BNF for Children 2011-2012

BNFC 2011–2012 6.3.2 Glucocorticoid therapy 371In acute hypersensitivity reactions, such as angioedemaof the upper respiratory tract and anaphylaxis, corticosteroidsare indicated as an adjunct to emergency treatmentwith adrenaline (epinephrine) (section 3.4.3). Insuch cases hydrocortisone (as sodium succinate) byintravenous injection may be required.In the management of asthma, corticosteroids are preferablyused by inhalation (section 3.2) but systemictherapy along with bronchodilators is required for theemergency treatment of severe acute asthma (section3.1.1).Betamethasone is used in women at risk of pretermdelivery to reduce the incidence of neonatal respiratorydistress syndrome [unlicensed use].Dexamethasone should not be used routinely for theprophylaxis and treatment of chronic lung disease inneonates because of an association with adverse neurologicaleffects.Corticosteroids may be useful in conditions such asauto-immune hepatitis, rheumatoid arthritis, and sarcoidosis;they may also lead to remissions of acquiredhaemolytic anaemia (section 9.1.3) and thrombocytopenicpurpura (section 9.1.4).High doses of a corticosteroid (usually prednisolone) areused in the treatment of glomerular kidney disease,including nephrotic syndrome. The condition frequentlyrecurs; a corticosteroid given in high doses and forprolonged periods may delay relapse but the higherincidence of adverse effects limits the overall benefit.Those who suffer frequent relapses may be treated withprednisolone given in a low dose (daily or on alternatedays) for 3–6 months; the dose should be adjusted tominimise effects on growth and development. Otherdrugs used in the treatment of glomerular kidney diseaseinclude levamisole (section 5.5.2), cyclophosphamideand chlorambucil (section 8.1.1), and ciclosporin(section 8.2.2). Congenital nephrotic syndrome may beresistant to corticosteroids and immunosuppressants;indometacin (section 10.1.1) and an ACE inhibitorsuch as captopril (section 2.5.5.1) have been used.Corticosteroids can improve the prognosis of seriousconditions such as systemic lupus erythematosus andpolyarteritis nodosa; the effects of the disease processmay be suppressed and symptoms relieved, but theunderlying condition is not cured, although it mayultimately remit. It is usual to begin therapy in theseconditions at fairly high dose and then to reduce thedose to the lowest commensurate with disease control.For other references to the use of corticosteroids seePrescribing in Palliative Care (p. 18), section 8.2.2(immunosuppression), section 10.1.2 (rheumatic diseases),section 11.4 (eye), section 12.1.1 (otitis externa),section 12.2.1 (allergic rhinitis), and section 12.3.1 (aphthousulcers).AdministrationWhenever possible local treatment with creams, intraarticularinjections, inhalations, eye-drops, or enemasshould be used in preference to systemic treatment. Thesuppressive action of a corticosteroid on cortisol secretionis least when it is given as a single dose in themorning. In an attempt to reduce pituitary-adrenalsuppression further, the total dose for two days cansometimes be taken as a single dose on alternatedays; alternate-day administration has not been verysuccessful in the management of asthma (section 3.2).Pituitary-adrenal suppression can also be reduced bymeans of intermittent therapy with short courses. Insome conditions it may be possible to reduce the dose ofcorticosteroid by adding a small dose of an immunosuppressivedrug (section 8.2.1).Cautions and contra-indications ofcorticosteroidsAdrenal suppressionDuring prolonged therapy with corticosteroids, adrenalatrophy develops and can persist for years after stopping.Abrupt withdrawal after a prolonged period canlead to acute adrenal insufficiency, hypotension, ordeath (see Withdrawal of Corticosteroids, below). Withdrawalcan also be associated with fever, myalgia, arthralgia,rhinitis, conjunctivitis, painful itchy skin nodules,and weight loss.To compensate for a diminished adrenocorticalresponse caused by prolonged corticosteroid treatment,any significant intercurrent illness, trauma, or surgicalprocedure requires a temporary increase in corticosteroiddose, or if already stopped, a temporary reintroductionof corticosteroid treatment. To avoid aprecipitous fall in blood pressure during anaesthesia orin the immediate postoperative period, anaesthetistsmust know whether a patient is taking or has beentaking a corticosteroid. A regimen for corticosteroidreplacement may be necessary before and after surgery.Children on long-term corticosteroid treatment shouldcarry a Steroid Treatment Card (see p. 373) which givesguidance on minimising risk and provides details ofprescriber, drug, dosage and duration of treatment.InfectionsProlonged courses of corticosteroids increase susceptibilityto infections and severity of infections; clinicalpresentation of infections may also be atypical. Seriousinfections, e.g. septicaemia and tuberculosis, may reachan advanced stage before being recognised, and amoebiasisor strongyloidiasis may be activated or exacerbated(exclude before initiating a corticosteroid in thoseat risk or with suggestive symptoms). Fungal or viralocular infections may also be exacerbated (see alsosection 11.4.1).Chickenpox Unless they have had chickenpox, childrenreceiving oral or parenteral corticosteroids forpurposes other than replacement should be regardedas being at risk of severe chickenpox (see Steroid TreatmentCard). Manifestations of fulminant illness includepneumonia, hepatitis and disseminated intravascularcoagulation; rash is not necessarily a prominent feature.Passive immunisation with varicella–zoster immunoglobulin(section 14.5.2) is needed for exposed nonimmunechildren receiving systemic corticosteroids orfor those who have used them within the previous 3months. Confirmed chickenpox warrants specialist careand urgent treatment (section 5.3.2.1). Corticosteroidsshould not be stopped and dosage may need to beincreased.6 Endocrine system