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6.3 Corticosteroids

Dexamethasone tablets, injection - see note
Prednisolone tablets, soluble tablets - see note and QIPP Detail Aid
Hydrocortisone tablets, injection
Betamethasone tablets, injection
Methylprednisolone tablets, injection - see note
Triamcinolone Injection
Fludrocortisone tablets

Notes:

1. Enteric Coated prednisolone tablets are several times the cost of the plain tablets, and as there is little evidence to suggest an advantage in terms of reduced gastric irritation, prescribers are urged to use plain tablets as first-line therapy. Click here for further information.

Prednisolone soluble tablets currently cost over 30 times as much as plain tablets. Both 1mg and 5mg strengths are relatively small tablets and do not present a problem in swallowing for the majority of patients. Soluble tablets may be justified in a limited number of clinical situations, for example those with fine-bore enteral feeding tubes. However, administration of plain prednisolone tablets is faster for nursing and care staff and may be more convenient for patients. Also, plain tablets may also disperse in water to form a fine suspension. Patients taking soluble tablets should be reviewed regularly with a view to changing to plain where appropriate. Click here for further information. 

Plain 5mg tablets of prednisolone are significantly cheaper than the 25mg tablets, and should be preferred for the majority of patients – see QIPP Detail Aid: Prednisolone – use 5mg not 25mg tablets

EQUIPOTENT ANTI-INFLAMMATORY DOSES of the following steroid preparations are:

Betamethasone 0.75mg
Dexamethasone 0.75mg   
Hydrocortisone 20mg
Methylprednisolone 4mg
Prednisolone 5mg
Triamcinolone 4mg

Oral and parenteral doses of steroid therapy are approximately equivalent. This does not take into account mineral corticosteroid effect or variation in duration of action.

2. STEROID REPLACEMENT - the standard recommended oral dosage of hydrocortisone for steroid replacement is 20mg in the morning and 10mg in the evening though this may be too much for some patients for which 10mg + 5mg + 5mg is a satisfactory regimen.

3. Steroid warning cards should be carried by those on long term treatment, both replacement and therapeutic. Patients on replacement therapy should be fully educated about the need to increase dosage during intercurrent illness or acutely stressful events.

4. Abrupt withdrawal of steroids following long term therapy (> 3 weeks) should be avoided. Steroids should be withdrawn gradually (symptom control permitting) until physiological dosage is reached (20-30 mg/day hydrocortisone or 7.5mg/da prednisolone) and then tapered off more cautiously.. Pituitary-adrenal suppression may persist to some extent for about a year after withdrawal of corticosteroids and may give rise to hypoadrenal crisis during surgery or other major stress if supplementation is not provided.

5. Patients who are given systemic corticosteroids for purposes other than replacement and who have not had chickenpox should be regarded as being at risk of severe chickenpox. This may be manifested as a fulminant illness without a prominent rash. Patients at risk should be advised to avoid close personal contact with chickenpox or herpes zoster; if so exposed they should seek urgent medical advice. Specific immunoglobulin should be given within 3 days and is available from the public health laboratory.

6. Methylprednisolone may be used in the management of acute relapses in multiple sclerosis, most usually at a dose of 1g IV infused over 1 hour, once daily, for 3 days. Alternatively, it may be given orally at a dose of 500mg daily for 5 days.

7. Dexamethasone ampoules 3.3mg/ml (Hospira brand) are reserved for use in pain clinic and eye theatre for neuraxial blocks / intraocular use ONLY. They are free from propylene glycol and sulphites.

 

For link to BNF section: 6.3 Corticosteroids