Corticosteroids
Key Points
- Corticosteroids are anti-inflammatory agents — they do NOT provide acute bronchodilation; NOT for acute asthma rescue
- Inhaled corticosteroids (ICS): Fluticasone, budesonide, beclomethasone — local anti-inflammatory effect; rinse mouth after use to prevent oral candidiasis
- Systemic corticosteroids (prednisone, methylprednisolone): For severe asthma exacerbations, COPD, allergic reactions, adrenal insufficiency
- NEVER stop abruptly after >10 days of systemic use — taper to prevent adrenal insufficiency (HPA axis suppression)
- Long-term systemic use: Cushing’s syndrome features, osteoporosis, immunosuppression, hyperglycemia, poor wound healing
- Before long-term systemic therapy, obtain baseline blood pressure, weight, glucose, lipid profile, CBC, and bone health risk data (including bone mineral density when indicated)
- Fludrocortisone is a mineralocorticoid used for aldosterone replacement in Addison’s disease; monitor for sodium-water retention and potassium loss
- For systemic dosing, morning administration is often preferred to reduce insomnia burden when regimen design allows.
- ICS + LABA (e.g., fluticasone/salmeterol): Standard combination for persistent asthma maintenance
Drug Class Overview
Corticosteroids mimic endogenous cortisol produced by the adrenal cortex. In respiratory care, they address the inflammatory component of asthma and COPD — reducing mucosal edema, decreasing mucus secretion, and suppressing airway hyperresponsiveness. They are the cornerstone of long-term asthma control therapy but provide no immediate bronchodilation; bronchodilators must be used for acute relief.
Mechanism: Stabilize leukocyte lysosomal membranes → reduce release of inflammatory mediators → suppress immune response → anti-inflammatory and immunosuppressive effects.
Inhaled Corticosteroids (ICS)
Preferred for long-term maintenance — deliver medication directly to airway mucosa with minimal systemic absorption. Fluticasone inhaler is commonly used in clients age 4 years and older, and fluticasone nasal spray is also used for perennial nonallergic rhinitis symptoms. In allergic-rhinitis care, intranasal corticosteroids are commonly used when symptoms remain uncontrolled despite decongestants, antihistamines, or intranasal cromolyn.
| Drug | Routes | Adult Dosing |
|---|---|---|
| Fluticasone (Flovent HFA) | Inhaled MDI, nasal spray | 88 mcg (2 inhalations of 44 mcg) twice daily |
| Budesonide (Pulmicort) | Inhaled DPI/nebulizer | 360 mcg twice daily (initial); max 720 mcg twice daily |
| Beclomethasone (Qvar) | Inhaled MDI | 40–80 mcg twice daily, ~12 hours apart |
Combination Products: Fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort) — ICS + LABA for persistent asthma or COPD.
ICS Adverse Effects:
- Oropharyngeal candidiasis (thrush): Most common — prevent by rinsing mouth and gargling with water after each use
- Spacer devices can reduce upper-airway deposition and help lower thrush risk when technique is appropriate.
- Hoarseness, dry mouth, cough, sore throat
- Epistaxis (nasal sprays)
Systemic Corticosteroids
Used for acute exacerbations or when inhaled therapy is insufficient.
| Drug | Routes | Key Use |
|---|---|---|
| Prednisone (Deltasone) | Oral | Asthma exacerbations, severe COPD, severe allergic reactions; initial dose 5–60 mg/day |
| Methylprednisolone (Solumedrol) | IV, IM | Rapid control of severe allergic/respiratory conditions, adjunct in sepsis-related systemic inflammation, and adrenal insufficiency; IV 10–40 mg per dose |
| Fludrocortisone | Oral | Mineralocorticoid replacement for aldosterone deficiency in adrenal-disorders (Addison’s disease); monitor for edema, hypertension, and hypokalemia; avoid/closely reassess in heart-failure or severe-renal-impairment contexts |
Methylprednisolone powder formulations require reconstitution with sterile diluent before IV administration per product guidance.
Systemic Adverse Effects:
| System | Adverse Effects |
|---|---|
| Metabolic | Hyperglycemia (monitor blood glucose), hypokalemia (↓K+), hypernatremia (↑Na+), weight gain |
| Cardiovascular | Fluid retention, edema, hypertension |
| GI | Nausea, vomiting, GI ulcer risk (administer with food) |
| CNS | Mood swings, insomnia, euphoria at high doses |
| Musculoskeletal | Bone resorption → osteoporosis, fracture risk (long-term) |
| Integumentary | Thin/fragile skin, bruising, impaired wound healing, acne |
| Immune | Immunosuppression → increased infection risk; infections may be masked |
| Endocrine | Adrenal suppression (HPA axis) with prolonged use → adrenal crisis if abrupt discontinuation |
Long-term Use → Cushing’s Syndrome: Moon face, central obesity, buffalo hump, striae, muscle weakness.
Never Abruptly Discontinue
Systemic corticosteroids taken for >10 days suppress the hypothalamic-pituitary-adrenal (HPA) axis. Abrupt discontinuation can cause adrenal insufficiency/crisis (severe hypotension, weakness, vomiting). Always taper the dose gradually.
Nursing Assessment
Before Administration:
- Verify indication: ICS for maintenance, systemic for acute exacerbation (NOT ICS for acute rescue)
- Verify age appropriateness for formulation (for example, fluticasone inhaler typically starts at age 4 years)
- Obtain baseline: blood pressure, weight, blood glucose, serum electrolytes (K+), lipid profile, CBC, and bone-fracture risk data (bone mineral density when indicated)
- Check for active infection (corticosteroids are contraindicated in untreated systemic infections, including systemic fungal infection)
- Use caution in untreated pulmonary infection pathways (for example active tuberculosis or untreated bacterial lung infection) because corticosteroids can suppress host defenses.
- Screen recent live-vaccine timing before systemic corticosteroid initiation; defer/coordinate per prescriber guidance when contraindication risk is present.
- History of GI ulcer, osteoporosis, diabetes, hypertension — all require extra monitoring
- In clients of childbearing potential, assess pregnancy status before long-term systemic therapy
During/After Administration (Systemic):
- Monitor blood glucose — especially in patients with diabetes
- Monitor blood pressure and weight regularly
- Assess for signs of infection (fever, inflammation may be masked)
- Monitor electrolytes: watch for hypokalemia and hypernatremia
- Assess mental status: mood changes, insomnia
- Monitor sleep pattern disruption during therapy and reinforce sleep-hygiene measures when insomnia emerges.
- Monitor for adrenal suppression (fatigue, malaise, nausea, vomiting, abdominal pain, hypotension, hypoglycemia); if suspected, anticipate early-morning cortisol testing
Patient Education:
- Inhaled: Rinse mouth and gargle with water after every use, and use a spacer when indicated — helps prevent thrush
- In allergic-rhinitis pathways, reinforce that intranasal symptom improvement may take several days to about 2 weeks.
- ICS is not a rescue inhaler — do NOT use for acute bronchospasm
- Reassess prolonged continuous intranasal use with the prescriber (often by about 30 days in symptom-flare pathways).
- Systemic: Take oral doses with food to reduce GI irritation
- For systemic corticosteroids with CYP3A4 interaction risk, avoid grapefruit or sour-orange products unless the prescriber confirms compatibility.
- Do NOT stop systemic corticosteroids abruptly — contact provider for tapering schedule
- Report signs of infection, unusual weight gain, mood/behavioral changes, increasing fatigue, unusual bruising, or muscle weakness
- Track weight daily when on systemic therapy and report rapid gain (for example >2-3 lb in 24 hours or >5 lb in 1 week).
- Limit sodium intake when fluid-retention risk is present and report worsening edema or dyspnea promptly.
- Long-term use: discuss bone health — calcium and vitamin D supplementation, fall prevention
- Ask the provider before receiving live or routine vaccines while on long-term glucocorticoids
- Nutrition teaching for long-term systemic therapy: prioritize protein, calcium, and potassium intake
Epidural Injection Risk
Epidural corticosteroid injection has a rare but serious neurologic risk profile (for example vision loss, stroke, paralysis, death). Verify indication, route, and consent pathway strictly.
Related Concepts
- bronchodilators — LABAs combined with ICS for asthma maintenance
- asthma-action-plan-and-exacerbation-management — Corticosteroids in step-based asthma management
- evidence-based-respiratory-care — Respiratory care protocols
- potassium-balance-disorders — Hypokalemia as systemic corticosteroid adverse effect
- anticoagulants — Increased GI bleeding risk when combined with NSAIDs or anticoagulants
- diabetes-mellitus — Corticosteroid-induced hyperglycemia
Self-Check
- A patient on prednisone 40 mg/day for 3 weeks wants to stop the medication suddenly because side effects are bothersome. What is the priority nursing intervention?
- A patient using fluticasone inhaler develops white patches in the mouth and throat. What condition do you suspect, and what preventive education should have been provided?
- Why are inhaled corticosteroids NOT appropriate for an acute asthma attack? What medication class should be used instead?