PRECAUTIONS
General
The lowest possible dose of corticosteroids should be used to control the condition under treatment.
When reduction in dosage is possible, the reduction should be gradual.
Since complications of treatment with corticosteroids are dependent on the size of the dose and the
duration of treatment, a risk/benefit decision must be made in each individual case as to dose and
duration of treatment and as to whether daily or intermittent therapy should be used.
Kaposi's sarcoma has been reported to occur in patients receiving corticosteroid therapy, most often for
chronic conditions. Discontinuation of corticosteroids may result in clinical improvement.
Cardio-Renal
As sodium retention with resultant edema and potassium loss may occur in patients receiving
corticosteroids, these agents should be used with caution in patients with congestive heart failure,
hypertension, or renal insufficiency.
Endocrine
Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of
dosage. This type of relative insufficiency may persist for months after discontinuation of therapy;
therefore, in any situation of stress occurring during that period, hormone therapy should be
reinstituted. Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should
be administered concurrently.
Gastrointestinal
Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal
anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation.
Signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids
may be minimal or absent.
There is an enhanced effect due to decreased metabolism of corticosteroids in patients with cirrhosis.
Musculoskeletal
Corticosteroids decrease bone formation and increase bone resorption both through their effect on
calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast
function. This, together with a decrease in the protein matrix of the bone secondary to an increase in
protein catabolism, and reduced sex hormone production, may lead to inhibition of bone growth in
pediatric patients and the development of osteoporosis at any age. Special consideration should be
given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating
corticosteroid therapy.
Neuro-Psychiatric
Although controlled clinical trials have shown corticosteroids to be effective in speeding the
resolution of acute exacerbations of multiple sclerosis, they do not show that they affect the ultimate
outcome or natural history of the disease. The studies do show that relatively high doses of
corticosteroids are necessary to demonstrate a significant effect. (see DOSAGE AND
ADMINISTRATION).
An acute myopathy has been observed with the use of high doses of corticosteroids, most often
occurring in patients with disorders of neuromuscular transmission (e.g., myasthenia gravis), or in
patients receiving concomitant therapy with neuromuscular blocking drugs (e.g., pancuronium). This
acute myopathy is generalized, may involve ocular and respiratory muscles, and may result in
quadriparesis. Elevation of creatinine kinase may occur. Clinical improvement or recovery after
stopping corticosteroids may require weeks to years.
Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia,
mood swings, personality changes, and severe depression, to frank psychotic manifestations. Also,
existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.
Ophthalmic
lntraocular pressure may become elevated in some individuals. If steroid therapy is continued for more
than 6 weeks, intraocular pressure should be monitored.
Carcinogenesis, Mutagenesis, Impairment Of Fertility
No adequate studies have been conducted in animals to determine whether corticosteroids have a
potential for carcinogenesis or mutagenesis.
Steroids may increase or decrease motility and number of spermatozoa in some patients.
Pregnancy
Teratogenic Effects
Pregnancy Category C
Corticosteroids have been shown to be teratogenic in many
species when given in doses equivalent to the human dose. Animal studies in which corticosteroids
have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in
the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids
should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Infants born to mothers who have received substantial doses of corticosteroids during pregnancy
should be carefully observed for signs of hypoadrenalism.
Nursing Mothers
Systemically administered corticosteroids appear in human milk and could suppress growth, interfere
with endogenous corticosteroid production, or cause other untoward effects. Because of the potential
for serious adverse reactions in nursing infants from corticosteroids, a decision should be made
whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug
to the mother.
Pediatric Use
The efficacy and safety of corticosteroids in the pediatric population are based on the well-established
course of effect of corticosteroids, which is similar in pediatric and adult populations. Published
studies provide evidence of efficacy and safety in pediatric patients for the treatment of nephrotic
syndrome (patients >2 years of age), and aggressive lymphomas and leukemias (patients >1 month of
age). Other indications for pediatric use of corticosteroids, e.g., severe asthma and wheezing, are based
on adequate and well-controlled trials conducted in adults, on the premises that the course of the
diseases and their pathophysiology are considered to be substantially similar in both populations.
The adverse effects of corticosteroids in pediatric patients are similar to those in adults (see
ADVERSE REACTIONS). Like adults, pediatric patients should be carefully observed with frequent
measurements of blood pressure, weight, height, intraocular pressure, and clinical evaluation for the
presence of infection, psychosocial disturbances, thromboembolism, peptic ulcers, cataracts, and
osteoporosis. Pediatric patients who are treated with corticosteroids by any route, including
systemically administered corticosteroids, may experience a decrease in their growth velocity. This
negative impact of corticosteroids on growth has been observed at low systemic doses and in the
absence of laboratory evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression (i.e.,
cosyntropin stimulation and basal cortisol plasma levels). Growth velocity may therefore be a more
sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used
tests of HPA axis function. The linear growth of pediatric patients treated with corticosteroids should
be monitored, and the potential growth effects of prolonged treatment should be weighed against
clinical benefits obtained and the availability of treatment alternatives. In order to minimize the potential
growth effects of corticosteroids, pediatric patients should be titrated to the lowest effective dose.
Geriatric Use
Clinical studies did not include sufficient numbers of subjects aged 65 and over to determine whether
they respond differently from younger subjects. Other reported clinical experience has not identified
differences in responses between the elderly and younger patients. In general, dose selection for an
elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the
greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other
drug therapy. In particular, the increased risk of diabetes mellitus, fluid retention and hypertension in
elderly patients treated with corticosteroids should be considered.