Corticosteroid Therapy

Corticosteroid Therapy

Corticosteroids are used extensively for adrenal insufficiency and are also widely used in suppressing inflammation and auto-immune reactions, controlling allergic reactions, and reducing the rejection process in transplantation. Commonly used cor-ticosteroid preparations are listed in Table 42-4. Their anti-inflammatory and antiallergy actions make corticosteroids effec-tive in treating rheumatic or connective tissue diseases, such as rheumatoid arthritis and systemic lupus erythematosus. They are also frequently used in the treatment of asthma, multiple sclero-sis, and other autoimmune disorders.

High doses appear to allow patients to tolerate high degrees of stress. Such antistress action may be caused by the ability of cor-ticosteroids to aid circulating vasopressor substances in keeping the blood pressure elevated; other effects, such as maintenance of the serum glucose level, also may keep blood pressure elevated.

SIDE EFFECTS

Although the synthetic corticosteroids are safer for some patients because of relative freedom from mineralocorticoid activity, most natural and synthetic corticosteroids produce similar kinds of side effects. The dose required for anti-inflammatory and anti-allergy effects also produces metabolic effects, pituitary and adrenal gland suppression, and changes in the function of the central nervous system. Thus, although corticosteroids are highly effective therapeutically, they may also be very dangerous. Dosages of these medications are frequently altered to allow high concentrations when necessary and then tapered in an attempt to avoid undesirable effects. This requires that patients be ob-served closely for side effects and that the dose be reduced when high doses are no longer required. Suppression of the adrenal cortex may persist up to a year after a course of corticosteroids of only 2 weeks’ duration.

THERAPEUTIC USES OF CORTICOSTEROIDS

The dosage of corticosteroids is determined by the nature and chronicity of the illness as well as the patient’s other medical problems. Rheumatoid arthritis, bronchial asthma, and multi-ple sclerosis are chronic disorders that corticosteroids do not cure; however, these medications may be useful when other measures do not provide adequate control of symptoms. In ad-dition, corticosteroids may be used to treat acute exacerbations of these disorders.

In such situations, the adverse effects of corticosteroids are weighed against the patient’s current problems. These medica-tions may be used for a period but then are gradually reduced or tapered as the symptoms subside. The nurse plays an im-portant role in providing encouragement and understanding during the times the patient may experience (or is apprehensive about experiencing) recurrence of symptoms while taking smaller doses.

Treatment of Acute Conditions

Acute flare-ups and crises are treated with large doses of corti-costeroids. Examples include emergency treatment for bronchial obstruction in status asthmaticus and septic shock from sep-ticemia caused by gram-negative bacteria. Other measures, such as anti-infective agents or medications, are also used with corti-costeroids to treat shock and other major symptoms. At times, corticosteroids are continued past the acute flare-up stage to pre-vent serious complications.

Eye Treatment

A different problem exists when corticosteroids are used in treat-ing eye infections. Outer eye infection can be treated by topical application of eye drops because these do not cause systemic tox-icity. However, long-term application may cause an increase in intraocular pressure, which leads to glaucoma in some patients. In some patients, prolonged use of corticosteroids leads to cataract formation.

Dermatologic Disorders

Topical administration of corticosteroids in the form of creams, ointments, lotions, and aerosols is especially effective in many dermatologic disorders. It may be more effective in some condi-tions to use occlusive dressings around the affected part to achieve maximum absorption of the medication. Penetration and ab-sorption are also increased if the medication is applied when the skin is hydrated or moist (eg, immediately after bathing).

Absorption of topical agents varies with body location. For ex-ample, absorption is greater through the layers of skin on the scalp, face, and genital area than on the forearm; as a result, use of topical agents on these sites increases the risk for side effects of the medication. The availability of over-the-counter topical cor-ticosteroids increases the risk for side effects in patients who are unaware of their potential risks. Excessive use of these agents, es-pecially on large surface areas of inflamed skin, can lead to de-creased therapeutic effects and increased side effects.

DOSAGE

Attempts have been made to determine the best time to ad-minister pharmacologic doses of steroids. When symptoms have been controlled on a 6-hour or 8-hour program, a once-daily or every-other-day schedule may be implemented. In keeping with the natural secretion of cortisol, the best time of the day for the total corticosteroid dose is in the early morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the gland is most active, pro-duces maximal suppression of the gland. A large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, hence minimizing cushingoid effects. If symptoms of the disorder being treated are suppressed, alternate-day therapy is helpful in reducing pituitary-adrenal suppression in patients re-quiring prolonged therapy. Some patients report discomfort as-sociated with symptoms of their primary illness on the second day; therefore, it is important to explain to patients that this regimen is necessary to minimize side effects and suppression of adrenal function.

TAPERING

Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. Up to 1 year or more after use of corticosteroids, the patient is still at risk for adrenal insufficiency in times of stress. For example, if surgery for any reason is necessary, the patient is likely to require intravenous corticosteroids during and after surgery to reduce the risk for acute adrenal crisis. Patients re-ceiving corticosteroids must have an adequate supply of medica-tion on hand, so that they do not miss a scheduled dose and increase their risk for adrenal insufficiency. Table 42-5 provides an overview of the effects of corticosteroid therapy and their nurs-ing implications.