What are the indications for corticosteroids?

Indications for Corticosteroids

Corticosteroids are indicated for a broad range of inflammatory, autoimmune, allergic, and endocrine conditions, with specific indications varying by route of administration, potency, and disease severity. 1

Endocrine Disorders

• Primary or secondary adrenocortical insufficiency requires corticosteroid replacement, with hydrocortisone or cortisone as first-line agents; mineralocorticoid supplementation is particularly important in infancy 1
• Acute adrenocortical insufficiency is treated with hydrocortisone or cortisone as the drug of choice, with mineralocorticoid supplementation when synthetic analogs are used 1
• Shock unresponsive to conventional therapy when adrenocortical insufficiency exists or is suspected 1
• Congenital adrenal hyperplasia 1
• Nonsuppurative thyroiditis, hyperthyroid states including thyroid storm, subacute thyroiditis, and ophthalmopathy of Graves' disease 1, 2
• Hypercalcemia associated with cancer 1

Rheumatic and Musculoskeletal Disorders

• Rheumatoid arthritis (including juvenile rheumatoid arthritis) as adjunctive therapy for acute episodes or exacerbations; selected cases may require low-dose maintenance therapy 1
• Post-traumatic osteoarthritis, synovitis of osteoarthritis, acute and subacute bursitis, epicondylitis, acute nonspecific tenosynovitis 1
• Acute gouty arthritis, psoriatic arthritis, ankylosing spondylitis 1
• Corticosteroids provide moderate short-term benefit (several weeks) for reducing joint pain and improving function, though long-term effectiveness is limited 3

Collagen Vascular Diseases

• Systemic lupus erythematosus during exacerbation or as maintenance therapy in selected cases 1
• Acute rheumatic carditis 1

Inflammatory Bowel Disease

• Crohn's disease: Systemic corticosteroids are suggested for induction of remission in moderate to severe disease for no longer than 8 weeks 4
• Budesonide is suggested for mild ileocaecal Crohn's disease for not more than 12 weeks 4
• Corticosteroids are NOT recommended for maintenance of remission in Crohn's disease 4
• Ulcerative colitis (systemic therapy) and regional enteritis to tide patients over critical periods 1
• Chronic refractory pouchitis not responding to antibiotics or locally-acting corticosteroids may require advanced immunosuppressive therapies 4

Respiratory Diseases

• Community-acquired pneumonia (CAP): Use corticosteroids for 5-7 days at daily dose <400 mg IV hydrocortisone or equivalent in hospitalized patients 4
• Bronchial asthma: Control of severe or incapacitating allergic conditions intractable to conventional treatment 1
• Symptomatic sarcoidosis, berylliosis 1
• Fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy 1
• Loeffler's syndrome not manageable by other means, aspiration pneumonitis 1
• Pneumocystis carinii pneumonia in AIDS patients to decrease morbidity and incidence of respiratory failure 2
• Croup to reduce need for hospitalization 2
• Influenza: Corticosteroids are suggested AGAINST in hospitalized adults due to increased mortality (OR 3.06) and superinfection risk 4

Dermatologic Diseases

• Pemphigus, severe erythema multiforme (Stevens-Johnson Syndrome), exfoliative dermatitis 1
• Bullous dermatitis herpetiformis, severe seborrheic dermatitis, severe psoriasis, mycosis fungoides 1
• Contact dermatitis, atopic dermatitis 1

Allergic States

• Seasonal or perennial allergic rhinitis, drug hypersensitivity reactions, serum sickness 1
• Urticarial transfusion reactions 1
• Acute noninfectious laryngeal edema (epinephrine is the drug of first choice) 1

Ophthalmic Diseases

• Severe acute and chronic allergic and inflammatory processes involving the eye: herpes zoster ophthalmicus, iritis, iridocyclitis, chorioretinitis, diffuse posterior uveitis and choroiditis 1
• Optic neuritis, sympathetic ophthalmia, anterior segment inflammation 1
• Allergic conjunctivitis, keratitis, allergic corneal marginal ulcers 1

Hematologic Disorders

• Acquired (autoimmune) hemolytic anemia 1
• Idiopathic thrombocytopenic purpura in adults (IV only; IM administration is contraindicated) 1
• Secondary thrombocytopenia in adults, erythroblastopenia (RBC anemia), congenital (erythroid) hypoplastic anemia 1

Neoplastic Diseases

• Palliative management of leukemias and lymphomas in adults, acute leukemia of childhood 1

Renal Diseases

• Nephrotic syndrome: To induce diuresis or remission of proteinuria in the idiopathic type or that due to lupus erythematosus, without uremia 1
• Minimal change disease (MCD): Oral prednisone 1 mg/kg/day (maximum 80 mg) or alternate-day 2 mg/kg (maximum 120 mg) 4
• Focal segmental glomerulosclerosis (FSGS): Prednisone 1 mg/kg/day (maximum 80 mg) for minimum 4 weeks, up to maximum 16 weeks or until complete remission 4

Neurologic Conditions

• Tuberculosis meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy 1
• Trichinosis with neurologic or myocardial involvement 1
• Cerebral edema associated with primary or metastatic brain tumor, craniotomy, or head injury (not a substitute for neurosurgical evaluation) 1
• Meningitis caused by Haemophilus influenzae or Mycobacterium tuberculosis to reduce complications 2

Immune-Related Adverse Events from Cancer Immunotherapy

• Immune-related rheumatic and systemic symptoms: When symptomatic treatment (NSAIDs, analgesics) is insufficient, systemic glucocorticoids should be considered based on disease severity 4
• Arthritis: Median dosage 20 mg/day prednisone equivalent 4
• Vasculitis: Median initial dosage 60 mg/day 4
• Sarcoidosis: Median initial dosage 55 mg/day 4
• Scleroderma: Initial dosage 1 mg/kg/day 4
• Target maintenance dose ≤10 mg/day prednisone equivalent to minimize impact on antitumor response 4

Cardiopulmonary Bypass Surgery

• Corticosteroids are suggested in patients undergoing cardiopulmonary bypass surgery to reduce mortality (RR 0.84), atrial fibrillation (RR 0.80), superinfection (RR 0.64), delirium (RR 0.79), and respiratory failure (RR 0.69) 4

Hepatic Conditions

• Severe alcoholic hepatitis with concomitant encephalopathy may have decreased mortality with systemic steroids 2

Pain Management

• Neuropathic and cancer-related pain as adjuvant analgesics 2

Important Precautions and Contraindications

• Screen for tuberculosis before initiating therapy in high-risk patients 5
• Prophylaxis against Pneumocystis jiroveci pneumonia for patients receiving prednisone equivalent ≥20 mg/day for ≥4 weeks 5
• Fungal prophylaxis with fluconazole for patients receiving prednisone equivalent ≥20 mg/day for ≥6 weeks 5
• Use histamine-2 blockers or proton pump inhibitors during steroid therapy, especially with NSAIDs or anticoagulants 5
• Supplement with calcium and vitamin D to reduce osteoporosis risk in long-term therapy 5
• Monitor blood glucose regularly, especially in diabetic patients 5
• Avoid long-term use due to severe side effects including adrenal suppression, growth suppression, dermal thinning, hypertension, diabetes, Cushing syndrome, cataracts, muscle weakness, and impaired immune function 4