Therapeutic: anti-inflammatories (steroidal)
Used systemically and locally in a wide variety of chronic diseases, including Inflammatory, Allergic, Hematologic, Endocrine, Neoplastic, Dermatologic, and Autoimmune disorders, Management of cerebral edema, Diagnostic agent in adrenal disorders. Unlabeled Use: Short-term administration to high-risk mothers before delivery to prevent respiratory distress syndrome in the newborn. Adjunctive management of nausea and vomiting from chemotherapy. Treatment of airway edema prior to extubation. Used in neonates with bronchopulmonary dysplasia to facilitate ventilator weaning.
In pharmacologic doses, suppresses inflammation and the normal immune response. Has numerous intense metabolic effects (see Adverse Reactions and Side Effects). Suppresses adrenal function at chronic doses of 0.75 mg/day. Has negligible mineralocorticoid activity. Therapeutic Effects: Suppression of inflammation and modification of the normal immune response.
Adverse Reactions/Side Effects
Adverse reactions/side effects are much more common with high-dose/long-term therapy CNS: depression, euphoria, hallucinations, headache, increased intracranial pressure (children only), insomnia, personality changes, psychoses, restlessness. EENT: cataracts, increased intraocular pressure. CV: hypertension, edema. GI: PEPTIC ULCERATION, anorexia, nausea, increased appetite, vomiting. Derm: acne, decreased wound healing, ecchymoses, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E: amenorrhea, hypokalemia, alkalosis. Hemat: THROMBOEMBOLISM, thrombophlebitis. Metab: weight gain. MS: muscle wasting, osteoporosis, aseptic necrosis of joints, muscle pain. Misc: ALLERGIC REACTIONS, cushingoid appearance (moon face, buffalo hump), increased susceptibility to infection.
PHYSICAL THERAPY IMPLICATIONS
Examination and Evaluation
Monitor signs of thrombophlebitis (lower extremity swelling, warmth, erythema, tenderness) and thromboembolism (shortness of breath, chest pain, cough, bloody sputum). Notify physician or nursing staff immediately, and request objective tests (Doppler ultrasound, lung scan, others) if thrombosis is suspected.
Monitor and report signs of peptic ulcer, including heartburn, nausea, vomiting blood, tarry stools, and loss of appetite.
Monitor signs of allergic reactions, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.
Assess any muscle or joint pain. Report persistent or increased musculoskeletal pain to determine presence of bone or joint pathology (aseptic necrosis, fracture).
Assess muscle strength periodically to determine degree of muscle wasting during long-term use.
Measure blood pressure periodically and compare to normal values (See Appendix F). Report a sustained increase in blood pressure (hypertension) to the physician.
Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.
Monitor personality changes, including depression, euphoria, restlessness, hallucinations, and psychosis. Notify physician if these changes become problematic.
Be alert for signs of low potassium levels (hypokalemia) and metabolic acidosis, including hyperventilation, cardiac arrhythmias, dizziness, and confusion. Notify physician immediately if these signs occur.
Report signs of adrenal suppression, including hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, and restlessness.
Monitor signs of hyperglycemia (confusion; drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing; polyuria; loss of appetite; unusual thirst). Insulin dosages may need to be adjusted to prevent repeated episodes of hyperglycemia.
Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight gain or weight loss.
Implement resistive exercises and weight-bearing activities to minimize muscle wasting and osteoporosis. Use caution to prevent musculoskeletal damage in patients with preexisting muscle and bone loss.
Protect skin from breakdown, especially over bony prominences.
Advise patient that wound healing may be delayed; instruct patient to check skin regularly and report any nonhealing sores.
Advise patient that corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.
Advise patients on long-term treatment to consult physician before stopping this medication. Stopping the medication suddenly may result in adrenocortical shock (severe hypotension, hypoglycemia, weakness, vomiting). If these signs appear, notify physician immediately; may be life threatening.
Instruct patient to report any loss of vision that might indicate cataracts or increased intraocular pressure.
Advise patient about possible cushingoid appearance, including puffiness in the face (moon face), increased fat in the torso, thin arms and legs, abdominal skin striations, bruising, and deposition of fat at the posterior base of the neck (buffalo hump). Discuss possible effects on body image, and help patient explore coping mechanisms.
Instruct patient and family/caregivers to report other troublesome side effects such as severe or prolonged headache, menstrual problems, GI reactions (nausea, vomiting, loss of appetite), or skin reactions (acne, hair growth).
Absorption: Well absorbed after oral administration. Sodium phosphate salt is rapidly absorbed after IM administration. Absorption from local sites (intraarticular, intralesional) is slow but complete.
Distribution: Widely distributed, crosses the placenta, and appears to enter breast milk.
Metabolism and Excretion: Mostly metabolized by the liver.
Half-life: Low-birth-weight infants with bronchopulmonary dysplasia (BPD): 9.3 hr; children 3 mo–16 yr: 4.3 hr; Adults: 3–4.5 hr (plasma), 36–54 hr (tissue); adrenal suppression lasts 2.75 days.
TIME/ACTION PROFILE (anti-inflammatory activity)
|ROUTE ||ONSET ||PEAK ||DURATION |
|PO ||unknown ||1–2 hr ||72 hr |
|IM, IV (phosphate) ||Rapid ||unknown ||72 hr |
Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis); Known alcohol or bisulfite hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients); Lactation (avoid chronic use).
Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Stress (surgery, infections); supplemental doses may be needed; Potential infections (may mask signs); OB: Safety not established; Pedi: Early postnatal administration of high doses can cause significant and persistent reductions in neuromotor and cognitive functioning; results in decreased growth; use lowest possible dose for shortest period of time.
Drug-Drug: ↑ risk of hypokalemia with thiazide and loop diuretics, amphotericin B, piperacillin, or ticarcillin. Hypokalemia may ↑ risk of digoxin toxicity. May ↑ requirement for insulin or oral hypoglycemic agents. May ↓ levels of phenytoin and isoniazid. Levels may be ↑ with oral contraceptives. ↑ risk of adverse GI effects with NSAIDs (including aspirin), alcohol, and caffeine. At chronic doses that suppress adrenal function, may ↓ the antibody response to and ↑ risk of adverse reactions from live-virus vaccines. May ↑ or ↓ the effects of warfarin. Levels may be ↓ when used with phenytoin, phenobarbital, or rifampin. May ↑ risk of tendon rupture when used with fluoroquinolones.
PO, IM, IV (Adults): Anti-inflammatory—0.75–9 mg daily in divided doses q 6–12 hr. Airway edema or extubation—0.5–2 mg/kg/day divided q 6 hr; begin 24 hr prior to extubation and continue for 24 hr postextubation. Cerebral edema—10 mg IV, then 4 mg IM or IV q 6 hr until maximal response achieved, then switch to PO regimen and taper over 5–7 days.
PO, IM, IV (Children): Airway edema or extubation—0.5–2 mg/kg/day divided q 6 hr; begin 24 hr prior to extubation and continue for 24 hr postextubation. Anti-inflammatory—-0.08–0.3 mg/kg/day or 2.5–10 mg/m2/day divided q 6–12 hr. Physiologic replacement—0.03–0.15 mg/kg/day or 0.6–0.75 mg/m2/day divided q 6–12 hr.
PO (Adults): Suppression test—1 mg at 11 PM or 0.5 mg q 6 hr for 48 hr.
IV (Children): Chemotherapy induced emesis—5–20 mg given 15–30 min before treatment. Cerebral edema—Loading dose 1–2 mg/kg followed by 1–1.5 mg/kg/day divided q 4–6 hr for 5 days (not to exceed 16 mg/day); then taper over 1–6 wk. Bacterial meningitis—0.6 mg/kg/day divided q 6 hr for 4 days (start at time of first antibiotic dose).
IV, PO (Adults): Chemotherapy induced emesis—10–20 mg given 15–30 min before each treatment or 10 mg q 12 hr on each treatment day. Delayed nausea/vomiting—4–10 mg PO 1–2 times/day for 2–4 days or 8 mg PO q 12 hr for 2 days, then 4 mg PO q 12 hr for 2 days or 20 mg PO 1 hr before chemotherapy, then 10 mg PO q 12 hr after chemotherapy, then 8 mg PO q 12 hr for 2 days, then 4 mg PO q 12 hr for 2 days.
IS (intrasynovial) (Adults): 0.4–6 mg/day.
Availability (generic available)
Tablets: 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg. Elixir (raspberry flavor): 0.5 mg/5 mL. Oral solution (cherry flavor): 0.5 mg/5 mL, 1 mg/mL. Solution for injection (sodium phosphate): 4 mg/mL, 10 mg/mL.