Drugs in Allergic Disorders: The Cortiscosteroids
The cortiscosteroids are of great value in treating acute asthmatic attacks or severe allergic reactions. They may act by enhancing the effect of natural occurring epinephrine to stimulate the beta adrenergic receptor. Longterm steroid therapy has many side effects and disadvantages. The major objective if steroids are required is to use the least amount consistent with achieving as normal a life as possible for the patient in as short a period of time as possible. The steroid of choice is a relatively short-acting one which will control the symptoms, such as prednisone. Start with 20 mg of prednisone bid. Once control has been achieved, reduce the dose to 10 mg bid. This stage can be maintained if no symptoms occur. Then cut down to 20 mg once a day in the morning, and reduce the dosage by five mg twice each week. If symptoms of asthma reappear, go back to 20 mg bid for control (usually 24-48 hours).
In asthmatics, an attempt should be made to switch to an alternate day schedule, since this has been found to depress the pituitary adrenal axis the least. Only short-acting steroids such as prednisone or methylprednisone can be used in alternate day therapy.
The new inhaled steroid, beclamethasone diproprionate, has received much attention. It has less systemic absorption and at a proper dosage, as an alternative to oral therapy, is reportedly free of adrenal suppressive properties. The drug must penetrate the airways; therefore, it cannot be expected to work during acute exacerbation of asthma. In this situation, it is much more logical to give a short course of oral steroids to bring about the improvement.
Aerosol steroids are not indicated, therefore, for a patient with infrequent but severe attacks of asthma who would normally have a few short courses of oral steroids during the year. Infrequent short courses of oral steroids do not usually cause side effects, and would certainly be more effective than the aerosol steroid. The aerosol is also not suitable for a mild asthmatic who can be controlled by the use of beta adrenergic bronchodilators and/or theophylline. The important group of patients who benefit from aerosol therapy are those chronic perennial asthmatics in need of continuous medication. It is best to start with 100 meg (two puffs) three times daily. Most severely asthmatic children need nine puffs per day or 450 meg. Some patients appear to benefit by inhaling one dose of a suitable aerosol if they are wheezy at the time. If an exacerbation occurs which is not rapidly controlled by an increase in aerosol dose, then the patient must receive oral steroids to treat the asthma attack, which can be very severe.
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