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