ADVANCING YOUR PRACTICE

Understanding corticosteroid therapy

Corticosteroids are used extensively for adrenal insufficiency and are also widely used in suppressing inflammation and autoimmune reactions, controlling allergic reactions, and reducing the rejection process in transplantation. See Commonly used corticosteroid preparations. Their anti-inflammatory and antiallergy actions make corticosteroids effective in treating rheumatic or connective tissue diseases, such as rheumatoid arthritis and systemic lupus erythematosus. They’re also frequently used in the treatment of asthma, multiple sclerosis, and other autoimmune disorders.

High doses appear to allow patients to tolerate high degrees of stress. Such anti-stress action may be caused by the ability of corticosteroids to aid circulating vasopressor substances in keeping the blood pressure elevated; other effects, such as maintenance of the serum glucose level, may also keep blood pressure elevated.

Adverse effects
Although the synthetic corticosteroids are safer for some patients because of relative freedom from mineralocorticoid activity, most natural and synthetic corticosteroids produce similar kinds of adverse effects. The dose required for anti-inflammatory and antiallergy effects also produces metabolic effects, pituitary and adrenal gland suppression, and changes in the function of the central nervous system. Therefore, although corticosteroids are highly effective therapeutically, they may also be very dangerous. Dosages of these medications are frequently altered to allow high concentrations when necessary and then tapered in an attempt to avoid undesirable effects. This requires that patients be observed closely for adverse effects and that the dose be reduced when high doses are no longer required. Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks’ duration.

Therapeutic uses of corticosteroids
The dosage of corticosteroids is determined by the nature and chronicity of the illness, as well as the patient’s other medical conditions. Rheumatoid arthritis, bronchial asthma, and multiple sclerosis are chronic disorders that corticosteroids don’t cure; however, these medications may be useful when other measures don’t provide adequate control of symptoms. In addition, corticosteroids may be used to treat acute exacerbations of these disorders.

In such situations, the adverse effects of corticosteroids are weighed against the patient’s current condition. These medications may be used for a period but then are gradually reduced or tapered as the symptoms subside. The nurse plays an important role in providing encouragement and understanding during times when the patient is experiencing (or is apprehensive about experiencing) recurrence of symptoms while taking smaller doses.

Treatment of acute conditions
Acute flare-ups and crises are treated with large doses of corticosteroids. Examples include emergency treatment for bronchial obstruction in status asthmaticus and for septic shock from septicemia caused by gram-negative bacteria. Other measures, such as anti-infective agents or medications, are also used with corticosteroids to treat shock and other major symptoms. At times, corticosteroids are continued past the acute flare-up stage to prevent serious complications.

Ophthalmologic treatment
A different problem exists when corticosteroids are used to treat eye infections. Outer eye infection can be treated by topical application of eye drops, because the agents don’t cause systemic toxicity. However, long-term application can cause an increase in intraocular pressure, which leads to glaucoma in some patients. In some patients, prolonged use of corticosteroids leads to cataract formation.

Treatment of dermatologic disorders
Topical administration of corticosteroids in the form of creams, ointments, lotions, and aerosols is especially effective in many dermatologic disorders. It may be more effective in some conditions to use occlusive dressings around the affected part to achieve maximum absorption of the medication. Penetration and absorption are also increased if the medication is applied when the skin is hydrated or moist (immediately after bathing).

Absorption of topical agents varies with body location. For example, absorption is greater through the layers of skin on the scalp, face, and genital area than on the forearm; as a result, use of topical agents on these sites increases the risk of adverse effects. The availability of over-the counter topical corticosteroids increases the risk of adverse effects in patients who are unaware of their potential risks. Excessive use of these agents, especially on large surface areas of inflamed skin, can lead to decreased therapeutic effects and increased adverse effects.

Dosage
Attempts have been made to determine the best time to administer pharmacologic doses of steroids. If symptoms have been controlled on a 6-hour or 8-hour program, a once-daily or every-other-day schedule may be implemented. In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the early morning, between 7 a.m. and 8 a.m. Large-dose therapy at 8 a.m.., when the adrenal gland is most active, produces maximal suppression of the gland. A large 8 a.m. dose is more physiologic because it allows the body to escape effects of the steroids from 4 p.m. to 6 a.m., when serum levels are normally low, hence minimizing cushingoid effects. If symptoms of the disorder being treated are suppressed, alternate-day therapy is helpful in reducing pituitary–adrenal suppression in patients requiring prolonged therapy. Some patients report discomfort associated with symptoms of their primary illness on the second day; therefore, it’s important to explain to patients that this regimen is necessary to minimize adverse effects and suppression of adrenal function.

Tapering
Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. Up to 1 year or longer after use of corticosteroids, the patient is still at risk for adrenal insufficiency in times of stress. For example, if surgery for any reason is necessary, the patient is likely to require I.V. corticosteroids during and after surgery to reduce the risk for acute adrenal crisis. Patients receiving corticosteroids must have an adequate supply of medication on hand, so that they don’t miss a scheduled dose and increase their risk of adrenal insufficiency. See Side effects of corticosteroid therapy and implications for nursing practice for an overview of the effects of corticosteroid therapy and their nursing implications.

Source: Smeltzer SC, et al. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007:1484-1486.