cortisone

General

Pronunciation:
kor-ti-sone


Trade Name(s)

  • Cortone Canadian Tradename

Ther. Class.
anti-inflammatories (steroidal)

Pharm. Class.
corticosteroids

Indications

  • Management of adrenocortical insufficiency; chronic use in other situations is limited because of mineralocorticoid activity.
  • Replacement therapy in adrenal insufficiency.

Action

  • In pharmacologic doses, suppresses inflammation and the normal immune response.
  • Has numerous intense metabolic effects (see Adverse Reactions and Side Effects).
  • Suppresses adrenal function at chronic doses of 20 mg/day.
  • Replaces endogenous cortisol in deficiency states.
  • Also has potent mineralocorticoid (sodium-retaining) activity.

Therapeutic Effect(s):

  • Suppression of inflammation and modification of the normal immune response.
  • Replacement therapy in adrenal insufficiency.

Pharmacokinetics

Absorption: Well absorbed after oral administration.

Distribution: Widely distributed; crosses the placenta and enters breast milk.

Metabolism and Excretion: Metabolized mostly by the liver to inactive metabolites.

Half-life: 0.5–2 hr (plasma), 8–12 hr (tissue).

TIME/ACTION PROFILE (anti-inflammatory activity)

ROUTEONSETPEAKDURATION
POrapid2 hr1.25–1.5 days

Contraindication/Precautions

Contraindicated in:

  • Active untreated infections (may be used in patients being treated for tuberculous meningitis)
  • Lactation: Avoid chronic use.

Use Cautiously in:

  • Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time), unless being used to treat adrenal insufficiency
  • Stress (surgery, infections); supplemental doses may be needed
  • Hypothyroidism
  • Cirrhosis
  • Ulcerative colitis
  • Potential infections may mask signs (fever, inflammation)
  • OB:  Safety not established
  • Pedi:  Chronic use will result in ↓ growth; use lowest possible dose for shortest period of time.

Adverse Reactions/Side Effects

Adverse reactions/side effects are much more common with high-dose/long-term therapy

CNS: depression, euphoria, headache, ↑ intracranial pressure (children only), personality changes, psychoses, restlessness

EENT: cataracts, ↑ intraocular pressure

CV: hypertension

GI: PEPTIC ULCERATION, anorexia, nausea, vomiting

Derm: acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae

Endo: adrenal suppression, hyperglycemia

F and E: fluid retention (long-term high doses), hypokalemia, hypokalemic alkalosis

Hemat: THROMBOEMBOLISM, thrombophlebitis

Metabolic: weight gain, weight loss

MS: avascular necrosis of joints, muscle wasting, osteoporosis, muscle pain

Misc: cushingoid appearance (moon face, buffalo hump), ↑ susceptibility to infection

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

  • Additive hypokalemia with thiazide  or  loop   diuretics, or  amphotericin B.
  • Hypokalemia may ↑ risk of  digoxin  toxicity.
  • May ↑ requirement for   insulins  or  oral hypoglycemic agents.
  •  Phenytoinphenobarbital, and  rifampin  stimulate metabolism; may ↓ effectiveness.
  •  Oral contraceptives  may ↓ metabolism.
  • ↑ risk of adverse GI effects with  NSAIDs  (including aspirin).
  • At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ the risk of adverse reactions from  live-virus vaccines.

Route/Dosage

PO (Adults): 25–300 mg/day in divided doses every 12–24 hr.

PO Children:  Adrenocortical insufficiency– 0.7 mg/kg/day (20–25 mg/m2 /day) in divided doses every 8 hr.   Other uses– 2.5–10 mg/kg/day (75–300 mg/m2 /day) in divided doses every 6–8 hr.

Availability (generic available)

Tablets: 25 mg

Assessment

  • Indicated for many conditions. Assess involved systems before and periodically during therapy.
  • Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) before and periodically during therapy.
  • Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional if these occur.
  • Children should have periodic evaluations of growth.

Lab Test Considerations:

Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. Patients on prolonged courses of therapy should routinely have hematologic values, serum electrolytes, and serum electrolytes evaluated. May decrease WBC counts. May decrease serum potassium and calcium and increase serum sodium concentrations.

  • Guaiac-test stools. Promptly report presence of guaiac-positive stools.
  • May ↑ serum cholesterol and lipid values. May ↓ uptake of thyroid 123 I or 131 I.
  • Suppresses reactions to allergy skin tests.
  • Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy.

Potential Diagnoses

Implementation

  • If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol.
  • PO 

    Administer with meals to minimize GI irritation.

    • Tablets may be crushed and administered with food or fluids for patients with difficulty swallowing.

Patient/Family Teaching

  • Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life threatening.

    • Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.
    • Caution patient to avoid vaccinations without first consulting health care professional.
    • Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes.
    • Advise patient to notify health care professional of medication regimen before treatment or surgery.
    • Discuss possible effects on body image. Explore coping mechanisms.
    • Instruct patient to inform health care professional if symptoms of underlying disease return or worsen.
    • Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history.
    • Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.
  • Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see food sources for specific nutrients). Alcohol should be avoided during therapy.

Evaluation/Desired Outcomes

  • Decrease in presenting symptoms with minimal systemic side effects.
  • Suppression of the inflammatory and immune responses in autoimmune disorders, allergic reactions, and neoplasms.
  • Management of symptoms in adrenal insufficiency.

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