Since glucocorticoids possess a wide range of effects on virtually every phase and component of the inflammatory and immune responses, they have assumed a major role in the treatment of a wide spectrum of diseases with an inflammatory or immune-mediated component. Rheumatoid arthritis is the original condition for which antiinflammatory steroids were used, and they remain a mainstay of therapy. Intraarticular glucocorticoid injections have proven to be efficacious, particularly in children. However, the detrimental effects of glucocorti-coids on growth are significant for children with active arthritis. Although steroids offer symptomatic relief from this disorder by abolishing the swelling, redness, pain, and effusions, they do not cure. Progressive deterioration of joint structures continues, and the disease process may be exacerbated after steroid therapy is terminated (see Chapter 36).
Based on the concept that asthma is an inflammatory disease that leads to airway obstruction, inhaled glucocorticoids are the first-line treatment for moderate to severe asthma. Inhaled preparations are particularly effective when used to prevent recurrent attacks. This therapy is often combined with an inhaled bron-chodilator such as a p-adrenergic agonist. The use of p-adrenergic agonists or theophylline enables use of a lower dose of glucocorticoid, especially in patients relatively resistant to therapy (see Chapter 39).
Steroids are used in other collagen diseases, such as lupus erythematosus; in hypersensitivity or allergic states, such as nephrotic syndrome, ulcerative colitis, and Crohn's disease; in granulomatous disease, such as sarcoid; and in a wide range of dermatological and ophthalmological conditions. Glucocorticoids may also be used at lower doses in combination with other drugs for the treatment of vasculitis, lupus nephritis, and amyloidosis. Steroids are valuable in the prevention and treatment of organ transplant rejection and in the improvement of muscle function in polymyositis.
Corticosteroids are the mainstay of therapy for inflammatory demyelinating polyneuropathies. In Guillain-Barre syndrome glucocorticoids reduce the inflammatory attack and improve final outcome, while in chronic inflammatory demyelinating polyneuropathy glucocor-ticoids suppress the immune reaction but may not retard the progression of the disease. Glucocorticoids also exert a facilitatory action on neuromuscular transmission that may contribute to their efficacy in certain neu-romuscular disorders. The fact that acetylcholine receptor antibodies are responsible for the neuromuscular transmission defect in myasthenia gravis has provided a rationale for exploiting the immunosuppressive effects of glucocorticoids (see Chapter 28).
Although infections are generally thought to be particularly frequent and possibly severe in patients treated with steroids, they have been used as short-term adjunctive therapy to reduce the severe symptoms associated with such bacterial infections as acute H. influenzae and miliary tuberculosis and in viral infections, such as hepatitis and infectious mononucleosis.
Glucocorticoids are also used in the treatment of a number of HIV-related disorders, including Pneumo-cystis carinii pneumonia, demyelinating peripheral neuropathies, tuberculous meningitis, and nephropathy. Glucocorticoids are used as adjunctive therapy in Pneumo cystitis carinii pneumonia to decrease the inflammatory response and allow time for antimicrobial agents to exert their effects. In patients who are im-munocompromised because of HIV infection, adjunctive steroids may be less beneficial in promoting survival.
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