BNF for Children 2011-2012

506 10.1.2 Corticosteroids BNFC 2011–201210 Musculoskeletal and joint diseasesTablets, (Feldene Melt c ), piroxicam 20 mg, net price30-tab pack = £10.53. Label: 10, patient informationleaflet, 21Excipients include aspartame equivalent to phenylalanine 140 micrograms/tablet(section 9.4.1)Note Tablets may be halved [unlicensed] to give 10-mg dose;tablet placed on tongue and allowed to dissolve or may beswallowed10.1.2 Corticosteroids10.1.2.1 Systemic corticosteroidsThe general actions, uses, and cautions of corticosteroidsare described in section 6.3. In children with rheumaticdiseases corticosteroids should be reserved forspecific indications (e.g. when other anti-inflammatorydrugs are unsuccessful) and should be used only underthe supervision of a specialist.Systemic corticosteroids may be considered for themanagement of juvenile idiopathic arthritis in systemicdisease or when several joints are affected. Systemiccorticosteroids may also be considered in severe, possiblylife-threatening conditions such as systemic lupuserythematosus, systemic vasculitis, juvenile dermatomyositis,Behçet’s disease, and polyarticular joint disease.In severe conditions, short courses (‘pulses’) of highdoseintravenous methylprednisolone or a pulsed oralcorticosteroid may be particularly effective for providingrapid relief, and has fewer long-term adverse effectsthan continuous treatment.Corticosteroid doses should be reduced with carebecause of the possibility of relapse if the reduction istoo rapid. If complete discontinuation of corticosteroidsis not possible, consideration should be given to alternate-day(or alternate high-dose, low-dose) administration;on days when no corticosteroid is given, or a lowerdose is given, an additional dose of a NSAID may behelpful. In some conditions, alternative treatment usingan antimalarial or concomitant use of an immunosuppressantdrug, such as azathioprine, methotrexate orcyclophosphamide may prove useful; in less severeconditions treatment with a NSAID alone may be adequate.Administration of corticosteroids may result in suppressionof growth and may affect the development ofpuberty. The risk of corticosteroid-induced osteoporosisshould be considered for those on long-term corticosteroidtreatment (section 6.6); corticosteroids may alsoincrease the risk of osteopenia in those unable to exercise.For the disadvantages of corticosteroid treatmentsee section 6.3.2.10.1.2.2 Local corticosteroid injectionsCorticosteroids are injected locally for an anti-inflammatoryeffect. In inflammatory conditions of the joints,including juvenile idiopathic arthritis, they are given byintra-articular injection as monotherapy, or as anadjunct to long-term therapy to reduce swelling anddeformity in one or a few joints. Aseptic precautions(e.g. a no-touch technique) are essential, as is a clinicianskilled in the technique; infected areas should beavoided and general anaesthesia, or local anaesthesia,or conscious sedation should be used. Occasionally anacute inflammatory reaction develops after an intraarticularor soft-tissue injection of a corticosteroid.This may be a reaction to the microcrystalline suspensionof the corticosteroid used, but must be distinguishedfrom sepsis introduced into the injection site.Triamcinolone hexacetonide [unlicensed] is preferredfor intra-articular injection because it is almost insolubleand has a long-acting (depot) effect. Triamcinoloneacetonide and methylprednisolone may also be consideredfor intra-articular injection into larger joints, whilsthydrocortisone acetate should be reserved for smallerjoints or for soft-tissue injections. Intra-articular corticosteroidinjections can cause flushing and, in adults, mayaffect the hyaline cartilage. Each joint should usually betreated no more than 3–4 times in one year.A smaller amount of corticosteroid may also be injecteddirectly into soft tissues for the relief of inflammation inconditions such as tennis or golfer’s elbow or compressionneuropathies, which occur rarely in children. Intendinitis, injections should be made into the tendonsheath and not directly into the tendon (due to theabsence of a true tendon sheath and a high risk ofrupture, the Achilles tendon should not be injected).Corticosteroid injections are also injected into soft tissuesfor the treatment of skin lesions (see section 13.4).LOCAL CORTICOSTEROIDINJECTIONSCautions see notes above and consult product literature;see also section 6.3.2Contra-indications see notes above and consult productliterature; avoid injections containing benzylalcohol in neonates (see preparation below)Side-effects see notes above and consult productliteratureLicensed use triamcinolone acetonide not licensedfor use in children under 6 yearsIndication and doseSee under preparationsHydrocortisone acetateHydrocortistab c (Sovereign) AInjection (aqueous suspension), hydrocortisoneacetate 25 mg/mL, net price 1-mL amp = £5.72Dose. By intra-articular injection(for details consult product literature)Child 1 month–12 years 5–30 mg according to size ofchild and jointChild 12–18 years 5–50 mg according to size of childand jointNote Where appropriate may be repeated at intervals of21 days; not more than 3 joints should be treated on anyone dayMethylprednisolone acetateDepo-Medrone c (Pharmacia) AInjection (aqueous suspension), methylprednisoloneacetate 40 mg/mL, net price 1-mL vial = £2.87; 2-mLvial = £5.15; 3-mL vial = £7.47Depo-Medrone c with Lidocaine (Pharmacia) AInjection (aqueous suspension), methylprednisoloneacetate 40 mg, lidocaine hydrochloride 10 mg/mL,net price 1-mL vial = £3.28; 2-mL vial = £5.88