medrol

Re: Medicines; Steroids; Methylprednisolone (Medrol tabs)
Fr: Pharmacia

• Properties
Group: synthetic glucocorticoids*
Effect: on inflammatory and immune process; also on carbohydrate, protein and fat metabolism; also act on cardiovascular system, skeletal muscles, and the CNS
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*properties of glucocortisoids:
(1) ANTI-INFLAMMATORY
(2) IMMUNOSUPRESSIVE
(3) ANTI-ALLERGIC

• Indications
A. Endocrine D/Os – adrenocortical insufficiency, congenital adrenal hyperplasia, nonsuppurative thyroiditis, hypercalcemia associates with cancer
B. Nonendocrine D/Os – rheumatic d/o (ex: rheumatoid arthritis), collagen d/e (ex: systemic lupus erythematosus), dermatologic d/e (ex: severe psoriasis), allergic states (ex: bronchial asthma), opthatmic d/e (ex: herpes zoster ophthalmicus), respiratory d/e (ex: aspiration pneumonitis), hematologic d/o (ex: RBC anemia), noeplastic d/e (ex: leukemias & lymphomas in adults), edematous states, gastrointestinal d/e (ex: ulcerative colitis), nervous system (ex: acute exacertabtions of MS), miscellaneous (ex: tuberculous meningitis), organ transplantation

• Dosage and administration
- Variable, individualized on the basis of d/e and px’s response
- Gradual withdrawal
- Constant monitoring needed
- Dosage adjustment situations:
(a) clinical status secondary to remissions or exacerbations
(b) px’s individual drug responsiveness
(c) “the effect of px exposure to STRESSFUL+ situations not directly related to the d/e….”
- ADT (alternate day therapy) to minimize undesirable effects, incl pituitary-adrenal suppression, the Cushingoid state*, corticoid withdrawal & growth suppression in children

• Contra-indications
- systemic fungal infections
- known hypersensitiviety to methylprednisolone

• Adverse reactions
- fluid & electrolyte disturbances – sodium retention, congestive heart failure in susceptible patients, hypertension, fluid retention, potassium loss and hypokalemic alkalosis
- musculoskeletal – steroid mypathy, muscle weakness, osteoporosis, pathologic fractures, vertebral compression fractures and aseptic necrosis
- gastrointestinal – peptic ulceration with possible perforation and hemorrhage, gastric hemorrhage, pancreatitis, esophagitis & perforation of the bowel
- dermatologic – impaired wound healing, petechiae & ecchymosis, & thin fragile skin
- metabolic – negative nitrogen balance due to protein catabolism
- neurological – increased intracranial pressure, pseudotumor cerebri, psychic derangements & seizures
- endocrine – menstrual irregularities, development of Cushingoid state*, suppression of pituitary-adrenal axis, decreased carbohydrate tolerace, manifestation of latent diabetes mellitus, increased requirements from insulin or oral hypoglycemic agents in diabetics & suppression of growth in children
- ophthalmic – posterior subcapsular cataracts, increased intraocular pressure and exophthalmos
- immune system – masking of infections, latent infections becoming active, opportunistic infections, hypersensitivity reactions during anaphylaxis & may suppress reactions to skin tests

• Special precaution
“In pxs on corticosteroid therapy subject to UNUSUAL STRESS+, in creased dosage of rapidly acting corticosteroids before, during & after the stressful situation is indicated.”
- there may be decreased resistance & inability to localize infection
- prolonged use may produce posterior subcapsular cataracts, glaucoma with possible damage to the optic nerves & may enhance the establishment of secondary ocular infections due to fungi or viruses
- allergic reactions (ex: angioedema) may occur
- may cause elevation of blood pressure, salt & water retention & increased excretion of potassium and calcium
- NB: no vaccination against smallpox & other immunization procedures while under therapy due to possible neurologic complications & lack of antibody response
- osteoporosis is a common but infrequently recognized adverse effect associated with a long-term use of large doses of glucocorticoids
- with impaired host defenses, susceptibility to fungus and bacterial and viral infections increases
- “Drug-induced 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….”
- psychic derangements may appear ranging from euphoria, insomnia, mood swings, personality changes & severe depression to frank psychotic manifestations. also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.
- “Corticosteroids should be used with caution in nonspecific ulcerative colitis if there is a probability of impending perforation, abscess or other pyogenic infection, verticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, renal insufficienty, hypertension, osteoporosis, or MYASTHENIA GRAVIS.
NB: “Because complications of treatment with glucocorticoids 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.”

• Pregnancy and lactation
- some animal studies showed fetal malformations when corticosteroids were administered to the mother at high doses

• Overdose
- no clinical syndrome of acute overdosage; repeated frequent doses over a protracted period may result in a Cushingoid state* & other complications or chronic steroid therapy.

• Storage
- room temperature below 25 degrees centigrade

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*Cushing’s Syndrome = A syndrome caused by an increased production of ACTH from a tumor of the adrenal cortex or of the anterior lobe of the pituitary gland, or by excessive intake of glucocorticoids. It is characterized by obesity and weakening of the muscles. [After Harvey Williams CUSHING = The American neurosurgeon Harvey Williams Cushing (1869-1939) who developed operative techniques that made brain surgery feasible..]
Cuhing's disease was first described by him. It is a disorder attributed to hyperactivity of the cortex of the adrenal glands and affects women more than men. The symptoms include obesity (moonface, an accumulation of fat at the back of the neck called buffalo hump, and abdominal protrusion), hypertension, hirsutism [abnormal hair growth], and easy bruisability. Treatment is by X-ray therapy if the pituitary body is involved or by surgical removal of one or both adrenal glands.
Symptoms of cortisol excess+ (resulting from medication or from the body's excess production of the hormone) include:
• weight gain
• an abnormal accumulation of fatty pads in the face (creating the distinctive "moon face" of Cushing's syndrome); in the trunk (termed "truncal obesity"); and over the upper back and the back of the neck (giving the individual what has been called a "buffalo hump")
• purple and pink stretch marks across the abdomen and flanks
• high blood pressure
• weak, thinning bones (osteoporosis)
• weak muscles
• low energy
• thin, fragile skin, with a tendency toward both bruising and slow healing
• abnormalities in the processing of sugars (glucose), with occasional development of actual diabetes
• kidney stones
• increased risk of infections
• emotional disturbances, including mood swings, depression, irritability, confusion, or even a complete break with reality (psychosis)
• irregular menstrual periods in women
• decreased sex drive in men and difficulty maintaining an erection
• abnormal hair growth in women (in a male pattern, such as in the beard and mustache area), as well as loss of hair from the head (receding hair line)
- sources: http://www.answers.com/topic/cushing-s-syndrome?cat=health, http://www.answers.com/topic/harvey-cushing?cat=health

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+cortisol = the “stress hormone”

personal comment:
today is 2007 oct 7 (feast of our lady of the rosary). coincidentally, it is also the death anniversary of the dr. Cushing (may his noble soul rest in peace!), the discoverer of Cushing’s disease and syndrome which reflect my medication’s (medrol or prednisone) side effects!