Glucocorticosteroids systemic

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Corticosteroids; Glucocorticoids systemic; Systemic glucocorticoids; Systemic glucocorticosteroids; System steroids

Definition
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Hormones of the adrenal cortex, which have a particular effect on carbohydrate and protein metabolism. S.a.u. Cushing's Threshold.

Half-life
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1,7 h (cortisol), other half-lives apply to the fluorinated and/or methylated cortisol derivatives.

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Indication
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Glucocorticoids are used in dermatology for a number of clinical pictures in acute or long-term therapy.

Limited indication
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Severe infections (only with simultaneous causal therapy), recent myocardial infarction, chronic inpatient psoriasis vulgaris, psychosis in the medical history, pregnancy 1st trimester (danger of cleft palate), lactation (growth inhibition possible), tuberculosis in the medical history (danger of reactivation).

Pregnancy/nursing period
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In a meta-analysis (9 case-control studies), a dose-response relationship was demonstrated with regard to the use of glucocorticosteroids in pregnancy and low birth weight. The risk for low birth weight was increased if the pregnant women took more than 300 g of a potent glucocorticosteroid during the entire pregnancy. This side effect was not detectable with moderately and weakly active glucocorticoids.

Undesirable effects
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Glaucoma, cataract, leukocytosis, amenorrhea, Cushing's syndrome, weight gain, menstrual disorders, metabolic alkalosis, edema, oligospermia, allergic reactions, petechiae, ecchymosis, skin atrophy, striae cutis distensae, acne, wound healing disorders, Increase in blood pressure, thrombosis, NNR insufficiency, susceptibility to infection, depression, pseudotumor cerebri, headache, sleep disorders, arthralgias, aseptic bone necrosis, myalgias, osteoporosis, spontaneous fractures, gastrointestinal ulcers, pancreatitis.

Contraindication
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Glaucoma, 8 weeks before to 2 weeks after vaccination, severe osteoporosis, poliomyelitis (exception: bulbar encephalitis), systemic mycoses, duodenal ulcers, varicella;

crystal suspension: children < 6 years

.

Literature
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  1. Chi CC et al.(2016) Safety of Topical Corticosteroids in Pregnancy. JAMA Dermatol 152:934-935.

Tables
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Glucocorticoid effects at therapeutic dosage

Antiproliferative effect

Suppression of fibroblast formation and collagen synthesis (in children, growth inhibition may result)

Anti-inflammatory effect

Reduction of local capillary permeability and vasodilatation

Decrease of leukocyte adherence at the vascular endothelium

Reduction of leukocyte chemotaxis and migration

Inhibition of the phagocytosis capacity of granulocytes and macrophages

Inhibition of granulocyte and macrophage accumulation at the site of inflammation

Inhibition of macrophage bactericide

Inhibition of the macrophage response to various lymphokines (e.g. IFN)

Inhibition of IL-1 production by macrophages

Inhibition of arachidonic acid metabolism by macrocortin-mediated phospholipase A2 inhibition

Immunosuppressive effect

Induction of lympho- and monocytopenia by redistribution

Reduction of the CD4/CD8 ratio by a stronger decrease of CD4+ than of CD8+ cells

Acceptance of B-cells

Increase of NK cells

Decrease in serum IgG concentration (catabolism, decreased production, reduced primary response)

Reduced antigen processing by antigen-presenting cells

Inhibition of IL-1 activity on antigen-activated T cells

Inhibition of IL-2 and IFNγ production by T cells

reduced T cell proliferation on mitogen, antigens and alloantigens

Suppression of the immune reaction of the delayed type


potency of commercial glucocorticosteroids

Glucocorticoid

Trade name

Plasma protein binding (%)

HWZ (min.)

relative glucocorticoid potency1

Cushing threshold dose (mg/day)

relative mineralocorticoid potency1

Betamethasone

Celestamine, Celestan

67

300-400

30

1

0

Cloprednol

Synthestane

85

110-126

8

3,75

0,6

Cortisol (hydrocortisone)

Ficortril, hydrocortisone

87

78-96

1

30

1

Cortisone

Cortisone CIBA

88

80-95

0,8

40

0,8

Deflazacort

Calcort

65

110-135

3

10

< 0,5

Dexamethasone

Fortecortin

75

201-255

30

1

0

Fluocortolone

Ultralan

89

58-92

5

6

0

6α methylprednisolone

Urbason

62

141-168

5

6

0

Prednisolone

Predni Hexal, Decortin H, Solu-Decortin H

87

162-240

4

7,5

0,6

Prednisone

Decortin, Prednisone Hexal, Rectodelt

87

162-240

4

7,5

0,6

Budesonide

Entocort

80-90

120-216

9,4

3

0

Triamcinolone

Berlicort, Delphicort, Volon

42

160-300

6

5

0


Indications of systemic glucocorticoids in dermatology (according to Niedner)

Diagnosis

Daily dose initial

(mg prednisolone equivalent)

Therapy duration

(weeks)

Maintenance dose

(mg prednisolone equivalent)

Duration of maintenance therapy

(weeks)

Acute febrile neutrophilic dermatosis

40-80

1-3 days

10-20

weeks

alopecia areata totalis

20-40

2-3

5-7

4-26

temporal arteritis

120

2-3

10-15

1-2 years

Drug exanthema

60-80

few days

-

-

M. Behçet

60

1-2

5-10

Months

Bullous pemphigoid

60-100

1-3

10

Months

cheilitis granulomatosa

40-60

1-2

Reduction

for weeks

dermatitis herpetiformis

20

Weeks to months (Dapson is better)

< 10

Week Months

Dermatomyositis

80-100

2-4

15

1-2 years

Pressure Urticaria

30-40

after course

5-15

Week Months

Dyshidrosis

40

1-2

5-15

Months, if applicable

Acute toxic contact eczema

40-60

Days

-

-

Allergic contact eczema

40-60

1-6

-

-

seborrheic eczema

40-60

1-3 (+ antimycotic)

-

-

Microbial eczema

40-80

2-5 (+ antibiotic)

-

-

Atopic eczema

40

1-2

< 15

Week Months

Eosinophilic fasciitis

60

4-6

10-20

weeks

Epidermolysis bullosa group

60-120

1-2

5

weeks

Erosive pustular dermatitis d. Scalp

60-100

1-2

10-15

weeks

Erythema exsudativum multiforme

60-80-100

1-3

-

-

Erythema nodosum

40-80

1-2

-

-

Erythrodermy

80-120

to 6

5-15

Months

annular granuloma

30-40

2

5-15

weeks

Hemangioma

1,5 mg/kg bw

2

-

-

Herpes gestationis

10-40

until healing

-

-

Herxheimer reaction

40

once

-

-

IgA linear dermatosis

40-60

1-2 months

5-10 (+ dapson)

weeks

impetigo herpetiformis

60-120

according to clinic

-

-

lichen planus exanthematicus

15-30

3

< 10

weeks

Lupus erythematosus, chronic discoid

60

few weeks

-

-

Lupus erythematosus, subacute cutaneous

60-80

1-2

5-10

Months

Lupus erythematosus, systemic

100-200

several weeks

5-15

Months - Years

mycosis fungoides

40

2

< 10

Months

panarteritis nodosa

80-120

2

10-20

Months

Parapsoriasis

20-40

2

5-10

weeks

pemphigus vulgaris

100-200-400

6-10

< 10

Months - Years

pityriasis rubra pilaris

20-40

2

5-10

weeks

Pseudoallergic drug reaction

60-80

few days

-

-

Progressive syst. Scleroderma

40-60

Week Months

5-15

Months

pustular psoriasis

40-80

4-6

-

-

pustulosis acuta generalisata

60-100

1-2

-

-

Pyoderma gangraenosum

60-80

until healing

5

weeks

Quincke's edema

100-200

once

-

-

Relapsing Polychondritis

80-100

2-3

25

weeks

Sarcoidosis

40-60

8-12

10-20

weeks

Sézary Syndrome

20-40

> 1 year

10-20

Months - Years

Toxic epidermal necrolysis

500

2-5 days (never longer)

-

-

vasculitis allergica

20-80

according to clinic

10-20

Weeks, rarely months

Scarring mucosal pemphigoid

40-120

Week Months

< 10

Week Months


Essential interactions of glucocorticoids

Active ingredients

Interactions

ACE inhibitors

Blood formation disorders ↑

Alcohol

Gastrointestinal bleeding

amphotericin B

Hypokalemia, superinfection

Anticholinergics

Intraocular pressure ↑ during long-term therapy

Antidepressants, tricyclic

Psychosis, exacerbation of steroidal psychosis

Antihistamines

Intraocular pressure ↑

Coumarins

Coumarin effect ↓, gastrointestinal ulcers

Diazoxide

Hypokalemia ↑

Cardiac glycosides

hypokalemia ↑, glycoside toxicity ↑

Insulin

Insulin action ↓

Laxatives

Hypokalemia ↑

Live virus vaccines

Avoid combination approx. 8 weeks before until 2 weeks after vaccination: Increased virus replication, severe reaction possible

Mesalazine

Gastrointestinal bleeding

Metformin

Metformin effect ↓

NSAID

Gastrointestinal ulcers

Pethidine

mutual toxicity ↑ in glaucoma

Phenobarbital

Glucocorticoid effect ↓ through increased degradation

Phenytoin

mutual effect ↓, symptom reduction of phenytoin-induced hepatotoxicity

Primidone

Glucocorticoid effect ↓

Salicylates

Salicylate effect ↓, gastrointestinal bleeding

Saluretics

Hypokalemia ↑

Loop diuretics

Hypokalemia ↑

Sulfonylureas

Sulfonylurea effect ↓

Thiazide diuretics

Hypokalemia ↑

Inactivated vaccines

combination approx. 8 weeks before until 2 weeks after vaccination, vaccine effect ↓

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Last updated on: 29.10.2020