25.2 Corticosteroids

Corticosteroids in Respiratory Treatment

Corticosteroids are powerful anti-inflammatory drugs used to manage chronic respiratory conditions like asthma and COPD. They work by mimicking the effects of glucocorticoids, hormones naturally produced by the adrenal cortex, to suppress inflammation and reduce immune overactivity in the airways.

These drugs come in several forms: inhaled corticosteroids (ICS) for long-term daily control, oral corticosteroids for acute exacerbations and severe cases, and intravenous corticosteroids for hospitalized patients with severe flare-ups. The route matters because it directly affects both the drug's effectiveness and its side effect profile.

Key Features of Corticosteroids

Corticosteroids are synthetic derivatives of the body's own glucocorticoids. In the lungs, they reduce airway inflammation, decrease mucus production, and lower airway hyperresponsiveness over time.

Commonly prescribed respiratory corticosteroids:

• Inhaled (ICS): beclomethasone, budesonide, fluticasone, mometasone
• Oral/IV: prednisone, methylprednisolone

ICS drugs are the backbone of long-term asthma control. They don't provide immediate relief during an acute attack. Oral and IV forms act more broadly and are reserved for exacerbations or severe disease because of their systemic effects.

Therapeutic Effects, Side Effects, and Drug Interactions

Therapeutic effects:

• Inhibit production of inflammatory mediators in the airways
• Decrease airway hyperresponsiveness and mucus secretion
• Prevent and control chronic symptoms of asthma and COPD (wheezing, coughing, shortness of breath)

Side effects differ by route:

Drug interactions to watch for:

• CYP3A4 inhibitors (ketoconazole, ritonavir) can increase corticosteroid blood levels, raising the risk of systemic side effects even with inhaled forms
• NSAIDs used alongside corticosteroids increase the risk of GI bleeding and ulceration

Nursing Considerations

Respiratory assessment:

• Assess respiratory status before and during therapy: breath sounds, symptoms, peak expiratory flow rate (PEFR), and oxygen saturation ($SpO_2$)
• Track whether the patient's symptoms are improving with therapy or worsening despite it

Proper ICS administration (teach and verify these steps):

1. Shake the inhaler well before use; prime it if new or not used recently
2. Have the patient exhale fully away from the inhaler
3. Place the mouthpiece in the mouth and seal lips around it
4. Inhale slowly and deeply while pressing down on the canister
5. Hold breath for 5 to 10 seconds, then exhale slowly
6. Rinse mouth thoroughly with water and spit (do not swallow) to prevent oral thrush

If a spacer is prescribed, make sure the patient knows how to use it. Spacers improve drug delivery to the lungs and reduce oral deposition.

Monitoring for systemic corticosteroids:

• Check blood glucose regularly, especially in patients with diabetes, since corticosteroids raise blood sugar
• Assess for signs of infection (fever, chills, persistent cough), because corticosteroids can mask early symptoms and delay diagnosis
• When discontinuing oral or IV corticosteroids, taper the dose gradually as ordered. Abrupt discontinuation can trigger adrenal insufficiency, a potentially life-threatening condition where the adrenal glands can't produce enough cortisol on their own

Patient Education Plan

For all patients on corticosteroids:

• Explain that these medications control inflammation over time but are not rescue inhalers. Consistent daily use is necessary for ICS to work.
• Stress the importance of not stopping oral corticosteroids abruptly. Patients should follow the prescribed taper schedule.
• Advise patients to report signs of infection (fever, chills, persistent cough) promptly, since corticosteroids reduce the body's immune response.

For ICS users specifically:

• Demonstrate proper inhaler technique and have the patient return-demonstrate
• Instruct them to rinse and spit after every use to prevent thrush
• Reassure them that ICS at prescribed doses have minimal systemic effects compared to oral forms

For patients on systemic corticosteroids:

• Encourage a balanced diet with adequate calcium and vitamin D to support bone health
• Recommend regular weight-bearing exercise to help counteract osteoporosis risk
• Diabetic patients should monitor blood glucose more frequently and report significant changes
• Emphasize regular follow-up appointments to assess treatment effectiveness, adjust dosing, and screen for side effects