Similarities Between Corticosteroids

The Science Journal of the Lander College of Arts and Sciences

Volume 7 Number 2 Spring 2014 -

1-1-2014

M. Einhorn Touro College

Follow this and additional works at: https://touroscholar.touro.edu/sjlcas

Part of the Chemical and Pharmacologic Phenomena Commons

Recommended Citation Einhorn, M. (2014). Similarities Between Corticosteroids. The Science Journal of the Lander College of Arts and Sciences, 7(2). Retrieved from https://touroscholar.touro.edu/sjlcas/vol7/iss2/6

This Article is brought to you for free and open access by the Lander College of Arts and Sciences at Touro Scholar. It has been accepted for inclusion in The Science Journal of the Lander College of Arts and Sciences by an authorized editor of Touro Scholar. For more information, please contact [email protected]. Similarities Between Corticosteroids

documented, and medical practitioners administer these ments fluctuates depending on the strength of the cortico- Similarities Between Corticosteroids drugs because the effects are beneficial to the patients. steroid. M. Einhorn Corticosteroids are sometimes referred to as a “miracle In a double blind study testing the bioavailability of drug” because of the diverse pathologies that are alleviat- different corticosteroids, desoximetasone 0.25%, clobeta- ed or managed by these drugs. The precise mechanism of Abstract sol17propionate .05%, hydrocortisone 1.0%, and betame- action, nevertheless, is as of yet unknown. Much research thasone dipropionate .064% were applied on the volar Corticosteroids are a class of potent drugs with important physiological effects on the body. Regular use is linked with has been done to discover this mechanism, and varying forearm of 30 healthy volunteers. After six hours, skin color common and serious side effects. This paper uses studies to analyze the similarities between various corticosteroids. All hypotheses have been suggested. There is a strong possi- changes were noted. The degree of skin blanching is asso- drugs in this class are molecules that contain the same steroid backbone and are therefore associated with the same bility that corticosteroids have numerous effects on a cellu- ciated with the efficacy of the corticosteroid. Though the cellular receptor. This results in a comparable mechanism and parallel overall effect in the body. Side effects of cortico- lar level, resulting in what seems to be several valid mecha- corticosteroid concentration in each cream was different, steroids are analogous as well. Using the knowledge of physiological changes in the body due to corticosteroids will al- nisms. low healthcare providers to determine the most effective corticosteroid least likely to cause adverse effects, and treat the vasoconstrictive effect of the corticosteroid, as seen by and monitor the patient accordingly. Corticosteroids function by diffusing into a cell and blanching of the skin was quite similar between three of binding to glucocorticoid receptors in the cytoplasm the four corticosteroids tested. Hydrocortisone caused (Barnes, 2005). The receptor corticosteroid complex stimu- milder skin blanching and in fewer individuals, but is known Introduction by typing corticosteroid along with other associated key- lates changes in the cell by influencing transcription. Re- to be a weak corticosteroid so the results were not atypical words, such as inflammation, into databases, such as search testing cardiovascular effects of the corticosteroid (Borelli et al., 2008). The clinical observation that three of Corticosteroids are a class of commonly prescribed Ebsco, Medline, ProQuest, and other similar databases. dexamethasone, found that treatment of cells with dexa- the four creams caused similar blanching despite differing drugs containing a backbone of four fused cycloalkanes. methasone and the glucocorticoid antagonist mifepristone concentrations, clearly demonstrated that corticosteroids These drugs are prescribed to treat a wide variety of ail- Similarity in Structure (RU 486) blocked the known effects of the corticosteroid differ in potency. ments including: autoimmune disorders, arthritis, asthma, Steroids are molecules with a backbone consisting (HafeziMoghdam et al., 2002). When cells are treated with dermatitis, cancer treatment, pain management and oth- Research has shown that each corticosteroid has a of three bonded cyclohexane rings fused with a cyclopen- mifepristone, the glucocorticoid receptor is inactivated. ers. Corticosteroid drug therapy is currently used in the different binding affinity to the glucocorticoid receptor be- tane. The backbone can vary in oxidation state as well as in When the cell with the inactivated receptor is treated with treatment of over 175 diseases. Additionally, these drugs cause of structural differences (Kelly, 2009). Clinical trials functional groups, producing numerous different steroid corticosteroid, no corticosteroid effect takes place. This are commonly used by patients, as seen by the fact that show that the change in binding affinity from one cortico- molecules. The body produces cholesterol and steroid hor- demonstrated that a corticosteroid must bind to the recep- Advair diskus, a corticosteroid inhaler, was sixth in retail steroid to another is associated with the potency of the mones as part of normal function, most importantly: aldos- tor for an effect to occur in the cell. sales during the year 2013. The drug can be administered corticosteroid (Kelly, 2009). This correlation that greater terone, and the sex hormones. Synthetic steroids can be and absorbed by the body in a variety of different forms: This theory was replicated in a study showing that the affinity of the corticosteroid to the receptor the more introduced into the body. topically applied creams, inhaled sprays, injected systemi- dexamethasone inhibits vasculogenesis in a tumor through powerful its effects, bolsters the theory that corticoster- cally, drops for the eyes or ears, and orally. What are the Corticosteroids are a class of drugs similar to the suppressing vascular endothelial growth factor A. Treat- oids need to bind to the glucocorticoid receptor to have common physiological effects of the different corticoster- hormone cortisol, and they contain this steroid backbone. ment of steroid along with mifepristone prevented this physiological effects. The corticosteroid receptor complex oids? The medications in this class share a common molec- Different corticosteroids vary somewhat in shape due to suppressive effect (Greenberger et al., 2010). A limit of the causes numerous changes in the cell, both in the short ular backbone and cause analogous effects on a cellular the differing functional groups and oxidation state. Though conclusion, however, is that both studies were done using term as well as long term. all steroid molecules are quite similar in structure, slight the same corticosteroid dexamethasone, and therefore, level. Much research has been done trying to determine an After binding to the corticosteroid, the activated changes between each molecule’s backbone results in does not prove that other corticosteroids need to bind to exact mechanism of steroidal function. Mechanisms have glucocorticoid receptor complex is transported from the differing affinity between the molecule and the corre- the glucocorticoid receptor to have an effect. been proposed, but as of today, they are hypotheses that cytoplasm into the nucleus and binds to the promoter of sponding glucocorticoid receptor . Structural changes also explain some, but not all, effects. Though corticosteroid Further proof of this theory lies in the clinically specific genes containing the glucocorticoid response ele- affect the bioavailability of a corticosteroid. Inhaled corti- drugs are used for seemingly disparate pathologies, there seen observation that different topical corticosteroids have ments. This induces transcription of glucocorticoid re- costeroids with a hydroxyl group on carbon 21 have been are many similarities in physiological effects of corticoster- different potencies. Corticosteroids are therefore separat- sponse elements mRNA (Barnes, 2005). In endothelial cells, shown both in vitro and in vivo to undergo esterification oids, both medicinal as well as detrimental. ed into classes. In the United States, corticosteroids are dexamethasone induced promoter activity for the gluco- inside lung cells and therefore take a longer period of time divided in classes from one, the extremely potent, to sev- corticoid response elements and caused transcription of Methods to eliminate from the body (Kelly, 2009). en, the least potent. In Europe, classes are numbered these genes beginning four hours after treatment of cells. The similarities between the corticosteroid class of drugs, Mechanism of Action differently with class one, the mild corticosteroids, to class Actinomycin D, which inhibits transcription, and 5,6 as well as the differences between specific corticosteroids, four, the strongest of the corticosteroids. Percentage of dichlorobenzimidazole riboside, which inhibits RNA poly- were analyzed using original studies and critiques obtained The physiological effects of corticosteroids are well active ingredient in corticosteroid creams, lotions, or oint- merase, given in conjunction with the corticosteroid

M. Einhorn is pursuing a B.S. in Biology. 38 39 Similarities Between Corticosteroids

M. Einhorn is pursuing a B.S. in Biology. 38 39 M. Einhorn Similarities Between Corticosteroids

blocked the promoter activity (HafeziMoghdam et al., alloproteinase 1, interleukin6, and monocyte chemo- less nuclear translocation, less transcription, and less trans- by cells exposed to corticosteroids and the physiological 2002). These results indicate the influence of corticoster- attractant protein 1. The latter two molecules are both lation of interleukins 4,5, and 13 (Maneechotesuwan et al., effects these proteins have on the cell. oids on transcription, which will subsequently affect pro- involved with the immune system (Greenberger et al., 2009).

teins produced by the cell. 2010). Inhibition of metalloproteinase is also seen in corti- Corticosteroids were found to have non Therapeutic Usage of Corticosteroids costeroid treatment of arthritic diseases (Fubini et al., Some of the genes contained within the glucocor- transcriptional effects as well. Treating endothelial cells 2001). Steroidal medications induce changes in gene ex- The properties listed above are what cause corti- ticoid response elements code for proteins with anti with dexamethasone stimulated endothelial nitric oxide pression. The expressed genes, as well as the repressed costeroids to have a therapeutic influence on a wide varie- inflammatory effects, such as interleukin 10. Leucine zip- synthase, an enzyme that has physiological effects on the genes, have physiological effects on the cell, which are ty of diseases. One of the most common uses of cortico- per protein and I kappa beta alpha (IkBα) are proteins syn- cells. Activating the enzyme begins with the corticosteroid attributed to the corticosteroid. steroids is in the treatment and management of asthma thesized in a cell exposed to corticosteroid. They suppress binding to the glucocorticoid receptor. The complex stimu- (Eurich et. al, 2013) and other diseases characterized by an an important proinflammatory transcription factor called Numerous studies demonstrate that corticoster- lates protein kinase B (also known as Akt) either directly or obstructed airway (Sibila et al, 2013). Corticosteroids are nuclear factor kappa B (Barnes, 2006). Some genes are oids affect transcription, but this does not explain all of the indirectly through the phosphoinositide 3kinase/Akt path- used to treat inflammation in other areas of the body as indirectly inhibited by corticosteroids through the suppres- physiological effects of corticosteroids. Corticosteroids way. Protein kinase B phosphorylates endothelial nitric well. Therefore, corticosteroid drug therapy is commonly sion of nuclear factor kappa B (Maneechotesuwan et al., inhibit cytokine production in T helper 2 cells, specifically oxide synthase thereby activating this enzyme (Hafezi used to treat inflammatory skin disease,s such as eczema 2009). There are also genes directly inhibited by cortico- interleukin 4, 5, and 13. The genes coding these interleu- Moghdam et al., 2002). Researchers carried out this exper- and psoriasis. Injections of corticosteroids are used in the steroids, and these genes are considered to be negative kins are not fully regulated by nuclear factor kappa B and iment with only one corticosteroid, dexamethasone, and controlling of inflammation and the suppression of matrix glucocorticoid response elements. Examples of these di- are not known to be part of the glucocorticoid response the cells were evaluated for the function of only one en- metalloproteinase activity in arthritic diseases (Fubini et rectly suppressed genes include genes that regulate oste- element (Maneechotesuwan et al., 2009). Additionally, zyme. This raises an important question whether a corre- al.,2001). Corticosteroids are beneficial for autoimmune ocalcin and keratin (Barnes, 2006). The suppression of effects of dexamethasone were seen in cells after only ten sponding mechanism applies to other corticosteroids and disorders because of the immunosuppressive effect. Some these proteins results in common side effects of cortico- minutes , quite a short time for the transcription of gluco- the phosphorylation and activation of other enzymes. pathologies, such as allergies, are aided by both the anti steroids, such as epidermal, and to a lesser extent, dermal corticoid response element genes and translation of corre- General Effects of Corticosteroid Drugs inflammatory and immunosuppressive effects of cortico- thinning and increased risk of fractures. sponding proteins. Furthermore, although the inhibitor of steroids. transcription actinomycin D blocked the promoter of the Based on proteins produced or inhibited, as well as Corticosteroids inhibit proteins that have deleteri- glucocorticoid response elements, overall the molecule did the enzymes activated in a cell exposed to corticosteroids, The proteins produced in cells exposed to cortico- ous effects on specific pathologies. As a result corticoster- not inhibit the physiological changes of a cell exposed to these drugs have predictable physiological effects. One of steroids are beneficial to some diseases. Cardiovascular oid therapies are beneficial for these diseases. A study dexamethasone (HafeziMoghdam et al., 2002). Based on the most important effects of corticosteroid drugs is the disease can be treated using corticosteroids, though a high seeking to explain the function of corticosteroid therapy in these observations, the theory that corticosteroids binding suppression of inflammation. This effect is so significant dose is needed to achieve results (HafeziMoghdam et al., the treatment of infantile hemangioma found that the me- to a receptor cause a cell to express certain genes and re- that other drugs that also have antiinflammatory proper- 2002). Dexamethasone increased the activity of the en- dicinal property was due to a negative glucocorticoid re- press others is insufficient. ties are separated into a class titled nonsteroidal anti zyme endothelial nitric oxide synthase (eNOS) and the pro- sponse elements and a decrease in amount of a corre- inflammatory drugs (NSAIDs). Healthcare practitioners duction of nitric oxide. This radical protects muscle mi- sponding protein. Corticosteroids suppressed the expres- T cells exposed to anti CD3 antibodies and anti CD therefore often prescribe corticosteroids in the treatment crovessels in mice after ischemia. Under normal condi- sion of vascular endothelial growth factor A mRNA and 28 antibodies cause GATA3, a transcription factor, to be of pathologies involving an inflammatory reaction. Inflam- tions, leukocytes are present in the blood and do not ad- protein in hemangioma stem cells in a dose dependent imported into the nucleus and stimulate the expression of mation is associated with the immune system, and cortico- here to venule walls. Following ischemia and reperfusion, manner, suggesting that corticosteroids may slow the interleukin 4 and 5. T lymphocytes that were exposed to steroids influence cytokine production, increasing some leukocytes’ velocity in the bloodstream decreases and they growth of cancer cells. . Untreated infantile hemangioma the corticosteroid, known as fluticasone propionate, were cytokines while decreasing others, resulting in an immuno- begin to stick to the venule walls. Mice given dexame- cells express larger quantities of vascular growth factor found to have inhibited GATA3, which affected interleukin suppressant effect. Repressing the immune system is ben- thasone, directly following the ischemia and reperfusion, than normal endothelial cells, but use of corticosteroids gene expression. Interleukin 4 expression, which is regulat- eficial for the treatment of pathologies caused by an over- did not have the decrease in leukocyte velocity and the inhibited growth factor mRNA and protein. This effect was ed by GATA3, was inhibited, and GATA3 did not bind to active immune system, but detrimental to a patient on increase in adhesion normally seen after ischemia and replicated using different corticosteroids including dexa- the promoter of interleukin 5. Research on this phenome- longterm corticosteroid therapy. Immune system suppres- reperfusion (HafeziMoghdam et al., 2002). This effect was methasone, prednisone, prednisolone, methylpredniso- na found that GATA3 uses importin alpha for protein to sion increases patient susceptibility to infections, which studied in the cremaster muscle, but corticosteroids were lone, and hydrocortisone (Greenberger et al., 2010) lead- enter the nuclear membrane. Activated glucocorticoid re- can become quite serious. This effect is especially deleteri- found to have beneficial effects on myocardium as well. ing to a conclusion that this effect is common to all cortico- ceptors use importin alpha for nuclear translocation as ous to patients with compromised immune system due to Dexamethasone treated mice were found to have myocar- steroids. Other proangiogenic factors were suppressed in well, leading to competition between GATA3 and the glu- other medical issues. Corticosteroids affect mRNA tran- dial infarctions affecting a smaller percentage of their re- the hemangioma stem cells, in addition to vascular endo- cocorticoid receptor for importin alpha. This decreased scription and proteins produced in the cell. Researchers gion at risk for infarction, while mice in the control group thelial growth factor A. These factors included matrix met- quantity of importin alpha available to GATA3 results in are studying the effects of proteins produced or repressed

40 41 M. Einhorn Similarities Between Corticosteroids blocked the promoter activity (HafeziMoghdam et al., alloproteinase 1, interleukin6, and monocyte chemo- less nuclear translocation, less transcription, and less trans- by cells exposed to corticosteroids and the physiological 2002). These results indicate the influence of corticoster- attractant protein 1. The latter two molecules are both lation of interleukins 4,5, and 13 (Maneechotesuwan et al., effects these proteins have on the cell. oids on transcription, which will subsequently affect pro- involved with the immune system (Greenberger et al., 2009). teins produced by the cell. 2010). Inhibition of metalloproteinase is also seen in corti- Corticosteroids were found to have non Therapeutic Usage of Corticosteroids costeroid treatment of arthritic diseases (Fubini et al., Some of the genes contained within the glucocor- transcriptional effects as well. Treating endothelial cells 2001). Steroidal medications induce changes in gene ex- The properties listed above are what cause corti- ticoid response elements code for proteins with anti with dexamethasone stimulated endothelial nitric oxide pression. The expressed genes, as well as the repressed costeroids to have a therapeutic influence on a wide varie- inflammatory effects, such as interleukin 10. Leucine zip- synthase, an enzyme that has physiological effects on the genes, have physiological effects on the cell, which are ty of diseases. One of the most common uses of cortico- per protein and I kappa beta alpha (IkBα) are proteins syn- cells. Activating the enzyme begins with the corticosteroid attributed to the corticosteroid. steroids is in the treatment and management of asthma thesized in a cell exposed to corticosteroid. They suppress binding to the glucocorticoid receptor. The complex stimu- (Eurich et. al, 2013) and other diseases characterized by an an important proinflammatory transcription factor called Numerous studies demonstrate that corticoster- lates protein kinase B (also known as Akt) either directly or obstructed airway (Sibila et al, 2013). Corticosteroids are nuclear factor kappa B (Barnes, 2006). Some genes are oids affect transcription, but this does not explain all of the indirectly through the phosphoinositide 3kinase/Akt path- used to treat inflammation in other areas of the body as indirectly inhibited by corticosteroids through the suppres- physiological effects of corticosteroids. Corticosteroids way. Protein kinase B phosphorylates endothelial nitric well. Therefore, corticosteroid drug therapy is commonly sion of nuclear factor kappa B (Maneechotesuwan et al., inhibit cytokine production in T helper 2 cells, specifically oxide synthase thereby activating this enzyme (Hafezi used to treat inflammatory skin disease,s such as eczema 2009). There are also genes directly inhibited by cortico- interleukin 4, 5, and 13. The genes coding these interleu- Moghdam et al., 2002). Researchers carried out this exper- and psoriasis. Injections of corticosteroids are used in the steroids, and these genes are considered to be negative kins are not fully regulated by nuclear factor kappa B and iment with only one corticosteroid, dexamethasone, and controlling of inflammation and the suppression of matrix glucocorticoid response elements. Examples of these di- are not known to be part of the glucocorticoid response the cells were evaluated for the function of only one en- metalloproteinase activity in arthritic diseases (Fubini et rectly suppressed genes include genes that regulate oste- element (Maneechotesuwan et al., 2009). Additionally, zyme. This raises an important question whether a corre- al.,2001). Corticosteroids are beneficial for autoimmune ocalcin and keratin (Barnes, 2006). The suppression of effects of dexamethasone were seen in cells after only ten sponding mechanism applies to other corticosteroids and disorders because of the immunosuppressive effect. Some these proteins results in common side effects of cortico- minutes , quite a short time for the transcription of gluco- the phosphorylation and activation of other enzymes. pathologies, such as allergies, are aided by both the anti steroids, such as epidermal, and to a lesser extent, dermal corticoid response element genes and translation of corre- General Effects of Corticosteroid Drugs inflammatory and immunosuppressive effects of cortico- thinning and increased risk of fractures. sponding proteins. Furthermore, although the inhibitor of steroids. transcription actinomycin D blocked the promoter of the Based on proteins produced or inhibited, as well as Corticosteroids inhibit proteins that have deleteri- glucocorticoid response elements, overall the molecule did the enzymes activated in a cell exposed to corticosteroids, The proteins produced in cells exposed to cortico- ous effects on specific pathologies. As a result corticoster- not inhibit the physiological changes of a cell exposed to these drugs have predictable physiological effects. One of steroids are beneficial to some diseases. Cardiovascular oid therapies are beneficial for these diseases. A study dexamethasone (HafeziMoghdam et al., 2002). Based on the most important effects of corticosteroid drugs is the disease can be treated using corticosteroids, though a high seeking to explain the function of corticosteroid therapy in these observations, the theory that corticosteroids binding suppression of inflammation. This effect is so significant dose is needed to achieve results (HafeziMoghdam et al., the treatment of infantile hemangioma found that the me- to a receptor cause a cell to express certain genes and re- that other drugs that also have antiinflammatory proper- 2002). Dexamethasone increased the activity of the en- dicinal property was due to a negative glucocorticoid re- press others is insufficient. ties are separated into a class titled nonsteroidal anti zyme endothelial nitric oxide synthase (eNOS) and the pro- sponse elements and a decrease in amount of a corre- inflammatory drugs (NSAIDs). Healthcare practitioners duction of nitric oxide. This radical protects muscle mi- sponding protein. Corticosteroids suppressed the expres- T cells exposed to anti CD3 antibodies and anti CD therefore often prescribe corticosteroids in the treatment crovessels in mice after ischemia. Under normal condi- sion of vascular endothelial growth factor A mRNA and 28 antibodies cause GATA3, a transcription factor, to be of pathologies involving an inflammatory reaction. Inflam- tions, leukocytes are present in the blood and do not ad- protein in hemangioma stem cells in a dose dependent imported into the nucleus and stimulate the expression of mation is associated with the immune system, and cortico- here to venule walls. Following ischemia and reperfusion, manner, suggesting that corticosteroids may slow the interleukin 4 and 5. T lymphocytes that were exposed to steroids influence cytokine production, increasing some leukocytes’ velocity in the bloodstream decreases and they growth of cancer cells. . Untreated infantile hemangioma the corticosteroid, known as fluticasone propionate, were cytokines while decreasing others, resulting in an immuno- begin to stick to the venule walls. Mice given dexame- cells express larger quantities of vascular growth factor found to have inhibited GATA3, which affected interleukin suppressant effect. Repressing the immune system is ben- thasone, directly following the ischemia and reperfusion, than normal endothelial cells, but use of corticosteroids gene expression. Interleukin 4 expression, which is regulat- eficial for the treatment of pathologies caused by an over- did not have the decrease in leukocyte velocity and the inhibited growth factor mRNA and protein. This effect was ed by GATA3, was inhibited, and GATA3 did not bind to active immune system, but detrimental to a patient on increase in adhesion normally seen after ischemia and replicated using different corticosteroids including dexa- the promoter of interleukin 5. Research on this phenome- longterm corticosteroid therapy. Immune system suppres- reperfusion (HafeziMoghdam et al., 2002). This effect was methasone, prednisone, prednisolone, methylpredniso- na found that GATA3 uses importin alpha for protein to sion increases patient susceptibility to infections, which studied in the cremaster muscle, but corticosteroids were lone, and hydrocortisone (Greenberger et al., 2010) lead- enter the nuclear membrane. Activated glucocorticoid re- can become quite serious. This effect is especially deleteri- found to have beneficial effects on myocardium as well. ing to a conclusion that this effect is common to all cortico- ceptors use importin alpha for nuclear translocation as ous to patients with compromised immune system due to Dexamethasone treated mice were found to have myocar- steroids. Other proangiogenic factors were suppressed in well, leading to competition between GATA3 and the glu- other medical issues. Corticosteroids affect mRNA tran- dial infarctions affecting a smaller percentage of their re- the hemangioma stem cells, in addition to vascular endo- cocorticoid receptor for importin alpha. This decreased scription and proteins produced in the cell. Researchers gion at risk for infarction, while mice in the control group thelial growth factor A. These factors included matrix met- quantity of importin alpha available to GATA3 results in are studying the effects of proteins produced or repressed

40 41 M. Einhorn Similarities Between Corticosteroids had a larger percentage of their region at risk affected by a infantile hemangioma. They suppress vascular endothelial thinning. Hydrocortisone, a mild corticosteroid, did not cleosis did not worsen the infection (Bergeson et al., 2013). myocardial infarction. Other studies have demonstrated growth factor A, thereby inhibiting tumor vasculogenesis cause significant atrophy. These studies did not follow up with the patients to see if that corticosteroids given to cardiovascular patients im- and limiting tumor growth (Greenberger et al., 2010). Ad- any longterm effect or nonimmediate reaction to the cor- It is evident from this study that in many cases, the proved shortterm survival following a myocardial infarc- ditional research is needed to determine whether this ticosteroid occurred. Additionally, it is possible that corti- skin, particularly the epidermis, is affected by corticoster- tion. In the experiments using mice, only very high doses effect extends to other forms of cancer and can be used costeroids cause subtle effects that are not detected by oid use (Cobman and Wezel, 2006). This effect is likely be- caused physiological effects, and an established clinical accordingly, as a part of treatment. Furthermore, the safe- laboratory means currently available. cause corticosteroids directly inhibit genes coding the pro- dose offered no cardiovascular protection (Hafezi ty of corticosteroid therapy in cancer patients must be tein keratin; these genes are part of the negative GRE. A low to medium dose of inhaled corticosteroid is Moghdam et al., 2002). evaluated as well. Healthcare providers should treat a patient using the least not likely to cause adverse effects (Kelly, 2009). As an im- Corticosteroids are effective in reducing pain, as Side Effects Common to Corticosteroids potent corticosteroid found to be effective and should munosuppressant, regular corticosteroid use may nega- evidenced by a study comparing the effectiveness of intra- monitor skin changes in the patient (Cobman and Wezel, tively impact the immune system’s ability to fight infection. The change in proteins produced by a cell exposed venous hydrocortisone plus conventional treatment versus 2006). Similar results were obtained in a study testing the Eighty nine patients, with a diagnosis of community to corticosteroids has numerous effects on the cell, both a placebo and conventional methods at reducing a severe effects of corticosteroids on different skin phototypes. An acquired pneumonia and had previously taken inhaled cor- positive and negative. Side effects of a corticosteroid de- postdural puncture headache. The results clearly showed additional side effect of corticosteroids was seen in the ticosteroids, were compared with a control group of 575 pend on the binding affinity, which is the potency of the the effectiveness of corticosteroids at reducing intense study: changed skin pigmentation (Shlivko et al., 2013). patients, with the same diagnosis who had not taken any given corticosteroid; the length of time for which it is tak- pain. Dural puncture is thought to cause a headache by inhaled corticosteroids. Inhaled corticosteroids are used in en; and the method of introduction in the body. Side The method used to introduce corticosteroids into the causing cerebral spinal fluid leakage and a lessening of the the control of disorders involving lung inflammation, such effects of topically applied corticosteroids generally affect body influences the side effects experienced by the pa- fluid cushioning around the brain. The mechanism for the as asthma and COPD. The corticosteroid inhaler is general- the location of application. tient. The effects of topical corticosteroids are concentrat- resolution of the headache is unknown, but possibilities ly used daily or on a regular basis. The patients, who had ed and limited to the location of application. Therefore, include the antiinflammatory properties of corticosteroids Skin atrophy is a common effect of corticosteroids previously used inhaled corticosteroids, were more likely topical corticosteroids may be more effective for treat- at the puncture site, the suppression of interleukins and (Cobman and Wezel, 2006). In a double blind study, twenty to have an illness caused by an antibacterial resistant mi- ment of the skin and are known to have a lower toxicity as prostaglandins, and causing the reabsorption of cerebro- healthy volunteers applied four different topical cortico- crobe and presented a more critical case of pneumonia compared to oral corticosteroids (Joly et al., 2002). spinal fluid (Alam et al., 2012). Similarly, corticosteroids, in steroids with differing potencies to their volar arm for four upon admission. Clinicians measure pneumonia by using addition to antibiotics, relieved the pain and symptoms of weeks. Researchers quantified skin atrophy, using optical Based on numerous studies, adverse effects of oral the Pneumonia Severity Index and Curb65 scores, which patients suffering strong discomfort from pharyngitis soon- coherence tomography to measure epidermal thickness, corticosteroids are not detected at low and infrequent dos- measures the likelihood of the pneumonia patient to die er than than antibiotics and a placebo did (Bergeson et. al., and using high frequency ultrasound to measure dermal es. Patients treated with oral corticosteroids were evaluat- from their disease within 30 days (Sibila et al., 2013). Simi- 2013). thickness. Additionally, they used a profilometer, an instru- ed for risk of bone fractures. Those on medium to high larly, a study of 6874 patients, who had community ment that measures the profile of a given surface, to quan- doses of prednisone or prednisolone were found to have acquired pneumonia, found that inhaled corticosteroid use Topical corticosteroids have the benefit of main- tify epidermal roughness. All of the volunteers experienced increased risk of fracture. Significantly, the fracture risk in highrisk patients increased the risk of a repeat incident taining a localized concentration of corticosteroids. Pa- epidermal thinning, demonstrating the frequency of this remained elevated for up to a year after the last dose, indi- of pneumonia by ninety percent (Eurich et al., 2013). tients with bullous pemphigoid, a potentially fatal autoim- side effect. The epidermis thickened considerably after cating that effects of corticosteroids linger even after dis- Healthcare providers should relay this risk to asthmatic mune disease of the skin, were divided into one group re- treatment was completed, but three weeks after finishing continuing drug therapy . Budesonide has a low systemic patients and instruct the patient, or the patient’s caregiver, ceiving treatment of 40 grams of the topical corticosteroid treatment, the epidermis was still measurably thinner than availability, as it is designed for release in the intestine. to seek medical care as soon as they feel symptoms of 0.5% clobetasol propionate twice daily, and the other it had been before treatment. The subjects were followed Due to the low systemic concentration, budesonide was pneumonia. Earlier diagnosis will lead to treatment and a group was treated with one milligram per kilogram of oral for only three weeks following steroid use, so the length of not associated with increased risk of fracture. Methylpred- better prognosis. prednisone. The topical corticosteroid was found to be time for which this effect persisted and the time needed nisolone is generally not used regularly, and as a result, did more effective at controlling the disease and caused a low- Treatment of arthritis using corticosteroids has for the epidermis to return to its original thickness was not not cause an increased risk of fractures. Likewise, low dos- er incidence of side effects than the oral corticosteroid been proven effective. There are negative effects, howev- determined in the study. The dermis of volunteers thinned es of corticosteroids and doses taken intermittently were (Joly et al., 2002). Similarly, topical steroids were found to er, and a healthcare provider should perform a benefit ver- as well. The dermal thinning, however, was less than that not associated with increased risk (Vestergaard et al., be effective at reducing inflammation and ear discharge in sus risk assessment and treat the patient accordingly. Cor- of the epidermal thinning. Additionally, three weeks post 2008). Similarly, shortterm use of corticosteroids in otitis media. Clinicians commonly prescribe ear drops, con- ticosteroid injections into joints negatively affected chon- treatment the dermis had almost returned to its original treating the intense pain of a postdural headache did not taining a combination of an antibiotic, such as Augmentin®, drocytes, in addition to the cartilage damaged by the ar- thickness. Using the profilometer, areas of corticosteroid cause shortterm negative effects (Alam et al., 2012). Addi- and a corticosteroid, to treat otitis media with discharge thritis. A single dose of methylprednisolone succinate sup- use had a decreased roughness. The effect of the cortico- tionally, in the study using corticosteroids to treat severe (Florea et al., 2006). pressed the expression of type 2 procollagen mRNA and steroid on the skin corresponded with its known potency; sore throat, the corticosteroids did not exacerbate illness. decreased the relative percentage of the fibronectin form Corticosteroids are used in oncology treatment of the more potent corticosteroids caused more significant Likewise, the use of corticosteroids in croup and mononu-

42 43 M. Einhorn Similarities Between Corticosteroids had a larger percentage of their region at risk affected by a infantile hemangioma. They suppress vascular endothelial thinning. Hydrocortisone, a mild corticosteroid, did not cleosis did not worsen the infection (Bergeson et al., 2013). myocardial infarction. Other studies have demonstrated growth factor A, thereby inhibiting tumor vasculogenesis cause significant atrophy. These studies did not follow up with the patients to see if that corticosteroids given to cardiovascular patients im- and limiting tumor growth (Greenberger et al., 2010). Ad- any longterm effect or nonimmediate reaction to the cor- It is evident from this study that in many cases, the proved shortterm survival following a myocardial infarc- ditional research is needed to determine whether this ticosteroid occurred. Additionally, it is possible that corti- skin, particularly the epidermis, is affected by corticoster- tion. In the experiments using mice, only very high doses effect extends to other forms of cancer and can be used costeroids cause subtle effects that are not detected by oid use (Cobman and Wezel, 2006). This effect is likely be- caused physiological effects, and an established clinical accordingly, as a part of treatment. Furthermore, the safe- laboratory means currently available. cause corticosteroids directly inhibit genes coding the pro- dose offered no cardiovascular protection (Hafezi ty of corticosteroid therapy in cancer patients must be tein keratin; these genes are part of the negative GRE. A low to medium dose of inhaled corticosteroid is Moghdam et al., 2002). evaluated as well. Healthcare providers should treat a patient using the least not likely to cause adverse effects (Kelly, 2009). As an im- Corticosteroids are effective in reducing pain, as Side Effects Common to Corticosteroids potent corticosteroid found to be effective and should munosuppressant, regular corticosteroid use may nega- evidenced by a study comparing the effectiveness of intra- monitor skin changes in the patient (Cobman and Wezel, tively impact the immune system’s ability to fight infection. The change in proteins produced by a cell exposed venous hydrocortisone plus conventional treatment versus 2006). Similar results were obtained in a study testing the Eighty nine patients, with a diagnosis of community to corticosteroids has numerous effects on the cell, both a placebo and conventional methods at reducing a severe effects of corticosteroids on different skin phototypes. An acquired pneumonia and had previously taken inhaled cor- positive and negative. Side effects of a corticosteroid de- postdural puncture headache. The results clearly showed additional side effect of corticosteroids was seen in the ticosteroids, were compared with a control group of 575 pend on the binding affinity, which is the potency of the the effectiveness of corticosteroids at reducing intense study: changed skin pigmentation (Shlivko et al., 2013). patients, with the same diagnosis who had not taken any given corticosteroid; the length of time for which it is tak- pain. Dural puncture is thought to cause a headache by inhaled corticosteroids. Inhaled corticosteroids are used in en; and the method of introduction in the body. Side The method used to introduce corticosteroids into the causing cerebral spinal fluid leakage and a lessening of the the control of disorders involving lung inflammation, such effects of topically applied corticosteroids generally affect body influences the side effects experienced by the pa- fluid cushioning around the brain. The mechanism for the as asthma and COPD. The corticosteroid inhaler is general- the location of application. tient. The effects of topical corticosteroids are concentrat- resolution of the headache is unknown, but possibilities ly used daily or on a regular basis. The patients, who had ed and limited to the location of application. Therefore, include the antiinflammatory properties of corticosteroids Skin atrophy is a common effect of corticosteroids previously used inhaled corticosteroids, were more likely topical corticosteroids may be more effective for treat- at the puncture site, the suppression of interleukins and (Cobman and Wezel, 2006). In a double blind study, twenty to have an illness caused by an antibacterial resistant mi- ment of the skin and are known to have a lower toxicity as prostaglandins, and causing the reabsorption of cerebro- healthy volunteers applied four different topical cortico- crobe and presented a more critical case of pneumonia compared to oral corticosteroids (Joly et al., 2002). spinal fluid (Alam et al., 2012). Similarly, corticosteroids, in steroids with differing potencies to their volar arm for four upon admission. Clinicians measure pneumonia by using addition to antibiotics, relieved the pain and symptoms of weeks. Researchers quantified skin atrophy, using optical Based on numerous studies, adverse effects of oral the Pneumonia Severity Index and Curb65 scores, which patients suffering strong discomfort from pharyngitis soon- coherence tomography to measure epidermal thickness, corticosteroids are not detected at low and infrequent dos- measures the likelihood of the pneumonia patient to die er than than antibiotics and a placebo did (Bergeson et. al., and using high frequency ultrasound to measure dermal es. Patients treated with oral corticosteroids were evaluat- from their disease within 30 days (Sibila et al., 2013). Simi- 2013). thickness. Additionally, they used a profilometer, an instru- ed for risk of bone fractures. Those on medium to high larly, a study of 6874 patients, who had community ment that measures the profile of a given surface, to quan- doses of prednisone or prednisolone were found to have acquired pneumonia, found that inhaled corticosteroid use Topical corticosteroids have the benefit of main- tify epidermal roughness. All of the volunteers experienced increased risk of fracture. Significantly, the fracture risk in highrisk patients increased the risk of a repeat incident taining a localized concentration of corticosteroids. Pa- epidermal thinning, demonstrating the frequency of this remained elevated for up to a year after the last dose, indi- of pneumonia by ninety percent (Eurich et al., 2013). tients with bullous pemphigoid, a potentially fatal autoim- side effect. The epidermis thickened considerably after cating that effects of corticosteroids linger even after dis- Healthcare providers should relay this risk to asthmatic mune disease of the skin, were divided into one group re- treatment was completed, but three weeks after finishing continuing drug therapy . Budesonide has a low systemic patients and instruct the patient, or the patient’s caregiver, ceiving treatment of 40 grams of the topical corticosteroid treatment, the epidermis was still measurably thinner than availability, as it is designed for release in the intestine. to seek medical care as soon as they feel symptoms of 0.5% clobetasol propionate twice daily, and the other it had been before treatment. The subjects were followed Due to the low systemic concentration, budesonide was pneumonia. Earlier diagnosis will lead to treatment and a group was treated with one milligram per kilogram of oral for only three weeks following steroid use, so the length of not associated with increased risk of fracture. Methylpred- better prognosis. prednisone. The topical corticosteroid was found to be time for which this effect persisted and the time needed nisolone is generally not used regularly, and as a result, did more effective at controlling the disease and caused a low- Treatment of arthritis using corticosteroids has for the epidermis to return to its original thickness was not not cause an increased risk of fractures. Likewise, low dos- er incidence of side effects than the oral corticosteroid been proven effective. There are negative effects, howev- determined in the study. The dermis of volunteers thinned es of corticosteroids and doses taken intermittently were (Joly et al., 2002). Similarly, topical steroids were found to er, and a healthcare provider should perform a benefit ver- as well. The dermal thinning, however, was less than that not associated with increased risk (Vestergaard et al., be effective at reducing inflammation and ear discharge in sus risk assessment and treat the patient accordingly. Cor- of the epidermal thinning. Additionally, three weeks post 2008). Similarly, shortterm use of corticosteroids in otitis media. Clinicians commonly prescribe ear drops, con- ticosteroid injections into joints negatively affected chon- treatment the dermis had almost returned to its original treating the intense pain of a postdural headache did not taining a combination of an antibiotic, such as Augmentin®, drocytes, in addition to the cartilage damaged by the ar- thickness. Using the profilometer, areas of corticosteroid cause shortterm negative effects (Alam et al., 2012). Addi- and a corticosteroid, to treat otitis media with discharge thritis. A single dose of methylprednisolone succinate sup- use had a decreased roughness. The effect of the cortico- tionally, in the study using corticosteroids to treat severe (Florea et al., 2006). pressed the expression of type 2 procollagen mRNA and steroid on the skin corresponded with its known potency; sore throat, the corticosteroids did not exacerbate illness. decreased the relative percentage of the fibronectin form Corticosteroids are used in oncology treatment of the more potent corticosteroids caused more significant Likewise, the use of corticosteroids in croup and mononu-

42 43 M. Einhorn Similarities Between Corticosteroids unique to cartilage. Researchers found that injecting the Alam M, Rahman M, Ershad R. Role of very shortterm intravenous recommended dose of methylprednisolone acetate into hydrocortisone in reducing postdural puncture headache. Journal Of protective effects of corticosteroids are mediated by nontranscriptional synovial fluid resulted in a high corticosteroid concentra- Anaesthesiology, Clinical Pharmacology [serial online]. April 2012;28 activation of endothelial nitric oxide synthase. Nature Medicine [serial tion, that was maintained for a longer period of time, be- (2):190193. Available from: Medline, Ipswich, MA. Accessed January 8, online]. May 2002;8(5):473. Available from: Academic Search Complete, 2014. Ipswich, MA. Accessed January 8, 2014. cause the halflife of corticosteroid in synovial fluid is found to be 10.3 hours (Fubini et al., 2001). Barnes P. How corticosteroids control inflammation: Quintiles Prize Joly P, Roujeau J, Benichou J, et al. A comparison of oral and topical Lecture 2005. British Journal Of Pharmacology [serial online]. June corticosteroids in patients with bullous pemphigoid. New England Jour- Conclusion 2006;148(3):245254. Available from: Medline, Ipswich, MA. Accessed nal of Medicine [serial online]. 2002;346(5):321327. Available from: Corticosteroids are a class of drugs with similarities January 8, 2014. ProQuest. Accessed January 8, 2014. in structure, and they have immunosuppressant and anti Bergeson K, Rogers N, Prasad S. PURLs: corticosteroids for a sore Kelly HW. Comparison of inhaled corticosteroids: an update. The Annals inflammatory properties with comparable mechanisms. throat?. The Journal of Family Practice [serial online]. July 2013;62 Of Pharmacotherapy [serial online]. March 2009;43:519527. Available Gene expression is affected by corticosteroids, with genes (7):372374. Available from: Medline, Ipswich, MA. Accessed January 8, from: Medline, Ipswich, MA. Accessed December 12, 2013. 2014. coding the glucocorticoid response elements expressed Maneechotesuwan K, Yao X, Barnes P, et al. Suppression of GATA3 Borelli C, Gassmueller J, Fluhr J W, et al. Activity of different more than normal, while other genes coding interleukins nuclear import and phosphorylation: a novel mechanism of corticoster- are inhibited. Various corticosteroids are used in a wide desoximetasone preparations compared to other topical corticosteroids oid action in allergic disease. Plos Medicine [serial online]. May 12, variety of disparate pathologies, because of their in the vasoconstriction assay. Skin Pharmacology and Physiology [serial 2009;6(5):e1000076. Available from: Medline, Ipswich, MA. Accessed immunosuppressant and antiinflammatory properties. online]. June 2008;21(3):181187. Available from Google Scholar. Ac- January 8, 2014. cessed January 12, 2014. These properties are responsible for the side effects of cor- Sibila O, Laserna E, Mortensen E, Anzueto A, Restrepo M. Effects of Cobmann M, Welzel J. Evaluation of the atrophogenic potential of differ- ticosteroids, including a decreased immune function and inhaled corticosteroids on pneumonia severity and antimicrobial re- ent changes in cells exposed to high concentrations of sistance. Respiratory Care [serial online]. September 2013;58(9):1489 corticosteroids. Differences in corticosteroid structure in- glucocorticoids using optical coherence tomography, 20MHz ultra- 1494. Available from: Medline, Ipswich, MA. Accessed January 8, 2014. sound and profilometry; a double blind, placebocontrolled trial. British fluence bioavailability and affinity to glucocorticoid recep- Shlivko IL, Kanmensky VA, Donchenko EV, Agrba P. Morphological Journal Of Dermatology [serial online]. October 2006;155(4):700706. tor; both of which are directly related to potency. Available from: Academic Search Complete, Ipswich, MA. Accessed Jan- changes in skin of different phototypes under the action of topical corti- Additionally, the method of introduction of corticosteroid uary 8, 2014. costeroid therapy and tacrolimus. Skin Research and Technology [serial online]. May 2013;0:15. Available from:Penn State Hershey ILL lending. into the body, as well as the place of introduction, are ma- Eurich DT, Colin L, Thomas JM, Sumit RM. Inhaled Corticosteroids and Accessed December 17, 2013. jor determinants of corticosteroid effects. risk of recurrent pneumonia: a populationbased, nested casecontrol Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with Overall, corticosteroids are an important method study. Clinical of Infectious Diseases [serial online]. 2013;57(8):1138 different types of oral corticosteroids and effect of termination of corti- of treatment for illnesses involving an overactive immune 1144. Available from Oxford Journals. Accessed December 2, 2013. costeroids on the risk of fractures. Calcified Tissue International [serial Florea A, Zwart J, Jung T, et al. Effect of topical dexamethasone versus system and/or inflammation. However, their use should be online]. March 2008;82(4):249257. Available from: Google Scholar. limited, as much as possible, due to their side effects. Be- rimexolone on middle ear inflammation in experimental otitis media Accessed January 12, 2014. fore prescribing corticosteroids, physicians and other with effusion. Acta OtoLaryngologica [serial online]. September healthcare providers should evaluate the patient’s overall 2006;126(9):910915. Available from: Academic Search Complete, Ips- wich, MA. Accessed January 8, 2014. Accessed January 8, 2014. immune function and assess the need for corticosteroid therapy. Healthcare providers should experiment with the Fubini SL, Todhunter RJ, BurtonWurster N, et al. Corticosteroids alter the patient to determine the least potent, lowest dose of corticosteroid found to be effective, particularly in patients re- Differentiated phenotype of articular chondrocytes. Journal of Ortho- paedic Research [serial online]. July 2001;19(4):688695. Available from: quiring longterm use. Patients or the primary caregiver, in ProQuest. Accessed December 29, 2013. the case of children or the elderly, need to be informed of Greenberger S, Boscolo E, Adini I, Mulliken J, Bischoff J. Corticosteroid the possible side effects such as increased risk of infection and thinning of the skin. Awareness of corticosteroid risk, suppression of VEGFA in infantile hemangioma derived stem cells. The New England Journal of Medicine [serial online]. March 18, 2010;362 along with monitoring by medical professionals, will likely (11):10051013. Available from: Medline, Ipswich, MA. Accessed Janu- diminish many of the adverse side effects accompanying ary 8, 2014. corticosteroid use. HafeziMoghdam A, Simoncini T, Liao J, et al. Acute Cardiovascular References

44 45 M. Einhorn Similarities Between Corticosteroids unique to cartilage. Researchers found that injecting the Alam M, Rahman M, Ershad R. Role of very shortterm intravenous recommended dose of methylprednisolone acetate into hydrocortisone in reducing postdural puncture headache. Journal Of protective effects of corticosteroids are mediated by nontranscriptional synovial fluid resulted in a high corticosteroid concentra- Anaesthesiology, Clinical Pharmacology [serial online]. April 2012;28 activation of endothelial nitric oxide synthase. Nature Medicine [serial tion, that was maintained for a longer period of time, be- (2):190193. Available from: Medline, Ipswich, MA. Accessed January 8, online]. May 2002;8(5):473. Available from: Academic Search Complete, 2014. Ipswich, MA. Accessed January 8, 2014. cause the halflife of corticosteroid in synovial fluid is found to be 10.3 hours (Fubini et al., 2001). Barnes P. How corticosteroids control inflammation: Quintiles Prize Joly P, Roujeau J, Benichou J, et al. A comparison of oral and topical Lecture 2005. British Journal Of Pharmacology [serial online]. June corticosteroids in patients with bullous pemphigoid. New England Jour- Conclusion 2006;148(3):245254. Available from: Medline, Ipswich, MA. Accessed nal of Medicine [serial online]. 2002;346(5):321327. Available from: Corticosteroids are a class of drugs with similarities January 8, 2014. ProQuest. Accessed January 8, 2014. in structure, and they have immunosuppressant and anti Bergeson K, Rogers N, Prasad S. PURLs: corticosteroids for a sore Kelly HW. Comparison of inhaled corticosteroids: an update. The Annals inflammatory properties with comparable mechanisms. throat?. The Journal of Family Practice [serial online]. July 2013;62 Of Pharmacotherapy [serial online]. March 2009;43:519527. Available Gene expression is affected by corticosteroids, with genes (7):372374. Available from: Medline, Ipswich, MA. Accessed January 8, from: Medline, Ipswich, MA. Accessed December 12, 2013. 2014. coding the glucocorticoid response elements expressed Maneechotesuwan K, Yao X, Barnes P, et al. Suppression of GATA3 Borelli C, Gassmueller J, Fluhr J W, et al. Activity of different more than normal, while other genes coding interleukins nuclear import and phosphorylation: a novel mechanism of corticoster- are inhibited. Various corticosteroids are used in a wide desoximetasone preparations compared to other topical corticosteroids oid action in allergic disease. Plos Medicine [serial online]. May 12, variety of disparate pathologies, because of their in the vasoconstriction assay. Skin Pharmacology and Physiology [serial 2009;6(5):e1000076. Available from: Medline, Ipswich, MA. Accessed immunosuppressant and antiinflammatory properties. online]. June 2008;21(3):181187. Available from Google Scholar. Ac- January 8, 2014. cessed January 12, 2014. These properties are responsible for the side effects of cor- Sibila O, Laserna E, Mortensen E, Anzueto A, Restrepo M. Effects of Cobmann M, Welzel J. Evaluation of the atrophogenic potential of differ- ticosteroids, including a decreased immune function and inhaled corticosteroids on pneumonia severity and antimicrobial re- ent changes in cells exposed to high concentrations of sistance. Respiratory Care [serial online]. September 2013;58(9):1489 corticosteroids. Differences in corticosteroid structure in- glucocorticoids using optical coherence tomography, 20MHz ultra- 1494. Available from: Medline, Ipswich, MA. Accessed January 8, 2014. sound and profilometry; a double blind, placebocontrolled trial. British fluence bioavailability and affinity to glucocorticoid recep- Shlivko IL, Kanmensky VA, Donchenko EV, Agrba P. Morphological Journal Of Dermatology [serial online]. October 2006;155(4):700706. tor; both of which are directly related to potency. Available from: Academic Search Complete, Ipswich, MA. Accessed Jan- changes in skin of different phototypes under the action of topical corti- Additionally, the method of introduction of corticosteroid uary 8, 2014. costeroid therapy and tacrolimus. Skin Research and Technology [serial online]. May 2013;0:15. Available from:Penn State Hershey ILL lending. into the body, as well as the place of introduction, are ma- Eurich DT, Colin L, Thomas JM, Sumit RM. Inhaled Corticosteroids and Accessed December 17, 2013. jor determinants of corticosteroid effects. risk of recurrent pneumonia: a populationbased, nested casecontrol Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with Overall, corticosteroids are an important method study. Clinical of Infectious Diseases [serial online]. 2013;57(8):1138 different types of oral corticosteroids and effect of termination of corti- of treatment for illnesses involving an overactive immune 1144. Available from Oxford Journals. Accessed December 2, 2013. costeroids on the risk of fractures. Calcified Tissue International [serial Florea A, Zwart J, Jung T, et al. Effect of topical dexamethasone versus system and/or inflammation. However, their use should be online]. March 2008;82(4):249257. Available from: Google Scholar. limited, as much as possible, due to their side effects. Be- rimexolone on middle ear inflammation in experimental otitis media Accessed January 12, 2014. fore prescribing corticosteroids, physicians and other with effusion. Acta OtoLaryngologica [serial online]. September healthcare providers should evaluate the patient’s overall 2006;126(9):910915. Available from: Academic Search Complete, Ips- wich, MA. Accessed January 8, 2014. Accessed January 8, 2014. immune function and assess the need for corticosteroid therapy. Healthcare providers should experiment with the Fubini SL, Todhunter RJ, BurtonWurster N, et al. Corticosteroids alter the patient to determine the least potent, lowest dose of corticosteroid found to be effective, particularly in patients re- Differentiated phenotype of articular chondrocytes. Journal of Ortho- paedic Research [serial online]. July 2001;19(4):688695. Available from: quiring longterm use. Patients or the primary caregiver, in ProQuest. Accessed December 29, 2013. the case of children or the elderly, need to be informed of Greenberger S, Boscolo E, Adini I, Mulliken J, Bischoff J. Corticosteroid the possible side effects such as increased risk of infection and thinning of the skin. Awareness of corticosteroid risk, suppression of VEGFA in infantile hemangioma derived stem cells. The New England Journal of Medicine [serial online]. March 18, 2010;362 along with monitoring by medical professionals, will likely (11):10051013. Available from: Medline, Ipswich, MA. Accessed Janu- diminish many of the adverse side effects accompanying ary 8, 2014. corticosteroid use. HafeziMoghdam A, Simoncini T, Liao J, et al. Acute Cardiovascular References

44 45