Various spaced-out schedules have been used in the aspiration of reducing hypothalamic/pituitary/ adrenal (HPA) suppression by allowing the plasma steroid concentration to fall between doses to pro vide time for pituitary recovery, e.g. prednisolone 40 on alternate days. But none has been successful in both completely avoiding suppression and at the same time controlling symptoms. The following are examples:
• Where a single daily dose is practicable it should be given in the early morning (to coincide with the natural activation of the HPA axis).
• Alternate day schedules are worth using, especially where immunosuppression is the objective (organ transplants) rather than antiinflammatory effect (rheumatoid arthritis).
• Short courses (a few days) may be practicable for some conditions without significant suppression, e.g. acute asthma of moderate severity.
• Another variant is to give enormous doses (grams, not mg), orally or i.v., e.g. methylprednisolone 1.0 g i.v. on 3 successive days, at intervals of weeks or months (megadose pulses). The technique is used particularly in collagen diseases.
• For oral replacement therapy in adrenocortical insufficiency:hydrocortisone should he used to supply glucocorticoid and some mincralocorticoid activity. In Addison's disease a small dose of a hormone with only minerabcorticoid effect (fludrocortisone) is normally needed in addition. Prednisolone on its own is not effective replacement therapy.
• For anti-inflammatory and antiallergic (immunosuppressive) effect, prednisolone, triamcinolone or dexomcthasone, It is not possible to rank these in firm order of merit. One or other may suit an individual patient best, especially as regards incidence of adverse effects such as muscle wasting fiy inhalation: beclomethasone or budesonide.
• For hypothalamic/pituitary/adrenocortkal suppression, e.g. in adrenal hyperplasia, prednisolone or dexamethasoné.
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