C H A P T E R 3 6
Adrenocortical agents
543
Budesonide is a relatively new steroid for intranasal
use.
Cortisone is used orally and parenterally.
Dexamethasone and triamcinolone are available in
multiple forms for dermatological, ophthalmological,
intra-articular, parenteral and inhalational uses. They
peak quickly and effects can last for 2 to 3 days.
Hydrocortisone has largely been replaced for other
uses (e.g. intra-articular, intravenous) by other steroid
hormones with less mineralocorticoid effect. It may be
preferred for use as a topical or ophthalmic agent.
Methylprednisolone is available in multiple forms,
including oral, parenteral, intra-articular and retention
enema preparations.
Prednisolone is an intermediate-acting cortico
steroid with effects lasting only a day or so. It is used
for intralesional and intra-articular injection and is also
available in oral and topical forms.
Prednisone is available only as an oral agent.
Contraindications and cautions
These drugs are contraindicated in the presence of
any known allergy to any steroid preparation
to avoid
hypersensitivity reactions
; in the presence of an acute
infection,
which could become serious or even fatal if
the immune and inflammatory responses are blocked
;
and with breastfeeding
because the anti-inflammatory
and immunosuppressive actions could be passed to the
baby.
Caution should be used in people with diabetes
because the glucose-elevating effects disrupt glucose
control
; with acute peptic ulcers
because steroid use is
associated with the development of ulcers
; with other
endocrine disorders,
which could be sent into imbal-
ance
; and in pregnancy
.
Use in children
Corticosteroids cause growth retardation in infancy,
childhood and adolescence, which may be irreversible
and therefore long-term administration of pharmaco-
logical doses should be avoided. If prolonged therapy is
necessary, treatment should be limited to the minimum
suppression of the hypothalamo-pituitary adrenal axis,
and the growth and development of infants and children
should be closely monitored. Treatment should be
administered where possible as a single dose on altern
ate days.
Children and adolescents should also be closely
monitored for osteoporosis, avascular necrosis of the
femoral heads, glaucoma or cataracts during prolonged
therapy. Children are at special risk from raised intra
cranial pressure.
Use in the elderly
Long-term use in the elderly should be planned bearing
in mind the more serious consequences of the common
side-effects of prednisone in old age, especially osteo
porosis, diabetes, hypertension, hypokalaemia, suscept
ibility to infection and thinning of the skin. Close
medical supervision is required to avoid life threatening
reactions.
Adverse effects
Children are at risk of growth retardation associated
with suppression of the hypothalamic–pituitary system.
Additional adverse effects associated with the gluco-
corticoids are related to the route of administration
that is used. Local use is associated with local inflam-
mations and infections, as well as burning and stinging
sensations.
Clinically important drug–drug interactions
Therapeutic and toxic effects increase if corticosteroids
are given with erythromycin or ketoconazole. Serum
levels and effectiveness may decrease if corticosteroids
are combined with salicylates, barbiturates, phenytoin
or rifampin.
TABLE 36.3
DRUGS IN FOCUS Adrenocortical agents (continued)
Drug name
Dosage/route
Usual indications
Mineralocorticoids (continued)
hydrocortisone
(Solu-Cortef)
Oral, IV, IM, topical, ophthalmic, rectal,
intra-articular
Adult: 20–240 mg/day PO; 100–500 mg IM
or IV q 2–6 hours; 100 mg half-strength by
retention enema; one applicator-full rectal
foam q.i.d. to b.d.; apply topical preparation
sparingly
Paediatric: base dose on response and
severity; 20–240 mg/day PO; 20–240 mg/day
IM or SC; 100 mg half-strength by retention
enema; one applicator-full rectal foam q.i.d. to
b.d.; apply topical preparation sparingly
Used for replacement therapy, treatment
of allergic and inflammatory disorders
