I. Basic principles of therapeutic application of glucocorticoids
Glucocorticoids are widely used in clinical practice, mainly for anti-inflammatory, anti-toxic, anti-shock and immunosuppression, and their application involves many clinical specialties. The application of glucocorticoids should be very cautious. The correct and rational application of glucocorticosteroids is the key to improving their efficacy and reducing adverse reactions. The correct and reasonable application mainly depends on the following two aspects: first, whether the therapeutic indications are accurate; second, whether the variety and drug delivery scheme are correct and reasonable.
(A) Strictly grasp the indications for glucocorticoid treatment.
Glucocorticoids are a class of drugs with a wide range of clinical indications, especially relative indications, but the clinical application is more arbitrary, and it is more common to administer them without strictly following the indications, such as using glucocorticoids simply for the purpose of reducing fever and relieving pain, especially for the purpose of reducing fever and relieving pain in infectious diseases. Glucocorticoids have pharmacological effects of suppressing autoimmunity, but they are not suitable for the treatment of all autoimmune diseases such as chronic lymphocytic infiltrative thyroiditis (Hashimoto’s disease), type 1 diabetes mellitus, and common psoriasis.
(B) Rational development of glucocorticoid treatment plan.
The glucocorticoid treatment plan should be formulated by integrating the patient’s condition and drug characteristics, and the treatment plan includes the choice of species, dose, course of treatment and route of administration. In this guideline, unless the route of administration is explicitly stated, all glucocorticosteroids are for systemic use, i.e. oral or intravenous administration.
1. Variety selection: The pharmacodynamic and human pharmacokinetic (absorption, distribution, metabolism and excretion processes) characteristics of various glucocorticoids are different, so they have different clinical indications.
2. Dosage: Physiological and pharmacological doses of glucocorticoids have different effects, and the dose should be selected according to different therapeutic purposes. It is generally believed that the dose (taking prednisone as an example) can be divided into the following cases: (1) long-term maintenance dose: 2.5~15.0 mg/d; (2) small dose: <0.5 mg/kg-1/d-1; (3) medium dose: 0.5~1.0 mg/kg-1/d-1; (4) large dose: >1.0 mg/kg-1/d-1; (5) impact dose: (taking methylprednisolone as an example) Dose: (for example, methylprednisolone) 7.5~30.0 mg・kg-1・d-1.
3. Duration of treatment: The duration of glucocorticoid treatment varies for different diseases and can be generally divided into the following cases.
(1) Shock therapy: The course of treatment is mostly less than 5 days. It is suitable for the rescue of critically ill patients, such as fulminant infection, anaphylaxis, severe asthma persistence, allergic laryngeal edema, lupus encephalopathy, severe herpetic skin disease, severe drug rash, acute nephritis, etc. Shock therapy must be combined with other effective therapeutic measures and can be stopped quickly. If it is ineffective in most cases, shock therapy must not be repeated within a short period of time.
(2) Short course of treatment: the course of treatment is less than 1 month, including stress treatment. It is suitable for infectious or allergic diseases, such as tuberculous meningitis and pleurisy, exfoliative dermatitis or acute rejection of organ transplantation. Short-course treatment must be combined with other effective therapeutic measures, and the dosage needs to be gradually reduced to discontinuation when stopping the drug.
(3) Medium course treatment: within 3 months of treatment. It is suitable for diseases with long duration and multi-organ involvement, such as rheumatic fever. After taking effect, reduce to the maintenance dose, and gradually decrease when stopping the drug.
(4) Long-term treatment: the course of treatment is more than 3 months. It is suitable for the prevention and treatment of rejection after organ transplantation and chronic autoimmune diseases with recurrent and multi-organ involvement, such as systemic lupus erythematosus, hemolytic anemia, systemic vasculitis, nodular disease, herpetic skin disease, etc. Maintenance therapy can be administered daily or every other day, and should also be gradually transitioned to every other day therapy before discontinuation.
(5) Lifetime replacement therapy: Applicable to primary or secondary chronic hyperalgesia, and appropriate dose increase in various stressful situations.
4. Route of administration: including systemic medication such as oral, intramuscular, intravenous or intravenous drip, and local medication such as inhalation, local injection, drip and application.
(C) Pay attention to the comprehensive treatment of the disease.
In many cases, glucocorticoid treatment is only a part of the comprehensive treatment of the disease, and should be combined with the actual situation of the patient and other treatments. For example, in patients with severe infections, glucocorticoids can be used for symptom relief if really needed under the premise of active and effective anti-infection treatment and various supportive treatments.
(iv) Monitor the adverse reactions of glucocorticosteroids.
The adverse reactions of glucocorticosteroids are obviously related to the variety, dose, course of treatment, dosage form and usage of the drug, and should be closely monitored during use, such as infection, metabolic disorders (water and electrolytes, blood sugar, blood lipids), weight gain, bleeding tendency, abnormal blood pressure, osteoporosis, femoral head necrosis, etc. The growth and development of pediatric patients should be monitored.
(E) Pay attention to the discontinuation reaction and rebound phenomenon.
Glucocorticoid reduction should be individualized under the premise of close observation of the condition and glucocorticoid response, and attention should be paid to the following phenomena that may occur.
1. Discontinuation reaction: When glucocorticosteroids are used for a long time in medium or large doses, too rapid a reduction or sudden discontinuation may lead to hyperalgesia-like symptoms, such as mental depression, fatigue, loss of appetite, joint and muscle pain in mild cases, fever, nausea, vomiting and hypotension in severe cases, and even adrenocortical crisis in critical cases, requiring timely rescue.
2. Rebound phenomenon: When glucocorticosteroids are used for a long time, too rapid reduction or sudden discontinuation may cause relapse or aggravation of the original disease, and glucocorticosteroid treatment should be resumed and the dose often needs to be increased, and then slowly reduced after stabilization.
Basic principles of glucocorticosteroid application in children, pregnancy and lactating women
(A) Application of glucocorticosteroids in children.
Long-term application of glucocorticosteroids in children should be strictly controlled and the treatment method should be appropriately selected. The glucocorticoid treatment plan should be determined according to age, weight (body surface area is better), severity of the disease and the response of the child to treatment. Close observation of adverse reactions should be paid attention to avoid or reduce the effects of glucocorticoids on the growth and development of the child.
(B) Application of glucocorticoids in women during pregnancy.
High-dose glucocorticosteroid users should not be pregnant. Glucocorticosteroids should be used with caution in pregnant women. For example, glucocorticoid replacement therapy should be adhered to during pregnancy in patients with chronic hyperalgesia and congenital adrenocortical hyperplasia, and glucocorticoid use can also be considered in severe herpes of pregnancy and gestational aspergillosis.
(C) Application of glucocorticoids in lactating women.
The application of physiological doses or maintenance doses of glucocorticoids in lactating women generally has no significant adverse effects on the infant. However, lactating women should not breastfeed if they are receiving moderate doses of glucocorticoids on an intermediate course treatment regimen to avoid adverse effects on the infant from glucocorticoids secreted through the breast milk.