What are contraindications for medications such as prednisone (corticosteroid) or methylprednisolone (corticosteroid)?

Contraindications for Corticosteroids (Prednisone and Methylprednisolone)

Corticosteroids such as prednisone and methylprednisolone are absolutely contraindicated in patients with systemic fungal infections and known hypersensitivity to components of these medications. 1

Absolute Contraindications

• Systemic fungal infections: Corticosteroids can exacerbate systemic fungal infections and should be avoided unless needed to control drug reactions 1
• Known hypersensitivity to components of the medication 1
• Active peptic ulcer disease: Particularly important with nonselective NSAIDs, but also applies to corticosteroids 2

Relative Contraindications (Use with Extreme Caution)

Cardiovascular Conditions

• Recent myocardial infarction: Risk of left ventricular free wall rupture 1
• Heart failure: Corticosteroids can cause fluid retention and exacerbate heart failure 2
• Hypertension: Steroids can elevate blood pressure and cause salt and water retention 1

Infectious Conditions

• Latent tuberculosis: Risk of reactivation; chemoprophylaxis should be considered 1
• Hepatitis B carriers: Risk of viral reactivation; screening recommended before starting immunosuppressive treatment 1
• Varicella or measles exposure in non-immune patients: Can lead to severe or fatal course 1
• Latent amebiasis: Corticosteroids may activate latent infection 1

Endocrine/Metabolic Conditions

• Uncontrolled diabetes: Corticosteroids increase blood glucose and can lead to brittle diabetes 3
• Osteoporosis: Increased risk of fractures, especially with long-term use 3

Other Conditions

• Chronic kidney disease: Use with caution due to potential for fluid retention and electrolyte disturbances 2
• Liver failure: Particularly relevant when considering acetaminophen co-administration 2
• Glaucoma: Corticosteroids can increase intraocular pressure 1
• Pregnancy: Some medications used to prevent steroid complications (e.g., bisphosphonates) have fetal risks 3

Special Considerations for Administration

Duration and Dosing

• Use the lowest effective dose for the shortest duration possible to minimize adverse effects 3
• For long-term therapy, consider alternate-day dosing to reduce adrenal suppression 2
• Tapering is necessary when discontinuing therapy to prevent adrenal insufficiency 1

Monitoring Requirements

1. Blood pressure: Regular monitoring for hypertension
2. Blood glucose: Monitor for hyperglycemia, especially in diabetic patients
3. Electrolytes: Particularly potassium levels due to risk of hypokalemia
4. Bone density: Baseline and follow-up testing for patients on long-term therapy
5. Eye examinations: Monitor for cataracts and glaucoma
6. Growth monitoring in children: Risk of growth suppression 2

Preventive Measures

• Osteoporosis prevention: Calcium (800-1000 mg daily) and vitamin D (800 IU daily) supplementation 3
• GI protection: Consider proton pump inhibitors for patients at risk of GI bleeding
• Infection prevention: Complete immunizations before starting therapy 3
• Adrenal insufficiency prevention: Gradual tapering when discontinuing therapy 1

Common Pitfalls to Avoid

1. Abrupt discontinuation: Can lead to adrenal crisis; always taper corticosteroids after prolonged use
2. Missing "hidden sources" of steroids when calculating total daily dose
3. Overlooking drug interactions: Particularly with medications that affect metabolism of corticosteroids
4. Failing to provide patients with steroid cards/alerts for emergency situations
5. Not considering prophylactic medications for high-risk patients (e.g., bisphosphonates for osteoporosis)
6. Overlooking the need for increased doses during periods of stress (surgery, trauma, illness)

Remember that the risk-benefit ratio must be carefully evaluated before initiating corticosteroid therapy, particularly for long-term use, and preventive strategies should be implemented from the outset to minimize potential complications.