are required. Spacer devices increase airway deposition and
reduce oropharyngeal deposition.Corticosteroids, replacement
therapy
Overview
The adrenal cortex normally secretes hydrocortisone
(cortisol) which has glucocorticoid activity and weak
mineralocorticoid activity. It also secretes the
mineralocorticoid aldosterone.
In deficiency states, physiological replacement is best
achieved with a combination of hydrocortisone p. 440 and
the mineralocorticoidfludrocortisone acetate p. 440 ;
hydrocortisone alone does not usually provide sufficient
mineralocorticoid activity for complete replacement.
InAddison’s diseaseor following adrenalectomy,
hydrocortisone by mouth is usually required. This is given in
2 – 3 divided doses, the larger in the morning and the smaller
in the evening, mimicking the normal diurnal rhythm of
cortisol secretion. The optimum daily dose is determined on
the basis of clinical response. Glucocorticoid therapy is
supplemented byfludrocortisone acetate.
Inacute adrenocortical insufficiency, hydrocortisone is
given intravenously (preferably as sodium succinate) every
6 to 8 hours in sodium chloride intravenous infusion 0. 9 %.
Inhypopituitarism, glucocorticoids should be given as in
adrenocortical insufficiency, but since production of
aldosterone is also regulated by the renin-angiotensin
system a mineralocorticoid is not usually required.
Additional replacement therapy with levothyroxine sodium
p. 485 and sex hormones should be given as indicated by the
pattern of hormone deficiency.
Incongenital adrenal hyperplasia, the pituitary gland
increases production of corticotropin to compensate for
reduced formation of cortisol; this results in excessive
adrenal androgen production. Treatment is aimed at
suppressing corticotropin using hydrocortisone. Careful and
continual dose titration is required to avoid growth
retardation and toxicity; for this reason potent, synthetic
glucocorticoids such as dexamethasone are usually reserved
for use in adolescents. The dose is adjusted according to
clinical response and measurement of adrenal androgens
and 17 -hydroxyprogesterone. Salt-losing forms of
congenital adrenal hyperplasia (where there is a lack of
aldosterone production) also require mineralocorticoid
replacement and salt supplementation (particularly in early
life). The dose of mineralocorticoid is adjusted according to
electrolyte concentration and plasma-renin activity.Glucocorticoid therapy
Glucocorticoid and mineralocorticoid activity
In comparing the relative potencies of corticosteroids in
terms of their anti-inflammatory (glucocorticoid) effects it
should be borne in mind that high glucocorticoid activity in
itself is of no advantage unless it is accompanied by
relatively low mineralocorticoid activity (see Disadvantages
of Corticosteroids). The mineralocorticoid activity of
fludrocortisone acetate p. 440 is so high that its anti-
inflammatory activity is of no clinical relevance.Equivalent anti-inflammatory doses
of corticosteroidsThis table takes no account of mineralocorticoid effects, nor
does it take account of variations in duration of action
Prednisolone 1 mg : Betamethasone 150 micrograms
: Deflazacort 1. 2 mg
: Dexamethasone 150 micrograms
: Hydrocortisone 4 mg
: Methylprednisolone 800 micrograms
: Triamcinolone 800 microgramsThe relatively high mineralocorticoid activity of
hydrocortisone p. 440 , and the resultingfluid retention,
makes it unsuitable for disease suppression on a long-term
basis. However, hydrocortisone can be used for adrenal
replacement therapy. Hydrocortisone is used on a short-term
basis by intravenous injection for the emergency
management of some conditions. The relatively moderate
anti-inflammatory potency of hydrocortisone also makes it a
useful topical corticosteroid for the management of
inflammatory skin conditions because side-effects (both
topical and systemic) are less marked.
Prednisolone p. 442 has predominantly glucocorticoid
activity and is the corticosteroid most commonly used by
mouth for long-term disease suppression.
Betamethasone p. 438 and dexamethasone p. 439 have
very high glucocorticoid activity in conjunction with
insignificant mineralocorticoid activity. This makes them
particularly suitable for high-dose therapy in conditions
wherefluid retention would be a disadvantage.
Betamethasone and dexamethasone also have a long
duration of action and this, coupled with their lack of
mineralocorticoid action makes them particularly suitable
for conditions which require suppression of corticotropin
(corticotrophin) secretion.
Some esters of betamethasone and of beclometasone
dipropionate p. 160 (beclomethasone) exert a considerably
more marked topical effect (e.g. on the skin or the lungs)
than when given by mouth; use is made of this to obtain
topical effects whilst minimising systemic side-effects (e.g.
for skin applications and asthma inhalations).
Deflazacort p. 438 has a high glucocorticoid activity; it is
derived from prednisolone.Corticosteroids (systemic) f
IMPORTANT SAFETY INFORMATION
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.lCONTRA-INDICATIONSAvoid injections containing benzyl
alcohol in neonates.avoid live virus vaccines in those
receiving immunosuppressive doses (serum antibody
response diminished).systemic infection (unless specific
therapy given)436 Corticosteroid responsive conditions BNFC 2018 – 2019
Endocrine system6