و‬
‫بصمة‬ ‫له‬ ‫التخصصات‬ ‫كل‬ ‫في‬
(
‫سلبي‬ ‫أو‬ ‫إيجابية‬
‫ة‬
)
‫األمراض‬ ‫معظم‬ ‫في‬
‫والضيق‬ ‫الزنقة‬ ‫وقت‬ ‫في‬ ‫الصديق‬

‫م‬ ‫يتعامل‬ ‫أو‬ ‫الكورتيزون‬ ‫يكتب‬ ‫لم‬ ‫منا‬ ‫ومن‬
‫عه؟‬

4. • A 30-year-old lady presented to me
with unilateral hip pain & limping.
• On probing, she admitted taking
steroids for > 1 year to gain weight.
• What is the likely hip pathology?
• How to assess?

6. Femoral head
avascular
necrosis

7. Corticosteroid-induced avascular
bone necrosis (aseptic bone
necrosis)

8. If the cause is unknown, give cortisone.
‫كده‬ ‫عشان‬ ‫إيه‬ ‫عندك‬ ‫أنت‬ ‫عارف‬ ‫مش‬ ‫أنا‬
‫هاكتب‬
‫كورتيزون‬ ‫لك‬
.

9. ‫المواطن‬
‫المصري‬
‫األصيل‬
‫ورأيه‬
‫في‬
‫الكورتيزون‬
‫مهما‬
‫كان‬
‫عليل‬

10. ‫إال‬
‫الكورتيزووووون‬
!!!
‫عمة‬ ‫بنت‬ ‫جوز‬ ‫أن‬ ‫بتقول‬ ‫جارتنا‬ ‫أحمد‬ ‫أم‬
‫فمات‬ ‫الكورتيزون‬ ‫خد‬ ‫خالتها‬ ‫خالة‬
!!!

11. !!!!!!!!!!
‫هل‬ ‫دكتور‬ ‫يا‬ ‫طيب‬
‫مشاكل؟‬ ‫يعمل‬ ‫ممكن‬

12. Glucocorticoids (GC) adverse effects
High doses of
glucocorticoids for a
few days
• can be administered
with little risk.
Chronic therapy
• Glucocorticoids
cannot be given
chronically without
the risk of adverse
effects.

13. ‫هل‬ ‫دكتور‬ ‫يا‬ ‫طيب‬
‫مشاكل؟‬ ‫يعمل‬ ‫ممكن‬
Glucocorticoids cannot be
given chronically without the
risk of adverse effects.

14. ‫دكتو‬ ‫يا‬ ‫أقلقتني‬
‫ر‬
!!
‫ما‬
‫تقلقش‬
.
‫ما‬ ‫طول‬
‫هنلتزم‬
‫الس‬ ‫بكلمة‬
‫ر‬
‫الصح‬ ‫االستعمال‬ ‫مع‬
.

15. ‫هي؟‬ ‫إيه‬
!
Monitoring.

16. Case
A 42-year-old female
with systemic lupus
erythematosus (SLE)
was prescribed
prednisolone 10 mg.
How to monitor
steroids for bone
adverse effects (AE)?

17. ACR GIOP Recommendations

19. https://www.
fraxplus.org/
calculation-
tool

20. Steroid
use
Pharmacologic (usually
supraphysiologic) doses
Inflammatory
disorders
Allergic
disorders
immunological
disorders
Physiologic replacement doses
treatment of adrenal insufficiency using

22. Let’s start our journey.
Case for discussion
• A 75 years old female patient presents with
acute severe headache, scalp tenderness, jaw
& tongue claudication & diplopia. The patient
also has bilateral shoulder & hip pain &
stiffness.
• What is the best next step?

23. • ESR, CRP
• Temporal artery
ultrasound
• Eye examination

24. ESR: 1st H.: 80 mm
CRP: +ve, 96 mg/dl
Temporal artery ultrasound?
Eye examination?
What is the expected cause of bilateral
shoulder & hip pain & stiffness?

26. Eye
AION
Non-
arteritic
DM,HTN,…
Arteitic
GCA

27. Temporal
artery biopsy?
Treatment?

29. High dose oral steroids.
What is the dose?
Which preparation?

30. What is low-dose, medium-dose & high-dose
daily prednisone therapy?
Very high dose >100 mg/day.
High dose ≥40 mg/day to 100 mg/day (2 mg/kg/day in children).
Medium dose 7.5 mg/day to <40 mg/day.
Low dose ≤7.5 mg/day.

31. When to give the
steroid dose?
Because natural
cortisol secretion has
a circadian rhythm
with the peak in the
morning, taking the
CS before ~ 10:00
am will result in less
suppression of the
hypothalamic–
pituitary–adrenal
(HPA) axis. When
taking CS long term
this probably is less
important.

32. What are the
most commonly
used oral steroid
preparations?

33. Which is better?

34. • Most commercially available prednisone &
prednisolone preparations appear to be
bioequivalent.

35. Liver (Hepatic)
Cortisone
Cortisol
Biologically
inactive

36. • So, patients with severe liver disease may have
difficulty converting prednisone to prednisolone;
in such patients, it is possible that one might not
get the same effect from prednisone as from
prednisolone.
• Certain drug interactions can affect the
metabolism & bioavailability of prednisone. As an
example, barbiturates, phenytoin, or rifampin
attenuate the biologic effects of GCs by enhancing
their metabolism

37. While the patient is on 40 mg prednisone, she
developed vomiting & diarrhea with fever &
she can’t take her steroid. How can you
manage this situation?
• Treat the gastroenteritis as appropriate.
• Shift to IV steroids.
• Which preparation? What is the dose?

38. IV steroid

39. Should we decrease the
dose due to infection?
Doses need to be
increased at times of
serious intercurrent
illness (defined as
presence of a fever),
accident & stress.
Double doses should
be taken during
these periods.

40. IV steroid
So, what is the dose?

41. Steroid dose
equivalent

42. Prednisolone 5 mg tab.
Dexamethasone
8 mg ampoule
≈ 10.5 tabs
Hydrocortisone
(Solu-Cortef) 100
mg vial
= 5 tabs
Depo-Medrol 40
mg vial
= 10 tabs
Solu-Medrol
1000 mg vial
= 250 tabs

43. • Potent synthetic glucocorticoids(eg, prednisone,
methylprednisolone, & dexamethasone) have little
mineralocorticoid, androgenic, or estrogenic activity.
• As a result, the major systemic side effects are those of suppression
of hypothalamic-pituitary-adrenal (HPA) function and Cushing's
syndrome. The time required to develop these complications
depends upon the dose and duration oftherapy and varies among
patients, probably because of differences in their rates of
glucocorticoid metabolism.

44. The mode of action of GCs
Genomic
• interactions between
the glucocorticoid
receptor & genomic
DNA
Nongenomic
• in high dosages.

45. Now after 1 month, the patient started
to feel better. How will you proceed?
• Follow up ESR  60 mm
• Follow up CRP  5 mg/dl
–Which one to follow: ESR or CRP?

46. After normalization of symptoms, ESR & CRP (usually takes
1 month) on prednisone at 30 mg twice a day,
The following tapering schedule can be tried:
• Taper the dose by 5 mg /1 to 2 weeks to 30 mg/day.
• -- the dose by 2.5 mg /1 to 2 weeks to 15 mg once a day.
• Further taper the dose by 2.5 mg /4 weeks to 10 mg daily.
• Decrease the dose by 1 mg /4 weeks until the patient is
off prednisone.
Clinical symptoms and CRP should be monitored for every
taper in dose. Spontaneous recurrences occur in up
to 50% of cases. Up to 40% of patients (especially women)
need corticosteroid therapy for years.

47. Tapering
• Steroid sparing

48. • While on 40 mg prednisolone, the patient
developed epigastric pain & nausea, so he
stopped the treatment till he meets you the
next week. 3 days later, he developed severe
vomiting, asthenia, you found BP to be 80/40.
RPG: 48mg/dl.
• How to proceed?

49. Addisonian crisis
IV hydrocortisone
IN normal saline
IV dextrose

50. • After 3 months off steroids which she had
taken for 2 years, the patient developed a
picture of typical appendicitis, the
surgeon consults you for any
precautions for surgery?

51. Any patient who:
1. is Cushingoid in appearance,
2. has received > 20 mg of daily prednisone for > a month in
the preceding year,
3. or has been on > 3 to 5 mg for
> a year
should be considered to have a
potentially suppressed HPA axis.

52. Full recovery of the HPA axis may take
• 6 to 9 months after stopping GC therapy. The
responsiveness of the adrenal gland to stress
can be tested with a short ACTH (Cortrosyn)
stimulation test.

53. • Any patient who was on long term
steroids if faced with stress should
receive stress dose steroids during the
12 months after steroid withdrawal or
do ACTH stimulation test.

54. Case
A 25 years old
female patient
presenting with
severe hypotension.
What is the best
steroid in acute
hypotension in the
ED?

55. ‫وإمكانياته‬ ‫سالحك‬ ‫اعرف‬
.

56. Mineralocorticoid Properties of
Glucocorticoid Preparations

57. What about chronic hypotension?

58. Case
A 30 years old female patient with lupus nephritis class II,
proteinuria 700 mg, arthritis was admitted & the resident
consulted you to give pulse Solumedrol 1 gm IV for 3 days.
What is your opinion?

59. EULAR recommendations for the management of
systemic lupus erythematosus: 2023
1. Hydroxychloroquine is recommended for all patients
(1b/A), unless contraindicated, at a target dose of 5
mg/kg real body weight/day (2b/B) but individualised
based on risk for flare (2b/B) and retinal toxicity.
2. Glucocorticoids, if needed, are dosed based on the
type & severity of organ involvement (2b/C).

60. • She is well-controlled on HCQ 400 mg daily &
prednisolone 15 mg daily.
• How to manage her GC dose?
• Withdraw.

61. ‫أوقف‬ ‫ممكن‬ ‫هل‬
‫يا‬ ‫الكورتيزون‬
‫دكتور؟‬
?????
She is still in remission while withdrawing
prednisolone to 2.5 mg daily.

62. EULAR recommendations for the management of
systemic lupus erythematosus: 2023
2. Glucocorticoids, if needed, are
dosed based on the type &
severity of organ involvement
(2b/C) & should be reduced to
maintenance dose of ≤5 mg/day
(prednisone equivalent) (2a/B) &,
when possible, withdrawn.

63. New target
Remission
on-steroid
Remission
off-steroid

64. EULAR recommendations for the management of
systemic lupus erythematosus: 2023
In patients with moderate-to-severe disease, pulses of intravenous
methylprednisolone (125–1000 mg/day, for 1–3 days) (3b/C) can be
considered.
3. In patients not responding to hydroxychloroquine (alone or in
combination with glucocorticoids) or patients unable to reduce
glucocorticoids below doses acceptable for chronic use, addition of
immunomodulating/immunosuppressive agents (eg, methotrexate (1b/B),
azathioprine (2b/C) or mycophenolate (2a/B)) and/or biological agents (eg,
belimumab (1a/A) or anifrolumab (1a/A)) should be considered.

65. While in remission,
she developed
generalized
puffiness & HTN.
Urine: glomerular
hematuria &protein
++++
Urine protein
creatinine ratio
4000 mg/gm.
S. creatinine rises
rapidly over days: 1
 1.5  2  2.3
mg/dl.
What to do? Renal biopsy.

66. EULAR recommendations for the management
of
systemic lupus erythematosus: 2023
In patients with moderate-to-
severe disease, pulses of
intravenous methylprednisolone
(125–1000 mg/day, for 1–3 days)
(3b/C) can be considered.

67. EULAR recommendations for the management
of
systemic lupus erythematosus: 2023
8. Patients with active proliferative lupus nephritis
should receive low-dose (EuroLupus) IV
cyclophosphamide (1a/A) or mycophenolate (1a/A) &
GCs (pulses of IV methylprednisolone followed by
lower oral doses); combination therapy with
belimumab (either with cyclophosphamide or
mycophenolate (1b/A)) or calcineurin inhibitors
(especially voclosporin or tacrolimus, combined with
mycophenolate, 1b/A) should be considered.

68. Case
• A 22-year-old female with SLE presents with
flare of skin disease while on
hydroxychloroquine 400 mg daily. No other
organ is affected now.
• How to manage?

69. EULAR recommendations for the management
of
systemic lupus erythematosus: 2023
5. Treatment of active skin disease should include
topical agents (glucocorticoids, calcineurin inhibitors)
(2b/B), antimalarials (hydroxychloroquine, chloroquine)
(1a/A), &/or systemic
glucocorticoids (4/C) as needed.

70. Her skin didn’t improve on topical
treatment & HCQ 400 mg daily,
so, we added 10 mg prednisolone
daily & she improved but she
relapses with any trial of
prednisolone withdrawal.
How to manage?

71. EULAR recommendations for the management
of
systemic lupus erythematosus: 2023
3. In patients not responding to HCQ (alone or in
combination with GCs) or patients unable to reduce GCs
below doses acceptable for chronic use,
addition of immunomodulating/immunosuppressive
agents (eg, methotrexate (1b/B), azathioprine (2b/C) or
mycophenolate (2a/B)) &/or biological agents (eg,
belimumab (1a/A) or anifrolumab (1a/A)) should be
considered.

72. EULAR recommendations for the management
of
systemic lupus erythematosus: 2023
5. Treatment of active skin disease should include
topical agents (glucocorticoids, calcineurin inhibitors)
(2b/B), antimalarials (hydroxychloroquine, chloroquine)
(1a/A), and/or systemic glucocorticoids (4/C) as needed,
with methotrexate (1b/B), mycophenolate (4/C),
anifrolumab (1a/A), or belimumab (1a/B) considered
as second-line therapy.

73. A
steroid
sparing
drug While steroids are effective in rapidly
suppressing inflammation, their long-
term use can lead to various side effects
A medication used to treat chronic
inflammatory conditions while aiming to
reduce the reliance
on glucocorticoid
use or
minimize the
dosage needed.

74. DMARDs Usual Time to Effect
• as early as 4 to 6 weeks
MTX
• relatively rapid within 4-8 weeks
Leflunamide
• It may take 6 weeks to 3 months to see the
effects.
Sulfasalazine
• 2 to 4 months is usual. Most agree that if no
response after 5-6 months, consider HCQ failure.
Hydroxychloroquine
• rapid onset of action sometimes with
improvements seen within 2 to 4 weeks
TNF inhibitors
Why not to use the steroid sparing alone from the start?

75. Case
A 30 years old male patient with
lupus nephritis class II,
proteinuria 700 mg, arthritis
presented for severe flare of RT
knee arthritis & the resident
consulted you to give pulse
Solumedrol 1 gm IV for 3 days.
What is your
opinion?
What do you
recommend
considering that
he is diabetic?

76. Synovial fluid analysis
for 3 C
• TLC 250
• Culture: negative.
– Pain and effusion
persisted.
– What will you do?

77. ‫أستخدم‬ ‫ليه‬
systemic
‫أستخدم‬ ‫ممكن‬ ‫لما‬
local
‫؟؟؟‬
!!!!

78. EULAR recommendations for the management of SLE
2023

79. Does local steroid injection
affect diabetes mellitus control?
• A steroid produces a hyperglycemic
effect that lasts for at least 5 days
after a local injection. Check the
patient’s blood glucose/ 4 to 6 hours
& adjust the doses as needed for 5 to
7 days postinjection.

80. Case
A 20-year-old RA patient on MTX 25 mg
weekly presented with moderate
disease activity with tender joint count 6
& swollen joint count 5.
She has no poor prognostic factors.
How to manage?

82. • 6. Short-term glucocorticoids should be considered when initiating
or changing csDMARDs, in different dose regimens & routes of
administration, but should be tapered & discontinued as rapidly as
clinically feasible. (1a A 9.3±1.2 92)

83. Low dose
glucocorticoids
<7.5 mg/day prednisone
equivalent
Short-term
Up to 3 months

84. Initiation of a csDMARD without short-term (<3 months) GCs is
conditionally recommended over initiation of a csDMARD with short-
term GCs for DMARD-naïve patients with moderate-to- high disease
activity.
Initiation of a csDMARD without longer term (≥3
months) GCs is strongly recommended over initiation of
a csDMARD with longer-term GCs for DMARD-naïve
patients with moderate-to-high disease activity

85. Case
A 20-year-old RA patient on
MTX 25 mg weekly presented
with low disease activity with
only right wrist tender hot red
swelling. CRP: 48 mg/l.
She has no poor
prognostic factors.
How to manage?

86. • Intralesional & intra-
articular injections of a
glucocorticoid can be very
effective & the risk of
causing a local bacterial
infection is very low.

87. • An ICU patient with
lymphoma on
chemotherapy on NPO (nil
per os) complains of severe
left big toe pain for 6 hours.
During examination, he was
found to have podagra and
serum urate 11 mg/dl. How
to manage him?
IV glucocorticoid
IM glucocorticoids
Intra-articular glucocorticoids
Arthrocentesis only with fluid analysis

88. •An ICU patient on NPO (nil
per os) complains of
severe left knee pain for 6
hours. During
examination, he was found
to have acute
monoarthritis & serum
urate 8 mg/dl. How to
manage his arthritis?
IV glucocorticoid
IM glucocorticoids
Intra-articular glucocorticoids
Arthrocentesis only with fluid analysis

89. Acute monoarthritis is septic until
proven otherwise.
Cells (WBCs)
Culture & sensitivity
Crystals by polarized
microscopy
•The 1st step is Arthrocentesis with fluid
analysis for 3C

90. We suggest arthrocentesis &
intraarticular injection of GCs in patients
who (Grade 2C).
are unable to take oral
medications &/or
have only one or two actively
inflamed joints
infection has been excluded.

91. We prefer Triamcinolone acetonide
large joint [eg,
knee]
40mg
medium joint
[eg, wrist, ankle,
elbow]
30 mg
small joint
10 mg
or equivalent doses of methylprednisolone acetate.

92. Case
A 20-year-old SLE patient got
pregnant while on
hydroxychloroquine 300 mg/day,
prednisolone 20 mg /day &
azathioprine 100 mg/day.
She is in remission.
What else to screen for
other than disease
activity?

93. • If SLE or SLE-like disease, SS, SSc, or
RA: Test once (early) for anti-Ro/SSA &
anti-La/SSB. (Strong)

96. • Echocardiography
follow up revealed
fetal 2nd degree
heart block.
• How to manage?

99. Case
A 20-year-old SLE patient got
pregnant while on
hydroxychloroquine 300 mg/day,
prednisolone 20 mg /day &
azathioprine 100 mg/day.
She is in remission.
Anti-Ro, anti-La are
negative.
How to manage?

101. ‫هاعمل‬
‫في‬ ‫إيه‬
‫يا‬ ‫الكورتيزون‬
‫دكتور؟‬
?????
She had a successful pregnancy & delivered a
healthy baby.

102. Low to moderate doses of prednisolone during
pregnancy appear to be safe.

103. Steroid target in pregnancy
• cross the placenta.
Fluorinated
glucocorticoids, such as
dexamethasone &
betamethasone
• largely metabolized before
they reach the fetus.
Low-to-moderate–dose
nonfluorinated
glucocorticoids, such as
prednisone & prednisolone

104. The concept of health care value
clinical
benefit costs & harms
For a given
intervention

105. • The goal of glucocorticoid therapy, as
with any therapy, is to obtain
maximum benefit with minimum
adverse side effects.

107. ‫خيرين‬ ‫دايما‬ ‫مش‬ ‫الخير‬ ‫زيادة‬
.
> +

108. Make sure that punishment fits the crime.

110. Case
• A 40 years old female patient
with ITP resistant to steroids and
is planned for splenectomy.
• Vaccines??

111. • Vaccination against S. pneumoniae, H.
influenzae type b & N. meningitidis,
– ideally at least 2 weeks prior to surgery
• Repeat vaccination against S. pneumoniae/5 y,
annual influenza vaccine
• Education about the risk of postsplenectomy
sepsis.

112. Our GCA patient improved &
discharged with the tapering schedule.
• In one of the follow up visits, the patient
complains of polyurea, polydipsia and
nocturia.
• You request plasma glucose screening.
• FPG: 200 mg/dl
• 2H ppPG: 260 mg/dl.
• What have happened?
• How to proceed?

113. Steroid & DM
• Steroid treatment in people
without pre-existing diabetes may
result in a rise in glucose,
‘steroid-induced diabetes’.

114. It may or may not resolve when
GCs are withdrawn.
Steroid-induced
DM, will it resolve?

115. Steroid & DM
• Steroid treatment in people with pre-existing
diabetes will undoubtedly result in worsening
glucose control, and this may be termed
‘steroid-induced hyperglycaemia’, and will
• warrant temporary additional, and more
active, glycaemic management.

116. Risk of long-term GC AE is dependent
on
Dose Duration

117. A study of 112 patients with
rheumatoid arthritis (RA)
5 to 10
mg/day
• odds ratio
4.5
10 to15
mg/day
• 32.3
There is a clear dose-dependence of AEs
Odds ratio
Data from Saag, KG, Koehnke, R, Caldwell, JR, et al. Am J Med 1994; 96:115.

118. How to decrease this effect?
Alternate
daily dose.
Use only
when highly
indicated.
Use the
lowest dose
for the
shortest
period.
Monitoring..
Monitoring..
Monitoring..

119. Alternate daily dose
Doubling the dosage &
administering the drug every
other day in the morning
more closely mimics the
endogenous corticosteroid
circadian rhythm.
This form of administration
enables the patient to
experience the therapeutic
effects while side effects are
minimized.

120. Relative Potency of Glucocorticoid
Administration Schedules

121. Monitoring..
Monitoring..
Monitoring..

122. Treatment
• PG 130, how to treat?
• PG 190, how to treat?
• PG 230, how to treat?

123. Treatment
• No success without goal.
• Now, the trend in
medicine is T2T.
• Set the goal, then go.

125. Tools to achieve the
goal
• Is it mandatory to use
insulin?

126. The 7 golden rules
1. Prescribe corticosteroids at the lowest possible dose and
discontinue as soon as the disease activity permits.
2. Encourage physical activities and avoid immobilization (helps
prevent myopathy).
3. Implement fall prevention program.
4. Prescribe dietary and supplemental calcium to achieve intake
of 1000-1500 mg/day.
5. Supply vitamin D at a minimum of 1000 international units per
day.
6. Consider bisphosphonate therapy implementation (if >7.5
mg/day for >3 months) particularly if postmenopausal.
(See Chapter 52).
7. Document patient education concerning the adverse effects of
therapy particularly risk of osteonecrosis.

127. Are cushingoid features reversible?

129. Case
• A young male with & recent deep vein
thrombosis with scrotal ulcers but no
oral ulcers.

130. Case
•This 30-year-old lady presents with
recurrent oral ulcers, superficial
thrombophlebitis.
•She was on repeated frequent
doses of oral steroids for her
painful oral ulcers.
•What is your diagnosis?
•What are the labs needed for this
diagnosis confirmation?

131. ‫تعطي‬ ‫ليه‬
systemic
‫تكتب‬ ‫ممكن‬ ‫لما‬
topical
‫؟‬
!!

132. ISG criteria for BD
Required Criteria (Recurrent oral ulcerations observed by
physician or patient, ≥ 3 times in 1 year: (minor or major
aphthous ulcers or herpetiform ulcers))
Minor
Criteria
Recurrent genital ulceration
(aphthous or scarring) observed by
physician or patient
Eye lesions
observed by
physician
Anterior uveitis Posterior uveitis
Cells in vitreous
on slit lamp
exam
Retinal vasculitis
observed by
ophthalmologist
Skin lesions
present
Erythema
nodosum (patient
or physician)
Pseudo folliculitis
(observed by
physician)
Papulopustular
lesions
(observed by
physician)
Acneiform nodules
(observed by
physician)
Positive pathergy
(Behcetine) test
read by physician
within 24-28 hours
1 required criteria
2 minor criteria
Patient meets
diagnostic criteria for
BD with:

133. ICBD
Ocular lesions 2
Genital aphthosis 2
Oral aphthosis 2
Skin lesions 1
Neurological symptoms 1
Vascular manifestations 1
+ve Pathergy test
*
1
*
*Pathergy test is optional, & the primary scoring system does not include pathergy testing. However, where
pathergy testing is conducted one extra point may be assigned for a positive result.
OGO (2) - BPCC (1)

134. ISG criteria for BD
Required Criteria (Recurrent oral ulcerations observed by
physician or patient, ≥ 3 times in 1 year: (minor or major
aphthous ulcers or herpetiform ulcers))
Minor
Criteria
Recurrent genital ulceration
(aphthous or scarring) observed by
physician or patient
Eye lesions
observed by
physician
Anterior uveitis Posterior uveitis
Cells in vitreous
on slit lamp
exam
Retinal vasculitis
observed by
ophthalmologist
Skin lesions
present
Erythema
nodosum (patient
or physician)
Pseudo folliculitis
(observed by
physician)
Papulopustular
lesions
(observed by
physician)
Acneiform nodules
(observed by physician
in post-adolescent
patients not on
steroids)
Positive pathergy
(Behcetine) test
read by physician
within 24-28 hours
1 required criteria
2 minor criteria
Patient meets
diagnostic criteria for
BD with:

135. Steroid
acne
folliculitis

136. Case
•A 10-year-old asthmatic &
allergic rhinitis patient
presented with these oral
white lesions.
•What are important items to
consider in history taking?

137. ICS, systemic GCs or antibiotics
Diabetes Cancer
Human
immunodeficiency
virus (HIV)
Dry mouth Pregnancy
Also, don’t forget.

138. Preventing Oral Thrush
From an Inhaler
Practicing good oral
hygiene is essential
to preventing
thrush.
Rinse your mouth
out with water or
brush your teeth
after every inhaler
use
Brush and floss
regularly
Avoid high sugar
foods or foods that
contain yeast
Stop smoking

140. Case •A 14-year-old female with a
history of comorbid allergic
asthma, eczema &allergic
rhinitis.

141. • The patient is attending the clinic because she has been
experiencing frequent asthma exacerbations. In total, 3
exacerbations in the past year, of which 2 were in the last
6 months. She currently uses rescue medications about 3
to 4 times/week & wakes up due to her asthma at least
once a week.
• Her ICS dose was increased to a medium dose about 10
months ago.
• What is the best next step?

142. Guidelines
for asthma

143. Box 3-12 © Global Initiative for Asthma, www.ginasthma.org
*Anti-inflammatory reliever (AIR)

144. • The patient is attending the clinic because she has been
experiencing frequent asthma exacerbations. In total, 3
exacerbations in the past year, of which 2 were in the last
6 months. She currently uses rescue medications about 3
to 4 times/week & wakes up due to her asthma at least
once a week.
• Her ICS dose was increased to a medium dose about 10
months ago & then a high dose approximately 5
months ago.
• What is the best next step?

145. Box 3-12 © Global Initiative for Asthma, www.ginasthma.org
*Anti-inflammatory reliever (AIR)

146. Box 3-13 © Global Initiative for Asthma, www.ginasthma.org

147. Box 6-6 © Global Initiative for Asthma, www.ginasthma.org

148. Case
• A 13-year-old boy presented with bilateral knee arthritis.
• His physician prescribed him Betafos (Durafos) ampoule.
• The ampoule relieved the symptoms markedly.

150. Case
A 4-year-old girl presents with 2 months history of
bilateral knee & right wrist arthritis.
What’s the best next step?
Put a D.D. to guide diagnosis plan.

151. Is this rheumatic fever? ASOT 600  800
Mostly no, duration, echocardiography: normal
Is this JIA?
JIA is a diagnosis of exclusion.
So, we requested ESR, CRP, ANA (IF) with titre, rheumatoid factor,
TSH, calcium, s. 25 OH vitamin D. All were non-significant.

152. This is
oligoarticular JIA.
How will you
treat?

154. ACR 2019
Polyarticular JIA
recommendations

155. ACR 2019 Recommendations for treatment of children & adolescents
with JIA & sacroiliitis

156. GC AEs
Displeasing to
patients (eg,
Cushingoid
appearance)
Varying
degrees of
morbidity
Life-
threatening
(eg, serious
infections).

157. Accelerated
reductions in
bone mineral
density
Acute vertebral
collapse
Early cataracts
Cataract
requiring
surgical
extraction
Some AEs may be largely asymptomatic until later
manifestations develop that require medical attention

158. ‫عليه‬ ‫علم‬ ‫الكورتيزون‬

160. ‫في‬ ‫الوسط‬ ‫محتاجين‬
‫هذا‬ ‫مع‬ ‫التعامل‬
‫السالح‬
• ‫اإلفراط‬ ‫من‬ ‫فاحذر‬
(
‫التساهل‬
‫داع‬ ‫بال‬ ‫االستعمال‬ ‫في‬
)
‫سحري‬
• ‫التفريط‬ ‫من‬ ‫فاحذر‬
(
‫التخويف‬
‫وجود‬ ‫عند‬ ‫االستعمال‬ ‫من‬
‫داع‬
)
‫قاتل‬

161. No 1 size fits all.
•A good doctor is a good tailor.

162. No 1 size fits
all patients.

163. ‫خيرا‬ ‫هللا‬ ‫جزاكم‬