Oral Meds: Corticosteroids
While topical steroids such as Pred Forte and Lotemax are
used daily in our practices, orally administered steroids are
not commonly used. Most all inflammatory eye conditions readily
respond to topical therapy.
However, if the tissue inflammation is “deeper” or topical
suppression is subtherapeutic, then oral prednisone almost
always accomplishes the goal of tissue restoration.
Some examples of where oral steroids may be indicated are:
• Uveitis not responding to topical therapy
• Orbital pseudotumor
• Bee stings to the ocular adnexa
• Acute allergic blepharodermatoconjunctivitis
• Contact blepharodermatitis not responding to topical therapy
• Episcleritis not responding to topical therapy
Almost without exception, the steroids we use are generic
prednisone or methylprednisolone.
Steroids: How Safe Are They?
Are steroids safe? The answer is “yes” and “no.” Let’s
qualify this. Keep in mind, oral steroids are a daily
mainstay in the practicing physician’s office, so they
must be highly prized drugs. Like topical steroids,
they are safe and effective short-term. Long-term,
the potential for a myriad of side effects is legendary.
Two critical questions to ask when contemplating the
use the use of oral steroids are:
• Does the patient have any gastrointestinal disease,
particularly peptic ulcer?
• Does the patient have diabetes?
A third critical question for women with childbearing
potential: Is there any chance she could be pregnant?
If there is peptic ulcer disease, then a telephone consult
with that patient’s primary care physician is in order.
Occasionally, co-therapy with a histamine (H2) antagonist,
such as ranitidine (Zantac) or famotidine (Pepcid), or
a proton pump inhibitor, such as omeprazole (Prilosec)
or lansoprazole (Prevacid) is indicated to protect the
stomach.
Patients with insulin-dependent diabetes should modify
their dosing based on a sliding scale. Non-insulin-dependent
patients may have to adjust their therapy during the
course of steroid treatment; this is, however, usually
unnecessary for treatment spanning only a few days.
If the patient is, or may be pregnant, consultation
with her obstetrician/gynecologist is required. The two
of you will need to “negotiate” the best middle-ground,
balancing efficacy with safety and risks with benefits.
As you ponder these three scenarios, it will become
apparent that for most patients most of the time, drawing
upon the healing power of oral steroid therapy is very
straightforward. As you mature in your clinical growth,
you will find yourself more and more co-managing your
patients with other medical specialties.
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Methylprednisolone is the steroid in the familiar “Dosepak.”
The most commonly used Dosepak is a composite of 4mg tablets,
where six tablets (i.e., 24mg) are taken on day one, and reduced
by one tablet per day over the next six days.
The bottom line: 24mg is suboptimum therapy in most instances
where an oral steroid is indicated, and Dosepaks are expensive
compared to generic prednisone. We felt it was important to
discuss these Dosepaks since they are commonly used in general
medical care, although they have limited utility in eye disease.
Prednisone tablets are widely available and cheap. We almost
always write for 10mg tablets because they are so easy to use.
Like all other topical and systemic medicines, dosage must
be individualized for the severity and nature of the condition.
That said, most inflammatory conditions that we treat respond
to dosages in the range of 40-60mg as an initial dose, and
tapering over a one- to three-week period. A typical dosing
schedule: 40mg for two days, 30mg for two days, 20mg for two
days, 10mg for two days and 5mg for two days.
We always recommend taking this medicine with meals to minimize
the potential for gastric distress. As a general rule, dosages
up to 60mg can be taken all at one time (i.e., taking all six
10mg tablets in one setting). In dosages at or above 80mg,
we write for one-half the daily dose to be taken with breakfast,
and the other half to be taken with the evening meal. The more
drug used initially, or the longer the duration of therapy
needed to suppress the inflammatory process, the longer the
timeframe of the taper.
While the concept of tapering is time-honored, a slight deviation
from this practice is worth noting. For example, when treating
a highly acute problem such as an abrupt onset of allergic
blepharodermatitis from a known chemical exposure, dosing can
be 40mg or 60mg for two days, then stop. Very short course
therapy in these select instances can be treated very effectively
without a taper.
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