Steroid therapy in children Dr. Devendra Nargawe
Steroid therapy in children
Dr. Devendra Nargawe
Corticosteroids
The adrenal gland secrets steroidal hormones which have glucocorticoid, mineralocorticoid and weakly androgenic activities.
Conventionally ,the term corticosteroid includes natural gluco- and mineralo-cortcoids and their synthetic analogues.
Stimuli Part Principal product
Angiotensin II Zona glomerulosa
ACTH Zona fasiculata & reticularis
Sympathetic nervous system
Medulla
Synthesis of corticosteroids
Mineralo-corticoids
Gluco- corticoids
Adrenaline &Nor-adrenaline
Types of Steroids
Glucocorticoids
• Short acting:(<12hr) hydrocortisone
• Intermediate acting: (12-36hr) • Prednisolone• methylprednisolone• triamcinolone
• Long acting: (>36hr) dexamethasone
Mineralocorticoids
• Aldosterone• Fludrocortisone• desoxycorticosterone
acetate
Mineralocorticoids Action
• Enhancement of sodium reabsorption in the DCT in kidney
• Increase in potassium and H+ excretion.
Mineralo- corticoid
s
Glucocorticoids actions• Promoting gluconeogenesis• Inhibit glucose utilization by
peripheral tissues• Increase protein breakdown and
mobilization of amino acid from peripheral tissues
On carbohydrate and protein metabolism
• Promote lipolysis due to glucagon growth hormone, thyroxine and cAMP induced breakdown of triglycerides is enhanced.
On fat metabolism
• Inhibit intestinal absorption and enhance renal excretion of calcium.
on calcium metabolism
• Enhance secretary activity of renal tubules
On water excretion
• Restrict capillary permeability • Maintain tone of arterioles and
myocardial contractility• When applied topically , they cause
cutaneous vasoconstriction
On CVS
• Optimum levels are needed for normal muscular activity
On skeletal muscles
• Maintain the level of sensory perception and normal excitability of neurons.On CNS
• Increase Secretion of gastric acid and pepsinStomach
• Enhance the rate of destruction of lymphoid cells
• Increase the number of RBCs , platelet and neutrophils in circulation.
• Decrease lymphocytes, eosinophils and basophils
Lymphoid tissue and
blood cells
• Covers all stage of inflammation . This include reduction of – increased capillary permeability , local exudation, cellular infiltration, phagocytic activity and late events like capillary proliferation, collagen deposition, fibroblastic activity and ultimately scar formation.
• Cardinal signs of inflammation – redness, heat, swelling and pain are suppressed .
Inflammatory responses
Anti-inflammatory actions of corticosteroids
Corticosteroid inhibitory effect
• Suppress all type of hyper sensitization and allergic phenomena
• Suppression of recruitment of leukocytes at the site of contact with antigen and of inflammatory response to immunological injury.
• Suppression of CMI in which T-cells are primarily involved.
Immunological and allergic responses
• Inhibit cell division or synthesis of DNA
• Delay the process of healing• Retard the growth of children
Growth and Cell division
Therapeutic Indications For The Use Of corticosteroids
Rheumatic disease of childhood
• Indicated only in severe cases as adjusents to NSAIDs when distress and disability persists despite of other measures.
Rheumatic arthritis
• Corticosteroids are used only in severe cases with carditis and CHF.Rheumatic fever
• In stable child – oral prednisolone 2 mg/kg/day• Children with GIT involvement iv methyl
prednisolone 30mg/kg/day (max.1g/day)
Juvenile dermatomyositits
• Induction period – oral pred. until manifestation improved
• Than gradually tapered in 6 -12 monthSarcoidosis
• Oral prednisone improves only GI symptoms and joint pain.HSP
Rheumatic disease of childhood
• Significant manifestation of SLE ; iv methylprednisolone (30mg/kg/day) or prednisolone 2 mg/kg/day
Systemic lupus erythematosus
• Oral prednisone or iv methyl prednisolone pulse therapy typically used.
Polyarteritis nodosa
• Superficial morphea – topical steroids • Lesions involving deeper structures- systemic therapy( iv methyl pred. 30mg/kg/day or oral pred. 0.5-2 mg/kg/day) includes 3 consecutive days in a month for 3 months.
Scleroderma
Allergic reactions
• Intranasal spray of beclomethasone and budesonide used in severe cases.
Allergic rhinitis
• Severe serum sickness require systemic cortcosterids
Serum sickness
• Delayed pressure urticaria requires oral corticosteroidsUrticaria
Hematological disorders
• In ITP oral therapy induce rapid rise in platelet count than untreated pt.
Idiopathic Thrombocytopenic
Purpura
• Glucocorticoids reduce hemolysis by blocking macrophage function, decreasing autoantibody and enhancing elution of antibody from the RBCs.
• 2mg/kg/day till rate of hemolysis decrease.
Auto Immune Hemolytic Anemia
• Due to lymphocytic action of corticosteroids are an essential component of combined chemotherapy in ALL ,Hodgkin’s and other lymphoma.
Malignancies
Bronchial asthma • Iv hydrocortisone 10mg/kg
stat followed by 5mg/kg/dose 6 hourly
Status asthmatcus
• Short course of intermediate acting CS (over several weeks to months), should be considered with close monitoring of patient’s symptoms and lung function.
Acute asthma exacerbation
• ICS therapy used for severe persistent asthma
• Budesonide DPI/ suspension for nebulization available
• Acc. To NIH guidelines • Step-2 –low dose ICS (0.25-.5
mg/day)• step 3&4 –medium dose ICS
(>0.5-1mg/day)• step 5&6 – high dose ICS ( 1-2
mg/day)
Severe chronic asthma
Other lung disease
• Decrease the edema in the laryngeal mucosa through anti-inflammatory action
• Dexamethasone 0.6mg/kg single dose or nebulized with budesonide for 8 days.
Croup
• Decrease edema of laryngeal mucosa through anti-inflammatory action.
Pulmonary edema due
to drowning
Infants with RDS who require respiratory support or who develop
BPD required systemic corticosteroids
Neurologic disorders
Cerebral edema• Corticosteroids limits the production of
inflammatory mediators which reduce risk of additional neurologic injury with worsening of CNS signs and symptoms
• Iv dexamethasone 0.15mg/kg/dose 6 hourly
Multiple sclerosis• Methyl prednisolone 20-30mg/kg/day for
5days followed by with or without prednisone.
Infections
Tuberculosis In tuberculous meningitis Endobronchial tuberculosis Pericardial effusion Severe miliary tuberculosis
Prescribed regimen is prednisone 1-2mg/kg/day in 2 divided doses for 4 -6 weeks followed by tapering dose.
Eye disease
• Allergic conjunctivitis • Iritis• Iridocyclitis• Keratitis
Topical uses
• Retinitis• Optic neuritis• uveitis
Systemic uses
Skin disordersTopical corticosteroids are potent anti-inflammatory agents
They are divided into 4 categories on the basis of strength
low- hydrocortisone, desonide and hydrocortisone butyrate
Medium –amcinonide , betamethasone cream 0.05%, flurandrenoilde, flucinolone 0.025% oint. , momitasone
High –fluocinonide 0.05% gel & halcinonide
Super potent – betamethasone dipropionate 0.05% and clobetasol 0.05% gel
Skin disease Hemangioma – oral prednisolone
Atopic dermatitis – topical medium potent corticosteroid
Vitiligo – topical steroids
toxic epidermal necrolysis- oral prednisolone
pemphigus vulgaris –iv methyl prednisolone 1-2 mg/kg/day
Pemphigus foliaceus- topical steroids
bullous phemphigoid- iv methyl prednisolone 1-2 mg/kg/day
linear IgA dermatosis- oral therapy with methyl prednisolone 1-2 mg/kg/day for 2 -4 years .
Contact dermatitis ( massive acute bullous reactions )- oral corticosteroids for 2 weeks (1mg/kg/day)
Linchen simplex chronicus – topical steroids.
Seborrheic dermatitis (inflamed lesions) –low potency steroids
Psoriasis – topical steroids used in 1st tier therapy.
Renal disease• 2mg/kg/ day (60mg/m2 /day) for
initial 6 week than 1.5mg/kg/day(40mg/m2 /day) alternate day
Minimal change Nephrotic syndrome
• Immunosuppressive therapy with corticosteroids may be beneficial
IgA nephropathy
• Immunosuppressive therapy with prednisolone
membranous glomerulopathy
• High dose methyl prednisolone with cyclophosphamide and plasmapheresis.
Goodpasture disease
Miscellaneous
In acute exacerbations of crohn disease because they effectively suppress acute inflammation, rapidly relieving symptoms. Prednisone 1-2mg/kg/day
Organ transplantation and skin allograft In thyroid strom- in which corticosteroids reduce
peripheral T4 to T3 coversion. Neurocystisercosis- oral prednisolone
1.5mg/kg/day for 2-4 weeks suppress the reaction to the dying larvae, After kill the cysticerci by albendazole/preziquental.
Adverse Effects
• Sodium and water retention
• Edema• Hypokalemic
alkalosis • Progressive rise in
plod pressure
Mineralo-corticoids
• Cushing’s habitus• Fragile skin , purple
striae• Hyperglycemia • Muscular weakness• Susceptibility of infection• Delayed healing • Peptic ulceration• Osteoporosis• Posterior subcapsular
cataract• Glaucoma• Growth retardion• Pshychiatric disturbance• Suppression of
hypothalamo-pituitary-adrenal axis
Gluco-corticoids
Contraindications
• Peptic ulcer • Diabetes mellitus• Hypertension• Viral and fungal infections• Tuberculosis and other
infections• Osteoporosis • Herpes simplex keratitis• Psychosis• Epilepsy• Congestive heart failure• Renal failure
The following diseases are
aggravated by corticosteroids. All of these are
relative contraindications
ReferencesEssentials of medical pharmacology –KD Tripathi 7th edi.
Nelson textbook of pediatrics -19th edi.
Essential pediatrics – OP Ghai 8th edi.
Basic and Clinical Pharmacology Katzung 13 edi.
Goodman and Gilman's The Pharmacological Basis of Therapeutics 12th Ed. (2011)
Thank you