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Rational Use of Steroids

This document discusses the rational use of steroids, specifically glucocorticoids. It provides examples of irrational steroid use and proposes more rational regimens. It classifies steroids by biological half-life and lists preferred steroids and dosing regimens for different indications like deficiency syndromes, immunosuppression, and HPA axis suppression. The document argues that intermittent high doses of steroids can cause HPA axis suppression and salt/water retention, and proposes lower daily or alternate day doses as more rational regimens.

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Prayoga Sirait
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127 views

Rational Use of Steroids

This document discusses the rational use of steroids, specifically glucocorticoids. It provides examples of irrational steroid use and proposes more rational regimens. It classifies steroids by biological half-life and lists preferred steroids and dosing regimens for different indications like deficiency syndromes, immunosuppression, and HPA axis suppression. The document argues that intermittent high doses of steroids can cause HPA axis suppression and salt/water retention, and proposes lower daily or alternate day doses as more rational regimens.

Uploaded by

Prayoga Sirait
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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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 Cortisone


8-12 hrs Hydrocortisone (Cortisol)
Intermediate acting Fludrocortisone
12-36 hrs Prednisone
Prednisolone
Methylprednisolone
Long acting Triamcinolone
36-72 hrs Dexamethasone
Betamethasone
Steroids – Classification
Glucocorticoid Mineralocorticoid
activity 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 Dose for, in mg/ day
corticoid
activity
Addisonian syndrome / Immuno
HPA axis suppression 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 Preferred indication


ralo-

Short Cortisol 1 1 For deficiency syndromes.


acting
Cortisone 0.8 0.8
Inter- Prednisone 4 0.8 For immunosupression
mediate
Prednisolone 4 0.8
Methylprednisolone 5 0.5
Long Dexamethasone 25 0 For HPA axis suppression, no
acting
risk of salt & water retention.
Betamethasone 25 0
Glucocorticoids – Dosing regimen

Preferred indication Dosing regimen


Cortisol For deficiency 10 mg PO, at 8 AM & 2 PM
syndromes.
Cortisone
Prednisone For immunosupression, 20 mg & upwards, at 8 AM
minimal risk of HPA daily/ on alternate days
Prednisolone
axis suppression.
Methylprednisolone

Dexamethasone For HPA axis 1-2 mg at bed time


suppression, no risk of
Betamethasone
salt & water retention.
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.

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