Search Straight Healthcare
HOME     ABOUT US     CONTACT US

  • CORTICOSTEROIDS
    • NOTE: This page is intended to be a quick reference for properties of corticosteroids. It is NOT a comprehensive review of these medications. Other drug interactions, side effects, precautions, and contraindications may exist for each drug.

CORTICOSTEROID OVERVIEW

CORTICOSTEROID DOSING

CORTICOSTEROID STUDIES





Drug Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Corticosteroids

  • Corticosteroids have a number of physiological effects
  • Their principal therapeutic effect is the suppression of inflammatory processes

  • Other effects include the following:
    • Promotion of glucose production
    • Inhibition of glucose utilization and anti-insulin properties
    • Depression of eosinophils and lymphocytes
    • Stimulation of red blood cell production and polymorphonuclear leukocytes
    • Stimulation of fat synthesis and storage
    • Increased urinary calcium excretion
    • Inhibition of wound healing
    • Retention of sodium and fluid, and loss of potassium (mineralocorticoid activity)
Inflammatory conditions
  • Steroids are indicated in many conditions
  • Conditions where the body's inflammatory response has detrimental effects are often treated with steroids

  • Examples:
    • Asthma and allergies
    • Rheumatoid arthritis
    • Lupus
    • Dermatitis and eczema
    • Crohn's disease and ulcerative colitis
    • Kidney diseases (ex. Nephrotic syndrome)
    • Multiple sclerosis
    • Organ transplants

Adrenal insufficiency
  • Steroids are also indicated in conditions where the body does not make sufficient amounts of cortisol. Cortisol is the the body's natural corticosteroid.
  • Side effects of corticosteroids depend on the length of use
  • Short-term use does not typically have lasting effects
  • Chronic steroid therapy can have a number of adverse effects

Short-term side effects (Incidence not well-defined)
  • Increased appetite
  • Elevated blood sugar - in one study, prednisone 25 - 60 mg a day increased the 2hr GTT by ∼ 100 mg/dl in nondiabetics [2]
  • Increased blood pressure
  • Gastric irritation
  • Behavior and mood changes

Long-term side effects (Incidence not well-defined)
  • Fluid retention
  • Weight gain
  • Potassium loss
  • Calcium loss
  • Cushing's syndrome
  • Menstrual changes
  • Diabetes
  • Skin atrophy and bruising
  • Poor wound healing
  • See Precautions/Contraindications for more
  • CYP3A4 inhibitors and inducers - corticosteroids are CYP3A4 substrates. CYP3A4 inhibitors and inducers may affect steroid levels.
  • NSAIDs (ibuprofen, naprosyn, aspirin, etc.) - corticosteroids may increase the risk of gastrointestinal side effects from NSAIDs
  • Thiazide diuretics - corticosteroids may worsen potassium loss from thiazide diuretics
  • Loop diuretics - corticosteroids may worsen potassium loss from loop diuretics
  • Anticholinesterase agents - Concomitant use of anticholinesterase agents and corticosteroids may produce severe weakness in patients with myasthenia gravis
  • Amphotericin B - corticosteroids may worsen the potassium loss caused by amphotericin B
  • Warfarin - corticosteroids may inhibit the effects of warfarin.
  • Isoniazid - corticosteroids may decrease isoniazid levels
  • Cholestyramine - cholestyramine may increase the clearance of corticosteroids
  • Cyclosporine - increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently
  • Digoxin - corticosteroids may increase the risk of arrhythmias due to hypokalemia
  • Estrogens and oral contraceptives - estrogens may decrease the hepatic metabolism of certain corticosteroids, thereby increasing their effect
  • Testosterone replacement therapies - testosterone may increase the fluid retention seen with corticosteroids. Use caution.
  • Vaccines - live and attenuated vaccines are contraindicated in patients receiving immunosuppressive doses of corticosteroids. Responses to inactivated vaccines may be diminished.
  • Hypothalamic-pituitary-adrenal (HPA) axis suppression - long-term steroid use can cause suppression of the HPA axis. Tapering steroids may help prevent suppression. See tapering steroids below for more.
  • Gastritis and peptic ulcers - steroids may worsen gastritis and peptic ulcers
  • Skin testing (e.g. allergy, PPD) - corticosteroids may suppress reactions with skin testing and interfere with interpretation
  • Diabetes - corticosteroids raise blood sugars and may worsen diabetes. Use caution in diabetics, particularly those who are uncontrolled.
  • Osteonecrosis of femoral or humeral heads - long-term steroids may increase the risk of osteonecrosis
  • Osteoporosis - long-term steroid use may cause osteoporosis through calcium loss and direct effects on bone formation. See glucocorticoid-induced bone loss for prevention recommendations.
  • Infection - steroids may increase the risk of infection. They may also cause existing infections to worsen.
  • Heart attack - steroids may increase the risk of ventricular free wall rupture in patients who have suffered a recent heart attack
  • Children - long-term steroid use may suppress bone growth and stunt adult heights in children
  • Cataracts - long-term steroids may increase the risk of cataracts
  • Glaucoma - long-term steroids may increase the risk of glaucoma
  • Myasthenia gravis - an acute myopathy has been observed with the use of high doses of corticosteroids in patients with myasthenia gravis
  • Kaposi's sarcoma - has been reported to occur in patients receiving corticosteroid therapy, most often for chronic conditions
  • Liver disease - clearance is decreased. Use caution.
  • Kidney disease - has not been studied extensively




Medication Dosage forms
Budesonide

(Entocort®)
(Uceris®)
Enteric coated capsule (Entocort®)
  • 3 mg ($$$$)
  • Only approved for use in Crohn's disease
  • See Crohn's disease for more

Enteric coated tablet (Uceris®)
Rectal foam (Uceris®)
  • 2 mg per actuation ($$$$)
  • Only approved for use in ulcerative colitis
  • See ulcerative colitis for more
Dexamethasone

(Decadron®)
Tablet
  • 0.5, 0.75, 1, 1.5, 2, 4, 6 mg tablet ($)

Solution
  • 0.5 mg/5 ml ($-$$)

Solution - Intensol
  • 1 mg/ml ($)

Elixir
  • 0.5 mg/5 ml ($$-$$$)

DexPak® TaperPak® ($$$-$$$$)
  • Contains 1.5 mg tablets
  • Comes in 6, 10, and 13 day taperpak
  • 6-day pak contains 21 tablets
  • 10-day pak contains 35 tablets
  • 13-day pak contains 51 tablets
Hydrocortisone

(Colocort®)
(Cortenema®)
(Cortifoam®)
Enema (Colocort®, Cortenema®)
  • 100 mg/60 ml ($$)
  • Only approved for use in ulcerative colitis
  • See ulcerative colitis for more

Rectal foam (Cortifoam®)
  • 80 mg per application ($$$$)
  • Only approved for use in ulcerative colitis
  • See ulcerative colitis for more
Methylprednisolone

(Medrol®)
Tablet
  • 2, 4, 8, 32 mg tablet ($)

Medrol Dosepak ($)
  • Contains twenty-one 4 mg tablets
  • Pills are taken over 6 days
  • On Day 1, 6 pills are taken, then dose is decreased by 1 pill each day
  • Pills are generally taken with meals
Prednisone Tablet
  • 1, 2, 2.5, 5, 10, 20, 50 mg tablet ($)

Solution
  • Prednisone 1 mg/ml ($-$$)
  • Prednisone Intensol® 5 mg/ml ($-$$)
Prednisolone

(Prelone®)
(Orapred®)
(Millipred®)
Tablet - Millipred®
  • 5 mg tablet ($$$$)

Tablet - Orapred ODT®
  • 10, 15, 30 mg disintegrating tablet ($$$-$$$$)

Syrup - Prelone®
  • Prednisolone 15 mg/5 ml (3 mg/ml) ($)

Solution - Orapred®
  • Prednisolone sodium phosphate
    • 5 mg/5 ml (1 mg/ml) ($)
    • 10 mg/5 ml (2 mg/ml)
    • 15 mg/5 ml (3 mg/ml) ($)
    • 20 mg/5 ml (4 mg/ml)
    • 25 mg/5 ml (5 mg/ml) ($$)

Suspension - Flo-Pred®
  • Prednisolone acetate 15 mg/5 ml (3 mg/ml) ($$$$)





Reference: NHLBI 2007 asthma guidelines
Acute asthma exacerbation
Medication Dosage forms Children
(≤ 12 years)
Adult Other
Prednisone Tablet
  • 1, 2, 2.5, 5, 10, 20, 50 mg tablet ($)

Solution
  • Prednisone 1 mg/ml ($-$$)
  • Prednisone Intensol® 5 mg/ml ($-$$)
1-2 mg/kg/day given in 2 divided doses (maximum = 60 mg/day) until PEF is 70% of predicted or personal best 40–80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best For outpatient “burst,” use 40–60 mg in single or 2 divided doses for total of 5–10 days in adults (children: 1–2 mg/kg/day maximum 60 mg/day for 3–10 days).
Prednisolone
(Prelone®)
(Orapred®)
Tablet
  • 5 mg tablet ($$$$)

Tablet - Orapred ODT®
  • 10, 15, 30 mg disintegrating tablet ($$$-$$$$)

Syrup - Prelone®
  • Prednisolone 15 mg/5 ml (3 mg/ml) ($)

Solution - Orapred®
  • Prednisolone sodium phosphate
    • 5 mg/5 ml (1 mg/ml) ($$)
    • 10 mg/5 ml (2 mg/ml)
    • 15 mg/5 ml (3 mg/ml) ($)
    • 20 mg/5 ml (4 mg/ml)
    • 25 mg/5 ml (5 mg/ml)

Suspension - Flo-Pred®
  • Prednisolone acetate 15 mg/5 ml (3 mg/ml) ($$$$)
1-2 mg/kg/day given in 2 divided doses (maximum = 60 mg/day) until PEF is 70% of predicted or personal best 40–80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best For outpatient “burst,” use 40–60 mg in single or 2 divided doses for total of 5–10 days in adults (children: 1–2 mg/kg/day maximum 60 mg/day for 3–10 days).
Methylprednisolone
(Medrol®)
Tablet
  • 2, 4, 8, 32 mg tablet ($)
1-2 mg/kg/day given in 2 divided doses (maximum = 60 mg/day) until PEF is 70% of predicted or personal best 40–80 mg/day in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best For outpatient “burst,” use 40–60 mg in single or 2 divided doses for total of 5–10 days in adults (children: 1–2 mg/kg/day maximum 60 mg/day for 3–10 days).
  • There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired.
  • The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of less than 1 week, there is no need to taper the dose. For slightly longer courses (e.g., up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids.
  • Inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation.



Reference: American Academy of Neurology 2012 recs PMID 2316264
Bell Palsy
  • The American Academy of Neurology recommends corticosteroids for the treatment of new-onset (within 72 hours of symptoms onset) Bell palsy. Trials cited in the recommendation used the following prednisone-equivalent doses:

    • Prednisone 50 - 60 mg a day for 5 - 10 days
    • See Bell palsy for more



Reference: American College of Gastroenterology Crohn's Disease Practice Guidelines 2009 [PMID 19174807]
Crohn's disease
  • In adults receiving corticosteroids for Crohn's disease, the American College of Gastroenterology gives the following recommendations:

    • Initial therapy: Prednisone 40 - 60 mg once daily
    • Prednisone is given until resolution of symptoms which typically occurs within 7 - 28 days
    • Prednisone is then tapered by 5 - 10 mg/week down to 20 mg. From 20 mg, it is tapered by 2.5 - 5 mg/week until stopped.
    • See Crohn's disease for more

    • NOTE: The oral steroid budesonide is also used in Crohn's disease. It has less systemic absorption and different recommendations. See budesonide for more.



Reference: BSR GCA Treatment recs 2010 PMID 20371504
Giant Cell Arteritis (GCA)
  • The British Society of Rheumatology recommends the following in patients with GCA:

    • GCA without jaw or tongue claudication or visual symptoms:
      • Prednisolone or prednisone 40 - 60 mg (not < 0.75 mg/kg) daily for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 - 4 weeks to 10 mg
      • Then by 1 mg every 1 - 2 months provided there is no relapse

    • GCA with visual symptoms:
      • Evolving visual loss or history of amaurosis fugax: IV methylprednisolone 500 mg to 1 g daily for 3 days
      • Established vision loss: at least 60 mg prednisolone or prednisone daily
      • Continue for 4 weeks (may need longer course if symptoms and laboratory abnormalities have not resolved)
      • Then dose is reduced by 10 mg every 2 weeks to 20 mg
      • Then by 2.5 mg every 2 - 4 weeks to 10 mg
      • Then by 1 mg every 1 - 2 months provided there is no relapse
      • See Giant cell arteritis for more



Reference: American College of Rheumatology 2012 Gout treatment recs PMID 23024029
Gout - treatment of acute flare
  • Systemic (one of the following)
    • Prednisone or prednisolone
      • Regimen 1 - at least 0.5 mg/kg/day for 5 - 10 days then discontinue
      • Regimen 2 - at least 0.5 mg/kg/day for 2 - 5 days, then taper for 7 - 10 days
    • Methylprednisolone (Medrol®) dose pack
  • Intramuscular
    • Triamcinolone acetonide 60 mg IM, followed by prednisone as above
    • IM triamcinolone may be given as monotherapy, but no consensus was reached on this recommendation
  • Intra-articular
    • Dosing should be based on size of the joint
    • Can be used in combination with NSAIDs, colchicine, or oral corticosteroids


Reference: IDSA 2007 Herpes zoster treatment recs PMID 17143845
Herpes zoster (shingles)
  • The IDSA recommends the following in select patients with herpes zoster:
    • Prednisone 60 mg a day for 7 days, then 30 mg a day for 7 days, then 15 mg a day for 7 days, then discontinue



Reference: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. PMID 21325604
Immune thrombocytopenia (ITP)
Children
  • The American Society of Hematology recommends the following in children with ITP:
    • First-line: Prednisone 1 - 2 mg/kg/day for a maximum of 14 days OR 4 mg/kg/day for 3 - 4 days
    • Nonresponders: High-dose dexamethasone 28 mg/m2/day
    • See immune thrombocytopenia for more


Adults
  • The American Society of Hematology recommends the following in adults with ITP:


Reference: BSR PR Treatment recs 2010 PMID 19910443
Polymyalgia Rheumatica (PR)
  • The British Society of Rheumatology recommends the following in patients with PR:
    • Prednisolone or prednisone 15 mg a day for 3 weeks
    • Then 12.5 mg for 3 weeks
    • Then 10 mg for 4 - 6 weeks
    • Then reduce by 1 mg every 4–8 weeks or alternate day reductions (e.g. 10/7.5 mg alternate days, etc.)
    • Typically, 1-2 years of treatment are needed
    • An alternative regimen with IM methylprednisolone is given as: 120 mg IM every 3-4 weeks, reducing by 20 mg every 2-3 months
    • See Polymyalgia rheumatica for more



Reference: EULAR RA management recs 2013, PMID 24161836
Rheumatoid Arthritis (RA)
  • The 2013 EULAR RA management recommendations state that corticosteroids for RA should be given at a dose ≤ 7.5 mg a day of prednisone or equivalent
  • The length of therapy is ideally ≤ 6 months
  • See Rheumatoid arthritis for complete recommendations
  • Intra-articular corticosteroids may be appropriate in some patients


Reference: PMID 24090799, 10430755, 23596348
Sarcoidosis
  • Prednisone 20 - 40 mg a day for 6 - 12 weeks
  • Then taper to 5 - 10 mg a day
  • Typical treatment duration is 12 months, although course may be shortened in quick responders
  • See Sarcoidosis for more information


Reference: American College of Gastroenterology Ulcerative Colitis Practice Guidelines 2010 [PMID 20068560]
Ulcerative colitis
  • In adults receiving corticosteroids for ulcerative colitis, the American College of Gastroenterology gives the following recommendations:

    • Initial therapy: Prednisone 40 - 60 mg once daily
    • Prednisone is given until significant improvement occurs
    • Prednisone is then tapered by 5 - 10 mg/week down to 20 mg. From 20 mg, it is tapered by 2.5 mg/week until stopped.
    • See ulcerative colitis for more

    Other
    • Budesonide is another steroid that is used to treat ulcerative colitis. It is available as a pill and as a rectal foam. The pill has less systemic absorption and different recommendations than other oral steroids. See budesonide for more.
    • Hydrocortisone foam and enemas are used as topical therapies to treat ulcerative colitis. See hydrocortisone for more.





Reference: Dexamethasone PI
Steroid Equivalent milligram
dosage
Cortisone 25
Hydrocortisone 20
Prednisolone 5
Prednisone 5
Methylprednisolone 4
Triamcinolone 4
Dexamethasone 0.75



  • CORTICOSTEROID TAPERING

    • One of the biggest issues with corticosteroids is knowing when and how to taper steroids in order to prevent, or facilitate the correction of hypothalamic-pituitary-adrenal (HPA) axis suppression
    • There is surprisingly little information in the medical literature to help guide these decisions, and there is no consensus among experts on how it should be done
    • A study in the NEJM that was performed in 1992 found no significant correlation between the length or dose of steroid therapy and HPA axis suppression. The study included patients who had been taking steroids for a period of 1 week to 15 years. [3]
    • Given the dearth of information, tapering decisions have to be made on an individual patient basis

      • General principles of corticosteroid tapering:
        • Individuals can vary greatly in their susceptibility to HPA axis suppression
        • Length and dose of steroid therapy are imperfect predictors of HPA axis suppression
        • In general, most patients who have been on steroids for less than 4 weeks will have minimal or no HPA axis suppression, although suppression can still be seen in a small number of patients [3]
        • A simple tapering regimen for patients who have been on extended therapy is to reduce the dose of steroids by 10 - 20% every 1 - 2 weeks
        • Patients on corticosteroids for > 1 month should receive perioperative IV hydrocortisone to protect against adrenal insufficiency [4]
        • Symptoms of adrenal insufficiency include: hypotension, weakness, fatigue, hypoglycemia, decreased appetite, nausea and vomiting, low sodium, and mental changes




Study Criteria Intervention Primary outcome Results
5 days
vs
14 days
of prednisone in COPD exacerbation


JAMA
2013

PubMed abstract


Inclusion criteria:
  • Exacerbation of COPD as defined by the presence of at least 2 of the following - change in baseline dyspnea, cough, or sputum quantity or purulence
  • Age older than 40 years
  • Smoking history of 20 pack-years or more

Exclusion criteria:
  • History of asthma
  • PFTs inconsistent with COPD
  • Pneumonia
Group 1 (157 patients) - Prednisone 40 mg for 5 days

Group 2 (157 patients) - Prednisone 40 mg for 14 days

  • On day 1, all patients received 40 mg of IV methylprednisolone instead of their first prednisone dose
  • All patients received an antibiotic, a SABA, a LABA, an ICS, and tiotropium throughout the study.
  • Primary outcome parameter was time to next exacerbation within 180 days. Exacerbation defined as an acute clinical deterioration beyond usual day-to-day variation, requiring interaction with a clinician.
  • Group 1 - 35.9% of patients experienced a re-exacerbation within 180 days
  • Group 2 - 36.8% of patients experienced a re-exacerbation within 180 days

  • Among patients with a re-exacerbation, the median time to event was 43.5 days in Group 1, and 29 days in Group 2


Study Criteria Intervention Primary outcome Results
Prednisone
vs
placebo
in community-acquired pneumonia


Lancet
2015

PubMed abstract


Inclusion criteria:
  • Hospital admission with community-acquired pneumonia defined by a new infiltrate on chest radiograph and the presence of ≥ 1 of the following: cough, sputum production, dyspnea, temp ≥ 100.4°F, abnormal breath sounds or rales, WBC > 10,000 or < 4000 cells/mm³

Exclusion criteria:
  • A condition requiring more than 0.5 mg/kg per day of prednisone equivalent
  • HIV with CD4 < 350 cells/mm³
  • Neutropenia
  • Active TB

Baseline characteristics:
  • Median age 74 years
  • Median duration of symptoms - 4 days
  • Average SaO2 - 94%
  • Bacteremia - 11%
Group 1 (392 patients) - Prednisone 50 mg daily + antibiotics

Group 2 (393 patients) - Placebo + antibiotics

  • Most patients started with amoxicillin plus clavulanic acid or ceftriaxone alone
  • In patients with clinical suspicion for legionellosis or in those requiring treatment in the intensive care unit, the beta-lactam was combined with clarithromycin.
  • The primary endpoint was time to clinical stability defined as time until stable vital signs for ≥ 24 hours

  • Stable vital signs were defined as:
    • Temp ≤ 100.4°F
    • Heart rate ≤ 100 bpm
    • Respiratory rate ≤ 24 breaths/min
    • SBP ≥ 90 mmHg (≥ 100 mmHg for patients with hypertension)
    • Mental status back to baseline
    • Oral intake
    • PaO₂ ≥ 60 mmHg or pulse oximetry ≥ 90% on room air
Primary outcome
  • Group 1 - median 3 days
  • Group 2 - median 4.4 days
  • Between group HR 1.33, 95%CI [1.15 to 1.50], p<0.0001

Other
  • Average length of stay was one day less in Group 1 than Group 2 (6 vs 7 days)
  • There was no significant difference in overall mortality (Group 1 - 4%, Group 2 - 3%, p=0.57)
  • Complications due to pneumonia: Group 1 - 3%, Group 2 - 6% (OR 0.49, 95%CI [0.23 to 1.02], p=0.056)
  • In-hospital hyperglycemia requiring insulin: Group 1 - 19%, Group 2 - 11% (OR 1.96, 95%CI [1.31 to 2.93], p=0.0010)