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C H A P T E R 3 6 Adrenocortical agents

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

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 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. cranial pressure. Use in the elderly