Download - Steroid therapy in children
![Page 1: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/1.jpg)
Steroid therapy in children
Dr. Devendra Nargawe
![Page 2: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/2.jpg)
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.
![Page 3: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/3.jpg)
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
![Page 4: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/4.jpg)
![Page 5: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/5.jpg)
Types of Steroids
Glucocorticoids
• Short acting:(<12hr) hydrocortisone
• Intermediate acting: (12-36hr) • Prednisolone• methylprednisolone• triamcinolone
• Long acting: (>36hr) dexamethasone
Mineralocorticoids
• Aldosterone• Fludrocortisone• desoxycorticosterone
acetate
![Page 6: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/6.jpg)
Mineralocorticoids Action
• Enhancement of sodium reabsorption in the DCT in kidney
• Increase in potassium and H+ excretion.
Mineralo- corticoid
s
![Page 7: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/7.jpg)
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
![Page 8: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/8.jpg)
• 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
![Page 9: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/9.jpg)
• 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
![Page 10: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/10.jpg)
• 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
![Page 11: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/11.jpg)
Anti-inflammatory actions of corticosteroids
Corticosteroid inhibitory effect
![Page 12: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/12.jpg)
• 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
![Page 13: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/13.jpg)
![Page 14: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/14.jpg)
• Inhibit cell division or synthesis of DNA
• Delay the process of healing• Retard the growth of children
Growth and Cell division
![Page 15: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/15.jpg)
Therapeutic Indications For The Use Of corticosteroids
![Page 16: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/16.jpg)
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
![Page 17: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/17.jpg)
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
![Page 18: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/18.jpg)
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
![Page 19: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/19.jpg)
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
![Page 20: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/20.jpg)
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
![Page 21: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/21.jpg)
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
![Page 22: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/22.jpg)
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.
![Page 23: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/23.jpg)
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.
![Page 24: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/24.jpg)
Eye disease
• Allergic conjunctivitis • Iritis• Iridocyclitis• Keratitis
Topical uses
• Retinitis• Optic neuritis• uveitis
Systemic uses
![Page 25: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/25.jpg)
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
![Page 26: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/26.jpg)
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.
![Page 27: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/27.jpg)
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
![Page 28: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/28.jpg)
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.
![Page 29: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/29.jpg)
Adverse Effects
![Page 30: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/30.jpg)
![Page 31: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/31.jpg)
• Sodium and water retention
• Edema• Hypokalemic
alkalosis • Progressive rise in
plod pressure
Mineralo-corticoids
![Page 32: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/32.jpg)
• 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
![Page 33: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/33.jpg)
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
![Page 34: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/34.jpg)
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)
![Page 35: Steroid therapy in children](https://reader036.vdocuments.net/reader036/viewer/2022081513/55cf6c8ebb61eb26588b47f1/html5/thumbnails/35.jpg)
Thank you