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Corticosteroids

  • Corticosteroids are potent immunosuppressants but can cause troublesome side-effects (weight gain, growth retardation, osteoporosis and cataracts) and the risk of adrenal suppression.
  • They can be used to control active disease usually as an adjunct to other therapies (Disease Modifying AntiRheumatic Drugs - DMARDS, cytotoxics or biological therapies).
  • Administration is given by oral, intra-articular, intravenous, intramuscular and topical routes (eyes).
  • Less systemic corticosteroid exposure has been enabled through increasing use of intra-articular corticosteroids and early use of disease-modifying anti-rheumatic drugs (DMARDs) with methotrexate (MTX) being the agent of choice.  
  • If a child is taking oral corticosteroids, optimizing dietary intake of calcium and vitamin D is important; the role of calcium and vitamin supplements or bisphosphonates to reduce the risk of osteoporosis is unclear.
  • Intra-articular corticosteroids are highly effective, safe and is first-line treatment for oligo-articular Juvenile Idiopathic Arthritis (JIA). Young children require sedation or anaesthetic for the procedure, although in the older child inhaled analgesia (e.g. nitrous oxide) may be used. 
  • Pulsed intravenous methylprednisolone is often used to induce remission at disease onset, during flares of polyarthritis or in those with features of systemic-onset JIA or multisystem disease, and is a useful bridging agent whilst starting MTX therapy.
  • Topical corticosteroids (eye drops) are often used to treat uveitis although systemic immunosuppression (including MTX or biologics) are often used if uveitis does not respond to eye drops alone. Periocular corticosteroid injections can be given to control uveitis.

Nursing issues

  • The patient and family need education and support to administer oral corticosteroids; they are given usually once per day, ideally after breakfast to reduce the impact on sleep routines; given later in the day the child may have difficulty settling to sleep and may have vivid dreams or nightmares.
  • Oral corticosteroids should not be stopped abruptly due (risk of adrenal crisis and disease flare).
  • Families should understand the need for the treatment, the duration of the treatment course and not to run out of medication prematurely. The dose may be tapered and families may need guidance about their regimes and how to recognise disease symptoms breaking through.
  • The use of an alert card for prolonged oral corticosteroid use needs consideration especially if there is risk of adrenal suppression.
  • Prolonged use of corticosteroids can contribute to weight gain, increased fullness around the face and striae (skin stretch marks) that can be distressing and upsetting. Striae will fade with time but not disappear completely. Camouflage make-up can be advised.
  • Corticosteroids used in combination with other treatments can result in the child being severely immunocompromised. The family need to know signs of infection and when to seek advice.
  • Immunisations may be contraindicated or delayed or less effective while on corticosteroids.
  • Varicella (Chicken pox), shingles and other childhood diseases can be potentially more serious and families need to know when and how to seek advice.
  • When corticosteroids are given intravenously patients may feel and appear flushed due to vasodilation effects. They may also complain of increased heart rate. Observations of temperature, pulse, respirations and blood pressure are important during the infusion to detect adverse events including hypertension.

 

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