steroid therapy

1. Steroid therapy
in children
Dr. Devendra Nargawe

2. Corticosteroids
 The adrenal gland secrets steroidal
hormones which have glucocorticoid,
mineralocorticoid and weakly
androgenic activities.
 Conventionally ,the term corticosteroid
includes natural gluco- and mineralo-
cortcoids and their synthetic analogues.

3. Stimuli Part Principal
product
Angiotensin II Zona
glomerulosa
ACTH Zona fasiculata
& reticularis
Sympathetic
nervous
system
Medulla
Synthesis of corticosteroids
Mineralo-
corticoids
Gluco- corticoids
Adrenaline &
Nor-adrenaline

5. Types of Steroids
Glucocorticoids
• Short acting:(<12hr)
hydrocortisone
• Intermediate acting:
(12-36hr)
• Prednisolone
• methylprednisolone
• triamcinolone
• Long acting: (>36hr)
dexamethasone
Mineralocorticoids
• Aldosterone
• Fludrocortisone
• desoxycorticosterone
acetate

6. Mineralocorticoids Action
•Enhancement of
sodium reabsorption
in the DCT in kidney
•Increase in potassium
and H+ excretion.
Mineralo-
corticoids

7. Glucocorticoids actions
•Promoting gluconeogenesis
•Inhibit glucose utilization by peripheral
tissues
•Increase protein breakdown and
mobilization of amino acid from
peripheral tissues
On
carbohydrate
and protein
metabolism
•Promote lipolysis due to glucagon
growth hormone, thyroxine and cAMP
induced breakdown of triglycerides is
enhanced.
On fat
metabolism
•Inhibit intestinal absorption and
enhance renal excretion of calcium.
on calcium
metabolism

8. •Enhance secretary activity of renal
tubules
On water
excretion
• Restrict capillary permeability
• Maintain tone of arterioles and myocardial
contractility
• When applied topically , they cause
cutaneous vasoconstriction
On CVS
• Optimum levels are needed for normal
muscular activity
On skeletal
muscles
• Maintain the level of sensory perception
and normal excitability of neurons.On CNS

9. • Increase Secretion of gastric acid
and pepsinStomach
• Enhance the rate of destruction of
lymphoid cells
• Increase the number of RBCs ,
platelet and neutrophils in
circulation.
• Decrease lymphocytes, eosinophils
and basophils
Lymphoid
tissue and
blood
cells

10. •Covers all stage of inflammation . This
include reduction of – increased capillary
permeability , local exudation, cellular
infiltration, phagocytic activity and late
events like capillary proliferation, collagen
deposition, fibroblastic activity and
ultimately scar formation.
•Cardinal signs of inflammation – redness,
heat, swelling and pain are suppressed .
Inflammatory
responses

11. Anti-inflammatory actions of corticosteroids
Corticosteroid inhibitory effect

12. •Suppress all type of hyper
sensitization and allergic
phenomena
•Suppression of recruitment of
leukocytes at the site of contact
with antigen and of inflammatory
response to immunological injury.
•Suppression of CMI in which T-
cells are primarily involved.
Immunological
and allergic
responses

14. • Inhibit cell division or synthesis of
DNA
• Delay the process of healing
• Retard the growth of children
Growth
and Cell
division

15. Therapeutic
Indications For
The Use Of
corticosteroids

16. Rheumatic disease of
childhood
• Indicated only in severe cases as adjusents to
NSAIDs when distress and disability persists
despite of other measures.
Rheumatic arthritis
• Corticosteroids are used only in severe cases with
carditis and CHF.Rheumatic fever
• In stable child – oral prednisolone 2 mg/kg/day
• Children with GIT involvement iv methyl
prednisolone 30mg/kg/day (max.1g/day)
Juvenile
dermatomyositits
• Induction period – oral pred. until manifestation
improved
• Than gradually tapered in 6 -12 month
Sarcoidosis
• Oral prednisone improves only GI symptoms and
joint pain.HSP

17. Rheumatic disease of
childhood
•Significant manifestation of SLE ; iv
methylprednisolone (30mg/kg/day) or
prednisolone 2 mg/kg/day
Systemic lupus
erythematosus
•Oral prednisone or iv methyl prednisolone pulse
therapy typically used.
Polyarteritis
nodosa
•Superficial morphea – topical steroids
•Lesions involving deeper structures- systemic
therapy( iv methyl pred. 30mg/kg/day or oral
pred. 0.5-2 mg/kg/day) includes 3 consecutive
days in a month for 3 months.
Scleroderma

18. Allergic reactions
•Intranasal spray of
beclomethasone and budesonide
used in severe cases.
Allergic
rhinitis
•Severe serum sickness require
systemic cortcosterids
Serum
sickness
•Delayed pressure urticaria requires
oral corticosteroidsUrticaria

19. Hematological disorders
• In ITP oral therapy induce rapid rise in
platelet count than untreated pt.
Idiopathic
Thrombocytopenic
Purpura
• Glucocorticoids reduce hemolysis by
blocking macrophage function, decreasing
autoantibody and enhancing elution of
antibody from the RBCs.
• 2mg/kg/day till rate of hemolysis decrease.
Auto Immune
Hemolytic Anemia
• Due to lymphocytic action of
corticosteroids are an essential component
of combined chemotherapy in ALL
,Hodgkin’s and other lymphoma.
Malignancies

20. Bronchial asthma
•Iv hydrocortisone 10mg/kg stat
followed by 5mg/kg/dose 6
hourly
Status
asthmatcus
• Short course of intermediate acting
CS (over several weeks to months),
should be considered with close
monitoring of patient’s symptoms
and lung function.
Acute asthma
exacerbation
• ICS therapy used for severe persistent
asthma
• Budesonide DPI/ suspension for
nebulization available
• Acc. To NIH guidelines
• Step-2 –low dose ICS (0.25-.5
mg/day)
• step 3&4 –medium dose ICS (>0.5-
1mg/day)
• step 5&6 – high dose ICS ( 1-2
mg/day)
Severe
chronic
asthma

21. Other lung disease
• Decrease the edema in the laryngeal
mucosa through anti-inflammatory action
• Dexamethasone 0.6mg/kg single dose or
nebulized with budesonide for 8 days.
Croup
•Decrease edema of laryngeal
mucosa through anti-
inflammatory action.
Pulmonary
edema due
to drowning
Infants with RDS who require
respiratory support or who develop
BPD required systemic corticosteroids

22. Neurologic disorders
Cerebral edema
• Corticosteroids limits the production of
inflammatory mediators which reduce risk of
additional neurologic injury with worsening of
CNS signs and symptoms
• Iv dexamethasone 0.15mg/kg/dose 6 hourly
Multiple sclerosis
• Methyl prednisolone 20-30mg/kg/day for
5days followed by with or without prednisone.

23. Infections
Tuberculosis
In tuberculous meningitis
Endobronchial tuberculosis
Pericardial effusion
Severe miliary tuberculosis
Prescribed regimen is prednisone 1-
2mg/kg/day in 2 divided doses for 4 -6
weeks followed by tapering dose.

24. Eye disease
•Allergic conjunctivitis
•Iritis
•Iridocyclitis
•Keratitis
Topical
uses
•Retinitis
•Optic neuritis
•uveitis
Systemic
uses

25. Skin disorders
Topical corticosteroids are potent anti-inflammatory
agents
They are divided into 4 categories on the basis of
strength
 low- hydrocortisone, desonide and hydrocortisone
butyrate
 Medium –amcinonide , betamethasone cream 0.05%,
flurandrenoilde, flucinolone 0.025% oint. , momitasone
 High –fluocinonide 0.05% gel & halcinonide
 Super potent – betamethasone dipropionate 0.05%
and clobetasol 0.05% gel

26. Skin disease
 Hemangioma – oral prednisolone
 Atopic dermatitis – topical medium potent corticosteroid
 Vitiligo – topical steroids
 toxic epidermal necrolysis- oral prednisolone
 pemphigus vulgaris –iv methyl prednisolone 1-2 mg/kg/day
 Pemphigus foliaceus- topical steroids
 bullous phemphigoid- iv methyl prednisolone 1-2 mg/kg/day
 linear IgA dermatosis- oral therapy with methyl prednisolone 1-2
mg/kg/day for 2 -4 years .
 Contact dermatitis ( massive acute bullous reactions )- oral
corticosteroids for 2 weeks (1mg/kg/day)
 Linchen simplex chronicus – topical steroids.
 Seborrheic dermatitis (inflamed lesions) –low potency steroids
 Psoriasis – topical steroids used in 1st tier therapy.

27. Renal disease
• 2mg/kg/ day (60mg/m2 /day) for initial
6 week than 1.5mg/kg/day(40mg/m2
/day) alternate day
Minimal change
Nephrotic
syndrome
• Immunosuppressive therapy with
corticosteroids may be beneficialIgA nephropathy
• Immunosuppressive therapy with
prednisolone
membranous
glomerulopathy
• High dose methyl prednisolone with
cyclophosphamide and
plasmapheresis.
Goodpasture
disease

28. Miscellaneous
In acute exacerbations of crohn disease
because they effectively suppress acute
inflammation, rapidly relieving symptoms.
Prednisone 1-2mg/kg/day
Organ transplantation and skin allograft
In thyroid strom- in which corticosteroids reduce
peripheral T4 to T3 coversion.
Neurocystisercosis- oral prednisolone
1.5mg/kg/day for 2-4 weeks suppress the reaction
to the dying larvae, After kill the cysticerci by
albendazole/preziquental.

29. Adverse Effects

31. •Sodium and water
retention
•Edema
•Hypokalemic alkalosis
•Progressive rise in
plod pressure
Mineralo-
corticoids

32. • Cushing’s habitus
• Fragile skin , purple striae
• Hyperglycemia
• Muscular weakness
• Susceptibility of infection
• Delayed healing
• Peptic ulceration
• Osteoporosis
• Posterior subcapsular
cataract
• Glaucoma
• Growth retardion
• Pshychiatric disturbance
• Suppression of
hypothalamo-pituitary-
adrenal axis
Gluco-
corticoids

33. Contraindications
• Peptic ulcer
• Diabetes mellitus
• Hypertension
• Viral and fungal infections
• Tuberculosis and other
infections
• Osteoporosis
• Herpes simplex keratitis
• Psychosis
• Epilepsy
• Congestive heart failure
• Renal failure
The following
diseases are
aggravated by
corticosteroids.
All of these are
relative
contraindications

34. References
Essentials of medical pharmacology –KD Tripathi
7th edi.
Nelson textbook of pediatrics -19th edi.
Essential pediatrics – OP Ghai 8th edi.
Basic and Clinical Pharmacology Katzung 13 edi.
Goodman and Gilman's The Pharmacological Basis
of Therapeutics 12th Ed. (2011)

35. Thank you