CONTRA-INDICATIONS, FURTHER INFORMATION
For further information on contra-indications associated
with intra-articular, intradermal and intralesional
preparations, consult product literature.
lCAUTIONSCongestive heart failure.diabetes mellitus
(including a family history of).diverticulitis.epilepsy.
glaucoma (including a family history of or susceptibility
to).history of steroid myopathy.history of tuberculosis or
X-ray changes (frequent monitoring required).
hypertension.hypothyroidism.infection (particularly
untreated).myasthenia gravis.ocular herpes simplex (risk
of corneal perforation).osteoporosis.peptic ulcer.
psychiatric reactions.recent intestinal anastomoses.
recent myocardial infarction (rupture reported).severe
affective disorders (particularly if history of steroid-
induced psychosis).should not be used long-term.
thromboembolic disorders.ulcerative colitis
CAUTIONS, FURTHER INFORMATIONFor further information
on cautions associated with intra-articular, intradermal
and intralesional preparations, consult product literature.
lSIDE-EFFECTS
▶Common or very commonAdrenal suppression.anxiety.
appetite increased.behaviour abnormal.cataract
subcapsular.cognitive impairment.Cushing’s syndrome.
diabetic control impaired.electrolyte imbalance.fluid
retention.gastrointestinal discomfort.glaucoma.
headache.healing impaired.hirsutism.hypertension.
increased risk of infection.leucocytosis.menstrual cycle
irregularities.mood altered.myocardial rupture
(following recent myocardial infarction).nausea.
osteoporosis.peptic ulcer.psychotic disorder.skin
reactions.sleep disorders.telangiectasia.weight
increased
▶UncommonAlkalosis hypokalaemic.bone fractures.
haemorrhage.heart failure.hyperhidrosis.myopathy.
oedema.osteonecrosis.pancreatitis.papilloedema.
seizure.thromboembolism.tuberculosis reactivation.
vertigo.vision blurred
▶Rare or very rareBruising.tendon rupture
▶Frequency not knownChorioretinopathy.eye disorders.
growth retardation.intracranial pressure increased with
papilloedema (usually after withdrawal)
SIDE-EFFECTS, FURTHER INFORMATION
Adrenal suppressionDuring prolonged therapy with
corticosteroids, particularly with systemic use, adrenal
atrophy develops and can persist for years after stopping.
Abrupt withdrawal after a prolonged period can lead to
acute adrenal insufficiency, hypotension, or death. To
compensate for a diminished adrenocortical response
caused by prolonged corticosteroid treatment, any
significant intercurrent illness, trauma, or surgical
procedure requires a temporary increase in corticosteroid
dose, or if already stopped, a temporary reintroduction of
corticosteroid treatment. Patients on long-term
corticosteroid treatment should carry a steroid treatment
card which gives guidance on minimising risk and provides
details of prescriber, drug, dosage and duration of
treatment.
InfectionsProlonged courses of corticosteroids increase
susceptibility to infections and severity of infections;
clinical presentation of infections may also be atypical.
Serious infections e.g. septicaemia and tuberculosis may
reach an advanced stage before being recognised, and
amoebiasis or strongyloidiasis may be activated or
exacerbated (exclude before initiating a corticosteroid in
those at risk or with suggestive symptoms). Fungal or viral
ocular infections may also be exacerbated.
ChickenpoxUnless they have had chickenpox, patients
receiving oral or parenteral corticosteroids for purposes
other than replacement should be regarded as being at risk
of severe chickenpox. Manifestations of fulminant illness
include pneumonia, hepatitis and disseminated
intravascular coagulation; rash is not necessarily a
prominent feature. Passive immunisation with varicella–
zoster immunoglobulin is needed for exposed non–
immune patients receiving systemic corticosteroids or for
those who have used them within the previous 3 months.
Confirmed chickenpox warrants specialist care and urgent
treatment. Corticosteroids should not be stopped and
dosage may need to be increased.
MeaslesPatients taking corticosteroids should be advised
to take particular care to avoid exposure to measles and to
seek immediate medical advice if exposure occurs.
Prophylaxis with intramuscular normal immunoglobulin
may be needed.
Psychiatric reactionsSystemic corticosteroids,
particularly in high doses, are linked to psychiatric
reactions including euphoria, insomnia, irritability, mood
lability, suicidal thoughts, psychotic reactions, and
behavioural disturbances. These reactions frequently
subside on reducing the dose or discontinuing the
corticosteroid but they may also require specific
management. Patients should be advised to seek medical
advice if psychiatric symptoms (especially depression and
suicidal thoughts) occur and they should also be alert to
the rare possibility of such reactions during withdrawal of
corticosteroid treatment. Systemic corticosteroids should
be prescribed with care in those predisposed to psychiatric
reactions, including those who have previously suffered
corticosteroid–induced psychosis, or who have a personal
or family history of psychiatric disorders.
lPREGNANCYThe benefit of treatment with corticosteroids
during pregnancy outweighs the risk. Corticosteroid cover
is required during labour. Following a review of the data on
the safety of systemic corticosteroids used in pregnancy
and breast-feeding the CSM (May 1998 ) concluded that
corticosteroids vary in their ability to cross the placenta
but there is no convincing evidence that systemic
corticosteroids increase the incidence of congenital
abnormalities such as cleft palate or lip. When
administration is prolonged or repeated during pregnancy,
systemic corticosteroids increase the risk of intra-uterine
growth restriction; there is no evidence of intra-uterine
growth restriction following short-term treatment (e.g.
prophylactic treatment for neonatal respiratory distress
syndrome). Any adrenal suppression in the neonate
following prenatal exposure usually resolves
spontaneously after birth and is rarely clinically important.
MonitoringPregnant women withfluid retention should be
monitored closely when given systemic corticosteroids.
lBREAST FEEDINGThe benefit of treatment with
corticosteroids during breast-feeding outweighs the risk.
lHEPATIC IMPAIRMENTThe plasma-drug concentration
may be increased (particularly on systemic use). Oral and
parenteral use should be undertaken with caution.
lRENAL IMPAIRMENTUse by oral and injectable routes
should be undertaken with caution.
lMONITORING REQUIREMENTSThe height and weight of
children receiving prolonged treatment with
corticosteroids should be monitored annually; if growth is
slowed, referral to a paediatrician should be considered.
lEFFECT ON LABORATORY TESTSSuppression of skin test
reactions.
lTREATMENT CESSATIONThe magnitude and speed of dose
reduction in corticosteroid withdrawal should be
determined on a case-by–case basis, taking into
consideration the underlying condition that is being
treated, and individual patient factors such as the
likelihood of relapse and the duration of corticosteroid
treatment.Gradualwithdrawal of systemic corticosteroids
should be considered in those whose disease is unlikely to
relapse and have:BNFC 2018 – 2019 Corticosteroid responsive conditions 437
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