Name of the IBD-Glucocorticoids Drugs
- Prednisolone
- Hydrocortisone
1.Prednisolone
| Prednisolone |
| Availability Oral solution: 5 mg/ml Suspension for injection (acetate): 25 mg/ml, 40 mg/ml, 50 mg/ml Suspension (ophthalmic): 0.12%, 0.125%, 1% Syrup: 5 mg/5 ml, 15 mg/5 ml Tablets: 5 mg Tablets (orally disintegrating, sodium phosphate): 10 mg, 15 mg, 30 mg |
| Indications and dosages Severe inflammation; immunosuppression Adults: Dosage individualized based on diagnosis, severity of condition, and response. Usual dosage ranges from 5 to 60 mg P.O. (prednisolone) daily in two to four divided doses, or 4 to 60 mg I.M. (acetate) daily in divided doses, or 5 to 50 mg P.O. (sodium phosphate) daily in divided doses. Acute exacerbation of multiple sclerosis Adults: 200 mg P.O. daily for 1 week, followed by 80 mg every other day for 1 month Refractory bronchial asthma Children: 1 to 2 mg/kg/day (sodium phosphate) as a single dose or in divided doses; may continue for 3 to 10 days or until symptoms resolve or patient achieves peak expiratory flow rate of 80% of personal best Nephrotic syndrome in children Children: 60 mg/m2 P.O. (sodium phosphate solution) daily in three divided doses for 4 weeks, then 4 weeks of alternate-day therapy at single doses of 40 mg/m2 Various allergic conditions and dermatologic, endocrine, GI, hematologic, neoplastic, nervous system, ophthalmic, respiratory, and rheumatic disorders Adults: Variable and individualized depending on condition being treated and patient response. Initially, 10 to 60 mg (ODT) P.O. daily. Children: Variable and individualized depending on condition being treated. Initial dosage range is 0.14 to 2 mg/kg/day P.O. in three or four divided doses. Steroid-responsive inflammatory eye conditions Adults: In severe cases, initially one to two drops (acetate or sodium phosphate) instilled into conjunctival sac q hour during day and q 2 hours at night. In mild or moderate inflammation or in severe cases that respond favorably, one to two drops q 3 to 12 hours. |
Mechanism of Action
Binds to intracellular glucocorticoid receptors and suppresses inflammatory and immune responses by:
- Inhibiting neutrophil and monocyte accumulation at inflammation site and suppressing their phagocytic and bactericidal activity
- Stabilizing lysosomal membranes
- Suppressing antigen response of macrophages and helper T cells
- Inhibiting synthesis of inflammatory response mediators, such as cytokines, interleukins, and prostaglandins
Pharmacokinetics
- Duration: 18-36 hr
- Peak plasma time: 5 min (IV); 1 hr (PO)
- Protein bound: 65-91% (lower in elderly)
- Metabolism: Extensively metabolized in liver
- Half-life: 3.6 hr (normal renal function); 3-5 hr (end-stage renal disease)
- Dialyzable: Haemodialysis
- Renal clearance: 9.5 mL/min
- Excretion: Urine (mainly)
Administration
- Be aware that prednisolone has many different formulations that may be given by various routes: P.O., I.M., or ophthalmic. Before administering, make sure formulation can be given by prescribed route.
- Don’t break ODT tablets.
- Place ODT tablet on tongue and either swallow tablet whole or allow it to dissolve in mouth with or without water.
- Inject I.M. form deep into gluteal muscle. Rotate injection sites.
- Avoid subcutaneous injection.
- In systemic therapy, don’t discontinue drug abruptly, even if inhaled steroid is added.
- Know that additional corticosteroids are needed during stress or trauma
Contraindications
- Hypersensitivity to drug, other corticosteroids, alcohol, bisulfite, or tartrazine (with some products)
- Systemic fungal infections
- Active untreated infections (except in selected patients with meningitis)
- Acute superficial herpes simplex, keratitis, fungal or viral eye diseases, tuberculosis of eye, or after uncomplicated removal of superficial corneal foreign body (ophthalmic use)
- Idiopathic thrombocytopenic purpura (with I.M. use)
- Live-virus vaccines (with immunosuppressive prednisolone dosages)
Precautions :
- Diabetes mellitus, glaucoma, renal or hepatic disease, hypothyroidism, cirrhosis, diverticulitis, nonspecific ulcerative colitis, recent intestinal anastomoses, inflammatory bowel disease, thromboembolic disorders, seizures, myasthenia gravis, heart failure, hypertension, osteoporosis, ocular herpes simplex, immunosuppression, emotional instability
- Pregnant or breastfeeding patients
- Children younger than age 6 (younger than age 2 when treated for nephrotic syndrome; younger than age 1 month when treated for aggressive lymphomas and leukemias with ODT form).
Adverse reactions
- CNS: headache, nervousness, depression, euphoria, personality changes, psychosis, vertigo, paresthesia, insomnia, restlessness, seizures, meningitis, increased intracranial pressure, hypertrophic cardiomyopathy in premature infants
- CV: hypotension, hypertension, vasculitis, thrombophlebitis, thromboembolism, fat embolism, arrhythmias, heart failure, shock
- EENT: cataracts, glaucoma, visual disturbances, exacerbation of ocular infection, secondary ocular infections, globe perforation at corneal or scleral thinning site, transient stinging or burning of eyes, dry eyes, corneal ulcers, mydriasis (all with ophthalmic use); posterior subcapsular cataracts (especially in children), glaucoma, nasal irritation and congestion, rebound congestion, sneezing, epistaxis, nasopharyngeal and oropharyngeal fungal infections, perforated nasal septum, anosmia, dysphonia, hoarseness, throat irritation (with long-term use)
- GI: nausea, vomiting, abdominal distention, rectal bleeding, dry mouth, esophageal candidiasis, esophageal ulcer, pancreatitis, peptic ulcer
- GU: amenorrhea, irregular menses Hematologic: purpura Metabolic: sodium and fluid retention, hypokalemia, hypocalcemia, hyperglycemia, decreased carbohydrate tolerance, growth retardation (in children), diabetes mellitus, cushingoid effects (with long-term use), hypothalamic-pituitary-adrenal suppression (with systemic use longer than 5 days), adrenal suppression (with high-dose, long-term use)
- Musculoskeletal: muscle weakness or atrophy, myalgia, myopathy, osteoporosis, aseptic joint necrosis, spontaneous fractures (with long-term use), osteonecrosis, tendon rupture Respiratory: cough, wheezing, bronchospasm
- Skin: urticaria, rash, pruritus, contact dermatitis, acne, striae, poor wound healing, thin fragile skin, bruising, hirsutism, petechiae, subcutaneous fat atrophy, urticaria, angioedema
- Other: aggravation or masking of infections, increased or decreased appetite, weight gain (with long-term use), facial edema and erythema, edema, hypersensitivity reaction
Patient monitoring
- Monitor weight, blood pressure, and electrolyte levels.
- Watch for cushingoid effects (moon face, central obesity, buffalo hump, hair thinning, high blood pressure, frequent infections).
- Assess patient for depression and psychosis.
- Monitor blood glucose level carefully in diabetic patient.
- Evaluate for signs and symptoms of infection, which drug may mask or exacerbate.
- Monitor for signs and symptoms of early adrenal insufficiency (fatigue, weakness, joint pain, fever, anorexia, shortness of breath, dizziness, syncope).
- Assess musculoskeletal status for joint, tendon, and muscle pain.
Patient teaching
- Tell patient to take oral dose with food or milk to reduce GI upset.
- Instruct patient to remove ODT tablet from blister just before taking.
- Instruct patient to place ODT tablet on tongue and either swallow tablet whole or allow it to dissolve in mouth with or without water. Caution patient not to cut, split, or break tablet.
- Teach patient to recognize and immediately report cushingoid effects and signs and symptoms of early adrenal insufficiency.
- Advise patient and significant other to immediately report depression or psychosis.
- Explain that drug increases risk of infection. Instruct patient to contact prescriber at first sign of infection.
- Caution patient not to suddenly stop drug (including ophthalmic forms). Instruct him to discuss any changes in therapy with prescriber.
- Tell patient to immediately report bleeding or joint, muscle, tendon, or abdominal pain.
- Inform patient that he may need higher dosage during periods of stress. Encourage him to wear or carry medical identification stating this.
- Tell patient to avoid vaccinations during therapy. Mention that others in household shouldn’t receive oral polio vaccine because they could pass poliovirus to him.
- Caution patient not to take over-thecounter drugs or herbs during therapy.
- Teach patient how to use eye drops. Caution him not to touch dropper tip to eye or any other surface.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Administer once-daily doses of prednisone in the morning to match body’s normal cortisol secretion schedule.
- Because prednisone can produce many adverse reactions, assess regularly for signs and symptoms of such reactions as heart failure and hypertension. Also monitor fluid intake and output and daily weight.
- Monitor growth pattern in children. Prednisone may retard bone growth.
- Be aware that prolonged use of prednisone may cause hypothalamic-pituitary-adrenal suppression.
2.Hydrocortisone
| Hydrocortisone |
| Availability Cream, gel, lotion, ointment, solution: various strengths Injection: 25 mg/ml, 50 mg/ml; 100 mg/ vial, 250 mg/vial, 500 mg/vial, 1,000 mg/vial Intrarectal aerosol foam: 90 mg Oral suspension: 10 mg/5 ml Retention enema: 100 mg/60 ml Spray (topical): 1% Tablets: 5 mg, 10 mg, 20 mg |
| Indications and dosages ➣ Replacement therapy in adrenocortical insufficiency; hypercalcemia due to cancer; arthritis; collagen diseases; dermatologic diseases; autoimmune and hematologic disorders; trichinosis; ulcerative colitis; multiple sclerosis; proctitis; nephrotic syndrome; aspiration pneumonia hydrocortisone, hydrocortisone cypionate— Adults and children: 20 to 240 mg/day P.O. hydrocortisone acetate (suspension)— Adults and children: 5 to 75 mg by intra-articular injection (depending on joint size) q 2 to 3 weeks hydrocortisone acetate (intrarectal foam)— Adults and children: One applicatorful of intrarectal foam daily or b.i.d. for 2 to 3 weeks; then one applicatorful every other day hydrocortisone sodium phosphate— Adults and children: 15 to 240 mg/day subcutaneously, I.M., or I.V., adjusted according to response hydrocortisone sodium succinate— Adults and children: 100 to 500 mg I.M. or I.V.; may repeat at 2-, 4-, or 6-hour intervals, depending on response and condition hydrocortisone retention enema— Adults and children: 100 mg P.R. at bedtime for 21 nights or until desired response; patient should retain enema for at least 1 hour. Itching and inflammation caused by skin conditions Adults and children: Thin film of topical preparation applied to affected area one to four times daily, depending on drug form and severity of condition |
Mechanism of Action
- Binds to intracellular glucocorticoid receptors and suppresses inflammatory and immune responses by:
- Inhibiting neutrophil and monocyte accumulation at inflammation site and suppressing their phagocytic and bactericidal activity
- Stabilizing lysosomal membranes
- Suppressing antigen response of macrophages and helper T cells
- Inhibiting synthesis of cellular mediators of inflammatory response, such as cytokines, interleukins, and prostaglandins.
Pharmacokinetics
- Bioavailability: PO, 96%
- Protein bound: 90%
- Metabolized in tissues and liver
- Half-life: Plasma, 1-2 hr; biologic, 8-12 hr
- Excretion: Urine (mainly), feces (minimally)
Administration
- Give oral form with food or milk to avoid GI upset.
- Give I.V. injection of sodium succinate form over 30 seconds to a few minutes.
- Know that drug may be given as intermittent or continuous I.V. infusion. Dilute in normal saline solution, dextrose 5% in water, or dextrose 5% in normal saline solution.
- Inject I.M. deep into gluteal muscle. Rotate injection sites to prevent muscle atrophy
- Be aware that subcutaneous administration may cause muscle atrophy or sterile abscess.
- Never abruptly discontinue highdose or long-term systemic therapy.
- Know that systemic forms typically are used for adrenal replacement rather than inflammation.
- Be aware that occlusive dressings, heat, hydration, inflammation, denuding, and thinning of skin increase topical drug absorption.
Contraindications
- Hypersensitivity to drug, alcohol, bisulfites, or tartrazine (with some products)
- Systemic fungal infections
- Concurrent use of other immunosuppressant corticosteroids
- Concurrent administration of live virus vaccines
Precautions :
- Hypertension, osteoporosis, glaucoma, renal or GI disease, hypothyroidism, cirrhosis, thromboembolic disorders, myasthenia gravis, heart failure
- Pregnant or breastfeeding patients
- Children ages 6 and younger (safety not established).
Adverse reactions
- CNS: headache, nervousness, depression, euphoria, personality changes, psychoses, vertigo, paresthesia, insomnia, restlessness, conus medullaris syndrome, meningitis, increased intracranial pressure, seizures
- CV: hypotension, hypertension, thrombophlebitis, heart failure, shock, fat embolism, thromboembolism, arrhythmias EENT: cataracts, glaucoma, increased intraocular pressure, epistaxis, nasal congestion, perforated nasal septum, dysphonia, hoarseness, nasopharyngeal or oropharyngeal fungal infections
- GI: nausea, vomiting, esophageal candidiasis or ulcer, abdominal distention, dry mouth,rectal bleeding, peptic ulceration, pancreatitis
- Hematologic: purpura
- Metabolic: sodium and fluid retention, hypokalemia, hypocalcemia, hyperglycemia, hypercholesterolemia, amenorrhea, growth retardation, diabetes mellitus, cushingoid appearance, hypothalamic-pituitary-adrenal suppression with secondary adrenal insufficiency (with abrupt withdrawal or high-dose, prolonged use)
- Musculoskeletal: osteoporosis, aseptic joint necrosis, muscle pain or weakness, steroid myopathy, loss of muscle mass, tendon rupture, spontaneous fractures
- Respiratory: cough, wheezing, rebound congestion, bronchospasm
- Skin: rash, pruritus, urticaria, contact dermatitis, acne, bruising, hirsutism, petechiae, striae, acneiform lesions, skin fragility and thinness, angioedema
- Other: altered taste; anosmia; appetite changes; weight gain; facial edema; increased susceptibility to infection; masking or aggravation of infection; adhesive arachnoiditis; injection site pain, burning, or atrophy; immunosuppression; hypersensitivity reactions including anaphylaxis
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 hypoglycemic dosage.
- Monitor 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.
- Urge 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.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Systemic hydrocortisone shouldn’t be given to immunocompromised patients, such as those with fungal and other infections, including amebiasis, hepatitis B, tuberculosis, vaccinia, and varicella.
- Give daily dose of hydrocortisone in morning to mimic normal peak in adrenocortical secretion of corticosteroids.
- When possible, give oral dose with food or milk to avoid GI distress.
- Don’t give acetate injectable suspension by I.V. route.
- Give hydrocortisone sodium succinate as a direct I.V. injection over 30 seconds to several minutes, or as an intermittent or a continuous infusion. For infusion, dilute to 1 mg/ml or less with D5W, normal saline solution, or dextrose 5% in normal saline solution.
- Inject I.M. form deep into gluteal muscle, and rotate injection sites to prevent muscle atrophy. Subcutaneous injection may cause atrophy and sterile abscess.
- Shake foam container vigorously for 5 to 10 seconds before each use. Gently withdraw applicator plunger past the fill-line on the applicator barrel while container is upright on a level surface. Administer rectal foam only with provided applicator. After each use, wash applicator, container cap, and underlying tip with warm water.
- High-dose therapy shouldn’t be given for longer than 48 hours. Be alert for depression and psychotic episodes.
- Monitor weight, blood pressure, and electrolyte levels regularly during therapy.
- Expect hydrocortisone to worsen infections or mask signs and symptoms.
- Monitor blood glucose level in diabetic patients, and increase insulin or oral antidiabetic drug dosage, as prescribed.
- Know that elderly patients are at high risk for osteoporosis during long-term therapy.
- Anticipate the possibility of acute adrenal insufficiency with stress, such as emotional upset, fever, surgery, or trauma. Increase hydrocortisone dosage, as prescribed
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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