- USES: Antiinflammatory agents used to treat a variety of clinical conditions, including adrenal insufficiency, asthma, various allergy disorders, and autoimmune disorders (eg, hemolytic anemia, rheumatoid arthritis, systemic lupus erythematosus). Corticosteroids are available in oral, parenteral, inhalational, and topical formulations. PHARMACOLOGY: Multiple mechanisms of action including anti-inflammatory activity, immunosuppressive properties, and antiproliferative actions. Anti-inflammatory effects result from decreased formation, release and activity of the mediators of inflammation (eg, kinins, histamine, liposomal enzymes, prostaglandins, leukotrienes) which reduced the initial manifestations of the inflammatory process. The immunosuppressive properties decrease the response to delayed and immediate hypersensitivity reactions (eg, type III and type IV). The antiproliferative effects reduce hyperplastic tissue characteristic of psoriasis. TOXICOLOGY: Corticosteroids decrease calcium absorption, increase calcium excretion, and inhibit osteoblast formation, leading to a decrease in bone formation and an increase in bone resorption, thereby contributing to the development of osteoporosis. EPIDEMIOLOGY: Acute toxicity following overdose is rare. OVERDOSE: Acute ingestion is rarely a clinical problem. Acute adrenal insufficiency rarely reported after overdose. ADVERSE EFFECTS: Cardiac dysrhythmias (ie, atrial fibrillation)(methylPREDNISolone), seizures (methylPREDNISolone), anaphylaxis. CHRONIC EXPOSURE: Cushingoid appearance, muscle wasting and weakness, hypertension, hyperglycemia, subcapsulary cataracts and glaucoma, osteoporosis, psychosis. ABRUPT WITHDRAWAL: Dysphoria, irritability, emotional liability, depression, fatigue, anxiety, depersonalization, myalgia, and arthralgia.
Range of Toxicity:
- TOXICITY: Acute ingestion is rarely a clinical problem; effects rarely occur with administration of less than three weeks duration. An adolescent ingested 30 mg dexamethasone and subsequently developed acute adrenal insufficiency. Patient recovered following administration of methylPREDNISolone. CHRONIC EXPOSURE: Six infants (aged 3 to 8 months) who were treated with large amounts (up to 10 tubes for 1.5 to 5 months) of topical corticosteroids for diaper dermatitis developed Cushing’s syndrome and adrenocortical insufficiency. Hepatomegaly and hepatosteatosis were observed in 5 and 3 patients, respectively. THERAPEUTIC DOSE: Varies with drug and indication.
- Support: MANAGEMENT OF TOXICITY: Treatment is symptomatic and supportive. Seizures have been reported with IV pulse methylPREDNISolone therapy. If seizures occur, administer IV benzodiazepines, barbiturates.
- Decontamination: PREHOSPITAL: Serious toxicity is not expected after ingestion of corticosteroids alone, and prehospital gastrointestinal decontamination is not routinely required. HOSPITAL: Significant toxicity is not expected after overdose; gastrointestinal decontamination is generally not necessary. Activated charcoal should be considered after extremely large ingestions or if more toxic coingestants are involved.
- Airway management: Endotracheal intubation and mechanical ventilation may be required in patients with severe allergic reactions, but this is rare.
- Antidote: None
- Acute allergic reaction: MILD/MODERATE: Monitor airway. Administer antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, corticosteroids, ECG monitoring and IV fluids.
- Monitoring of patient: Routine laboratory studies are not likely to be necessary after acute overdose. Serum electrolytes and glucose are useful to assess for adverse effects from chronic therapy. Monitor vital signs, fluid and electrolyte status as indicated. Monitor neurologic status as indicated in symptomatic patients. Plasma concentrations are not readily available or clinically useful in the management of overdose.
- Enhanced elimination procedure: Hemodialysis and hemoperfusion are UNLIKELY to be of value because of the high degree of protein binding and large volume of distribution.
- Patient disposition: HOME CRITERIA: Patients with a minor unintentional exposure who are asymptomatic or have mild symptoms can likely be managed at home. OBSERVATION CRITERIA: Moderate to severely symptomatic patients and those with deliberate overdose should be sent to a healthcare facility for evaluation and treated until symptoms resolve. ADMISSION CRITERIA: Patients who remain symptomatic despite adequate treatment should be admitted. CONSULT CRITERIA: Consult a Poison Center for assistance in managing patients with severe toxicity or in whom the diagnosis is unclear.