hydrocortisone p. 440 can be used in septic shock that is
resistant to volume expansion and catecholamines, and is
accompanied by suspected or proven adrenal insufficiency.
The suppressive action of glucocorticoids on the
hypothalamic-pituitary-adrenal axis is greatest and most
prolonged when they are given at night. In most adults a
single dose of dexamethasone p. 439 at night is sufficient to
inhibit corticotropin secretion for 24 hours. This is the basis
of the‘overnight dexamethasone suppression test’for
diagnosing Cushing’s syndrome.
Betamethasone p. 438 and dexamethasone are also
appropriate for conditions where water retention would be a
disadvantage.
A corticosteroid may be used in the management of raised
intracranial pressure or cerebral oedema that occurs as a
result of malignancy (see Prescribing in palliative care p. 20 );
high doses of betamethasone or dexamethasone are
generally used. However, a corticosteroid shouldnotbe used
for the management of head injury or stroke because it is
unlikely to be of benefit and may even be harmful.
In acute hypersensitivity reactions, such as angioedema of
the upper respiratory tract and anaphylaxis, corticosteroids
are indicated as an adjunct to emergency treatment with
adrenaline/epinephrine p. 136. In such cases hydrocortisone
(as sodium succinate) by intravenous injection may be
required.
In the management of asthma, corticosteroids are
preferably used by inhalation but systemic therapy along
with bronchodilators is required for the emergency
treatment of severe acute asthma.
Betamethasone is used in women at risk of preterm
delivery to reduce the incidence of neonatal respiratory
distress syndrome [unlicensed use].
Dexamethasone should not be used routinely for the
prophylaxis and treatment of chronic lung disease in
neonates because of an association with adverse
neurological effects.
Corticosteroids may be useful in conditions such as auto-
immune hepatitis, rheumatoid arthritis, and sarcoidosis;
they may also lead to remissions of acquired haemolytic
anaemia and thrombocytopenic purpura.
High doses of a corticosteroid (usually prednisolone
p. 442 ) are used in the treatment ofglomerular kidney disease,
includingnephrotic syndrome. The condition frequently
recurs; a corticosteroid given in high doses and for
prolonged periods may delay relapse but the higher
incidence of adverse effects limits the overall benefit. Those
who suffer frequent relapses may be treated with
prednisolone given in a low dose (daily or on alternate days)
for 3 – 6 months; the dose should be adjusted to minimise
effects on growth and development. Other drugs used in the
treatment of glomerular kidney disease include levamisole
p. 383 , cyclophosphamide p. 535 , chlorambucil p. 534 , and
ciclosporin p. 519 .Congenital nephrotic syndromemay be
resistant to corticosteroids and immunosuppressants;
indometacin and an ACE inhibitor such as captopril p. 112
have been used.
Corticosteroids can improve the prognosis of serious
conditions such as systemic lupus erythematosus and
polyarteritis nodosa; the effects of the disease process may
be suppressed and symptoms relieved, but the underlying
condition is not cured, although it may ultimately remit. It is
usual to begin therapy in these conditions at fairly high dose
and then to reduce the dose to the lowest commensurate
with disease control.
For other references to the use of corticosteroids see:
Prescribing in Palliative Care, immunosuppression,
rheumatic diseases, eye, otitis externa, allergic rhinitis, and
aphthous ulcers.
Side-effects
MHRA/CHM advice: Corticosteroids: rare risk of central
serous chorioretinopathy with local as well as systemic
administration (August 2017)
Central serous chorioretinopathy is a retinal disorder that
has been linked to the systemic use of corticosteroids.
Recently, it has also been reported after local administration
of corticosteroids via inhaled and intranasal, epidural, intra-
articular, topical dermal, and periocular routes. The MHRA
recommends that patients should be advised to report any
blurred vision or other visual disturbances with
corticosteroid treatment given by any route; consider
referral to an ophthalmologist for evaluation of possible
causes if a patient presents with vision problems.
Overdosage or prolonged use can exaggerate some of the
normal physiological actions of corticosteroids leading to
mineralocorticoid and glucocorticoid side-effects.Mineralocorticoid side effects
.hypertension
.sodium retention
.water retention
.potassium loss
.calcium loss
Mineralocorticoid side effects are most marked with
fludrocortisone acetate, but are significant with
hydrocortisone, corticotropin, and tetracosactide.
Mineralocorticoid actions are negligible with the high
potency glucocorticoids, betamethasone and
dexamethasone, and occur only slightly with
methylprednisolone, prednisolone, and triamcinolone.Glucocorticoid side effects
.diabetes
.osteoporosis
.in addition high doses are associated with avascular
necrosis of the femoral head.
.Muscle wasting (proximal myopathy) can also occur.
.Corticosteroid therapy is also weakly linked with peptic
ulceration and perforation.
.Psychiatric reactions may also occur.
Managing side-effects
Side-effects can be minimised by using lowest effective dose
for minimum period possible. The suppressive action of a
corticosteroid on cortisol secretion is least when it is given as
a single dose in the morning. In an attempt to reduce
pituitary-adrenal suppression further, the total dose for two
days can sometimes be taken as a single dose on alternate
days; alternate-day administration has not been very
successful in the management of asthma. Pituitary-adrenal
suppression can also be reduced by means of intermittent
therapy with short courses. In some conditions it may be
possible to reduce the dose of corticosteroid by adding a
small dose of an immunosuppressive drug.
Whenever possiblelocal treatmentwith creams, intra-
articular injections, inhalations, eye-drops, or enemas
should be used in preference tosystemic treatment.
Inhaled corticosteroids have considerably fewer systemic
effects than oral corticosteroids, but adverse effects
including adrenal suppression have been reported. Use of
other corticosteroid therapy (including topical) or
concurrent use of drugs which inhibit corticosteroid
metabolism should be taken into account when assessing
systemic risk. In children, growth restriction associated with
systemic corticosteroid therapy does not seem to occur with
recommended doses of inhaled therapy; although initial
growth velocity may be reduced, there appears to be no
effect on achieving normal adult height. Large-volume
spacer devices should be used for administering inhaled
corticosteroids in children under 15 years; they are also
useful in older children and adults, particularly if high dosesBNFC 2018 – 2019 Corticosteroid responsive conditions 435
Endocrine system6