Corticosteroids TENOXICAM
10.1.2 Corticosteroids TENOXICAM
Indications pain and inflammation in rheumatic dis- ease and other musculoskeletal disorders
10.1.2.1 Systemic corticosteroids
Cautions see notes above; breast-feeding (Appendix 5); interactions: Appendix 1 (NSAIDs)
The general actions, uses, and cautions of corticoster- Contra-indications
oids are described in section 6.3. Treatment with corti- see notes above
costeroids in rheumatic diseases should be reserved for
Side-effects see notes above specific indications, e.g. when other anti-inflammatory Dose
drugs are unsuccessful. Corticosteroids can induce
Musculosk
. By mouth , rheumatic disease, 20 mg daily; CHILD not osteoporosis, and prophylaxis should be considered on recommended
long-term treatment (section 6.6). Acute musculoskeletal disorders, 20 mg daily for 7
In severe, possibly life-threatening, situations a high days; max. duration of treatment 14 days (including
initial dose of corticosteroid is given to induce remission
eletal
treatment by intravenous or intramuscular injection); and the dose is then reduced gradually and discontinued CHILD not recommended
altogether. Relapse may occur as the dose of cortico- . By intravenous or intramuscular injection , initial
steroid is reduced, particularly if the reduction is too
and
treatment for 1–2 days if oral administration not rapid. The tendency is therefore to increase the main- possible, 20 mg once daily; CHILD not recommended
joint
tenance dose and consequently the patient becomes
Tenoxicam (Non-proprietary) A dependent on corticosteroids. For this reason pulse Injection , powder for reconstitution, tenoxicam, net
doses of corticosteroids (e.g. methylprednisolone up to
diseases
1 g intravenously on 3 consecutive days) are used to Mobiflex c
price 20-mg vial = £3.98
suppress highly active inflammatory disease while long- (Roche) A er-term treatment with a disease-modifying drug is
Tablets , yellow, f/c, tenoxicam 20 mg, net price 30-
commenced.
tab pack = £12.92. Label: 21 Prednisolone 7.5 mg daily may reduce the rate of joint destruction in moderate to severe rheumatoid arthritis of
less than 2 years’ duration. The reduction in joint Indications
TIAPROFENIC ACID
destruction must be distinguished from mere sympto- pain and inflammation in rheumatic dis-
matic improvement (which lasts only 6 to 12 months at ease and other musculoskeletal disorders
this dose) and care should be taken to avoid increasing Cautions see notes above; breast-feeding (Appendix
the dose above 7.5 mg daily. Evidence supports main- 5); interactions: Appendix 1 (NSAIDs)
tenance of this anti-erosive dose for 2–4 years only after Contra-indications see notes above; also active
which treatment should be tapered off to reduce long- bladder or prostate disease (or symptoms) and history
term adverse effects.
10.1.2 Corticosteroids BNF 57 Polymyalgia rheumatica and giant cell (temporal) arteritis
LOCAL CORTICOSTEROID
are always treated with corticosteroids. The usual initial
dose of prednisolone in polymyalgia rheumatica is 10–
INJECTIONS
15 mg daily and in giant cell arteritis 40–60 mg daily (the Indications local inflammation of joints and soft tis- higher dose being used if visual symptoms occur).
sues (for details, consult product literature) Treatment should be continued until remission of dis-
Cautions see notes above and consult product litera- ease activity and doses are then reduced gradually to
ture; see also section 6.3.2 about 7.5 –10 mg daily for maintenance. Relapse is
common if therapy is stopped prematurely. Many Contra-indications see notes above and consult pro- patients require treatment for at least 2 years and in
duct literature; avoid injections containing benzyl some patients it may be necessary to continue long-
alcohol in neonates (see preparations below) term low-dose corticosteroid treatment.
Side-effects see notes above and consult product
literature
Polyarteritis nodosa and polymyositis are usually treated
Dose
with corticosteroids. An initial dose of 60 mg of pred- nisolone daily is often used and reduced to a mainte-
. See under preparations nance dose of 10–15 mg daily. Systemic lupus erythematosus is treated with corticoster-
Betamethasone oids when necessary using a similar dosage regimen to c Betnesol (UCB Pharma) A
that for polyarteritis nodosa and polymyositis (above). Injection , betamethasone (as sodium phosphate) Patients with pleurisy, pericarditis, or other systemic
4 mg/mL, net price 1-mL amp = £1.22. manifestations will respond to corticosteroids. It may
then be possible to reduce the dosage; alternate-day Dose calculated as dexamethasone treatment is sometimes adequate, and the drug may be
Dexamethasone (Organon) A s gradually withdrawn. In some mild cases corticosteroid
Injection , dexamethasone 4 mg/mL (as sodium treatment may be stopped after a few months. Many
phosphate) (: dexamethasone sodium phosphate mild cases of systemic lupus erythematosus do not
5.2 mg/mL : dexamethasone phosphate 4.8 mg/ disease require corticosteroid treatment. Alternative treatment
mL), net price 1-mL amp = 83p; 2-mL vial = £1.27 with anti-inflammatory analgesics, and possibly chloro-
Dose by intra-articular or intrasynovial injection (for details quine or hydroxychloroquine, should be considered.
consult product literature), 0.6–3 mg (calculated as dexa-
joint
methasone) according to size; where appropriate may be repeated Ankylosing spondylitis should not be treated with long-
at intervals of 3–21 days according to response
and term corticosteroids; rarely, pulse doses may be needed and may be useful in extremely active disease that does not respond to conventional treatment.
Dose calculated as dexamethasone phosphate Dexamethasone (Hospira) A
eletal
Injection , dexamethasone phosphate 4 mg/mL (as sodium phosphate) (: dexamethasone 3.3 mg/mL :
ulosk
10.1.2.2 dexamethasone sodium phosphate 4.4 mg/mL), net Local corticosteroid injections
price 1-mL amp = £1.00; 2-mL vial = £1.98
Musc
Dose by intra-articular or intrasynovial injection (for details Corticosteroids are injected locally for an anti-inflamm-
consult product literature), 0.4–4 mg (calculated as dexa- atory effect. In inflammatory conditions of the joints,
methasone phosphate) according to size ( 10 by soft-tissue infiltration
particularly in rheumatoid arthritis, they are given by 2–6 mg); where appropriate may be repeated at intervals of 3–21 intra-articular injection to relieve pain, increase mobility,
days
and reduce deformity in one or a few joints. Full aseptic precautions are essential; infected areas should be
Hydrocortisone acetate avoided. Occasionally an acute inflammatory reaction
Hydrocortistab c (Sovereign) A develops after an intra-articular or soft-tissue injection
Injection (aqueous suspension), hydrocortisone of a corticosteroid. This may be a reaction to the
acetate 25 mg/mL, net price 1-mL amp = £5.72 microcrystalline suspension of the corticosteroid used,
Dose by intra-articular or intrasynovial injection (for details but must be distinguished from sepsis introduced into
consult product literature), 5–50 mg according to size; where the injection site.
appropriate may be repeated at intervals of 21 days; not more than 3 joints should be treated on any one day; CHILD 5–30 mg
Smaller amounts of corticosteroids may also be injected
(divided)
directly into soft tissues for the relief of inflammation in conditions such as tennis or golfer’s elbow or compression
Methylprednisolone acetate neuropathies. In tendinitis, injections should be made into
Depo-Medrone c (Pharmacia) A the tendon sheath and not directly into the tendon (due
Injection (aqueous suspension), methylprednisolone to the absence of a true tendon sheath, the Achilles
acetate 40 mg/mL, net price 1-mL vial = £2.87; 2-mL tendon should not be injected). A soluble preparation
vial = £5.15; 3-mL vial = £7.47 (e.g. containing betamethasone or dexamethasone sod-
Dose by intra-articular or intrasynovial injection (for details ium phosphate) is preferred for injection into the carpal
consult product literature), 4–80 mg, according to size; where tunnel.
appropriate may be repeated at intervals of 7–35 days; also for intralesional injection
Hydrocortisone acetate or one of the synthetic analo- gues is generally used for local injection. Intra-articular
Depo-Medrone c with Lidocaine (Pharmacia) A corticosteroid injections can cause flushing and may
Injection (aqueous suspension), methylprednisolone affect the hyaline cartilage. Each joint should usually be
acetate 40 mg, lidocaine hydrochloride 10 mg/mL, treated no more than 3 times in one year.
net price 1-mL vial = £3.28; 2-mL vial = £5.88 Corticosteroid injections are also injected into soft tis-
Dose by intra-articular or intrasynovial injection (for details sues for the treatment of skin lesions (see section 13.4). consult product literature), 4–80 mg, according to size; where appropriate may be repeated at intervals of 7–35 days
Prednisolone acetate Deltastab c (Sovereign) A Injection (aqueous suspension), prednisolone acetate
25 mg/mL, net price 1-mL amp = £5.73 Dose by intra-articular or intrasynovial injection (for details consult product literature), 5–25 mg according to size; not more than 3 joints should be treated on any one day; where appropriate may be repeated when relapse occurs For intramuscular injection , see section 6.3.2
Triamcinolone acetonide Adcortyl c Intra-articular/Intradermal (Squibb) A Injection (aqueous suspension), triamcinolone acetonide 10 mg/mL, net price 1-mL amp = £1.02; 5- mL vial = £4.14 Excipients include benzyl alcohol (avoid in neonates, see Excipients,
p. 2) Dose by intra-articular injection or intrasynovial injection (for details consult product literature), 2.5–15 mg according to size (for larger doses use Kenalog ); where appropriate may be repeated when relapse occurs By intradermal injection , (for details consult product literature): 2–
3 mg; max. 5 mg at any one site (total max. 30 mg); where appropriate may be repeated at intervals of 1–2 weeks CHILD under 6 years not recommended
Kenalog c Intra-articular/Intramuscular (Squibb) A Injection (aqueous suspension), triamcinolone acetonide 40 mg/mL, net price 1-mL vial = £1.70; 1- mL prefilled syringe = £2.11; 2-mL prefilled syringe = £3.66 Note Intramuscular needle with prefilled syringe should be replaced for intra-articular injection Dose by intra-articular or intrasynovial injection (for details consult product literature), 5–40 mg according to size; total max.
80 mg (for doses below 5 mg use Adcortyl Intra-articular/ Intradermal ); where appropriate may be repeated when relapse occurs; CHILD under 6 years not recommended For intramuscular injection , see section 6.3.2