Does dexamethasone (Corticosteroid) cause psychosis in a patient with a history of psychosis symptoms to prednisone (Corticosteroid), and what alternative corticosteroids can be used for Chronic Obstructive Pulmonary Disease (COPD) exacerbation that do not cause psychosis?

Dexamethasone Can Cause Psychosis in Patients with Prior Prednisone-Induced Psychosis; Consider Alternative Treatments for COPD Exacerbation

Yes, dexamethasone can cause psychosis in patients who have previously experienced psychosis with prednisone, and methylprednisolone should be considered as an alternative corticosteroid at the lowest effective dose for COPD exacerbation management.

Risk of Steroid-Induced Psychosis

• All systemic corticosteroids, including dexamethasone, carry a risk of causing psychosis, especially in patients with a history of steroid-induced psychiatric symptoms 1, 2
• Corticosteroid-induced psychosis can present with symptoms including paranoia, hallucinations, delusions, emotional lability, anxiety, insomnia, and memory impairment 3
• Patients receiving daily doses of 40 mg of prednisone or its equivalent are at greater risk for developing steroid psychosis, but cases have been reported with lower doses as well 2, 3
• Psychotic reactions are twice as likely to occur during the first 5 days of treatment 3

Cross-Reactivity Between Different Corticosteroids

• A history of psychosis with one corticosteroid (prednisone) indicates increased risk with other corticosteroids (dexamethasone) due to their similar mechanisms of action 1
• Corticosteroids should be avoided in patients with a history of steroid-induced psychosis or depression when possible 4
• The Canadian Association of Gastroenterology specifically recommends avoiding corticosteroids in patients with a history of steroid-induced psychosis 4

Alternative Management Options for COPD Exacerbation

First-Line Options (Preferred):

• Bronchodilators: Increase the dose of inhaled bronchodilators (beta-agonists and/or anticholinergic drugs) as the primary treatment for COPD exacerbation 4

  • Use appropriate inhaler devices that the patient can use effectively 4

• Antibiotics: Consider if there are signs of bacterial infection (increased sputum purulence, increased sputum volume, increased dyspnea) 4

Alternative Corticosteroid Options (If Steroids Necessary):

• Methylprednisolone at lowest effective dose: If a corticosteroid is absolutely necessary, methylprednisolone may be considered at the lowest possible dose to minimize risk of psychosis 1, 5

  • A comparative study showed methylprednisolone and dexamethasone have similar efficacy in COPD exacerbation management, allowing selection based on side effect profile 5

• Short duration therapy: Limit corticosteroid treatment to 5-7 days to reduce risk of adverse effects 6

  • A dose of 40 mg prednisone equivalent per day for 5 days is the standard recommendation for those without contraindications 6

• Oral route when possible: Oral administration is equally effective as intravenous for most patients 6

Monitoring and Management if Steroids Are Used:

• Use the lowest possible effective dose of corticosteroid to minimize risk 1
• Monitor closely for psychiatric symptoms, especially during the first 5 days 3
• If psychotic symptoms develop, consider discontinuation of the corticosteroid if possible 7
• Antipsychotics (particularly risperidone) have been used successfully to treat steroid-induced psychosis when steroids cannot be discontinued 7

Important Considerations and Caveats

• The decision to use any systemic corticosteroid in a patient with prior steroid-induced psychosis should be made only when absolutely necessary and after careful risk-benefit assessment 4
• Inhaled corticosteroids have fewer systemic side effects than oral corticosteroids but still carry some risk of systemic absorption 4
• Long-term oral corticosteroids should be avoided due to numerous side effects including psychiatric disorders 4
• Roflumilast, a phosphodiesterase-4 inhibitor, may be considered for prevention of future exacerbations in patients with chronic bronchitis and a history of exacerbations 4

Conclusion

For a patient with a history of prednisone-induced psychosis requiring treatment for COPD exacerbation, maximize bronchodilator therapy and consider antibiotics if indicated. If a corticosteroid is absolutely necessary, use methylprednisolone at the lowest effective dose for the shortest duration possible (5 days) with close monitoring for psychiatric symptoms.