Application of glucocorticoids in clinical diseases.👀

The applications of glucocorticoids are very extensive and vary with the dose.
Glucocorticoids secreted under physiological conditions mainly affect the metabolism of substances. It will cause metabolic disorders and death when lacking. When glucocorticoids are pharmacological doses, in addition to affecting substance metabolism, it also have immunosuppressive , anti-inflammatory, detoxify and anti-shock effects.

1. Classification and difference of common glucocorticoids

According to the duration of action, glucocorticoids can be divided into three categories:

Category	Drug	Dose equivalent (mg)	Effective drug duration (hours)
Short-acting	Cortisone	25	8-12
	Hydrocortisone	20
Medium-acting	Prednisone	5	12-36
	Prednisolone	5
	Methylprednisolone	4
Long-acting	Dexamethasone	0.75	36-54
	Betamethasone	0.6

2. Glucocorticoid treatment course and withdrawal

Pulse therapy: The course of treatment is usually less than 5 days. It indicated for rescue of critically ill patients. The drug can be withdrawn quickly.

Short-term treatment: The course of treatment is less than 1 month. It indicated for infection or allergic diseases. Withdraw the drug by gradually reducing.

Medium-term treatment: The course of treatment is during within 3 months. It indicated for long term and multiple organ involvement disease. Withdraw the drug by gradually reducing.

Long-term treatment: The course of treatment is more than 3 months. It indicated for chronic autoimmune diseases, such as systemic lupus erythematosus. Before stopping the drug, the drug treatment should be gradually transitioned to alternate day therapy, then reduce the dose gradually and slowly.

Alternative therapy: Lifetime use. It indicated for primary or secondary chronic adrenocortical insufficiency.

3. Application of glucocorticoids in common diseases

Hyperthyroidism crisis: The level of thyroid hormones is sudden increase in the body. It is always related to the patients with insufficient treatment in severe or chronic hyperthyroidism. 

Treatment: Inorganic iodides, antithyroid drugs, β-receptor blockers and glucocorticoids (glucocorticoids can inhibit the conversion of peripheral T4 to T3).

Graves' ophthalmopathy: It is an organ-specific autoimmune disease related to the thyroid. It mainly manifests as exophthalmos, eyelid contracture, periorbital edema, bulbar conjunctival edema and eyeball activity dysfunction.

Treatment: For mild, the main treatment is to control hyperthyroidism or hypothyroidism. For moderate to severe, intravenous or oral glucocorticoid therapy is the main treatment.

Autoimmune hemolytic anemia: It is caused by lymphocytes function abnormally. Lymphocytes produce antibodies against the red blood cells, which accelerates the destruction of red blood cells in the body.

Treatment: For acute hemolytic attacks, intravenous infusion of dexamethasone or methylprednisolone is the first choice. Oral prednisone is the first choice for milder conditions (Taken in the morning).

Idiopathic thrombocytopenic purpura: The patient produces anti-platelet autoantibodies in the body.

Treatment: Glucocorticoids are the first choice. Immunosuppressants are needed for ineffectiveness and large doses of intravenous γ-globulin are used for severe bleeding.

Aplastic anemia: Abnormal activation and hyperfunction of T lymphocytes cause bone marrow damage.

Treatment: Antithymus/lymphocyte globulin (daily simultaneous application of glucocorticoids to prevent allergic reactions) and cyclosporine are commonly used.

Graft-versus-host disease: It is the most common complication of allogeneic hematopoietic stem cell transplantation and involving a variety of immune cells and inflammatory cytokines.

Treatment: For acute, use glucocorticoids (common use methylprednisolone and prednisone) combined with calcineurin inhibitors. For chronic, use cyclosporine A combined with glucocorticoids.

Nephrotic syndrome: It is characterized by massive proteinuria and it often accompanied by hypoalbuminemia (≤30g/L), edema and hyperlipidemia.

Treatment: Glucocorticoids or combined immunosuppressive agents (cyclophosphamide, cyclosporine A, mycophenolate mofetil, etc.).

Lupus nephritis: It refers to systemic lupus erythematosus complicated by kidney damage. It has varying clinical manifestations, such as hematuria, tubular urine, persistent proteinuria or decreased renal function.

Treatment: Oral glucocorticoid therapy is the main treatment. If it is necessary, glucocorticoid pulse therapy or other immunosuppressive agents should be added.

Adrenal crisis: Acute reduction of adrenal cortex function induced by infection, trauma and other stress conditions or withdrawal of hormones. It leads to high fever, drop in blood pressure and so on. 

Treatment: Intravenous infusion of glucocorticoid (hydrocortisone), correction of dehydration and electrolyte disturbances and treatment of hypoglycemia.

Systemic lupus erythematosus: It is an autoimmune-mediated diffuse connective tissue disease characterized by immune inflammation.

Treatment: For mild, use no or small doses glucocorticoids. For medium, glucocorticoids + other immunosuppressive agents (cyclophosphamide or mycophenolate mofetil). For severe conditions, it is required large doses of glucocorticoids + other immunosuppressive agents. If it is necessary pulse treatment, methylprednisolone can be used.

Bronchial asthma: Asthma is a chronic airway inflammatory disease involving a variety of cells and cellular components.

Treatment: Inhaled glucocorticosteroids (ICS) are the first choice for long-term treatment of asthma. For chronic severe persistent asthma that cannot be controlled by high-dose ICS + LABA (Long-acting beta-agonists, such as formoterol.), low-dose oral glucocorticoid maintenance therapy can be added. Generally use a short half-life glucocorticoids (such as prednisone.), and take it in the morning. 

Idiopathic pulmonary fibrosis (IPF): It is a chronic, progressive and fibrotic interstitial pneumonia of unknown etiology. The median survival time from diagnosis is only 2 to 3 years.

Treatment: Anti-fibrosis agents pirfenidone and nintedanib can delay the decline of pulmonary function in patients with IPF. Patients with acute exacerbations should be treated with glucocorticoids as appropriate and avoiding glucocorticoids in the stable phase is beneficial to prolong the natural progress of the disease.

Ulcerative colitis (UC): Inflammatory bowel disease refers specifically to inflammatory bowel disease of unknown etiology, including ulcerative colitis and Crohn's disease. The cause is unknown and there is no cure for the time being. The lesions of UC were distributed continuously.

Treatment: For mild, use aminosalicylic acid preparations (such as mesalazine). For moderate, adequate aminosalicylic acid preparations are not well controlled and switch to glucocorticoid therapy. Thiopurine drugs can be used for glucocorticoid-ineffective or dependent patients. If the above treatments are ineffective, it should consider using infliximab.

Crohn's disease: Crohn's disease is also an inflammatory bowel disease of unknown etiology and the lesions are distributed in segments.

Treatment: For mild, use aminosalicylic acid preparations (such as mesalazine). For moderate to severe, use glucocorticoid. For those who fail to treat glucocorticoids or sulfa drugs, switch to or add azathioprine, cyclosporine and other immunosuppressive agents Agent. If the above treatments are ineffective, consider using infliximab.

Ankylosing spondylitis: It is a chronic inflammatory disease that mainly affects the sacroiliac joints, spine, paraspinal soft tissues and peripheral joints. It may be accompanied by extra-articular manifestations. In severe cases, spinal deformity and rigidity can occur.

Treatment: First using the drugs  to improve symptoms and disease progress, such as NSAIDs, sulfasalazine and anti-TNFα antagonists. Systemic corticosteroid therapy is generally not recommended. Glucocorticoids are usually used as local adjuvant drugs to improve Symptoms (such as injection into the joint cavity).

Rheumatoid arthritis: It is an autoimmune disease with erosive arthritis as the main clinical manifestation. It can occur at any age.

Treatment: The first choice is methotrexate alone. If it does not achieve treatment effect, it combined with leflunomide, sulfasalazine, and tocilizumab. Patients with moderate/high disease activity, combined with glucocorticoid therapy to quickly control symptoms.

👉When taking glucocorticoids for a long time, calcium and active vitamin D should be supplemented regularly to prevent osteoporosis and femoral head necrosis.

👉Patients with long-term use of glucocorticoids should check their weight, blood pressure, blood lipids, blood sugar, electrolytes, growth and development regularly.