Corticosteroids

Name of the Corticosteroids Drugs

Systemic

1. Hydrocortisone
2. Prednisolone

Inhalational

1. Beclomethasone dipropionate
2. Budesonide
3. Fluticasone propionate
4. Flunisolide
5. Ciclesonide

SYSTEMIC CORTICOSTEROID DRUGS

1.HYDROCORTISONE

Patient monitoring

In high-dose therapy (which should not exceed 48 hours), watch closely for signs and symptoms of depression or psychotic episodes.

• Monitor blood pressure, weight, and electrolyte levels regularly.
• Assess blood glucose levels in diabetic patients. Expect to increase insulin or oral hypoglycaemic dosage. 2Monitor patient’s response during weaning from drug. Watch for adrenal crisis, which may occur if drug is discontinued too quickly.

Patient teaching

• Instruct patient to take daily P.O. dose with food by 8 A.M. 2Urge patient to immediately report unusual weight gain, face or leg swelling, epigastric burning, vomiting of blood, black tarry stools, irregular menstrual cycles, fever, prolonged sore throat, cold or other infection, or worsening of symptoms.
• Tell patient using topical form not to apply occlusive dressing unless instructed by prescriber.
•  Advise patient to discontinue topical drug and notify prescriber if local irritation occurs.
• Instruct patient to eat small, frequent meals and to take antacids as needed to minimize GI upset.
• Tell patient that response to drug will be monitored regularly.
• Caution patient not to stop taking drug abruptly.
•  In long-term use, instruct patient to have regular eye exams.
•  Instruct patient to wear medical identification stating that he’s taking this drug.

2.PREDNISOLONE

INHALATION CORTICOSTEROID DRUGS

1.BECLOMETHASONE DIPROPIONATE

Nursing Considerations

• Instruct patient to hold inhaled drug in airway for several seconds before exhaling and to wait 1 minute between inhalations.
• Advise patient to rinse mouth after using inhaler and to wash and dry inhaler thoroughly to help prevent fungal infections and sore throat.
• Encourage patient to document use of drug and his response in a diary.
• If patient is also using a bronchodilator, teach him to use it at least 15 minutes before beclomethasone.
• As appropriate, review all other significant and life-threatening adverse reactions.

PATIENT TEACHING

• Advise patient not to abruptly stop taking beclomethasone because adrenal insufficiency may occur. Urge her to notify prescriber if she develops signs of adrenal insufficiency, such as nausea, fatigue, anorexia, dyspnoea, hypotension, fever, malaise, dizziness, and fainting.
•  Before patient uses nasal spray for first time, instruct her to prime pump by placing her thumb on its base and her index and middle fingers on its shoulder area and then pressing her thumb firmly and quickly against the bottle several times or until fine mist appears. Before patient uses nasal inhalation canister for first time, instruct her to shake it and check that it’s working properly by spraying it once in the air while looking for fine mist.
• Teach patient to inhale deeply after each nasal spray or inhalation, exhaling through mouth and tilting head back to let drug spread over the nasopharynx.
• Teach patient how to properly use oral inhalation aerosol, shaking canister well before using. If patient has trouble using device and coordinating inhalation with it, suggest using a spacer device.
• If two inhalations are prescribed, advise patient to wait a minute between them.
•   If patient uses an inhaled bronchodilator with beclomethasone oral inhalation, tell her to use bronchodilator first, wait 5 minutes, and then use beclomethasone.

2.BEDESONIDE

Nursing Considerations

• Use budesonide cautiously if patient has tubercular infection; untreated fungal, bacterial, or systemic viral infection; or ocular herpes simplex.
• Closely monitor a child’s growth pattern; budesonide may stunt growth. WARNING Assess patient who switches from a systemic corticosteroid to inhaled budesonide for adrenal insufficiency (fatigue, hypotension, lassitude, nausea, vomiting, weakness), which may be life-threatening. Hypothalamic-pituitary-adrenal axis function may take several months to recover after stopping systemic corticosteroids. Stopping budesonide abruptly may cause adrenal insufficiency.
• Administer Repulse by jet nebulizer connected to an air compressor.
• Patient exposed to chickenpox may receive varicella zoster immune globulin or pooled I.V. immunoglobulin. If chickenpox develops, give antiviral as ordered. A patient exposed to measles may need pooled I.M. immunoglobulin.
• Assess patient for effectiveness of budesonide therapy, especially if being weaned from a systemic corticosteroid. If patient has increased asthma or an immunologic condition previously suppressed by systemic corticosteroid—such as rhinitis, conjunctivitis, an eosinophilic condition, eczema, or arthritis—notify prescriber.
•   Pulmicort Flexhaler contains small amounts of lactose, which may trigger coughing, wheezing, or bronchospasm in a patient with a severe milk-protein allergy.
• Monitor patient for evidence of hypersensitivity, such as contact dermatitis, rash, urticaria, angioedema, bronchospasm, or anaphylaxis. If present, notify prescriber immediately. Expect to stop budesonide and provide emergency supportive care.

Patient teaching

• Teach patient proper use of inhaler.

• Tell patient to swallow capsules whole without crushing or chewing them. 2Instruct patient to contact prescriber immediately if he develops itching, rash, fever, swelling of face and neck, or difficulty breathing.
• Encourage patient to document medication use and his response in diary.
•   Advise patient to report signs and symptoms of fungal infections of mouth.
•   Tell female patient to inform prescriber if she is pregnant or plans to become pregnant.
• Caution patient to avoid exposure to chickenpox and measles, if possible.
•   Emphasize importance of rinsing mouth after each inhaler treatment and washing and drying inhaler thoroughly after each use.
• Instruct patient to avoid high-fat meals, grapefruit, and grapefruit juice.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and foods mentioned above.

3.FLUTICASONE PROPIONATE

Patient monitoring

•  Monitor patient for withdrawal symptoms after Flovent is discontinued.
• Stay alert for systemic corticosteroid effects when administering Flovent, Floneses, or Veramyst.
• Observe for reduced growth rate in child or adolescent using Flovent, Floneses, or Veramyst.
• When giving Flovent, watch for eosinophilic conditions, such as Churg Strauss syndrome.
• When giving Floneses, assess for epistaxis, wheezing, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure (rare reaction).
• When giving Veramyst, assess for epistaxis, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure (rare reaction).

Patient teaching

• Tell patient to take drug exactly as prescribed.
• Teach patient proper use of prescribed form. 2Advise patient to immediately report signs of allergic reaction.
•  Caution patient to avoid exposure to people with chickenpox or measles.
• Advise female patient taking Floneses, Flovent, or Veramyst to inform prescriber if she is pregnant or breastfeeding. 
•  As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

4.FLUNISOLIDE

Nursing Considerations

• Use flunisolide cautiously in patients with ocular herpes simplex, pulmonary tuberculosis, or untreated systemic bacterial, fungal, parasitic, or viral infection.
• If patient receives an oral corticosteroid, expect to taper it slowly 1 week after changing to flunisolide. For patient who receives prednisone, expect to reduce it by no more than 2.5 mg daily at weekly intervals, beginning at least 1 week after flunisolide therapy starts
• Monitor growth in children; corticosteroids may increase risk of growth suppression.

Patient teaching

Teach patient to recognize and immediately report serious adverse reactions.

•  Teach patient proper use of drug. Caution him not to use more than prescribed amount; doing so may cause serious side effects.
• Tell patient maximum drug effects may not occur for several weeks.
• Tell patient to avoid people with measles, chickenpox, and other transmissible infections.
• Caution patient to withhold dose and contact prescriber if infection occurs.
•  Instruct female patient to tell prescriber if she becomes pregnant.
• Tell female patient not to breastfeed without consulting prescriber.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the tests mentioned above.

5.CICLESONIDE

Nursing Considerations

• Use cautiously in patients with tuberculosis; fungal, bacterial, viral, or parasitic infection; ocular herpes simplex; or measles or chickenpox because these conditions may worsen with ciclesonide therapy.
• Also use cautiously in patients with a history of increased intraocular pressure, glaucoma, or cataracts because ciclesonide may increase intraocular pressure or cause cataract formation and in patients with major risk factors for decreased bone mineral content, such as prolonged immobilization, family history of osteoporosis, or long-term use of drugs that can reduce bone mass, such as anticonvulsants and oral corticosteroids.
• Inspect patient’s oral cavity regularly for abnormalities. Have patient rinse mouth following inhalation of ciclesonide to reduce risk of oral candidiasis. If oral candidiasis occurs, expect to continue ciclesonide therapy, unless severe.
• If patient takes a systemic corticosteroid, expect to taper dosage by no more than 2.5 mg/day at weekly intervals, starting 1 week after ciclesonide therapy begins

PATIENT TEACHING

• Urge patient to use ciclesonide regularly, as prescribed, but not for acute bronchospasm. Also tell her never to increase or decrease the dosage without consulting prescriber.
• Tell patient to use ciclesonide only with the actuator supplied with the product. Explain that when the dose indicator shows a red zone in the window, about 20 inhalations are left, indicating a need for a refill. When the indicator shows zero, she should discard the inhaler. Advise against relying solely on the dose indicator, especially if inhaler has been dropped, but to keep track of number of inhalations used.
• Instruct patient to use inhaler according to package instructions. Stress needs to make sure canister is firmly seated in the plastic mouthpiece adapter before each use and to press inhaler slowly but firmly until it can go no further in the adapter for each spray. Inform patient that she doesn’t need to shake inhaler before use.
• Tell patient to always replace cap after use, to keep mouthpiece clean, and to clean mouthpiece once a week with a clean, dry tissue or cloth.
• Explain that the full effect of drug may not occur for 4 weeks or more

REFERENCES

1. Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
2. McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
3. April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
4. Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
5. Nursebro.com, Search – Nursebro

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