Glucocorticoid

Glucocorticoids are defined as "a group of corticosteroids that affect carbohydrate metabolism (gluconeogenesis, liver glycogen deposition, elevation of blood sugar), inhibit adrenocorticotropic hormone secretion, and possess pronounced anti-inflammatory activity. These steroids also play a role in fat and protein metabolism, maintenance of arterial blood pressure, alteration of the connective tissue response to injury, reduction in the number of circulating lymphocytes, and functioning of the central nervous system."

Glucocorticoids are commonly used for treating rheumatological diseases and are categorised as disease-modifying antirheumatic drugs (DMARDs).

Dosage

Equivalent dosage calculators:

• http://www.globalrph.com/corticocalc.htm
• http://www-users.med.cornell.edu/~spon/picu/referenc/steroids.htm

Adverse effects

Drug toxicity from glucocorticoids is common. The European League Against Rheumatism (EULAR) has made recommenations on the avoidance of adverse effects from glucocorticoids. EULAR states that risk factors for adverse effects include "hypertension, diabetes, peptic ulcer, recent fractures, presence of cataract or glaucoma, presence of (chronic) infections, dyslipidemia and co-medication with non-steroidal anti-inflammatory drugs". EULAR recommends monitoring of "body weight, blood pressure, peripheral oedema, cardiac insufficiency, serum lipids, blood and/or urine glucose and ocular pressure".

Adrenal insufficiency

EULAR recommends:

• "All patients on glucocorticoid therapy for longer than 1 month, who will undergo surgery, need perioperative management with adequate glucocorticoid replacement to overcome potential adrenal insufficiency"
• "For moderate physical stress-inducing procedures, a single dose of 100 mg of hydrocortisone intravenously has been proposed, and for major surgery, 100 mg of hydrocortisone intravenously before anaesthesia and every 8 h 4 times thereafter. The dose can be gradually tapered by half per day afterwards."

Gastrointestinal toxicity

EULAR recommends:

• "Patients treated with glucocorticoids and concomitant non-steroidal anti-inflammatory drugs (NSAIDs) should be given appropriate gastro-protective medication, such as proton pump inhibitors (PPIs) or misoprostol, or alternatively could switch to a cyclo-oxygenase-2 selective inhibitor (coxib)."
• "For moderate physical stress-inducing procedures, a single dose of 100 mg of hydrocortisone intravenously has been proposed, and for major surgery, 100 mg of hydrocortisone intravenously before anaesthesia and every 8 h 4 times thereafter. The dose can be gradually tapered by half per day afterwards. However, several other schemes of GC-replacement exist."

Growth retardation in children

The European League Against Rheumatism (EULAR) recommends:

• "Children receiving glucocorticoids should be checked regularly for linear growth and considered for growth-hormone replacement in case of growth impairment."

Osteoporosis

The European League Against Rheumatism (EULAR) recommends:

• "patient is started on prednisone >=7.5 mg daily and continues on prednisone for more than 3 months, calcium and vitamin D supplementation should be prescribed".
• "Antiresorptive therapy with bisphosphonates to reduce the risk of glucocorticoid-induced osteoporosis should be based on risk factors, including bone-mineral density (BMD) measurement."

A more recent randomized controlled trial suggests that teriparatide improved bone mass more than alendronate does.