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.