Injections with any pathogen viral, bacterial, fungal, protozoan, or helminthic in any location of the body may be associated with the use of corticosteroids alone or in combination with other immunosuppressive agents.
These infections may be mild, but can be severe and at times fatal. With increasing doses of corticosteroids, the rate of occurrence of infections complications increases.
Corticosteroids may also mask some signs of current infection. Do not use intra-articularly, intrabursally or for intratendinous administration for local effect in the presence of acute local infection.
A study has failed to establish the efficacy of methylprednisolone sodium succinate in the treatment of sepsis syndrome and septic shock. The study also suggests that treatment of these conditions with methylprednisolone sodium succinate may increase the risk of mortality in certain patients i.
Corticosteroids may exacerbate systemic fungal infections and therefore should not be used in the presence of such infections unless they are needed to control drug reactions.
Special pathogens. Latent disease may be activated or there may be an exacerbation in intercurrent infections due to pathogens, including those caused by Amoebe, Candida, Cryptococcus, Myobacterium, Nocardia, Pneumocystis, Toxoplasma. It is recommended that latent amebiasis or active amebiasis be ruled out before initiating corticosteroid therapy in any patient who has spent time in the tropics or in any patient with unexplained diarrhea.
Similarly, corticosteroids should be used with great care in patients with known or suspected Strongyloides threadworm infestation. In such patients, corticosteroid-induced immunosuppression may lead to Stronglyoides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia. Corticosteroids should not be used in cerebral malaria.
There is currently no evidence of benefit from steroids in this condition. The use of corticosteroids in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for the management of the disease in conjunction with appropriate antituberculous regimen. If corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary as reactivation of the disease may occur.
During prolonged corticosteroid therapy, these patients should receive chemoprophylaxis. Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids. Killed or inactivated vaccines may be administered. However, the response to such vaccines can not be predicted. Immunization precedures may be undertaken in patients receiving corticosteroids as replacement therapy, e.
Chicken pox and measles can have a more serious or even fatal course in pediatric and adult patients on corticosteroids. In pediatric and adult patients who have not had these diseases, particular care should be taken to avoid exposure. If exposed to chicken pox, prophylaxis with varicella zoster immune globulin VZIG may be indicated. If exposed to measles, prophylaxis with immunoglobulin IG may be indicated.
If chicken pox develops, treatment with antiviral agents should be considered. Use of corticosteroids may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves, and may enhance the establishment of secondary ocular infections due to bacteria, fungi, or viruses.
The use of oral corticosteroids is not recommended in the treatment of potic neuritis and may lead to an increase in the risk of new episodes. Corticosteroids should be used cautionsly in patients with ocular herpes simplex because of corneal perforation.
Corticosteroids should not be used in active ocular herpes simplex. This product, like many other steroid formulations, is sensitive to heat. Therefore, it should not be autoclaved when it is desirable to sterilize the exterior of the vial. The lowest possible dose of corticosteroid should be used to control the condition under treatment.
When reduction in dosage is possible, the reduction should be gradual. Discontinuation of corticosteroids may result in clinical improvement. As sodium retention with resultant edema and potassium loss may occur in patients receiving corticosteroids, these agents should be used with caution in patients with congestive heart failure, hypertension, or renal insufficiency.
Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. Metabolic clearance of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients.
Changes in thyroid status of the patient may necessitate adjustment in dosage. Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses and nonspecific ulcerative colitis, since they may increase the risk of a perforation.
Sings of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent. There is an enhanced effect due to decreased metabolism of corticosteroids in patients with cirrhosis. Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation i. This, together with a decrease in the protein matrix of the bone secondary to an increase in protein catabolism, and reduced sex hormone production, may lead to inhibition of bone growth in pediatric patients and the development of osteoporosis at any age.
Special consideration should be given to patients at increased risk of osteoporosis i. Although controlled clinical trials have shown corticosteroids to be effective in speeding the resolution of acute exacerbations of multiple sclerosis, they do not show that corticosteroids affect the ultimate outcome or natural history of the disease. The studies do show that relatively high doses of corticosteroids are necessary to demonstrate a significant effect.
An acute myopathy has been observed with the use of high doses of corticosteroids, most often occurring in patients with disorders of neuromuscular transmission e.
This acute myopathy is generalized, may involve ocular and respiratory muscles, and may result in quadriparesis. Elevations of creatine kinase may occur. Clinical improvement or recovery after stopping corticosteroids may require weeks to years. Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations.
Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids. Intraocular pressure may become elevated in some individuals. If steroid therapy is continued for more than 6 weeks, intraocular pressure should be monitored.
Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision, to advise any medical attendants that they are taking corticosteroids, and to seek medical advice at once should they develop fever or other signs of infection.
Persons who are on corticosteroids should be warned to avoid exposure to chicken pox or measles. Patients should also be advised that if they are exposed, medical advice should be sought without delay. Aminoglutethimide : Aminoglutethimide may lead to a loss of corticosteroid-induced adrenal suppression. Amphotericin B injection and potassium-depleting agents : When corticosteroids are administered concomitantly with potassium-depleting agents i.
There have been cases reported in which concomitant use of amphotericin B and hydrocortisone was followed by cardiac enlargement and congestive heart failure. Antibiotics : Macrolide antibiotics have been reported to cause a significant decrease in corticosteroid clearance see Drug Interactions , Hepatic Enzyme Inhibitors. Anticholinesterases : Concomitant use of anticholinesterase agents and corticosteroids may produce sever weakness in patients with myasthenia gravis.
If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy.
Anticoagulants, oral : Coadministration of corticosteroids and warfarin usually results in inhibition of response to warfarin, although there have been some conflicting reports. Therefore, coagulation indices should be monitored frequently to maintain the desired anticoagulant effect.
Antidiabetics : Because corticosteroids may increase blood glucose concentrations, dosage adjustments of antidiabetic agents may be required. Antitubercular drugs : Serum concentrations of isoniazid may be decreased. Cholestyramine : Cholestyramine may increase the clearance of corticosteroids.
Cyclosporine : Increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently. Convulsions have been reported with this concurrent use. Digitalis glycosides : Patients on digitalis glycosides may be at increased risk of arrhythmias due to hypokalemia. Estrogens, including oral contraceptives : Estrogens may decrease to hepatic metabolism of certain corticosteroids, thereby increasing their effect.
Hepatic Enzyme Inducers e. Hepatic Enzyme Inhibitors e. Nonsteroidal anti-inflammatory agents NSAIDS : Concomitant use of aspirin or other nonsteroidal anti-inflammatory agents and corticosteroids increases the risk of gastrointestinal side effects. Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. The clearance of salicylates may be increased with concurrent use of corticosteroids.
Vaccines : Patients on prolonged corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response. Corticosteroids may also potentiate the replication of some organisms contained in live attenuated vaccines. No adequate studies have been conducted in animals to determine whether corticosteroids have a potential for carcinogenesis or mutagenesis.
Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose. Avoid abrupt cessation. Use lowest effective dose. Pregnancy Cat. Nursing mothers: not recommended. Potentiated by CYP3A4 inhibitors eg, ketoconazole, macrolides , cyclosporine, estrogens. Antagonized by CYP3A4 inducers eg, barbiturates, phenytoin, carbamazepine, rifampin , cholestyramine. May potentiate cyclosporine seizure risk. May antagonize oral anticoagulants monitor , isoniazid.
Increased risk of arrhythmias with digitalis. May need to adjust dose of antidiabetic agents. Monitor for hypokalemia with potassium-depleting drugs eg, amphotericin B, diuretics. Concomitant neuromuscular blocking agents; increased risk of myopathy.
Withdraw anticholinesterase agents at least 24hrs before initiating corticosteroid therapy. Aminoglutethimide may lead to loss of corticosteroid-induced adrenal suppression. Caution with aspirin in hypoprothrombinemia. May suppress reactions to skin tests. HPA axis suppression, increased susceptibility to infection, glaucoma, cataracts, secondary infections, hypokalemia, hypocalcemia, hypernatremia, hypertension, CHF, psychic disorders, myopathy, osteoporosis, peptic ulcer, dermal atrophy, increased intracranial pressure, carbohydrate intolerance.
If you need to take IV methylprednisolone or oral prednisone on an ongoing basis, the long-term side effects of corticosteroids include but are not limited to weight gain, acne, thinning of skin, stretch marks, elevated blood sugar, elevated cholesterol, peptic ulcers, cataracts, glaucoma, weight gain, decreased bone density, increased risk of osteonecrosis of the bone, growth suppression, muscle wasting, and increased susceptibility to infection. Tell your rheumatology provider if you are concerned you may be experiencing any side effects, or if you develop a fever or any new symptoms after starting this medication, as it may cause an increased risk for infection.
If you miss a scheduled infusion, notify your rheumatology provider. Talk to your rheumatology provider about which vaccines are appropriate for you. If you are pregnant or are considering pregnancy, discuss this with your rheumatology provider before starting medication. This patient fact sheet is provided for general education only.
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