Patients on prolonged treatment with prednisolone and other corticosteroids can develop thinning of bone osteoporosis and an increased risk of bone fractures. Supplemental calcium and vitamin D are encouraged to slow this process of bone thinning. In some patients, medications used to treat osteoporosis may be prescribed. In rare individuals, destruction of large joints osteonecrosis can occur while undergoing treatment with prednisolone or other corticosteroids.
These patients experience severe pain in the involved joints, and can require replacement of joints. The reason behind such destruction is not clear.
Dosage requirements of corticosteroids vary among individuals and the diseases being treated. The usual starting dose range is 5 mg to 60 mg daily depending on the disease being treated. Ophthalmic prednisolone is contraindicated in cornea and conjunctiva fungal infections and most other infections and diseases of the cornea and conjunctiva. Herpes infection, measles, tuberculosis, varicella, viral infection Use of ophthalmic formulations is contraindicated in most forms of cornea and conjunctiva viral infection including epithelial herpes simplex keratitis dendritic keratitis , vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures.
Further, corticosteroid therapy can mask the symptoms of infection and should not be used in cases of viral or bacterial infection that are not adequately controlled by antiinfective agents. Prescribe ophthalmic or systemic therapy with caution, if at all, in patients with herpes infection.
Secondary infections have been reported during corticosteroid therapy see Adverse Reactions. Systemic corticosteroids can reactivate tuberculosis and should not be used in patients with a history of active tuberculosis except when chemoprophylaxis is instituted concomitantly. Patients receiving immunosuppressive doses of corticosteroids should be advised to avoid exposure to measles or varicella and, if exposed to these diseases, to seek medical advice immediately.
Myocardial infarction Corticosteroid therapy has been associated with left ventricular free-wall rupture in patients with recent myocardial infarction; therefore, prednisolone should be used cautiously in these patients. Heart failure, hypertension Corticosteroids cause edema, which can exacerbate congestive heart failure or hypertension; therefore, prednisolone should be used with caution in these patients. Cataracts, glaucoma, visual disturbance Corticosteroids should be used cautiously in patients with glaucoma or other visual disturbance.
Corticosteroids are well known to cause cataracts and can exacerbate glaucoma during long-term administration. Patients receiving topical or systemic prednisolone chronically should be periodically assessed for cataract formation.
Diverticulitis, GI disease, hepatic disease, inflammatory bowel disease, peptic ulcer disease, ulcerative colitis Corticosteroids should be used with caution in patients with GI disease, diverticulitis, intestinal anastomosis because of the possibility of perforation , or hepatic disease causing hypoalbuminemia such as cirrhosis. While used for the short-term treatment of acute exacerbations of chronic inflammatory bowel disease such as ulcerative colitis and Crohn's disease, prednisolone should not be used in patients where there is a possibility of impending GI perforation, abscess, or pyogenic infection.
Some patients may require long-term corticosteroid therapy to suppress disease activity, but generally this practice is not recommended. Corticosteroids should not be used in patients with peptic ulcer disease except under life-threatening circumstances.
Diabetes mellitus, hyperthyroidism, hypothyroidism, osteoporosis, psychosis, renal disease, seizure disorder, thyroid disease Prednisolone should be used with extreme caution in patients with psychosis, emotional instability, renal disease, osteoporosis, diabetes mellitus, or seizure disorder because the drugs can exacerbate these conditions. Cautious use is advised in patients with thyroid disease as corticosteroid clearance may be decreased in patients with hypothyroidism and increased in hyperthyroidism; consider dosage adjustments following thyroid status changes.
Myasthenia gravis Prednisolone should be used with caution in patients with myasthenia gravis or other neuromuscular disease. Corticosteroid-induced acute myopathy is reported more frequently in such patients and corticosteroids may interact with anticholinesterase agents see Interactions.
Muscle weakness can be transiently increased during the initiation of glucocorticoid therapy in patients with myasthenia gravis, necessitating respiratory support. Clinical improvement or recovery may require weeks to years following steroid discontinuation. Coagulopathy, thromboembolic disease Glucocorticoids rarely can increase blood coagulability and cause intravascular thrombosis, thrombophlebitis, and thromboembolism.
Therefore, prednisolone should be used with caution in patients with coagulopathy or thromboembolic disease. Pregnancy Prednisolone should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. There are no adequate well-controlled studies in pregnant women. Prednisolone has been shown to be teratogenic in mice when given in doses 1 to 10 times the human dose. Prednisolone and other corticosteroids were ocularly applied to both eyes of pregnant mice 5 times per day on days 10 through 13 of gestation and a significant increase in the incidence of cleft palate was observed in the fetuses of the treated mice.
Complications, including cleft palate, stillbirth, and premature birth, have been reported when systemic corticosteroids like prednisolone were administered chronically during pregnancy.
If these drugs must be used systemically during pregnancy, the potential risks should be discussed with the patient. Newborns born to women receiving large doses of corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency, and appropriate therapy should be initiated, if necessary.
Breast-feeding Systemic corticosteroids distribute into breast milk, and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects in nursing infants; some manufacturers of prednisolone advise a decision be made to discontinue the drug or to discontinue nursing. However, in clinical use, systemic use of prednisone and prednisolone is usually considered compatible with breast-feeding.
At higher daily prednisolone doses, avoidance of breast-feeding during times of peak milk concentrations can help limit infant exposure. Due to lowered systemic absorption, ophthalmic use of prednisolone poses little concern to the nursing infant and is considered compatible with breast-feeding. There are published case reports of systemic prednisolone use during pregnancy that indicate little risk to a nursing infant due to lack of reported side effects.
Peak concentrations in human milk appear in about 1 hour after a dose, and the total daily dose reaching the infant is approximately 0. Prednisone and methylprednisolone have similar data available regarding systemic use during lactation.
Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.
Children, growth inhibition, increased intracranial pressure, infants Although published studies include pediatric patients as young as 1 month of age for select diseases children more than 2 years for nephrotic syndrome and infants 1 month and older for aggressive lymphomas and leukemias , pediatric-specific issues should be considered prior to treatment initiation with systemic corticosteroids, such as prednisolone.
The potential for growth inhibition should be monitored during prolonged therapy, and the potential for growth effects should be weighed against the clinical benefit obtained and the availability of other treatment alternatives. Administration of corticosteroids to pediatric patients should be limited to the least amount compatible with an effective therapeutic regimen.
Further, children receiving corticosteroids are immunosuppressed and are therefore more susceptible to infection. Normally innocuous infections can become fatal in children receiving systemic corticosteroids, so care should be taken to avoid exposure to patients with infectious diseases. Like adults, pediatric patients may develop cardiovascular, ocular, emotional, gastrointestinal, and skeletal adverse events during therapy; monitoring is advised. Abrupt discontinuation, hypothalamic-pituitary-adrenal HPA suppression Pharmacologic doses of systemic corticosteroids, such as prednisolone, administered for prolonged periods may result in hypothalamic-pituitary-adrenal HPA suppression.
Acute adrenal insufficiency and even death may occur following abrupt discontinuation. Withdrawal from prolonged oral corticosteroid therapy should be gradual; HPA suppression can last for up to 12 months following cessation of therapy, and patients may need supplemental corticosteroid treatment during periods of physiologic stress, such as surgery, acute blood loss, or infection, even after the drug has been discontinued.
Also, a non-HPA withdrawal syndrome may occur following abrupt discontinuation of corticosteroid therapy, and is apparently unrelated to adrenocortical insufficiency. These effects are thought to be due to the sudden change in glucocorticoid concentration rather than due to low corticosteroid levels. Sulfite hypersensitivity Some commercially available formulations of prednisolone may contain sulfites.
Sulfites may cause allergic reactions in some people. They should be used with caution in patients with known sulfite hypersensitivity. Patients who are asthmatic are more likely to experience this sensitivity reaction than non-asthmatic patients.
Tartrazine dye hypersensitivity Some oral preparations of prednisolone contain tartrazine dye and should be used with caution in patients with a known tartrazine dye hypersensitivity. Patients allergic to aspirin are often at risk. Benzyl alcohol hypersensitivity, neonates, premature neonates Several commercial injections of prednisolone should be avoided in premature neonates because these products contain benzyl alcohol; these products should be used cautiously in patients with benzyl alcohol hypersensitivity.
Administration of benzyl alcohol to neonates can result in 'gasping syndrome,' which is a potentially fatal condition characterized by metabolic acidosis and CNS, respiratory, circulatory, and renal dysfunction. Cushing's syndrome Glucocorticoids like prednisolone can produce or aggravate Cushing's syndrome; monitoring is advised.
Further, use this medication with caution, if at all, in patients with pre-existing Cushing's disease. Vaccination Corneal abrasion, increased intraocular pressure, myopia, open-angle glaucoma Use ophthalmic and systemic corticosteroids with caution in those with pre-existing ophthalmic disorders.
Ophthalmic prednisolone should be used with caution in patients with corneal abrasion. Prednisolone can cause increased intraocular pressure; monitor intraocular pressure IOP in patients receiving ophthalmic products every 2—4 weeks for the first 2 months and every 1—2 months thereafter and in patients receiving systemic products monitor IOP periodically if therapy is continued beyond 6 weeks.
Patients with a history of open-angle glaucoma, diabetes mellitus, myopia, or Krukenberg's spindle may be at increased risk of developing ocular hypertension during therapy.
Bacterial keratitis has been reported in patients who have received ophthalmic preparations that were dispensed in multidose containers. This reaction most likely is due to contamination of the solution, so patients should be instructed not to allow the tip of the applicator to touch the eye or any other surfaces.
Contamination of ophthalmic preparations can lead to severe ocular infection, damage, and possible blindness. Geriatric Use systemic corticosteroids with caution in the geriatric patient; the risks and benefits of therapy should be considered for any individual patient.
According to the Beers Criteria, systemic corticosteroids are considered potentially inappropriate medications PIMs for use in geriatric patients with delirium or at high risk for delirium and should be avoided in these patient populations due to the possibility of new-onset delirium or exacerbation of the current condition.
The Beers expert panel notes that oral and parenteral corticosteroids may be required for conditions such as exacerbation of chronic obstructive pulmonary disease COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. According to the OBRA guidelines, the need for continued use of a glucocorticoid, with the exception of topical or inhaled formulations, should be documented, along with monitoring for and management of adverse consequences.
Intermediate or longer-term use may cause hyperglycemia, psychosis, edema, insomnia, hypertension, osteoporosis, mood lability, or depression. Contact lenses Instruct patients to avoid wearing soft contact lenses prior to application of prednisolone ophthalmic suspension.
The suspension contains benzalkonium chloride, which may be absorbed by soft contact lenses; the lenses may be reinserted 15 minutes following its administration. Moderate Concomitant use of immunosuppressives, as well as long-term corticosteroids, may potentially increase the risk of serious infection in abatacept treated patients. Advise patients taking abatacept to seek immediate medical advice if they develop signs and symptoms suggestive of infection.
While there is controversy regarding the ulcerogenic potential of corticosteroids alone, concomitant administration of corticosteroids with aspirin may increase the GI toxicity of aspirin and other non-acetylated salicylates. Withdrawal of corticosteroids can result in increased plasma concentrations of salicylate and possible toxicity. Although some patients may need to be given corticosteroids and NSAIDs concomitantly, which can be done successfully for short periods of time without sequelae, prolonged coadministration should be avoided.
Moderate Coadministration may result in decreased exposure to prednisolone. Monitor for decreased response to prednisolone during concurrent use. Acetaminophen; Butalbital; Caffeine; Codeine: Acetaminophen; Caffeine; Magnesium Salicylate; Phenyltoloxamine: Acetaminophen; Caffeine; Phenyltoloxamine; Salicylamide: Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: Moderate The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone.
Monitor patients for increased pressor effect if these agents are administered concomitantly. Acetaminophen; Chlorpheniramine; Phenylephrine; Phenyltoloxamine: Basic principles and indications for corticosteroid therapy should apply. The benefits of alternate-day therapy should not encourage the indiscriminate use of steroids. Alternate-day therapy is a therapeutic technique primarily designed for patients in whom long-term pharmacologic corticoid therapy is anticipated.
In less severe disease processes in which corticoid therapy is indicated, it may be possible to initiate treatment with alternate-day therapy. More severe disease states usually will require daily divided high dose therapy for initial control of the disease process. The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases.
It is important to keep the period of initial suppressive dose as brief as possible particularly when subsequent use of alternate-day therapy is intended. Once control has been established, two courses are available: Theoretically, course a may be preferable. Because of the advantages of alternate-day therapy, it may be desirable to try patients on this form of therapy who have been on daily corticoids for long periods of time e. While on corticosteroid therapy, patients should not be vaccinated against smallpox.
Other immunization procedures should not be undertaken in patients who are on corticosteroids, especially on high dose, because of possible hazards of neurological complications and a lack of antibody response. Persons who are on drugs which suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in non-immune children or adults on corticosteroids. In such children or adults who have not had these diseases, particular care should be taken to avoid exposure.
How the dose, route and duration of corticosteroid administration affects the risk of developing a disseminated infection is not known.
If exposed to chickenpox, prophylaxis with varicella zoster immune globulin VZIG may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin IG may be indicated. If chickenpox develops, treatment with antiviral agents may be considered.
These tests may include: Blood tests, such as tests to check your blood sugar levels. Prednisone can increase your blood sugar level and raise your risk of diabetes. Prednisone can increase your risk for bone loss and osteoporosis weak and brittle bones. Prednisone can increase pressure inside your eyes. Keep the container tightly closed and away from light.
Travel When traveling with your medication:
Corticosteroid-induced acute myopathy is reported more frequently in such patients and corticosteroids may interact with anticholinesterase agents see Interactions. Talk to your doctor if you have questions about whether this medication is working. It is important to prednisolone the period of child suppressive dose as brief as possible particularly when subsequent use of alternate-day therapy is intended. Moderate A dose adjustment of prednisolone may be necessary when administered concurrently with rifamycins, due to the potential for decreased exposure of prednisolone, prednisolone daily children. Persons who are on drugs which suppress the immune system are more susceptible to infections than daily individuals. In multiple sclerosis MS clinical trials, an increase in children was seen in patients concurrently receiving short prednisolones of corticosteroids. Many of the serious prednisolones occurred in patients on immunosuppressive therapy who received certolizumab. Coagulopathy, prednisolone daily children, thromboembolic disease Glucocorticoids rarely can increase blood coagulability and cause intravascular thrombosis, prednisolone daily children, thrombophlebitis, and thromboembolism. Travel When traveling with your medication: Patients receiving topical or systemic prednisolone chronically should be periodically assessed for cataract formation. Normally the HPA system is characterized by diurnal circadian rhythm. Combining aspirin or other nonsteroidal anti-inflammatory drugs NSAIDs and corticosteroids increases the risk of daily side effects. Elevation of creatine kinase may occur. While therapy is daily to take advantage of this effect, patients may be predisposed to over-immunosuppression resulting in an increased child for the development of severe infections. The maximal activity of the adrenal cortex is between 2 a. Major Desmopressin, when used in the treatment of nocturia is contraindicated with corticosteroids because of the risk of azithromycin can useful treating hyponatremia. Bismuth Subsalicylate; Metronidazole; Tetracycline:
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