A Nurse’s Guide to Corticosteroids as Treatment for Respiratory Diseases

• Corticosteroids are essential medications for managing respiratory diseases like asthma due to their anti-inflammatory properties and are available in various formulations such as inhaled, oral, and intravenous. 
• While inhaled corticosteroids are the primary treatment for long-term asthma management, oral and intravenous corticosteroids are also used in acute attacks; however, careful monitoring of potential adverse effects and drug interactions is necessary. 
• Nurses play a crucial role in the safe and effective use of corticosteroids in respiratory disease management by following nursing processes, monitoring patients, and providing education to minimize potential risks. 

Respiratory diseases, such as asthma, can significantly impact an individual’s quality of life and overall health. Corticosteroids have emerged as a crucial component in the management of various respiratory conditions, owing to their potent anti-inflammatory properties. These medications come in various formulations and routes of administration, including inhaled, oral, and intravenous.

The following text will delve into the different types of corticosteroids, their indications, mechanisms of action, potential drug interactions, and adverse reactions. Moreover, we will discuss the nursing processes and best practices for patients undergoing corticosteroid therapy for respiratory diseases. 

Introduction to Corticosteroids

Corticosteroids are medications designed to reduce inflammation caused by an overactive immune system. They can be administered parenterally, orally, or through inhaled formulations and encompass a range of drugs with varying potencies. 

These drugs are frequently employed in the treatment of respiratory conditions, particularly in cases of asthma where the immune system becomes excessively activated. 

Inhaled corticosteroids are: 

• beclomethasone dipropionate 
• budesonide 
• ciclesonide 
• flunisolide 
• fluticasone propionate 
• triamcinolone acetonide
  

Oral corticosteroids are: 

• prednisolone 
• prednisone
  

Intravenous corticosteroids are: 

• dexamethasone 
• hydrocortisone sodium succinate 
• methylprednisolone sodium succinate 

Inhaled corticosteroids have minimal absorption in the body and primarily exert their effects on the respiratory tract, making them suitable for long-term asthma management. During acute asthma attacks, oral and intravenous corticosteroids may also be administered. Oral prednisone is quickly absorbed and converted into prednisolone, the active form. While intravenous formulations provide a rapid onset of action, they do not present any significant advantages compared to oral forms. 

Corticosteroids work by inhibiting: 

 The production of cytokines, leukotrienes, and prostaglandins 

• Recruitment of eosinophils 
• Release of other inflammatory mediators 
  

Corticosteroids remain essential agents in the treatment and management of asthma. Systemic formulations are used in acute asthma exacerbation. However, use them in the lowest possible dose and for the shortest period because of their severe adverse effects.  

Inhaled corticosteroids remain the mainstay therapy for the long-term management of mild to severe asthma. They help prevent using systemic corticosteroids by preventing asthma exacerbations and do not have adverse effects when given in low doses. However, inhaled steroids should not be used in acute asthma attacks. Instead, use a beta-2 adrenergic agonist. Educate your patients about it as well.  

Corticosteroids—Formulation, Route of Administration, and Brand Names

Beclomethasone

Available as: Aerosol (oral inhalation), QVAR: 40 mcg/inhalation, 80 mcg/inhalation, aerosol (spray, intranasal), Qnasl: 80 mcg/inhalation, suspension (intranasal), Beconase: 42 mcg/inhalation 

Route of administration: Inhalation and Intranasal 

Brand names: Beconase, Qnasl, QVAR 

Betamethasone

Available as: Injection 6mg/ml 

Route of administration: Intravenous, intralesional, intra-articular 

Brand names: Celestone  

Budesonide

Available as: Nasal spray 32 mcg/spray and suspension for nebulization—250 mcg, 500 mcg 

Route of administration: Intranasal 

Brand names: Pulmicort and Rhinocort

Cortisone

Available as: Tablets 5, 10, and 25 mg 

Route of administration: Oral  

Brand names: Cortone 

Dexamethasone

Available as: Tablets 0.5 mg, 1 mg, 4 mg, 6 mg, oral suspension 0.5 mg/5 ml, and injection 4 mg/ml, 10 mg/ml  

Route of administration: Oral and parenteral  

Brand name: Decadron

Fludrocortisone

Available as: Tablet 0.1mg 

Route of administration: Oral 

Brand name: Florinef

Flunisolide

Available as: Nasal preparation 25 mcg/spray 

Route of administration: Inhalation and intranasal 

Brand name: Nasalide

Fluticasone

Available as: Inhalation—44 mcg, 110 mg, 220 mcg and nasal—50 mg, 100 mcg 

Route of administration: Inhalation and intranasal  

Brand name: Flovent and Flonase 

Hydrocortisone

Available as: Tablets- 5 mg, 10 mg, 25 mg and injections -100 mg, 250 mg, 500 mg, 1 g 

Route of administration: Oral and parenteral 

Brand name: Solu-Cortef 

Methylprednisolone

Available as: Tablet—4 mg and injection—40 mg, 125 mg, 500 mg, 1 g, 2 g 

Route of administration: Oral and parenteral 

Brand name: Solu-Medrol

Prednisolone

Available as: Tablet—5 mg and oral solution- 5 mg/5 ml, 15 mg/5 ml 

Route of administration: Oral  

Brand name: Prelone

Prednisone

Available as: Tablets—1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg 

Route of administration: Oral  

Brand name: Deltasone  

Triamcinolone

Available as: Injection suspension—10 mg/ml, 40 mg/ml, and intranasal suspension: 55 mcg/ inhalation 

Route of administration: Intramuscular and inhalation (nasal) 

Brand name: Kenalog and Nasacort AQ

Drug Interactions and Adverse Effects

Drug Interactions

Although drug interactions involving inhaled corticosteroids are uncommon, they can occur with oral or parenteral formulations. Some examples of these interactions include: 

• Hormonal contraceptives, ketoconazole, and macrolide antibiotics can increase the activity of corticosteroids. Therefore you need to decrease the dose of steroids.  
• Barbiturates, cholestyramine, and phenytoin can decrease the effectiveness of corticosteroids. Therefore you need to increase their dose.

Adverse Reactions

Inhaled corticosteroids 

• Oral candidiasis  
• Cough and hoarseness
• Upper respiratory tract infections
• Mouth irritation 
  

Oral corticosteroids 

• Insomnia 
• Hyperglycemia 
• Headache 
• Growth suppression in children
• Gastrointestinal distress  

Oral corticosteroids often lead to gastrointestinal side effects, including gastroesophageal reflux disease, stomach ulcers, and perforation. These issues arise because corticosteroids suppress the secretion of prostaglandins, which normally protect the gastrointestinal system. To help minimize these adverse effects, advise patients to take corticosteroids with food. Utilizing enteric-coated formulations can also assist in preventing gastrointestinal complications. 

Corticosteroid Warnings

• Corticosteroids suppress the inflammatory mediators and the immune system. They affect the body’s defense mechanism, leading to an increased risk of infection. Nurses must take extra care of the patients on corticosteroids so that any co-infection does not occur.  
• During corticosteroid treatment, fungal infections can frequently occur. As a result, if a patient is on long-term steroid therapy, it is crucial to examine their mouth for signs of fungal infection. Additionally, for women, vaginal fungal infections are relatively common. It is important to advise them to promptly report any symptoms, such as vaginal itching or abnormal discharge, to their healthcare provider. 
• In children, administer the corticosteroids at the lowest possible dose and for the minimum possible time because it can affect their growth. It can suppress growth hormone secretion, which can lead to stunted growth.  
• When administering high doses of inhaled corticosteroids over an extended period or using oral or parenteral therapy, it is essential to closely monitor the patient’s bone health, particularly in older individuals. These treatments can have detrimental effects on bone health and may even result in osteoporosis. Consequently, encourage patients to make appropriate dietary and lifestyle changes that can aid in safeguarding their bones. 
• Corticosteroids can affect blood glucose levels. Therefore you have to take extra care of patients with diabetes. Check their blood glucose levels and adjust insulin or oral hypoglycemic accordingly. Make sure to maintain efficient glycemic control. However, steroid therapy can also affect the blood glucose levels of a person without diabetes if given at high doses for a long time. Therefore you must monitor their blood glucose levels and manage them well.  
• Corticosteroid levels are negligible in the breast milk of mothers receiving less than 20 mg/day of oral prednisone. The amount found in breast milk can be minimized if the mother waits at least 4 hours after taking prednisone to breastfeed the infant. 
• Give the lowest possible dose of inhaled steroids to prevent their side effects. Ask the patient to take the inhaler with a spacer and keep it clean. Also, tell them to rinse their mouth after taking the corticosteroid inhaler because it can lead to fungal infections of the oral cavity. Therefore they need to take extra care of their oral hygiene.
  

Corticosteroids and the Nursing Process

For patients taking corticosteroid therapy for respiratory diseases, follow these nursing processes: 

Assessment

• Assess the respiratory condition of the patient regularly before and after starting the therapy. Record peak flow meter readings. 
• Remain alert for drug interactions and adverse drug reactions. 
• Evaluate the knowledge of corticosteroid therapy of the patient and his family members.  

Key Nursing Diagnoses

• Ineffective breathing pattern. 
• Impaired gas exchange due to underlying health condition. 
• Inadequate knowledge of drug therapy. 

Planning Outcome Goals

• Improvement in the breathing pattern evidenced by regular and even respiratory rate and rhythm. 
• Adequate gas exchange—evidenced by improved peak flow rates, oxygen saturation, and ABG levels. 
• The patient and their family members are informed about the drug therapy, and will demonstrate correct drug administration.  

Implementation

• If the patient is not getting relieved with the prescribed dose of corticosteroids, inform the physician so that they can increase the dose. Also, check if the dose is appropriate according to the patient’s weight and health conditions.  
• To avoid gastrointestinal adverse effects with oral corticosteroid formulation, administer with food. Enteric-coated tablets can also help prevent that. Moreover, you can administer a proton pump inhibitor with oral corticosteroid therapy if the patient has a complaint of gastroesophageal reflux disease already.  
• Take precautions to protect the patient from exposure to infections.  
• Do not discontinue the drug abruptly if you are giving it at high doses for a long period of time. Doing so can lead to a sharp drop in blood glucose levels and blood pressure. Taper the drug so the patient can tolerate it.  
• Inform the prescriber if the patient has severe and persistent adverse effects.  
• Avoid long-term usage of corticosteroids in high doses, especially in children as it can affect their growth.  

Evaluation

• The patient exhibits improvement in the breathing pattern.  
• The gas exchange is improved.  
• The patient and his family members have an understanding of drug therapy. 

The Bottom Line

In summary, corticosteroids play a vital role in the treatment and management of respiratory diseases, offering relief and control of symptoms for patients. They are available in various formulations and routes of administration, with inhaled corticosteroids being the mainstay of long-term asthma management. However, they are not without potential adverse effects and drug interactions, necessitating careful monitoring and patient education.  

Nurses play a crucial role in ensuring the safe and effective use of corticosteroids in respiratory disease management. By following the outlined nursing processes and maintaining close communication with patients and healthcare providers, the therapeutic benefits of corticosteroids can be maximized while minimizing potential risks. 

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