1. Rational use of Steroids Sachin Kuchya, MD DNB

2. Steroids - Introduction Three classes, Glucocorticoids – The daily secretion of cortisol is about 20 mg/ day with diurnal variation, peaks during early morning hrs, lowest during late evening hrs. Also exert feedback inhibition on HPA axis, maximal inhibition during late evening hours Mineralocorticoids – for salt & water balance Sex steroids – for reproductive function

3. IRRATIONAL USE ? Glucocorticoids – most common.

4. Example 1 Methylprednisolone 4 mg / Prednisolone 4 mg / Dexamethasone 0.5 –1.0 – 2 mg three times daily for treating an episode of Asthma exacerbation / attack of Gouty arthritis. Why Irrational – Inadequate Immunosupression & risk of HPA axis suppression

5. Example 2 IV Hydrocortisone 100 – 200 mg every 6 hourly / IV Methyl prednisolone 40 – 125 mg every 8 hourly for status asthmaticus (even included in some guidelines) Why Irrational –Risk of salt & water retention ( greater with hydrocortisone) & risk of HPA axis suppression

6. Steroids – Classification (on the basis of biological half lives) Short acting 8-12 hrs Cortisone Hydrocortisone (Cortisol) Intermediate acting 12-36 hrs Fludrocortisone Prednisone Prednisolone Methylprednisolone Long acting 36-72 hrs Triamcinolone Dexamethasone Betamethasone

7. Steroids – Classification Glucocorticoid activity Mineralocorticoid activity Short actingCortisol11 Cortisone0.8 Fludrocortisone10125 IntermediatePrednisone40.8 Prednisolone40.8 Methylprednisolone50.5 Long actingTriamcinolone50 Dexamethasone250 Betamethasone250

8. Glucocorticoids - Indications As hormone replacement therapy – in deficiency syndromes like Addisonian states ( physiological replacement doses) For HPA axis suppression, in Congenital Adrenal Hyperplasia (physiological doses are sufficient) Anti Inflammatory activity / Immunosuppressive action (5- 20 times of physiological doses)

9. Glucocorticoid - Doses Gluco corticoid activity Dose for, in mg/ day Addisonian syndrome / HPA axis suppression Immuno suppression Cortisol 1 20100- 400 Cortisone 0.825 Prednisone 45 20-100 Prednisolone 45 20-100 Methylprednisolone 54 16 - 1000 Triamcinolone 54 Dexamethasone 25 1.0 4- 16 Betamethasone 25 1.0 4- 16

10. Glucocorticoid – Preferred ones Gluco-Mine ralo- Preferred indication Short acting Cortisol11For deficiency syndromes. Cortisone0.8 Inter- mediate Prednisone40.8For immunosupression Prednisolone40.8 Methylprednisolone50.5 Long acting Dexamethasone250For HPA axis suppression, no risk of salt & water retention. Betamethasone250

11. Glucocorticoids – Dosing regimen Preferred indicationDosing regimen CortisolFor deficiency syndromes. 10 mg PO, at 8 AM & 2 PM Cortisone PrednisoneFor immunosupression, minimal risk of HPA axis suppression. 20 mg & upwards, at 8 AM daily/ on alternate days Prednisolone Methylprednisolone DexamethasoneFor HPA axis suppression, no risk of salt & water retention. 1-2 mg at bed time Betamethasone

12. Rational use…. Example 1 Methylprednisolone 4 mg / Prednisolone 4 mg / Dexamethasone 0.5 – 2 mg three times daily for treating an episode of Asthma exacerbation / attack of Gouty arthritis. The rational regimen for treating an episode of Asthma exacerbation / attack of Gouty arthritis - Methylprednisolone 16 - 32 mg / Prednisolone 20 - 60 mg once daily / on alternate days, repeated at 8 AM in the morning.

13. Rational use….. Example 2 IV Hydrocortisone 100 – 200 mg every 6 hourly / IV Methyl prednisolone 40 – 125 mg every 8 hourly for status asthmaticus (even included in some guidelines) The rational regimen for status asthmaticus – IV Methylprednisolone 125 – 1000mg stat followed by oral regimen stated above (example 1), once the condition settles down.

14. Benefit of RUD - Glucocorticoids Better immunosupression in patients with Br Asthma / RA / without any HPA axis inhibition Adequate inhibition of HPA axis in patients with Congenital Adrenal Hyperplasia, without salt & water overloading.

15. Thank you, wish to have your views & comments. Based on Goodman & Lawrence.