1. Rational use of Steroids
Sachin Kuchya, MD DNB

2. 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

3. IRRATIONAL USE ?
• Glucocorticoids – most common.

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. Thank you, wish to have your
views & comments.
Based on Goodman & Lawrence.