PH7.5 | PH7.5 | Corticosteroid Pharmacotherapy — SDL Guide — Summary & Reflection

KEY TAKEAWAYS

Corticosteroid Pharmacotherapy — Key Takeaways:

• Potency ranking (relative to hydrocortisone=1): hydrocortisone (GC1, MC1) → prednisolone (GC4, MC0.8) → methylprednisolone (GC5, MC0.5) → dexamethasone (GC25–30, MC≈0) → fludrocortisone (GC10, MC125 — mineralocorticoid).
• Dexamethasone: preferred for cerebral oedema, anti-emetic, fetal lung maturation adjunct (betamethasone for fetal surfactant), COVID-19 (RECOVERY trial) — negligible mineralocorticoid activity.
• Mechanism: GR nuclear transactivation (annexin A1 → inhibit PLA2 → block prostaglandins/leukotrienes) + transrepression (NF-κB/AP-1 → inhibit IL-1/IL-6/TNF-α/COX-2).
• ADR prevention: three mandatory concurrent prescriptions for long-term high-dose steroids: bisphosphonate + calcium/vitamin D (GIO) + PPI (GI).
• HPA suppression: >3 weeks → MUST taper; never stop abruptly. Stress-dose doubles for surgery/illness.
• Steroid card/bracelet: every patient on steroids >2 weeks must have written identification for emergency situations.
• Inhaled steroids: rinse mouth (oral candidiasis); dysphonia; systemic effects minimal but possible at high doses.

REFLECT

Imagine you are a junior doctor in a general medicine ward. You prescribed prednisolone 40 mg/day for a patient 6 weeks ago for severe Crohn's disease. The patient has been stable and you want to step down treatment. Write: (1) your tapering plan (how many mg per week?), (2) what you would co-prescribe if not already started, (3) what patient education you would provide including what to do if they have a fever or need surgery. Now reflect: a colleague insists 'we don't need to taper — she feels fine.' How do you explain the pharmacological basis for why 6 weeks of steroids requires a taper even in a clinically well patient?