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    Methylprednisolone

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    Jul.16.2024

    methylPREDNISolone

    Indications/Dosage

    Labeled

    • acute lymphocytic leukemia (ALL)
    • acute respiratory distress syndrome (ARDS)
    • Addison's disease
    • adrenocortical insufficiency
    • adrenogenital syndrome
    • allergic conjunctivitis
    • allergic rhinitis
    • alopecia
    • anaphylaxis
    • angioedema
    • ankylosing spondylitis
    • anterior segment inflammation
    • asthma exacerbation
    • asthma maintenance
    • atopic dermatitis
    • berylliosis
    • bursitis
    • chorioretinitis
    • chronic lymphocytic leukemia (CLL)
    • congenital adrenal hyperplasia
    • contact dermatitis
    • corneal ulcer
    • corticosteroid-responsive dermatoses
    • Crohn's disease
    • cutaneous T-cell lymphoma (CTCL)
    • dermatitis
    • dermatitis herpetiformis
    • dermatomyositis
    • discoid lupus erythematosus
    • drug-resistant tuberculosis infection
    • drug-susceptible tuberculosis infection
    • eosinophilic pneumonia
    • epicondylitis
    • erythema multiforme
    • erythroblastopenia
    • exfoliative dermatitis
    • food allergy
    • gout
    • gouty arthritis
    • granuloma annulare
    • Graves' ophthalmopathy
    • hemolytic anemia
    • herpes zoster ocular infection
    • Hodgkin lymphoma
    • hypercalcemia
    • hypoplastic anemia
    • immune thrombocytopenic purpura (ITP)
    • iritis
    • juvenile rheumatoid arthritis (JRA)/juvenile idiopathic arthritis (JIA)
    • keloids
    • keratitis
    • kidney transplant rejection
    • lichen planus
    • lichen simplex
    • Loeffler's syndrome
    • lupus nephritis
    • multiple sclerosis
    • myasthenia gravis
    • mycosis fungoides
    • necrobiosis lipoidica diabeticorum
    • nephrotic syndrome
    • non-Hodgkin's lymphoma (NHL)
    • optic neuritis
    • osteoarthritis
    • pemphigus
    • perennial allergies
    • pneumonitis
    • polymyositis
    • postoperative ocular inflammation
    • proteinuria
    • psoriasis
    • psoriatic arthritis
    • rheumatic carditis
    • Rhus dermatitis
    • sarcoidosis
    • seasonal allergies
    • seborrheic dermatitis
    • serum sickness
    • status asthmaticus
    • Stevens-Johnson syndrome
    • systemic lupus erythematosus (SLE)
    • temporal arteritis
    • tenosynovitis
    • thrombocytopenia
    • thyroiditis
    • trichinosis
    • tuberculosis infection
    • ulcerative colitis
    • urticaria
    • uveitis
    • vernal keratoconjunctivitis

    General dosing information for systemic therapy

    • Dosage requirements are variable. Individualize doses based on the condition being treated and the response of the patient.[30015]
    • Gradual withdrawal of prednisolone after high-dose or prolonged therapy is recommended due to the possibility of hypothalamic-pituitary-adrenal (HPA) axis suppression. The following recommendations for withdrawal of corticosteroids based on the duration of therapy have been made: less than 2 weeks-may abruptly discontinue; 2 to 4 weeks-taper dose over 1 to 2 weeks; more than 4 weeks-taper slowly over 1 to 2 months to physiologic dose (approximately 2.5 mg/m2/day of prednisolone or 2 mg/m2/day of methylprednisolone) and discontinue after assessment of adrenal function has demonstrated recovery.[54137]

     

    Estimated equivalent systemic Glucocorticoid dosages. These are general approximations and may not apply to all diseases or routes of administration.[41361]

    Cortisone-25 mg

    Hydrocortisone-20 mg

    Prednisolone-5 mg

    Prednisone-5 mg

    Methylprednisolone-4 mg

    Triamcinolone-4 mg

    Dexamethasone-0.75 mg

    Betamethasone-0.75 mg

     

    General Instructions for Methylprednisolone dose packs (e.g., Medrol DosePak and generic equivalents)

    NOTE: While packages are typically labeled with the following instructions, the proper dosage tapers should be determined by decreasing the initial dosage in small decrements at appropriate time intervals. Dosage adjustments may be necessary for changes in clinical status (remissions or exacerbations in the disease process), the patient's individual drug responsiveness, and patient exposure to stressful situations; in the latter situation, it may be necessary to increase dosage for a period of time. Constant monitoring is needed in regard to drug dosage.

    NOTE: Dosage requirements are variable and must be individualized on the basis of the indication for treatment and patient response.

    Oral dosage (21-tablet dose packs):

    Adults:

    -1st day: 2 tablets (8 mg) PO before breakfast, 1 tablet (4 mg) PO after lunch, 1 tablet (4 mg) PO after supper, and 2 tablets (8 mg) PO at bedtime.

    -2nd day: 1 tablet (4 mg) PO before breakfast. 1 tablet (4 mg) PO after lunch, 1 tablet (4 mg) PO after supper, and 2 tablets (8 mg) PO at bedtime.

    -3rd day: 1 tablet (4 mg) PO before breakfast, 1 tablet (4 mg) PO after lunch, 1 tablet (4 mg) PO after supper, and 1 tablet (4 mg) PO at bedtime.

    -4th day: 1 tablet (4 mg) PO before breakfast, 1 tablet (4 mg) PO after lunch, and 1 tablet (4 mg) PO at bedtime.

    -5th day: 1 tablet (4 mg) PO before breakfast, and 1 tablet (4 mg) PO at bedtime.

    -6th day: 1 tablet (4 mg) PO before breakfast.

    Off-Label

    • acute disseminated encephalomyelitis
    • acute interstitial nephritis (AIN)
    • allergic bronchopulmonary aspergillosis
    • carpal tunnel syndrome
    • chronic obstructive pulmonary disease (COPD)
    • coronavirus disease 2019 (COVID-19)
    • e-cigarette or vaping product use-associated lung injury
    • encephalitis
    • endophthalmitis
    • graft-versus-host disease (GVHD)
    • heart transplant rejection
    • idiopathic interstitial pneumonia
    • Kawasaki disease
    • multiple myeloma
    • multisystem inflammatory syndrome in children (MIS-C)
    • Pneumocystis pneumonia (PCP)
    • polymyalgia rheumatica
    • pregnancy-induced nausea/vomiting
    • pulmonary fibrosis
    • severe acute respiratory syndrome (SARS)
    • severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection
    • spinal cord injury
    • thrombotic thrombocytopenia purpura
    • toxic epidermal necrolysis
    • vasculitis
    • fat embolism syndrome prophylaxis
    † Off-label indication

    INVESTIGATIONAL USE: For adjunctive use in the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection†, the virus that causes coronavirus disease 2019 (COVID-19)†

    Oral dosage

    Adults

    8 mg PO every 6 hours or 16 mg PO every 12 hours for 7 to 10 days. The World Health Organization strongly recommends the use of systemic corticosteroids in patients with severe or critical COVID-19.[65876] The National Institutes of Health (NIH) COVID-19 treatment guidelines recommend methylprednisolone as an alternative corticosteroid for hospitalized patients who require supplemental oxygen, including those on high-flow oxygen, noninvasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). The NIH recommends 32 mg PO once daily (or in 2 divided doses) for up to 10 days or until hospital discharge (whichever comes first). The NIH advises clinicians to review the patient's medical history and assess the potential risks and benefits before starting methylprednisolone.[65314]

    Intravenous dosage

    Adults

    8 mg IV every 6 hours or 16 mg IV every 12 hours for 7 to 10 days. The World Health Organization strongly recommends the use of systemic corticosteroids in patients with severe or critical COVID-19.[65876] The National Institutes of Health (NIH) COVID-19 treatment guidelines recommend methylprednisolone as an alternative corticosteroid for hospitalized patients who require supplemental oxygen, including those on high-flow oxygen, noninvasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). The NIH recommends 32 mg IV once daily (or in 2 divided doses) for up to 10 days or until hospital discharge (whichever comes first). The NIH advises clinicians to review the patient's medical history and assess the potential risks and benefits before starting methylprednisolone.[65314]

    For the treatment of status asthmaticus

    Intravenous, Intramuscular, Intraosseal† dosage (methylprednisolone sodium succinate)

    Adults

    40 to 80 mg/day IV or IM in 1 to 2 divided doses until peak expiratory flow is 70% of predicted or personal best is recommended by the NAEPP.[33558]

    Infants, Children, and Adolescents

    2 mg/kg IV, IM, or IO load (Max: 60 mg/dose), then 0.5 mg/kg/dose IV every 6 hours or 1 mg/kg/dose IV every 12 hours (Max: 120 mg/day).[54288] Some experts recommend 0.5 to 1 mg/kg/dose IV every 4 to 6 hours.[59746]

    For the treatment of asthma exacerbation

    Oral dosage

    Adults

    40 to 80 mg/day PO in 1 to 2 divided doses for 5 to 10 days.[33558]

    Children and Adolescents 12 to 17 years

    40 to 80 mg/day PO in 1 to 2 divided doses for 3 to 10 days.[33558] [64934]

    Infants and Children 1 to 11 years

    1 to 2 mg/kg/day (Max: 60 mg/day) PO in 1 to 2 divided doses for 3 to 10 days.[33558] [64934]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    40 to 80 mg/day IV or IM in 1 to 2 divided doses for 5 to 10 days.[33558]

    Children and Adolescents 12 to 17 years

    40 to 80 mg/day IV or IM in 1 to 2 divided doses for 3 to 10 days.[33558] [64934]

    Children 6 to 11 years

    1 to 2 mg/kg/day (Max: 60 mg/day) IV or IM in 1 to 2 divided doses for 3 to 10 days.[33558]

    Infants and Children 1 to 5 years

    1 to 2 mg/kg/day (Max: 60 mg/day) IV or IM in 1 to 2 divided doses for 3 to 10 days.[33558] May consider 1 mg/kg/dose IV every 6 hours on day 1.[69016]

    Intramuscular dosage (methylprednisolone acetate injection suspension, e.g., Depo-Medrol)

    Adults

    240 mg IM as a single dose may be used in place of a short burst of oral steroids for persons who are vomiting or if compliance is an issue.[33558]

    Children and Adolescents 5 to 17 years

    240 mg IM as a single dose may be used in place of a short burst of oral steroids for persons who are vomiting or if compliance is an issue.[33558]

    Infants and Children 1 to 4 years

    7.5 mg/kg/dose (Max: 240 mg/dose) IM as a single dose may be used in place of a short burst of oral steroids for persons who are vomiting or if compliance is an issue.[33558]

    For the treatment of the acute respiratory distress syndrome (ARDS)

    Intravenous (methylprednisolone sodium succinate injection) and Oral dosage

    Adults

    Corticosteroid use in ARDS is controversial. If there are no signs of improvement 7 to 14 days after ARDS onset, 1.6 to 3.2 mg/kg/day IV in divided doses for 7 to 14 days has been recommended.[23999] Alternatively, a tapered dosage (2 mg/kg/day on days 1 to 14; 1 mg/kg/day on days 15 to 21; 0.5 mg/kg/day on days 22 to 28; 0.25 mg/kg/day on days 29 to 30; 0.125 mg/kg/day on days 31 to 32) is used. Initiate with the IV route, given in 4 divided doses; PO doses are administered as a single daily dose.[25077]

    For asthma maintenance treatment

    Oral dosage

    Adults

    7.5 to 60 mg PO once daily or every other day as needed for symptom control. Use the lowest effective dose; alternate day therapy may produce less adrenal suppression.[33558] [66299] Consider add-on low dose oral corticosteroids (7.5 mg/day or less of prednisone equivalent) only for those with poor symptom control and/or frequent exacerbation despite good inhaler technique and treatment adherence. Add corticosteroids only after exclusion of other contributory factors and consideration of other add-on treatments.[64807]

    Children and Adolescents 12 to 17 years

    7.5 to 60 mg PO once daily or every other day as needed for symptom control. Use the lowest effective dose; alternate day therapy may produce less adrenal suppression.[33558] [66299] In pediatric patients, the use of oral corticosteroids is usually limited to a few weeks until asthma control is improved and the patient can be stabilized on other, preferred treatments.[64807]

    Children 6 to 11 years

    0.25 to 2 mg/kg/dose (Usual Max: 40 mg/dose) PO once daily or every other day as needed for symptom control. Use the lowest effective dose; alternate day therapy may produce less adrenal suppression.[33358] [66299] [64807] In pediatric patients, the use of oral corticosteroids is usually limited to a few weeks until asthma control is improved and the patient can be stabilized on other, preferred treatments.[64807]

    Children 3 to 5 years

    0.25 to 2 mg/kg/dose (Usual Max: 30 mg/dose) PO once daily or every other day as needed for symptom control. Use the lowest effective dose; alternate day therapy may produce less adrenal suppression.[33358] [66299] [64807] In pediatric patients, the use of oral corticosteroids is usually limited to a few weeks until asthma control is improved and the patient can be stabilized on other, preferred treatments.[64807]

    Infants and Children 1 to 2 years

    0.25 to 2 mg/kg/dose (Usual Max: 20 mg/dose) PO once daily or every other day as needed for symptom control. Use the lowest effective dose; alternate day therapy may produce less adrenal suppression.[33358] [66299] [64807] In pediatric patients, the use of oral corticosteroids is usually limited to a few weeks until asthma control is improved and the patient can be stabilized on other, preferred treatments.[64807]

    For the treatment of aspiration pneumonitis, eosinophilic pneumonia, berylliosis, or Loeffler's syndrome

    for chronic oral management of non-asthmatic respiratory conditions

    Oral dosage

    Adults

    4 to 48 mg, depending on disease treated, PO per day administered in 4 divided doses.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697]

    for parenteral management of non-asthmatic respiratory conditions when oral dosing not feasible or severity or compromised airway warrants

    Intramuscular or Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    Initially, 10 to 40 mg IV or IM. Subsequent IV/IM doses are determined by response and condition.[41361]

    Children and Adolescents

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Adjust to patient condition and response.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 120 mg IM. Frequency of dosing varies with the condition being treated and patient response.[41362]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day IM (a single injection during each 24-hour period equal to the total daily oral dose is usually sufficient). Determine need for repeat IM doses based on condition and patient response.[41362]

    For chronic maintenance therapy for idiopathic pulmonary fibrosis†

    Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    High-dose (pulse doses) of 1 to 2 grams IV once weekly or every other week; however, there is no proven advantage over oral corticosteroids.[26496]

    For the management of symptomatic sarcoidosis

    Oral dosage

    Adults

    Initially, 24 to 32 mg PO per day. Alternatively, 40 to 48 mg PO every other day has also been used. Taper after several weeks to the lowest effective maintenance dose (often 8 to 12 mg PO every other day). Treatment with corticosteroids is usually indicated only if elevated calcium is present or if there is a decline in the function of a vital organ (lungs, kidneys, eyes, heart, or CNS).

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    A dose of 30 mg/kg IV once a week for 6 weeks, with or without oral maintenance corticosteroid therapy, has been used. Therapy produced immediate improvement in all patients, however, 66% relapsed 1 year later. One patient without oral maintenance corticosteroids and 3 patients with oral maintenance corticosteroids showed persistent improvement.[25160] Treatment with corticosteroids is usually indicated only if elevated calcium is present or if there is a decline in the function of a vital organ (lungs, kidneys, eyes, heart, or CNS).

    For the treatment of acute spinal cord injury†

    Intravenous infusion dosage (methylprednisolone sodium succinate)

    Adults, Adolescents, and Children

    30 mg/kg IV given over 15 minutes, followed 45 minutes later by 5.4 mg/kg/hour IV infusion given for 23 hours. Although not widely employed or recommended, the continuous infusion has been repeated for an additional 23 hours in selected patients. Use has been controversial, as small benefits in mortality, motor function, or sensation have not translated to clinically relevant outcomes for long-term recovery, and treatment may result in an increased risk for adverse events such as embolus, hyperglycemia, or infection.[55710] [55705] [55709] [50683]

    For the treatment of a critical period of regional enteritis (Crohn's disease)

    Oral dosage

    Adults

    48 mg/day PO in divided doses after response is achieved with IV therapy, initially. The maximum recommended duration at full dose is 2 weeks. Taper dose by 4 to 8 mg/week until complete discontinuation within 8 to 12 weeks. Systemic corticosteroids are helpful to induce remission.[30015] [50733] [55608] [62699] Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible.[64397]

    Children and Adolescents

    1 to 1.5 mg/kg/day (Max: 60 mg/day) PO in 1 to 2 divided doses for 2 to 4 weeks, initially; after response is achieved, taper dose over several weeks for inflammatory bowel disease in pediatrics.[55494] [55495] Usual dose: 0.5 to 1.7 mg/kg/day PO in divided doses.[52618] [62697] Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible.[64397]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    0.75 to 1 mg/kg/day (Max: 60 to 80 mg/day) IV once daily, initially. The maximum recommended duration at full dose is 2 weeks; transition to oral therapy once a response is achieved, and then taper dose over 8 to 12 weeks. Systemic corticosteroids are helpful to induce remission.[50733] [55608] [62699] Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible.[64397]

    Children and Adolescents

    1 to 1.5 mg/kg/day (Max: 60 mg/day) IV or IM in 1 to 2 divided doses for 2 to 4 weeks, initially; transition to oral therapy once a response is achieved, and then taper dose over several weeks.[55494] [55495] Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible.[64397]

    For the treatment of corticosteroid-responsive dermatoses and dermatologic disorders, including alopecia areata, atopic dermatitis, bullous dermatitis herpetiformis, contact dermatitis including Rhus dermatitis due to poison ivy, cutaneous T-cell lymphoma (CTCL) or mycosis fungoides, discoid lupus erythematosus, exfoliative dermatitis, granuloma annulare, keloids, lichen planus, lichen simplex, necrobiosis lipoidica diabeticorum, pemphigus, psoriasis, seborrheic dermatitis, erythema multiforme, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis† (TEN)

    for the treatment of atopic dermatitis, bullous dermatitis herpetiformis, contact dermatitis, cutaneous T-cell lymphoma (CTCL) or mycosis fungoides, exfoliative dermatitis, pemphigus, and erythema multiforme

    Oral dosage

    Adults

    4 to 48 mg/day PO in 4 divided doses. Individualize dose based on the nature and severity of the disease and response.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate, standard dose)

    Adults

    10 to 40 mg IV or IM once daily, initially; after favorable response, decrease initial dose in small decrements at appropriate time intervals until the lowest dose which will maintain an adequate clinical response is reached. Individualize dose based on the nature and severity of the disease and response.[41361]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses, initially; after favorable response, decrease initial dose in small decrements at appropriate time intervals until the lowest dose which will maintain an adequate clinical response is reached. Individualize dose based on the nature and severity of the disease and response.[41361] [52618] [62697]

    Intravenous dosage (methylprednisolone sodium succinate, high dose)

    Adults

    30 mg/kg/dose IV every 4 to 6 hours for 2 to 3 days.[41361]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    40 to 120 mg IM weekly for 1 to 4 weeks.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IM, initially; after favorable response, decrease initial dose in small decrements at appropriate time intervals until the lowest dose which will maintain an adequate clinical response is reached. Individualize dose based on the nature and severity of the disease and response.[41362]

    for the treatment of plaque psoriasis

    Oral dosage

    Adults

    4 to 48 mg/day PO in 4 divided doses. Individualize dose based on the nature and severity of the disease and response.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intralesional dosage (methylprednisolone acetate)

    Adults

    20 to 60 mg by intralesional injection; may divide dose for large lesions.[41362]

    for the treatment of seborrheic dermatitis

    Oral dosage

    Adults

    4 to 48 mg/day PO in 4 divided doses. Individualize dose based on the nature and severity of the disease and response.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    80 mg IM once weekly, initially; after favorable response, decrease initial dose in small decrements at appropriate time intervals until the lowest dose which will maintain an adequate clinical response is reached.[41362]

    for the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis† (TEN)

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    500 to 1,000 mg IV once daily for 3 days.[68070] [68094] [68095] [68096] The FDA-approved dosage is 30 mg/kg/dose IV every 4 to 6 hours for 2 to 3 days.[41361]

    Children and Adolescents

    30 mg/kg/dose IV once daily for 3 days.[68070] [68093] [68097] The FDA-approved dosage is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses.[41361]

    for the treatment of alopecia areata, discoid lupus erythematosus, granuloma annulare, keloids, lichen planus, lichen simplex, and necrobiosis lipoidica diabeticorum

    Intralesional dosage (methylprednisolone acetate)

    Adults

    20 to 60 mg by intralesional injection; may divide dose for large lesions.[41362]

    For the treatment of acute exacerbations of multiple sclerosis

    Oral dosage

    Adults

    500 mg PO once daily for 5 days.[69791] The FDA-approved dosage is 160 mg PO once daily for 1 week, followed by 64 mg PO every other day for 1 month.[30015]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    1,000 mg IV once daily for 3 to 5 days.[69791] The FDA-approved dosage is 160 mg IV once daily for 1 week, followed by 64 mg IV every other day for 1 month.[41361] 

    For the treatment of myasthenia gravis in patients who are poorly controlled with cholinesterase inhibitor therapy

    Oral dosage

    Adults and Adolescents

    Initially, 12 to 20 mg PO per day. Increase, as needed, by 4 mg PO every 2 to 3 days until there is marked clinical improvement or to a maximum of 40 mg/day PO. Dose is usually continued for 1 to 3 months and then is gradually tapered to an alternate-day dosage. Some clinicians use initial dosages of 48 to 64 mg PO per day with gradual tapering. Although higher initial dosages may provide more rapid benefit, early exacerbations of myasthenic weakness may be more common than with lower initial dosages. The methylprednisolone dosage listed is based on a recommended prednisone dose converted to an equivalent methylprednisolone dose.

    For adjunctive therapy in the treatment of rheumatic disorders including ankylosing spondylitis, juvenile rheumatoid arthritis (JRA)/juvenile idiopathic arthritis (JIA), post-traumatic osteoarthritis, psoriatic arthritis, or rheumatoid arthritis, or for the treatment of acute episodes or exacerbation of nonrheumatic inflammatory conditions including acute and subacute bursitis, epicondylitis, and acute non-specific tenosynovitis

    Oral dosage

    Adults

    4 to 48 mg/day PO, administered in 4 divided doses. Adjust to response and severity of condition.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697]

    Intra-articular injection or Intra-lesional dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 80 mg at the appropriate site, depending upon degree of inflammation and size and location of affected area. Repeat doses are not usually required for 1 to 5 weeks. Dosage ranges for specific joints: large joints: 20 to 80 mg; medium joints: 10 to 40 mg; small joints: 4 to 10 mg. Suggested intralesional dosage range is 20 to 60 mg.[41362]

    Intramuscular or Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    Initially, 10 to 40 mg IV or IM. Subsequent IV/IM doses are determined by response and condition.[41362]

    Children and Adolescents

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Adjust to patient condition and response.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 120 mg IM. Subsequent doses may be given determined by patient response and condition.[41362]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day IM (a single injection during each 24-hour period equal to the total daily oral dose is usually sufficient). Determine need for repeat IM doses based on condition and patient response.[41362]

    For the treatment of connective tissue or collagen disorders, including acute rheumatic carditis, polymyalgia rheumatica†, systemic dermatomyositis (polymyositis), systemic lupus erythematosus (SLE), and temporal arteritis

    for the treatment of acute rheumatic carditis

    Oral dosage

    Adults

    4 to 48 mg/day PO, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    10 to 40 mg IV or IM, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/dose IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    for the treatment of dermatomyositis or polymyositis

    Oral dosage

    Adults

    4 to 48 mg/day PO, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    250 to 1,000 mg IV once daily for 3 to 5 days followed by oral corticosteroid extended taper.[68308] [68311] [68312] [70295] When high-dose therapy is desired, the FDA-approved dosage is 30 mg/kg/dose IV every 4 to 6 hours for 48 to 72 hours. In other indications, 10 to 40 mg IV or IM, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Infants, Children, and Adolescents

    15 to 30 mg/kg/dose (Max: 1,000 mg/dose) IV once daily for 3 to 5 days followed by oral corticosteroid extended taper.[68312] [68313] [68314] [68315] [68317] [68318] [70295] The FDA-approved dosage is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/dose IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    for the treatment of polymyalgia rheumatica†

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    120 mg IM every 3 weeks for 12 weeks, initially. Taper dose by 20 mg/month every 3 months. For relapses, increase the dose to the prerelapse dose and taper dose more gradually.[70473] [70474]

    for the treatment of systemic lupus erythematosus (SLE)

    Oral dosage

    Adults

    4 to 48 mg/day PO, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    100 to 1,000 mg IV once daily for 1 to 3 days followed by oral corticosteroid extended taper.[69025] [70847] When high-dose therapy is desired, the FDA-approved dosage is 30 mg/kg/dose IV every 4 to 6 hours for 48 to 72 hours. In other indications, 10 to 40 mg IV, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Infants, Children, and Adolescents

    30 mg/kg/dose (Max: 1,000 mg/dose) IV once daily for 1 to 3 days followed by oral corticosteroid extended taper.[65218] [70847] The FDA-approved dosage is 0.11 to 1.6 mg/kg/day IV in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    80 to 120 mg IM once daily for 1 to 3 days followed by oral corticosteroid extended taper.[69025] [70847] The FDA-approved initial dosage is 10 to 40 mg IM, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/dose IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    for the treatment of temporal arteritis

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    0.25 to 1 g IV once daily for up to 3 to 5 days followed by oral corticosteroid extended taper.[70292] [70293] [70294] The FDA-approved initial dosage is 10 to 40 mg IV or IM, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    For the palliative management of leukemia and lymphoma in adults and acute leukemias of childhood including acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), Hodgkin lymphoma, non-Hodgkin's lymphoma (NHL), or multiple myeloma†

    Oral dosage

    Adults

    4 to 48 mg/day PO, administered in 4 divided doses. Adjust to severity of condition and patient response.[30015]

    Children

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697]

    Intramuscular or Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    Initially, 10 to 40 mg IV or IM. Subsequent IV/IM doses are determined by response and condition.[41361]

    Children

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Adjust to patient condition and response.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 120 mg IM. Subsequent doses are determined by patient response and condition.[41362]

    Children

    0.5 to 1.7 mg/kg/day IM (a single injection during each 24-hour period equal to the total daily oral dose is usually sufficient). Determine need for repeat IM doses based on condition and patient response.[41362]

    For the treatment of hypercalcemia associated with certain types of cancer

    Oral dosage

    Adults

    32 to 80 mg PO per day is usually effective for hypercalcemia due to hematologic cancers. 12 to 24 mg PO per day may be sufficient for other tumors (e.g., breast cancer). The dosage listed is based on a recommended prednisone dose converted to an equivalent methylprednisolone dose.

    For the treatment of non-neoplastic hematologic disorders including immune thrombocytopenic purpura (ITP), secondary thrombocytopenia in adults, acquired (autoimmune) hemolytic anemia, erythroblastopenia (RBC anemia), and congenital hypoplastic anemia

    Oral dosage

    Adults

    4 to 48 mg/day PO, administered in 4 divided doses. Adjust to severity of condition and patient response.[30015]

    Children

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate injection)

    Adults

    Initially, 10 to 40 mg IV or IM. Subsequent IV/IM doses are determined by response and condition. IM administration is contraindicated in patients with ITP.[41361]

    Children

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Adjust to patient condition and response. IM administration is contraindicated in ITP.[41361] [52618] [62697]

    For the treatment of adrenocortical function abnormalities, such as adrenocortical insufficiency, congenital adrenal hyperplasia (CAH), chronic primary (Addison's disease) or secondary adrenocortical insufficiency, or adrenogenital syndrome

    Oral dosage

    Adults

    4 to 48 mg/day PO, administered in 4 divided doses. Adjust depending on severity of the condition treated and patient response. Hydrocortisone and cortisone are the preferred drugs; methylprednisolone has little to no mineralocorticoid properties. For acute conditions, parenteral therapy is recommended. Dosing is highly variable.[30015]

    Children

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697] Hydrocortisone and cortisone are the preferred drugs; methylprednisolone has little to no mineralocorticoid properties. For acute conditions, parenteral therapy is recommended. Dosing is highly variable.

    Intravenous or intramuscular dosage (methylprednisolone sodium succinate injection)

    Adults

    Initially, 10 to 40 mg IV. Subsequent IV/IM doses are determined by response and condition. Hydrocortisone and cortisone are the preferred drugs; methylprednisolone has little to no mineralocorticoid properties. For acute conditions, parenteral therapy is recommended. Dosing is highly variable.

    Children

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Hydrocortisone and cortisone are the preferred drugs; methylprednisolone has little to no mineralocorticoid properties. For acute conditions, parenteral therapy is recommended. Dosing is highly variable.[41361]

    For the treatment of trichinosis with neurologic or myocardial involvement

    Oral or Intravenous dosage

    Adults

    The optimal dosage has not been established; critically-ill patients may require high doses (e.g., 48 mg PO or IV per day) for 2 or more weeks. The dosage listed is based on a recommended prednisone dose converted to an equivalent methylprednisolone dose.

    For the treatment of Pneumocystis pneumonia (PCP)†

    Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    30 to 45 mg IV 2 to 3 times daily; taper dose after 5 to 7 days over 1 to 2 weeks. A suggested taper is 30 mg IV twice daily on days 1 to 5; then 30 mg IV once daily on days 6 to 10; then 15 mg IV once daily on days 11 to 21. Start therapy as early as possible and within 72 hours after starting specific PCP therapy. Recommended for patients with moderate to severe infection, defined by a PaO2 less than 70 mmHg at room air or an alveolar-arterial DO2 gradient of 35 mmHg or more. The benefits of starting corticosteroids after 72 hours are unclear.[34362] [64856] [64858] [64860] [64862] [64907]

    Adolescents

    30 to 45 mg IV 2 to 3 times daily; taper dose after 5 to 7 days over 1 to 2 weeks. A suggested taper is 30 mg IV twice daily on days 1 to 5; then 30 mg IV once daily on days 6 to 10; then 15 mg IV once daily on days 11 to 21. Start therapy as early as possible and within 72 hours after starting specific PCP therapy. Recommended for patients with moderate to severe infection, defined by a PaO2 less than 70 mmHg at room air or an alveolar-arterial DO2 gradient of 35 mmHg or more. The benefits of starting corticosteroids after 72 hours are unclear.[34362] [64856] [64858] [64860] [64862] [64907]

    Infants and Children

    1 mg/kg/dose IV every 6 hours on days 1 to 7; then 1 mg/kg/dose IV twice daily on days 8 to 9; then 0.5 mg/kg/dose twice daily on days 10 to 11; then 1 mg/kg/dose IV once daily on days 12 to 16. Start therapy as early as possible and within 72 hours after starting specific PCP therapy. Recommended for patients with moderate to severe infection, defined by a PaO2 less than 70 mmHg at room air or an alveolar-arterial DO2 gradient more than 35 mmHg.[34361] [64856] [64858] [64860] [64862] [64907]

    For the treatment of Severe Acute Respiratory Syndrome (SARS)†

    Intravenous dosage

    Adults

    A treatment protocol based on the treatment of 31 patients with probable SARS (diagnosed according to WHO criteria) in Hong Kong, suggests methylprednisolone 1 mg/kg IV every 8 hours for 5 days, followed by 1 mg/kg IV every 12 hours for 5 days, in conjunction with ribavirin, and followed by prednisolone PO to complete a 21-day corticosteroid regimen.[27413] Another regimen used ribavirin IV with methylprednisolone 240 to 320 mg daily IV in divided doses or hydrocortisone IV (4 mg/kg every 8 hours, tapered to 200 mg every 8 hours).[27341] Other than supportive care, there is no established treatment for SARS. Due to lack of efficacy data, ribavirin and methylprednisolone combination therapy should be reserved for patients with the following: extensive or bilateral chest radiographic involvement; persistent chest radiographic involvement and persistent high fever for 2 days; clinical, chest radiographic, or laboratory findings suggestive of worsening; or oxygen saturation less than 95% on room air.[27413]

    For the treatment of nonsuppurative thyroiditis

    Oral dosage

    Adults

    Glucocorticoids are reserved for severe cases. Although prednisone is commonly used, a methylprednisolone dosage of 16 to 32 mg/day PO has similar potency.

    For the treatment of proteinuria in nephrotic syndrome, without uremia, of the idiopathic type or due to lupus nephritis

    for the treatment of proteinuria in nephrotic syndrome, without uremia, of the idiopathic type

    Oral dosage

    Adults

    4 to 48 mg/day PO, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    10 to 40 mg IV or IM, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/dose IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    for the treatment of lupus nephritis

    Oral dosage

    Adults

    4 to 48 mg/day PO, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day PO divided every 6 to 12 hours.[52618] [62697]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    250 to 1,000 mg IV once daily for 1 to 3 days followed by oral corticosteroid extended taper.[69025] [70847] When high-dose therapy is desired, the FDA-approved dosage is 30 mg/kg/dose IV every 4 to 6 hours for 48 to 72 hours. In other indications, 10 to 40 mg IV, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Infants, Children, and Adolescents

    30 mg/kg/dose (Max: 1,000 mg/dose) IV once daily for 1 to 3 days followed by oral corticosteroid extended taper.[65218] [70847] The FDA-approved dosage is 0.11 to 1.6 mg/kg/day IV in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    10 to 40 mg IM, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Children and Adolescents

    0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day), initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    4 to 120 mg IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    Children and Adolescents

    0.11 to 1.6 mg/kg/dose IM once daily, initially, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    for the treatment of steroid resistant nephrotic syndrome (SRNS)†

    Intravenous dosage (methylprednisolone sodium succinate)

    Children and Adolescents

    500 mg/m2/day IV for 3 days prior to initiating treatment with cyclosporine or tacrolimus, followed by alternate day oral prednisolone taper over 6 months.[67356]

    For the treatment of acute interstitial nephritis (AIN)†

    Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    There is variation in the literature with regard to dosage regimens. Methylprednisolone 125 mg IV every 6 hours for a few days, followed by prednisone or prednisolone tapered over 3 to 6 weeks is commonly reported. Following biopsy to confirm diagnosis, corticosteroids are usually instituted soon afterward. Corticosteroid use is an adjunctive measure; removal of the suspected offending agent /cause is the primary treatment. While many case reports suggest a possible net benefit to the use of corticosteroids for AIN, some experts advocate for more prospective study of their value.[32123]

    Children

    There is variation in the literature with regard to dosage regimens. Methylprednisolone 1 mg/kg IV every 6 hours for a few days, followed by oral prednisone or prednisolone tapered over 3 to 6 weeks has been reported.

    For the treatment of acute kidney transplant rejection

    Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults, Adolescents and Children

    250 to 1,000 mg IV given once daily or on alternate days for 3 to 5 doses. Renal transplant guidelines recommend corticosteroids for the initial treatment of acute rejection.[51730] [51731]

    For the treatment of graft-versus-host disease (GVHD)†

    for the treatment of grade II acute GVHD†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    1 mg/kg/dose IV once daily for 5 to 7 days, followed by a taper.[55032]

    Infants, Children, and Adolescents

    1 mg/kg/dose IV once daily for 5 to 7 days, followed by a taper.[55032]

    for the treatment of grades III or IV acute GVHD†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    2 mg/kg/dose IV once daily for 5 to 7 days, followed by a taper. Add a second-line agent if progression within 72 hours or no improvement after 5 days.[55032]

    Infants, Children, and Adolescents

    2 mg/kg/dose IV once daily for 5 to 7 days, followed by a taper. Add a second-line agent if progression within 72 hours or no improvement after 5 days.[55032]

    for the treatment of chronic GVHD†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    10 mg/kg/dose IV once daily for 4 days, followed by a taper. Pulsed corticosteroids are recommended as a third-line treatment option in refractory chronic GVHD.[55037]

    Infants, Children, and Adolescents

    10 mg/kg/dose IV once daily for 4 days, followed by a taper. Pulsed corticosteroids are recommended as a third-line treatment option in refractory chronic GVHD.[55037]

    For the treatment of heart transplant rejection†

    Intravenous dosage (methylprednisolone sodium succinate injection)

    Adults

    According to guidelines, 250 to 1,000 mg/day IV for 3 days is first line for symptomatic acute cellular rejection irrespective of ISHLT endomyocardial biopsy grade. The regimen should also be used for asymptomatic severe (ISHLT 3R) acute cellular rejection and can be used for for asymptomatic moderate acute cellular rejection (ISHLT 2R). Also consider for hyperacute rejection and for antibody-mediated rejection. A taper can be considered.[51803]

    For the systemic treatment of ophthalmic disorders including allergic conjunctivitis, allergic marginal corneal ulcer, anterior segment inflammation, chorioretinitis, endophthalmitis†, Graves' ophthalmopathy, herpes zoster ocular infection (herpes zoster ophthalmicus), iritis, keratitis, postoperative ocular inflammation, optic neuritis, diffuse posterior uveitis, or vernal keratoconjunctivitis

    Oral dosage

    Adults

    4 to 48 mg/day PO, administered in 4 divided doses. Adjust to condition severity and response.[30015]

    Children

    0.5 to 1.7 mg/kg/day PO, given in divided doses every 6 to 12 hours.[52618] [62697]

    Intramuscular or Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    Initially, 10 to 40 mg IV or IM. Subsequent IV/IM doses are determined by response and condition.[41361]

    Children

    In pediatric patients, the initial dose range is 0.11 to 1.6 mg/kg/day IV or IM in 3 or 4 divided doses (3.2 to 48 mg/m2/day). Adjust to patient condition and response.[41361] [52618] [62697]

    Intramuscular dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 120 mg IM. Subsequent doses are determined by response and condition.[41362]

    Children

    0.5 to 1.7 mg/kg/day IM (a single injection during each 24-hour period equal to the total daily oral dose is usually sufficient). Determine need for repeat IM doses based on condition and patient response.[41362]

    For adjunctive therapy in the treatment of carpal tunnel syndrome†

    Local injection (methylprednisolone acetate injection suspension)

    Adults

    40 to 80 mg as a single injection adjacent to the carpal tunnel. Reassess at 6 to 8 weeks. To avoid median-nerve injury, use specialized administration techniques. Use of 2 or more repeat injections is not advised; local tendon damage may occur. The definitive treatment for median-nerve entrapment is surgery. Corticosteroids are temporary measures; patients who have intermittent pain and paresthesias without any fixed motor-sensory deficits may respond to conservative therapy.

    For the treatment of IVIG-refractory Kawasaki disease†

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate injection)

    Infants, Children, and Adolescents

    30 mg/kg/dose (Max: 1 g/dose) IV or IM once daily for 1 to 3 days.[55690] [55691] [55692] [55693] [61950] High-dose pulse steroids may be considered as an alternative to a second infusion of IVIG or for retreatment of children who have had recurrent or recrudescent fever after additional IVIG, but should not be used as routine primary therapy with IVIG in children with Kawasaki disease.[61950] Corticosteroid treatment has been shown to shorten the duration of fever in children with IVIG-refractory Kawasaki disease or children at high risk for IVIG-refractory disease.[55690] [55692] [55693] A reduction in the frequency and severity of coronary artery lesions has also been reported with pulse dose methylprednisolone treatment.[55690] [55691] [55693]

    For fat embolism syndrome prophylaxis†

    Intravenous dosage

    Adults

    Dosage not established. 1 or 1.5 mg/kg IV every 8 hours for 6 doses or 30 mg/kg IV every 4 hours for 2 doses has been used.[58690] [58691] [58692]

    For the management of multisystem inflammatory syndrome in children (MIS-C) post SARS-CoV-2 exposure†

    Intravenous dosage

    Infants, Children, and Adolescents

    1 to 2 mg/kg/day IV in 1 to 2 divided doses administered at the same time as IVIG. Increase to 10 to 30 mg/kg/day (Max: 1,000 mg/day) IV for 1 to 3 days in patients with refractory MIS-C who do not improve within 24 hours of initial immunomodulatory therapy. Tapering over 3 weeks is recommended to avoid rebound inflammation.[65314] [65707] [65720] [66644] The National Institutes of Health (NIH) treatment guidelines recommend against the routine use of methylprednisolone monotherapy for the treatment of MIS-C, unless IVIG is unavailable or contraindicated.[65314]

    For the treatment of allergic disorders including anaphylaxis or anaphylactoid reactions, angioedema, acute noninfectious laryngeal edema, hypersensitivity reactions (drug or food allergy), urticaria, and serum sickness

    for the treatment of anaphylaxis

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    1 to 2 mg/kg/dose (Max: 125 mg/dose) IV as a single dose. Subsequent doses are determined by response and condition. Corticosteroids are not indicated as initial treatment for anaphylaxis but can be given as adjunctive therapy after the administration of epinephrine.[60464] [64934] [66106] [69080]

    Infants, Children, and Adolescents

    1 to 2 mg/kg/dose (Max: 125 mg/dose) IV as a single dose. Subsequent doses are determined by response and condition. Corticosteroids are not indicated as initial treatment for anaphylaxis but can be given as adjunctive therapy after the administration of epinephrine.[60464] [64934] [66106] [69080]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    Short courses of 40 to 125 mg/day IV can be given for the late phase of an acute reaction for drug-induced angioedema failing to respond to epinephrine or H1-blockers.[24005] The FDA- approved dosage is 10 to 40 mg IV infused over several minutes.[41361]

    Infants, Children, and Adolescents

    1 to 2 mg/kg (not to exceed 125 mg/dose) IV or IM load. Follow with 0.5 mg/kg/dose IV every 6 hours or 1 mg/kg/dose IV every 12 hours for 1 to 2 days.[55733] [60464] [64934] [66106] Short courses can be given for the late phase of an acute reaction for drug-induced angioedema failing to respond to epinephrine or H1-blockers.[24005] The initial FDA- approved dosage is 0.11 to 1.6 mg/kg/day in 3 to 4 divided doses.[41361]

    for non-emergent treatment of hypersensitivity or allergic conditions

    Oral dosage

    Adults

    4 to 48 mg/day PO, given in 4 divided doses; adjust dose to condition treated and patient response.[30015]

    Infants, Children, and Adolescents

    0.11 to 2 mg/kg/day PO in 1 to 4 divided doses is the general initial dose range for methylprednisolone.[30015] Similar dosing has been used IM or IV if needed.[41361]

    Intramuscular dosage (methylprednisolone acetate injection suspension)

    Adults

    10 to 120 mg IM. Subsequent IM doses are determined by response and condition.[41362]

    Children and Adolescents

    0.5 to 1.7 mg/kg/day IM (a single injection during each 24-hour period equal to the total daily oral dose is usually sufficient). Determine need for repeat IM doses based on condition and patient response.[41362]

    For the treatment of severe perennial allergies or seasonal allergies, including allergic rhinitis, that are intractable to adequate trials of conventional treatment

    Oral dosage

    Adults

    4 to 48 mg/day PO, given in 4 divided doses; adjust dose to condition treated and patient response.[30015]

    Infants, Children, and Adolescents

    0.11 to 2 mg/kg/day PO in 1 to 4 divided doses is the general initial dose range for methylprednisolone.[30015]

    For the treatment of pregnancy-induced nausea/vomiting†

    Oral dosage

    Adults

    16 mg PO every 8 hours for 3 days, initially. Taper dose over 2 weeks to the lowest effective dose. Limit use to 6 weeks. Discontinue use if no response within 3 days, as response is unlikely. Avoid use as first-line agent before 10 weeks gestation.[66066]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    16 mg IV every 8 hours for 3 days, initially. Taper dose over 2 weeks to the lowest effective dose. Limit use to 6 weeks. Discontinue use if no response within 3 days, as response is unlikely. Avoid use as first-line agent before 10 weeks gestation.[66066]

    For the treatment of drug-susceptible tuberculosis infection or drug-resistant tuberculosis infection as adjunctive therapy in combination with antituberculous therapy

    Oral dosage

    Adults

    2.13 mg/kg/day PO with a taper over 6 to 8 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[30015] [61094] [69585] [69587] [69589]

    Infants, Children, and Adolescents

    1.6 to 3.2 mg/kg/day PO for 4 to 6 weeks, then taper over 2 to 4 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[30015] [34361] [41361] [61094] [66745] [69585] [69587] [69589]

    Intramuscular or Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    2.13 mg/kg/day IV or IM with a taper over 6 to 8 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[41361] [61094] [69585] [69587] [69589]

    Infants, Children, and Adolescents

    1.6 to 3.2 mg/kg/day IV or IM for 4 to 6 weeks, then taper over 2 to 4 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[34361] [41361] [61094] [66745] [69585] [69587] [69589]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    2.13 mg/kg/day IM with a taper over 6 to 8 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[41362] [61094] [69585] [69587] [69589]

    Infants, Children, and Adolescents

    1.6 to 3.2 mg/kg/day IM for 4 to 6 weeks, then taper over 2 to 4 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit.[34361] [41362] [61094] [66745] [69585] [69587] [69589]

    For the treatment of e-cigarette or vaping product use-associated lung injury†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    120 to 500 mg/day IV divided every 6 to 12 hours or alternately, 1 mg/kg/dose IV every 24 hours followed by a taper of oral prednisone.[67717] [67718] [67719] [67720] [67721] [67724]

    Adolescents

    30 to 60 mg/dose IV every 6 to 24 hours or alternately, 1 mg/kg/dose IV every 6 or 24 hours followed by a taper of oral prednisone.[67722] [67723] [67730]

    For the treatment of ulcerative colitis

    Oral dosage

    Adults

    4 to 48 mg/day PO in 4 divided doses, initially.[30015] [62699] Taper dose by 4 to 8 mg/week based on clinical symptoms, cumulative steroid exposure, and onset of action of alternate therapies; limit use to the shortest duration possible with early initiation of steroid-sparing therapy. Guidelines recommend oral corticosteroids to induce remission in persons with ulcerative colitis; however, guidelines recommend against systemic corticosteroids for the maintenance of remission.[62699] [64393]

    Children and Adolescents

    1 to 1.5 mg/kg/day (Max: 60 mg/day) PO in 1 to 2 divided doses, initially.[54978] [55499] [55716] Usual dose: 0.5 to 1.7 mg/kg/day.[52618] [62697] Taper dose based on clinical symptoms, cumulative steroid exposure, and onset of action of alternate therapies; limit use to the shortest duration possible with early initiation of steroid-sparing therapy. Guidelines recommend oral corticosteroids to induce remission in persons with ulcerative colitis; however, guidelines recommend against systemic corticosteroids for the maintenance of remission.[54978] [64393]

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    0.75 to 1 mg/kg/dose (Max: 80 mg/dose) IV once daily, initially.[41361] [62699] [64393] Taper dose by 4 to 8 mg/week based on clinical symptoms, cumulative steroid exposure, and onset of action of alternate therapies; limit use to the shortest duration possible with early initiation of steroid-sparing therapy. Guidelines recommend intravenous methylprednisolone in persons with acute severe ulcerative colitis; however, guidelines recommend against systemic corticosteroids for the maintenance of remission.[64393]

    Children and Adolescents

    1 to 1.5 mg/kg/day (Max: 60 mg/day) IV once daily, initially.[41361] [54978] [55499] [55716] Alternately, 20 to 30 mg/kg/day (Max: 1 g/day) IV for 3 days (pulse therapy) has also been used.[55498] Taper dose based on clinical symptoms, cumulative steroid exposure, and onset of action of alternate therapies; limit use to the shortest duration possible with early initiation of steroid-sparing therapy. Guidelines recommend intravenous methylprednisolone in persons with acute severe ulcerative colitis; however, guidelines recommend against systemic corticosteroids for the maintenance of remission.[54978] [64393]

    For the treatment of immune-mediated encephalitis†, including acute disseminated encephalomyelitis† (ADEM)

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    1,000 mg IV once daily for 3 to 7 days, followed by pulse doses or oral corticosteroid extended taper over up to 12 months.[34213] [67800] [67917] [67918] [67919] [67920] [67921]

    Infants, Children, and Adolescents

    20 to 30 mg/kg/day (Max: 1,000 mg/day) IV for 3 to 7 days, followed by pulse doses or oral corticosteroid extended taper over up to 12 months.[34213] [67801] [67917] [67918] [67919] [67920]

    For the treatment of acute gout or gouty arthritis as adjunctive therapy

    Oral dosage

    Adults

    4 to 48 mg/day PO in divided doses, initially, depending on the disease being treated. Lower doses are generally sufficient for situations of less severity, while in selected persons higher initial doses may be required. Continue or adjust the initial dosage until a satisfactory response is noted. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[30015]

    Intravenous or Intramuscular dosage (methylprednisolone sodium succinate)

    Adults

    0.5 to 2 mg/kg/dose IV or IM as a single dose.[64373] The FDA-approved initial dosage is 10 to 40 mg IV or IM, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41361]

    Intramuscular dosage (methylprednisolone acetate)

    Adults

    0.5 to 2 mg/kg/dose IM as a single dose.[64373] The FDA-approved initial dosage is 4 to 120 mg IM, depending on the specific disease being treated. After a favorable response is noted, determine the maintenance dose by decreasing the dose in small decrements at appropriate intervals until the lowest dose which will maintain an adequate clinical response is reached. If discontinuing after long-term therapy, withdraw the drug gradually rather than abruptly.[41362]

    For the treatment of idiopathic interstitial pneumonia†, specifically acute interstitial pneumonia†

    Intravenous dosage (methylprednisolone sodium succinate, standard dose)

    Adults

    0.6 to 2 mg/kg/day IV in divided doses for several days, followed by oral corticosteroid taper over weeks to months.[37185] [69341] [69350]

    Intravenous dosage (methylprednisolone sodium succinate, high dose)

    Adults

    500 to 1,000 mg IV for once daily for 3 days, followed by standard dose IV methylprednisolone or oral corticosteroid taper over weeks to months. Corticosteroid therapy duration has been reported from 28 days to 6 months or longer.[37185] [69341] [69351] [69352]

    For the treatment of allergic bronchopulmonary aspergillosis†

    Intravenous dosage

    Adults

    10 to 20 mg/kg/dose IV once daily for 3 consecutive days every 3 to 4 weeks until clinical and laboratory resolution.[69436] [69437]

    Children and Adolescents

    10 to 20 mg/kg/dose IV once daily for 3 consecutive days every 3 to 4 weeks until clinical and laboratory resolution.[69436] [69437]

    For the treatment of chronic obstructive pulmonary disease (COPD)† exacerbations

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    40 mg IV once daily for 5 days.[69470] [69526] Systemic glucocorticoids shorten recovery time and improve lung function (FEV1), oxygenation, the risk of early relapse, treatment failure, and the length of hospitalization.[69470]

    For the treatment of IgA vasculitis†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    1 g IV once daily for 3 days, followed by oral corticosteroid at low-dose or taper over up to 6 months. May repeat 1 g IV once daily for 3 days at 2 and 4 months.[69595] [69596] [69669] [69670]

    Infants, Children, and Adolescents

    10 to 30 mg/kg/dose (Max: 1 g/dose) IV once daily for 3 days, followed by oral corticosteroid taper over up to 6 months.[67356] [69595] [69669]

    For the treatment of thrombotic thrombocytopenia purpura†

    Intravenous dosage (methylprednisolone sodium succinate)

    Adults

    10 mg/kg/dose (Max: 1 g/dose) IV once daily for 3 days.[69938] [69939] [69967]

    Children and Adolescents

    10 mg/kg/dose (Max: 1 g/dose) IV once daily for 3 days.[69939] [69964] [69968] [69969]

    Therapeutic Drug Monitoring

    Maximum Dosage Limits

      Patients with Hepatic Impairment Dosing

      Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed. There is an enhanced effect of corticosteroids in individuals with cirrhosis.[30015][41361]

      Patients with Renal Impairment Dosing

      Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

      † Off-label indication
      Revision Date: 07/16/2024, 03:02:57 PM

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Methylprednisolone pulse therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis: clinical evaluation and analysis of biomarkers. J Am Acad Dermatol 2013;69:496-7.68096 - Yamane Y, Matsukura S, Watanabe Y, et al. Retrospective analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis in 87 Japanese patients - treatment and outcome. Allergol Int 2016;65:74-81.68097 - Sato S, Kanbe T, Tamaki Z, et al. Clinical features of Stevens-Johnson syndrome and toxic epidermal necrolysis. Pediatr Int 2018;60:697-702.68308 - Kohsaka H, Mimori T, Kanda T, et al. Treatment consensus for management of polymyositis and dermatomyositis among rheumatologists, neurologists and dermatologists. Mod Rheumatol 2019;29:1-19.68311 - de Souza FHC, de Araujo DB, Vilela VS, et al. Guidelines of the Brazilian Society of Rheumatology for the treatment of systemic autoimmune myopathies. Adv Rheumatol 2019;59:1-12.68312 - Schmidt J. Current classification and management of inflammatory myopathies. J Neuromuscul Dis 2018;5:109-29.68313 - Bader-Meunier B, Gitiaux C, Belot A, et al. French expert opinion for the management of juvenile drmatomyositis. Arch Pediatr 2019;26:120-5.68314 - Enders FB, Bader-Meunier B, Baildam E, et al. Consensus-based recommendations for the management of juvenile dermatomyositis. Ann Rheum Dis 2017;76:329-40.68315 - Giancane G, Lavarello C, Pistorio A, et al. The PRINTO evidence-based proposal for glucocorticoids tapering/discontinuation in new onset juvenile dermatomyositis patients. Pediatr Rheumatol Online J 2019;17:24.68317 - Kobayashi I, Akioka S, Kobayashi N, et al. Clinical practice guidance for juvenile dermatomyositis (JDM) 2018-update. Mod Rheumatol 2020;30:411-23.68318 - Huber AM, Robinson AB, Reed AM, et al. Consensus treatments for moderate juvenile dermatomyositis: beyond the first two months. Results of the second Childhood Arthritis and Rheumatology Research Alliance consensus conference. Arthritis Care Res (Hoboken) 2012;64:546-53.69016 - Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2023. Available from: https://ginasthma.org/. Accessed May 22, 2023.69025 - Gordon C, Amissah-Arthur MB, Gayed M, et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology (Oxford) 2018;57:e1-e45.69080 - McHugh K, Repanshek Z. Anaphylaxis: emergency department treatment. Emerg Med Clin North Am 2022;40:19-32.69341 - Suh GY, Kang EH, Chung MP, et al. Early intervention can improve clinical outcome of acute interstitial pneumonia. Chest. 2006;129:753-61.69350 - Vourlekis JS. Acute interstitial pneumonia. Clin Chest Med. 2004;25:739-47.69351 - Xia Y, Liang Z, Fu Z, et al. Clinical management of acute interstitial pneumonia: a case report. Case Rep Pulmonol. 2012;2012:678249.69352 - Mastan A, Murugesu N, Hasnain A, et al. Hamman-Rich syndrome. Respir Med Case Rep. 2017;23:13-17.69436 - Moss RB. Treatment options in severe fungal asthma and allergic bronchopulmonary aspergillosis. Eur Respir J 2014;43:1487-50069437 - Cohen-Cymberknoh M, Blau H, Shoseyov D, et al. Intravenous monthly pulse methylprednisolone treatment for ABPA in patients with cystic fibrosis. J Cyst Fibros 2009;8:253-7.69470 - Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Retrieved 12/5/2023. Available on the World Wide Web at https://goldcopd.org/wp-content/uploads/2023/12/GOLD-2024_v1.1-1Dec2023_WMV.pdf69526 - Ding Z, Li X, Lu Y, et al. A randomized, controlled multicentric study of inhaled budesonide and intravenous methylprednisolone in the treatment on acute exacerbation of chronic obstructive pulmonary disease. Respir Med. 2016;121:39-47.69585 - Barss L, Connors WJA, Fisher D. Canadian tuberculosis standards 8th ed chapter 3: extra-pulmonary tuberculosis. Can J Respir Crit Care Sleep Med 2022;6:S1,87-108.69587 - World Health Organization. WHO operation handbook on tuberculosis: module 4:drug-resistant tuberculosis treatment. Geneva: World Health Organization; 2022. Retrieved Oct 10, 2023. Available on the World Wide Web at: https://www.who.int/publications/i/item/9789240065116.69589 - National Institute for Health and Care Excellence (NICE), United Kingdom. Tuberculosis. NICE guidelines. Sep 12, 2019. Retrieved Oct 10, 2023. Available on the World Wide Web at: www.nice.org.uk/guidance/ng33.69595 - Audemard-Verger A, Pillebout E, Guillevin L, et al. IgA vasculitis (Henoch-Shonlein purpura) in adults: Diagnostic and therapeutic aspects. Autoimmun Rev 2015;14:579-85.69596 - Pozzi C, Bolasco PG, Fogazzi GB, et al. Corticosteroids in IgA nephropathy: a randomised controlled trial. Lancet 1999;353:883-7.69669 - Ozen S, Marks SD, Brogan P, et al. European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis-the SHARE initiative. Rheumatology (Oxford). 2019;58:1607-1616.69670 - Pillebout E, Alberti C, Guillevin L, et al; CESAR study group. Addition of cyclophosphamide to steroids provides no benefit compared with steroids alone in treating adult patients with severe Henoch Schonlein Purpura. Kidney Int. 2010;78:495-502.69791 - National Clinical Guideline Centre (UK). Multiple Sclerosis in Adults: Management. London: National Institute for Health and Care Excellence (UK); (NICE Clinical Guideline No 220). 2022 Jun. Accessed: November 7 2023. Available at: www.nice.org.uk/guidance/ng220/resources/multiple-sclerosis-in-adults-management-pdf-6614382894867769938 - Blombery P, Scully M. Management of thrombotic thrombocytopenic purpura: current perspectives. J Blood Med 2014;5:15-23.69939 - Scully M, Rayment R, Clark A, et al; BSH Committee. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023;203:546-563.69964 - Loirat C, Coppo P, Veyradier A. Thrombotic thrombocytopenic purpura in children. Curr Opin Pediatr 2013;25:216-24.69967 - Balduini CL, Gugliotta L, Luppi M, et al; Italian TTP Study Group. High versus standard dose methylprednisolone in the acute phase of idiopathic thrombotic thrombocytopenic purpura: a randomized study. Ann Hematol. 2010;89:591-6.69968 - Szymanik-Grzelak H, Przychodzen J, Stelmaszczyk-Emmel A, et al. Thrombotic thrombocytopenic purpura in the course of systemic lupus erythematosus in a 15-year-old girl. Cent Eur J Immunol. 2017;42:407-408.69969 - Jung JY, Kim JW, Suh CH, et al. Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report. Medicine (Baltimore). 2022;101:e28908.70292 - Hellmich B, Agueda A, Monti S, et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2020;79:19-30.70293 - Mackie SL, Dejaco C, Appenzeller S, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology 2020;59:e1-e23.70294 - Maz M, Chung SA, Abril A, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Rheumatol 2021;73:1349-1365.70295 - Oldroyd AGS, Lilleker JB, Amin T, et al. British Society for Rheumatology guideline on management of paediatric, adolescent and adult patients with idiopathic inflammatory myopathy. Rheumatology (Oxford) 2022;61:1760-8.70473 - Dasgupta B, Gray J, Fernandes L, et al. Treatment of polymyalgia rheumatica with intramuscular injections of depot methylprednisolone. Ann Rheum Dis 1991 ;50:942-5.70474 - Dejaco C, Singh YP, Perel P, et al; European League Against Rheumatism; American College of Rheumatology. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol 2015;67:2569-80.70847 - Fanouriakis A, Kostopoulou M, Andersen J, et al. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024;83:15-29.

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      Methylprednisolone Sodium Succinate 1g Powder for Injection (43598-0130) (Dr. Reddy's Laboratories, Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 1g Powder for Injection (63323-0265) (Fresenius Kabi AG) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 1g Powder for Injection (00143-9851) (Hikma Pharmaceuticals USA inc.) null

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      Methylprednisolone Sodium Succinate 1g Powder for Injection (25021-0810) (Sagent Pharmaceuticals) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 1g Powder for Injection (00009-0698) (Pfizer Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 1g Powder for Injection (00009-3389) (Pfizer Inc.) (off market)Solu-Medrol 1g Powder for Injection package photo

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      Solu-Medrol 1g Powder for Injection (00009-0018) (Pfizer Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 1g Powder for Injection (PREMIER ProRX) (00009-0698) (Pfizer Inc.) null

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      A-Methapred 40mg Powder for Injection (00409-5684) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (70121-1000) (Amneal Biosciences) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (55390-0209) (Bedford Laboratories, a Hikma Company) (off market)

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (43598-0127) (Dr. Reddy's Laboratories, Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (63323-0255) (Fresenius Kabi AG) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (00143-9753) (Hikma Pharmaceuticals USA inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Methylprednisolone Sodium Succinate 40mg Powder for Injection (25021-0807) (Sagent Pharmaceuticals) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 40mg Powder for Injection (00009-0113) (Pfizer Inc.) (off market)Solu-Medrol 40mg Powder for Injection package photo

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      Solu-Medrol 40mg Powder for Injection (00009-0039) (Pfizer Inc.) nullSolu-Medrol 40mg Powder for Injection package photo

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      Solu-Medrol 40mg Powder for Injection (NOVAPLUS) (00009-0039) (Pfizer Inc.) null

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      Solu-Medrol 40mg Powder for Injection (PREMIER ProRx) (00009-0039) (Pfizer Inc.) null

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      A-Methapred 125mg Powder for Injection (00409-5685) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

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      Methylprednisolone Sodium Succinate 125mg Powder for Injection (70121-1001) (Amneal Biosciences) null

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      Methylprednisolone Sodium Succinate 125mg Powder for Injection (00143-9754) (Hikma Pharmaceuticals USA inc.) null

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      Methylprednisolone Sodium Succinate 125mg Powder for Injection (25021-0808) (Sagent Pharmaceuticals) null

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      Solu-Medrol 125mg Powder for Injection (50090-0271) (A-S Medication Solutions LLC) null

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      Solu-Medrol 125mg Powder for Injection (00009-0047) (Pfizer Inc.) nullSolu-Medrol 125mg Powder for Injection package photo

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 125mg Powder for Injection (NOVAPLUS) (00009-0047) (Pfizer Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      Solu-Medrol 125mg Powder for Injection (PREMIER ProRx) (00009-0047) (Pfizer Inc.) null

      Methylprednisolone Sodium Succinate Powder for solution for injection

      A-Methapred 500mg Powder for Injection (00074-5630) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

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      Methylprednisolone Sodium Succinate 500mg Powder for Injection (55390-0218) (Bedford Laboratories, a Hikma Company) (off market)

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      Methylprednisolone Sodium Succinate 500mg Powder for Injection (00143-9850) (Hikma Pharmaceuticals USA inc.) null

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      A-Methapred 1000mg Powder for Injection (00074-5631) (Hospira Worldwide, Inc., a Pfizer Company) (off market)

      Description/Classification

      Description

      Methylprednisolone and its derivatives, methylprednisolone sodium succinate and methylprednisolone acetate, are synthetic glucocorticoids used orally or parenterally as antiinflammatory or immunosuppressive agents. Methylprednisolone is used in many conditions in adult and pediatric patients, including many allergic, dermatologic, and inflammatory states when systemic treatment is medically necessary. The drug is commonly used parenterally when a patient cannot take oral prednisone. Methylprednisolone has very little mineralocorticoid activity and is therefore not used to manage adrenal insufficiency unless a more potent mineralocorticoid is administered concomitantly.[55610][64995] Systemic corticosteroids may be added to other long-term maintenance medications in the management of uncontrolled severe persistent asthma. Once stabilization of asthma is achieved, regular attempts should be made to reduce or eliminate the use of systemic corticosteroids due to the side effects associated with chronic administration.[64807][66299] Short courses of systemic corticosteroid treatment may be used in moderate to severe exacerbations of asthma or COPD.[62784][64807][69470] If long-term therapy with methylprednisolone is required for any indication, the lowest possible effective dose should be used.[30015][41361]

       

      Updates for coronavirus disease 2019 (COVID-19):

      The World Health Organization strongly recommends the use of systemic corticosteroids, including methylprednisolone, in patients with severe or critical COVID-19; but suggests against use in patients with non-severe COVID-19.[65876] The National Institutes of Health (NIH) COVID-19 treatment guidelines recommend using another corticosteroid, dexamethasone, in hospitalized patients with COVID-19 who require supplemental oxygen, including those on high-flow oxygen, noninvasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO); however, methylprednisolone may be used as an alternative corticosteroid if dexamethasone is unavailable. The NIH recommends against the use of corticosteroids in patients with mild to moderate COVID-19 (i.e., non-hospitalized patients or hospitalized patients that do not require supplemental oxygen).[65314]

      Classifications

      • Systemic Hormonal Agents (excluding Sex Hormones)
        • Systemic Corticosteroids
          • Systemic Corticosteroids, Plain
      Revision Date: 07/16/2024, 03:02:57 PM

      References

      30015 - Medrol (methylprednisolone) tablet package insert. New York, NY: Pfizer; Pharmacia and Upjohn Company LLC; 2024 June41361 - Solu-Medrol (methylprednisolone sodium succinate for injection) package insert. New York, NY: Pharmacia and Upjohn Co; 2024 June55610 - Neary N, Nieman L. Adrenal insufficiency- etiology, diagnosis and treatment. Curr Opin Endocrinol Diabetes Obes 2010;17:217-223.62784 - Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309:2223-2231.64807 - Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2020. Available from: http://www.ginasthma.org. Accessed May 20th, 2020.64995 - Auron M, Raissouni N. Adrenal insufficiency. Pediatr Rev 2015;36:92-102.65314 - COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Accessed March 1, 2024. Available at https://www.covid19treatmentguidelines.nih.gov/65876 - World Health Organization Guideline Panel. Corticosteroids for COVID-19. World Health Organization. Accessed September 3, 2020. Available on the World Wide Web at: https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.166299 - Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146:1217-1270.69470 - Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Retrieved 12/5/2023. Available on the World Wide Web at https://goldcopd.org/wp-content/uploads/2023/12/GOLD-2024_v1.1-1Dec2023_WMV.pdf

      Administration Information

      General Administration Information

      NOTE: Dosage must be individualized and is very variable depending on the nature and severity of the disease, and on the patients response. If therapy is continued for more than a few days, withdrawal must be gradual.

       

      For storage information, see the specific product information within the How Supplied section.

      Route-Specific Administration

      Oral Administration

      • Administer methylprednisolone with meals to minimize indigestion or GI irritation. If given once daily or every other day, administer in the morning to coincide with the body's normal cortisol secretion.
      • For 'Dose-Packs': Follow the administration and dose titration schedule as indicated on the package.

      Injectable Administration

      • NOTE: Only methylprednisolone sodium succinate (Solu-Medrol) may be administered intravenously. NEVER administer methylprednisolone acetate suspension (Depo-Medrol, Sano-Drol, Methacort, Cortimed, and others) intravenously.
      • Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

      Intravenous Administration

      Direct intravenous injection:

      • Use only methylprednisolone sodium succinate.
      • Reconstitute with provided diluent or add 2 ml of bacteriostatic water (with benzyl alcohol) for injection.
      • May be administered undiluted.
      • Administer directly into a vein over 3—15 minutes. Doses >= 2 mg/kg or 250 mg should be given by intermittent infusion (see below), unless the potential benefits of direct IV injection outweigh the potential risks (e.g., life-threatening shock).

       

      Intermittent intravenous infusion:

      • Use only methylprednisolone sodium succinate.
      • Dilute in D5W, 0.9% Sodium Chloride (NS), or D5NS injection. Haze may form upon dilution.
      • Infuse over 15—60 minutes. Large doses (e.g., >= 500 mg) should be administered over at least 30—60 minutes.

      Intramuscular Administration

      Intramuscular injection:

      • Use methylprednisolone acetate or sodium succinate.
      • Shake suspension well before withdrawing into the syringe.
      • Inject deeply into a well-developed muscle. Rotate sites of injection.

      Other Injectable Administration

      Intra-articular injection:

      • Use only methylprednisolone acetate.
      • Using sterile technique, attach a 20—24 gauge needle to an empty syringe and insert the needle into the synovial cavity. Withdraw a few drops of synovial fluid to confirm that the needle is in the joint. With the needle still in place, exchange the aspirating syringe with the syringe containing methylprednisolone and inject the drug into the joint.

       

      Intralesional injection:

      • Use only methylprednisolone acetate.
      • Using a tuberculin syringe with a 25-gauge, 0.5-inch needle, inject methylprednisolone intradermally (not subcutaneously).

      Clinical Pharmaceutics Information

      From Trissel's 2‚Ñ¢ Clinical Pharmaceutics Database

      Methylprednisolone acetate

      pH Range
      pH 3.5 to 7
      ReferencesAnon. Manufacturer's information and labeling. (Package insert).
      Stability
      Methylprednisolone acetate injectable suspension in intact vials stored as directed by the manufacturer is stable until the labeled expiration date.
      ReferencesAnon. Manufacturer's information and labeling. (Package insert).
      Other Information
      Other drugs: The manufacturer indicates that methylprednisolone acetate should not be mixed with other drugs because of the potential for incompatibilities.
      ReferencesAnon. Manufacturer's information and labeling. (Package insert).
      Stability Max
      Maximum reported stability period: Combined with ropivacaine hydrochloride - 30 days refrigerated and at room temperature with and without light exposure.
      ReferencesRobustelli della Cuna FS, Mella M, Magistrali G, et al. Stability and compatibility of methylprednisolone acetate and ropivacaine hydrochloride in polypropylene syringes for epidural administration. Am J Health-Syst Pharm. 2001; 58

      Methylprednisolone sodium succinate

      pH Range
      pH 7 to 8
      ReferencesSolu-Medrol (methylprednisolone sodium succinate) injection package insert. New York, NY. Pharmacia & Upjohn Co. 2024; Jun
      Sodium Content
      Methylprednisolone sodium succinate 1 g provides 2.01 mEq of sodium.
      ReferencesRaymond G, Day P, Rabb M. Sodium content of commonly administered intravenous drugs. Hosp Pharm. 1982; 17
      Osmolality/Osmolarity
      The manufacturer indicates that the osmolarities of the various concentrations of reconstituted methylprednisolone sodium succinate are as noted: 40 mg/mL is 500 mOsm/L; 62.5 mg/mL is 400 mOsm/L; 65.4 mg/mL is 420 mOsm/L; and 125 mg/mL is 440 mOsm/L The calculated osmolalities of methylprednisolone sodium succinate 20 mg/mL in dextrose 5% or sodium chloride 0.9% are 318 mOsm/kg and 345 mOsm/kg, respectively. The calculated osmolalities of methylprednisolone sodium succinate 10 mg/mL in dextrose 5% or sodium chloride 0.9% are 291 mOsm/kg and 318 mOsm/kg, respectively. The calculated osmolalities of methylprednisolone sodium succinate 5 mg/mL in dextrose 5% or sodium chloride 0.9% are 275 mOsm/kg and 301 mOsm/kg, respectively.
      ReferencesAnon. Manufacturer's information and labeling. (Package insert).
      ReferencesWermeling DP, Rapp RP, DeLuca PP, et al. Osmolality of small-volume intravenous admixtures. Am J Hosp Pharm. 1986; 42
      Stability
      The containers should not be autoclaved to sterilize the exterior of the containers because of heat sensitivity of the drug. The manufacturer indicates that reconstituted methylprednisolone sodium succinate is stable for 48 hours at room temperature. It is subject to ester hydrolysis resulting in the formation of decomposition products that include less soluble free methylprednisolone and precipitate formation. The reconstituted injection should be clear and should be discarded if not free of particulates. Nahata et al. reported that Upjohn methylprednisolone sodium succinate reconstituted with sterile water for injection to a concentration of 4 mg/mL packaged in glass vials was stable for 24 hours at room temperature and 7 days refrigerated. HPLC analysis found 10% drug loss in 24 hours at 22 degrees C and 6% loss in 7 days at 4 degrees C. The loss increased to 17% in 14 days under refrigeration. Infusion Solutions: The manufacturer recommends dilution of methylprednisolone sodium succinate in dextrose 5%, dextrose 5% in sodium chloride 0.9%, or in sodium chloride 0.9% for intravenous infusion. Methylprednisolone sodium succinate may appear hazy upon dilution, although improvements in manufacturing have substantially reduced the amount of haze compared to the past. The haziness may be higher in dextrose 5% than in sodium chloride 0.9%. Pyter et al. reported that increasing drug concentration also played a role in increasing haze. In addition, they noted that simple ester hydrolysis did not explain differences in observed haze. Instead, they suggested that the solubility of free methylprednisolone in various concentrations of methylprednisolone sodium succinate may be important. The solubility of free methylprednisolone increases with increasing concentrations of methylprednisolone sodium succinate reducing haze and precipitation in concentrations over 10 mg/mL. Differences between dextrose 5% and sodium chloride 0.9% were attributed to the pH of the dextrose and the electrolyte content of the sodium chloride 0.9%. Packaged in Syringes: Gupta reported that Pharmacia & Upjohn methylprednisolone sodium succinate 10 mg/mL in sodium chloride 0.9% packaged in Becton Dickinson and Monoject polypropylene syringes remained clear and stable for 7 days at room temperature and at least 21 days refrigerated. HPLC analysis found about 10% loss occurred in 7 days at 25 degrees C and about 4% loss occurred in 21 days at 5 degrees C. Intrathecal Solutions D'Hondt et al. reported the stability of a 3-drug intrathecal combination in 0.9% sodium chloride. The 3-drug combination contained cytarabine 3.85 mg/mL, methotrexate sodium 1.54 mg/mL, and methylprednisolone sodium succinate 0.51 mg/mL. The 3-drug mixture was packaged in plastic syringes (PhaSeal, Carmel Pharma) and Type I brown glass vials. Samples were stored refrigerated at 5 degrees C, room temperature of 25 degrees C, and elevated temperature of 40 degrees C all protected from exposure to light. The samples were evaluated for physical and chemical stability over 48 hours. All of the samples were found to be physically compatible throughout the study period. Stability-indicating HPLC analysis found cytarabine and methotrexate were both chemically stable for 48 hours at all three temperature in both containers. However, methylprednisolone sodium succinate proved to be the least stable component exhibiting losses of about 6 to 7% in 48 hours at 5 degrees C, 5% and 10 to 14% losses in 8 and 24 hours, respectively, at 25 degrees C , and 10% or more in 4 hours at 40 degrees C . In addition, if exposed to intense ultraviolet or visible light, substantial losses of methotrexate sodium occurred. The authors concluded that the 3-drug mixture was only stable for 12 hours if refrigerated and protected from exposure to light.
      ReferencesD'Hondt M, Vangheluwe E, Van Dorpe S, et al. Stability of extemporaneously prepared cytarabine, methotrexate sodium, and methylprednisolone sodium succinate. Am J Health-Syst Pharm. 2012; 69
      ReferencesGupta VD. Chemical stability of methylprednisolone sodium succinate after reconstitution in 0.9% sodium chloride injection and storage in polypropylene syringes. Int J Pharmaceut Compound. 2001; 5
      ReferencesNahata MC, Morosco RS, Hipple TF. Stability of diluted methylprednisolone sodium succinate injection at two temperatures. Am J Hosp Pharm. 1994; 51
      ReferencesPyter RA, Hsu LCC, Buddenhagen JD. Stability of methylprednisolone sodium succinate in 5% dextrose and0.9% sodium chloride injections. Am J Hosp Pharm. 1983; 40
      ReferencesUlsaker G, Teien G. Degradation of methylprednisolone sodium succinate in a diluent-containing vial. Am J Health-Syst Pharm. 2002; 59
      ReferencesSolu-Medrol (methylprednisolone sodium succinate) injection package insert. New York, NY. Pharmacia & Upjohn Co. 2024; Jun
      pH Effects
      The pH exhibiting the minimum rate of ester hydrolysis is pH 3.5. Between pH 3.4 and 7.4 acyl migration is the principal route of decomposition.
      ReferencesAnderson BD, Taphouse V. Initial rate studies of hydrolysis and acyl migration in methylprednisolone 21-hemisuccinate and 17-hemisuccinate. J Pharm Sci. 1981; 70
      Light Exposure
      Methylprednisolone sodium succinate should be protected from exposure to light during long-term storage. D'Hondt et al. evaluated the stability of methylprednisolone sodium succinate 0.51 mg/mL in a 3-drug intrathecal injection exposed to intense ultraviolet and visible light at 25 degrees C. Stability-indicating HPLC analysis found little change in the methylprednisolone sodium succinate concentration after 48 hours exposed to ultraviolet light and 192 hours exposed to visible light.
      ReferencesD'Hondt M, Vangheluwe E, Van Dorpe S, et al. Stability of extemporaneously prepared cytarabine, methotrexate sodium, and methylprednisolone sodium succinate. Am J Health-Syst Pharm. 2012; 69
      ReferencesSolu-Medrol (methylprednisolone sodium succinate) injection package insert. New York, NY. Pharmacia & Upjohn Co. 2024; Jun
      Freezing
      Ho and Goeman reported that reconstituted methylprednisolone sodium succinate 62.5 mg/mL was stable when frozen exhibiting no loss of drug for 4 weeks frozen at -20 degrees C. Sewell and Palmer reported that methylprednisolone sodium succinate 4.6 mg/mL (500 mg/108 mL) in sodium chloride 0.9% frozen at -20 degrees C was physically and chemically stable. No visible particulates or increase in microparticles occurred, and HPLC analysis found no loss of drug in 12 months of frozen storage with microwave thawing.
      ReferencesHo NFH, Goeman JA. Prediction of pharmaceutical stability of parenteral solutions. Drug Intell Clin Pharm. 1970; 4
      ReferencesSewell GJ, Palmer AJ. The chemical and physical stability of three intravenous infusions subjected to fozen storage and microwave thawing. Int J Pharm. 1991; 72
      Filtration
      Pall reported that methylprednisolone sodium succinate 4 mg/mL underwent little or no loss due to filtration through a Supor membrane filter.
      ReferencesAnon. Pall Medical Supor-membrane IV filter device drug-adsorption data. Data on file. 2004; 8
      Sorption Leaching
      Methylprednisolone sodium succinate has not been found to undergo substantial sorption to polyvinyl chloride (PVC), polyethylene, ethylene vinyl acetate (EVA), polypropylene (in syringes), or glass containers, or to elastomeric pump reservoirs. In addition, Xu et al. reported no sorption occurred to a polyurethane central catheter from Arrow International as well as no leaching of the chlorhexidine antimicrobial in it.
      ReferencesAnon. Guidelines for the administration of drugs using the Homepump Eclipse and C-Series disposable elastomeric infusion systems. Lake Forest, CA: I-Flow Corporation. 2004;
      ReferencesGupta VD. Chemical stability of methylprednisolone sodium succinate after reconstitution in 0.9% sodium chloride injection and storage in polypropylene syringes. Int J Pharmaceut Compound. 2001; 5
      ReferencesStewart JT, Warren FW, King AD. Stability of ranitidine hydrochloride and seven medications. Am J Hosp Pharm. 1994; 51
      ReferencesTrissel LA, Zhang Y. Stability of methylprednisolone sodium succinate in AutoDose infusion system bags. J Am Pharm Assoc. 2002; 42
      ReferencesXu QA, Zhang Y, Trissel LA, et al. Adequacy of a new chlorhexidine-bearing polyurethane central catheter for administration of 82 selected parenteral drugs. Ann Pharmacother. 2000; 34
      ReferencesZeidler C, Dettmering D, Schrammer W, et al. Compatibility of various drugs used in intensive care medicine in polyethylene, PVC, and glass infusion containers. Eur Hosp Pharm. 1999; 5
      Other Information
      Other Drugs: Amphotericin B is compatible with limited concentrations of methylprednisolone sodium succinate but precipitation may appear at higher concentrations. Irinotecan mixed with methylprednisolone sodium succinate resulted in an admixture pH over 6.5; 10% loss of irinotecan will occur in about 3 hours at this pH.
      ReferencesMcEvoy GK (ed). AHFS Drug Information (current edition). Bethesda, MD: American Society of Health-System Pharmacists.
      ReferencesTanque N, Ueda H, Moriyama Y, et al. Compatibility of irinotecan hydrochloride injection with other injections. Jpn J Hosp Pharm. 1996; 22
      ReferencesTrissel LA, Leissing NC. Trissel's Tables of Physical Compatibility. Lake Forest, IL: MultiMatrix, Inc. 1996;
      Stability Max
      Maximum reported stability periods: Reconstituted solution- 48 hours at room temperature. In D5W- 48 hours at room temperature. In NS- 48 hours at room temperature and 30 days refrigerated.
      ReferencesAnon. Manufacturer's information and labeling. (Package insert).
      ReferencesStewart JT, Warren FW, King AD. Stability of ranitidine hydrochloride and seven medications. Am J Hosp Pharm. 1994; 51
      ReferencesTrissel LA, Zhang Y. Stability of methylprednisolone sodium succinate in AutoDose infusion system bags. J Am Pharm Assoc. 2002; 42
      Revision Date: 07/16/2024, 03:02:57 PMCopyright 2004-2024 by Lawrence A. Trissel. All Rights Reserved.

      References

      Adverse Reactions

      Moderate

      • adrenocortical insufficiency
      • cataracts
      • constipation
      • Cushing's syndrome
      • depression
      • diabetes mellitus
      • edema
      • EEG changes
      • elevated hepatic enzymes
      • erythema
      • euphoria
      • exophthalmos
      • fluid retention
      • gastritis
      • glycosuria
      • growth inhibition
      • hepatitis
      • hepatomegaly
      • hypercholesterolemia
      • hyperglycemia
      • hypernatremia
      • hypertension
      • hypocalcemia
      • hypokalemia
      • hypotension
      • hypothalamic-pituitary-adrenal (HPA) suppression
      • immunosuppression
      • impaired wound healing
      • metabolic alkalosis
      • myopathy
      • neuritis
      • ocular infection
      • osteoporosis
      • palpitations
      • peripheral neuropathy
      • phlebitis
      • physiological dependence
      • pseudotumor cerebri
      • psychosis
      • scleroderma renal crisis
      • sinus tachycardia
      • sodium retention
      • urinary incontinence
      • withdrawal

      Mild

      • abdominal pain
      • acne vulgaris
      • alopecia
      • amenorrhea
      • anorexia
      • appetite stimulation
      • arthralgia
      • arthropathy
      • diaphoresis
      • diarrhea
      • dysmenorrhea
      • ecchymosis
      • emotional lability
      • fever
      • headache
      • hiccups
      • hirsutism
      • hypertrichosis
      • infection
      • injection site reaction
      • insomnia
      • irritability
      • lactose intolerance
      • lethargy
      • leukocytosis
      • malaise
      • menstrual irregularity
      • myalgia
      • nausea
      • paresthesias
      • petechiae
      • rash
      • restlessness
      • skin hyperpigmentation
      • skin hypopigmentation
      • striae
      • syncope
      • urinary urgency
      • urticaria
      • vertigo
      • vomiting
      • weakness
      • weight gain
      • xerosis

      Severe

      • anaphylactoid reactions
      • angioedema
      • arrhythmia exacerbation
      • avascular necrosis
      • bone fractures
      • bradycardia
      • cardiac arrest
      • cardiomyopathy
      • esophageal ulceration
      • exfoliative dermatitis
      • GI perforation
      • heart failure
      • increased intracranial pressure
      • ocular hypertension
      • optic neuritis
      • pancreatitis
      • papilledema
      • peptic ulcer
      • pulmonary edema
      • retinopathy
      • seizures
      • skin atrophy
      • tendon rupture
      • thromboembolism
      • thrombosis
      • tumor lysis syndrome (TLS)
      • vasculitis
      • visual impairment

      Glucocorticoids are responsible for protein metabolism, and prolonged therapy can result in various musculoskeletal manifestations, including: myopathy (myalgia, muscle wasting, muscle weakness, quadriparesis), impaired wound healing, bone matrix atrophy (osteoporosis), bone fractures such as vertebral compression fractures or fractures of long bones, and avascular necrosis of femoral or humoral heads. These effects are more likely to occur in older or debilitated patients. Glucocorticoids interact with calcium metabolism at many sites, including: calcinosis, decreasing the synthesis by osteoblasts of the principle proteins of bone matrix, malabsorption of calcium in both the nephron and the gut, and reduction of sex hormone concentrations. Although all of these actions probably contribute to glucocorticoid-induced osteoporosis, the actions on osteoblasts is most important. Glucocorticoids do not modify vitamin D metabolism.[24837] Postmenopausal women, in particular, should be monitored for signs of osteoporosis during methylprednisolone therapy. Because of retardation of bone growth, children receiving prolonged corticosteroid therapy may have growth inhibition. Intra-articular injections of corticosteroids can cause Charcot-like arthropathy and postinjection flare. Atrophy at the site of injection has been reported following administration of soluble glucocorticoids. Tendon rupture has also been reported.[30015] [41361] [41362]

      Methylprednisolone can mask the symptoms of infection and should be avoided during an acute viral, fungal, or bacterial infection; as well, patients receiving corticosteroids are more susceptible to infections than are healthy individuals. Leukocytosis has been reported and is a common physiologic effect of systemic corticosteroid therapy and may need to be differentiated from the leukocytosis that occurs with inflammatory or infectious processes.[30943] [65096] [65097] Immunosuppression is most likely to occur in patients receiving high-dose (e.g., equivalent to 1 mg/kg or more of prednisone daily), systemic corticosteroid therapy for any period of time, particularly in conjunction with corticosteroid-sparing drugs (e.g., troleandomycin) and/or concomitant immunosuppressant agents; however, patients receiving moderate dosages of systemic corticosteroids for short periods or low dosages for prolonged periods also may be at risk. Corticosteroids can reactivate tuberculosis and should not be used in patients with a history of active tuberculosis except when chemoprophylaxis is instituted concomitantly. Patients receiving immunosuppressive doses of corticosteroids should be advised to avoid exposure to measles or varicella (chickenpox) and, if exposed to these diseases, to seek medical advice immediately.[30015] [41361] [41362]

      Corticosteroids are divided into two classes: mineralocorticoids and glucocorticoids. Methylprednisolone is a glucocorticoid with minimal mineralocorticoid activity. Mineralocorticoids alter electrolyte and fluid balance by facilitating sodium retention and hydrogen and potassium excretion at the level of the distal renal tubule, resulting in increased plasma volume. Although the incidence of effects with this medication are not well elicited, mineralocorticoid properties can cause fluid retention; electrolyte disturbances (hypokalemia, hypokalemic metabolic alkalosis, hypernatremia, hypocalcemia); and edema. In a review of 93 studies of corticosteroid use, hypertension was found to develop approximately 4 times as often in steroid recipients compared to control groups.[24362] As a result of the steroid-induced edema and elevated blood pressure, congestive heart failure can occur in susceptible patients. Dietary salt restriction and potassium supplementation may be needed in persons receiving treatment with methylprednisolone.[30015] [41361] [41362]

      Cardiovascular adverse events have been reported during and/or after treatment with parenteral methylprednisolone. These adverse events include bradycardia, cardiac arrest, cardiac arrhythmia exacerbation, cardiac failure, cardiomegaly, fat (lipid) emboli, hypertrophic cardiomyopathy (in premature infants), pulmonary edema, sinus tachycardia, syncope, and vasculitis. Additionally, corticosteroid therapy has also been associated with ruptures of the left ventricular free wall in persons having recently experienced a myocardial infarction; thus, caution is advised when prescribing methylprednisolone to these patients.[41361] [41362]

      Although corticosteroids are used to treat Graves' ophthalmopathy, ocular effects, such as exophthalmos, posterior subcapsular cataracts, retinopathy, or ocular hypertension, can result from prolonged use of methylprednisolone and could result in glaucoma or ocular nerve damage including optic neuritis. Temporary or permanent visual impairment, including blindness, has been reported with glucocorticoid administration by several routes of administration including intranasal and ophthalmic administration. Secondary bacterial, fungal, and viral ocular infection can be exacerbated by corticosteroid therapy. Corneal perforation may occur if corticosteroids are administered to patients with ocular herpes simplex and, thus, should not be used during active ocular herpes simplex infection.[30015] [41361] [41362]

      Prolonged therapy of methylprednisolone can adversely affect the endocrine system, resulting in hypercorticism (Cushing's syndrome), menstrual irregularity including amenorrhea or dysmenorrhea, and decreased carbohydrate and glucose tolerance.[30015] [41361] [41362] Systemic corticosteroids are a common cause of drug-induced hyperglycemia. In the hospital setting, there is evidence that more than 50% of the patients receiving high-dose systemic steroids develop hyperglycemia, with many more having at least 1 episode of hyperglycemia or a mean blood glucose of 140 mg/dL or greater. Long-term use produces metabolic and endocrine effects that include insulin resistance that may lead to new diagnoses of diabetes mellitus (DM) in patients without a history of hyperglycemia or DM prior to corticosteroid use. Glucosuria (glycosuria) and aggravation of existing diabetes mellitus may also occur.[68700]

      Adverse GI effects associated with long-term corticosteroid administration include nausea, vomiting, and anorexia. Appetite stimulation with weight gain, diarrhea, constipation, abdominal pain and distention, esophageal ulceration, gastritis, GI perforation, and pancreatitis also have been reported. A few patients receiving prolonged corticosteroid administration have experienced production, reactivation, perforation, or delayed healing of peptic ulcer disease. Although it was once believed that corticosteroids like methylprednisolone contributed to the development of peptic ulcer disease, in a published review of 93 studies of corticosteroid use, the incidence of peptic ulcer disease was not found to be higher in steroid recipients compared to control groups.[24362] Cases of hepatomegaly and elevated hepatic enzymes (reversible upon discontinuation) have been associated with the use of methylprednisolone.[30015] [41361] [41362] Rarely, high doses of cyclically pulsed IV methylprednisolone can induce a toxic form of acute hepatitis. This may occur several weeks after exposure and resolution has been observed after treatment is discontinued. However, serious liver injury may occur, which could result in acute hepatic failure and death. Discontinue IV methylprednisolone if toxic hepatitis occurs. Avoid future use of high dose IV methylprednisolone in patients with toxic hepatitis caused by methylprednisolone.[41361]

      Adverse neurologic effects have been reported with methylprednisolone and other corticosteroid administration include headache, insomnia, vertigo, restlessness, ischemic peripheral neuropathy, neuritis, seizures or convulsions, and EEG changes. Methylprednisolone and other systemic corticosteroids may cause mood swings (emotional lability) and psychiatric side effects; irritability, depression, euphoria, changes in mood and behavior, personality changes and psychosis have been reported.[30015] [41361] [41362] [68690] [68691]

      Various adverse dermatologic effects reported during corticosteroid therapy include rash (unspecified), skin atrophy, dry skin or xerosis, acne vulgaris, alopecia or thinning scalp hair, diaphoresis, impaired wound healing, facial erythema, striae, petechiae, hirsutism or hypertrichosis, ecchymosis, and easy bruising. Hypersensitivity reactions may manifest as allergic dermatitis, urticaria, anaphylactoid reactions, and/or angioedema.[30015] Paresthesias (burning or tingling) in the perineal area may occur following IV injection of corticosteroids like methylprednisolone. Parenteral corticosteroid therapy has also produced skin hypopigmentation, skin hyperpigmentation, scarring, and other types of injection site reaction (e.g., induration, delayed pain or soreness, subcutaneous and cutaneous atrophy, and sterile abscesses); use via incorrect route of administration and/or excessive doses may increase risk of such effects.[41361] [41362]

      Pharmacologic doses of methylprednisolone administered for prolonged periods can result in physiological dependence due to hypothalamic-pituitary-adrenal (HPA) suppression. Exogenous corticosteroids exert negative feedback on the pituitary, inhibiting the secretion of adrenocorticotropin (ACTH). This inhibition decreases ACTH-mediated synthesis of endogenous corticosteroids and androgens by the adrenal cortex. The severity of glucocorticoid-induced secondary adrenocortical insufficiency varies among individuals and is dependent on the dose, frequency, time of administration, and duration of therapy. Administering the drug on alternate days may help to alleviate this adverse effect. Patients with HPA suppression will require increased doses of corticosteroids during periods of physiologic stress. Acute adrenal insufficiency and even death can occur if sudden withdrawal of the drugs is undertaken. Withdrawal from prolonged oral corticosteroid therapy should be gradual; HPA suppression can last for up to 12 months following cessation of therapy, and patients may need supplemental corticosteroid treatment during periods of physiologic stress such as surgery, acute blood loss, or infection, even after the drug has been discontinued. A non-HAP withdrawal syndrome can occur following abrupt discontinuance of corticosteroid therapy and is apparently unrelated to adrenocortical insufficiency. This syndrome includes symptoms such as anorexia, lethargy, nausea, vomiting, headache, fever, arthralgia, myalgia, exfoliative dermatitis, weight loss, and hypotension. These effects are believed to be due to the sudden change in glucocorticoid concentration rather than to low corticosteroid levels. Increased intracranial pressure with papilledema (i.e., pseudotumor cerebri) has also been reported with withdrawal of glucocorticoid therapy.[30015] [41361] [41362]

      Hypercholesterolemia, atherosclerosis, fat (lipid) emboli, thrombosis, thromboembolism, and phlebitis, specifically, thrombophlebitis have been associated with corticosteroid therapy. Other adverse events reported during treatment with corticosteroids include abnormal fat deposits (moon face), hiccups, malaise, and changes (increase or decrease) in the motility and number of spermatozoa. Palpitations, glossitis, stomatitis, urinary incontinence, and urinary urgency have been rarely reported. Corticosteroids like methylprednisolone may also decrease serum concentrations of vitamin C (ascorbic acid) and vitamin A which may rarely produce symptoms of vitamin A deficiency or vitamin C deficiency.[30015] [41361] [41362]

      The Solu-Medrol 40 mg presentation contains lactose monohydrate produced from cow's milk. In situations where allergic symptoms worsen or new allergic symptoms occur after administration of this preparation, consider the potential for hypersensitivity reactions to cow's milk ingredients. Additionally, lactose intolerance symptoms such as nausea/vomiting, bloating, abdominal pain (cramps), and flatulence may occur. Use appropriate precautions when administering to patients with a cow's milk sensitivity or lactose intolerance. If hypersensitivity reactions occur with the Solu-Medrol 40 mg presentation, consider discontinuing treatments and using alternative treatments, including corticosteroid formulations that do not contain ingredients produced from cow's milk.[41361]

      An increased incidence of scleroderma renal crisis (SRC) has been observed in patients with systemic sclerosis (systemic scleroderma) treated with corticosteroids. SRC is characterized by malignant hypertension and acute renal failure (unspecified) that may be accompanied by oliguria or anuria.[30015] [41361] [41362]

      Tumor lysis syndrome (TLS) has been reported during postmarketing surveillance of systemic corticosteroids alone or in combination with other chemotherapeutic agents in patients with malignancies, including hematological malignancies and solid tumors. Patients at high risk of TLS, such as patients with tumors that have a high proliferative rate, high tumor burden and high sensitivity to cytotoxic agents, should be monitored closely and appropriate precautions should be taken.[30015] [41362] [41361]

      Revision Date: 07/16/2024, 03:02:57 PM

      References

      24362 - Conn HO, Poynard T. Corticosteroids and peptic ulcer: meta-analysis of adverse events during steroid therapy. J Intern Med 1994;236:619-32.24837 - Reid IR. Preventing glucocorticoid-induced osteoporosis. N Engl J Med 1997;337:420-1.30015 - Medrol (methylprednisolone) tablet package insert. New York, NY: Pfizer; Pharmacia and Upjohn Company LLC; 2024 June30943 - Schimmer B, Parker K. Adrenocorticotropic hormone; adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormones. In: Hardman JG, Limbird LE, Molinoff PB, et al., eds. Goodman and Gilman's the Pharmacological Basis of Therapeutics, 10th edition. New York: McGraw Hill, 2001;1649-1674.41361 - Solu-Medrol (methylprednisolone sodium succinate for injection) package insert. New York, NY: Pharmacia and Upjohn Co; 2024 June41362 - Depo-Medrol (methylprednisolone acetate for injection, suspension) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 Dec.65096 - Abramson N, Melton B. Leukocytosis: basic of clinical assessment. Am Fam Physician 2000;62:2053-60.65097 - Shoenfeld Y, Gurewich Y, Gallant LA, et al. Prednisone-induced leukocytosis. Influenced of dosage, method and duration of administration on the degree of leukocytosis. Am J Med 1981;71:773-8.68690 - Sarnes E, Crofford L, Watson M, et al. Incidence and US costs of corticosteroid-associated adverse events: a systematic literature review. Clin Ther. 2011;33:1413-1432. Epub 2011 Oct 13.68691 - Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort study. BMJ. 2017;357:j1415.68700 - Tamez-Perez HE, Quintanilla-Flores DL, Rodriguez-Gutierrez R, et al. Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J Diabetes. 2015;6:1073-1081.

      Contraindications/Precautions

      Absolute contraindications are italicized.

      • corticosteroid hypersensitivity
      • fungal infection
      • intrathecal administration
      • milk protein hypersensitivity
      • abrupt discontinuation
      • amebiasis
      • breast-feeding
      • cardiomyopathy
      • cataracts
      • cerebral malaria
      • coagulopathy
      • Cushing's syndrome
      • diabetes mellitus
      • diverticulitis
      • epidural administration
      • geriatric
      • GI perforation
      • glaucoma
      • growth inhibition
      • head trauma
      • heart failure
      • helminth infection
      • hepatic disease
      • hepatitis B exacerbation
      • herpes infection
      • hypertension
      • hyperthyroidism
      • hypothalamic-pituitary-adrenal (HPA) suppression
      • hypothyroidism
      • immune thrombocytopenic purpura (ITP)
      • immunosuppression
      • increased intracranial pressure
      • increased intraocular pressure
      • infection
      • intravenous administration
      • Kaposi's sarcoma
      • measles
      • myasthenia gravis
      • myocardial infarction
      • neonates
      • neoplastic disease
      • neurologic events
      • ocular infection
      • osteoporosis
      • peptic ulcer disease
      • pregnancy
      • premature neonates
      • renal disease
      • scleroderma
      • surgery
      • thromboembolic disease
      • thyroid disease
      • tuberculosis
      • tumor lysis syndrome (TLS)
      • ulcerative colitis
      • vaccination
      • varicella
      • visual disturbance

      Increased dosages of rapid-acting corticosteroids may be necessary for patients undergoing physiologic stress such as major surgical procedure, acute infection, or blood loss. Methylprednisolone should be administered before, during, and after the stressful situation.

      Severe medical events have occurred following administration of parenteral methylprednisolone via an incorrect route; to minimize the incidence of adverse events, care must be taken to administer the drug as intended and to not exceed recommended doses in each injection. Use of methylprednisolone is contraindicated for intrathecal administration.[41361] [41362] Do not give methylprednisolone acetate (e.g., Depo-Medrol) via intravenous administration.[41362] Do not administer any form of parenteral methylprednisolone into the deltoid muscle as subcutaneous atrophy occurs with high frequency following such use.[41361] [41362] Epidural administration of corticosteroids should be used with great caution. Rare, but serious neurologic events, including cortical blindness, stroke, spinal cord infarction, paralysis, seizures, nerve injury, brain edema, and death have been associated with epidural administration of injectable corticosteroids. These events have been reported with and without the use of fluoroscopy. Many cases were temporally associated with the corticosteroid injection; reactions occurred within minutes to 48 hours after injection. Some cases were confirmed through magnetic resonance imaging (MRI) or computed tomography (CT) scan. Many patients did not recover from the reported adverse effects. Discuss the benefits and risks of epidural corticosteroid injections with the patient before treatment. If a decision is made to proceed with corticosteroid epidural administration, counsel patients to seek emergency medical attention if they experience symptoms after injection such as vision changes, tingling in the arms or legs, dizziness, severe headache, seizures, or sudden weakness or numbness of face, arm, or leg.[41361] [57053]

      Systemic corticosteroids, including methylprednisolone, may cause immunosuppression and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens. Corticosteroids can: 1) Reduce resistance to new infections, 2) Exacerbate existing infections, 3) Increase the risk of disseminated infections, 4) Increase the risk of reactivation or exacerbation of latent infections 5) Mask some signs of infection. Corticosteroid-associated infections can be mild but can be severe and at times fatal. The rate of infectious complications increases with increasing corticosteroid dosages. Monitor for the development of infection and consider corticosteroid withdrawal or dosage reduction as needed. Do not administer methylprednisolone injections by an intraarticular, intrabursal, iintratendinous, or intralesional route in the presence of acute local infection. If methylprednisolone is used to treat a condition in patients with latent tuberculosis (TB) or tuberculin reactivity, reactivation of TB may occur. Closely monitor such patients for TB reactivation. During prolonged methylprednisolone therapy, patients with latent TB or tuberculin reactivity should receive chemoprophylaxis. Viral infection, such as varicella zoster (chickenpox or shingles) and measles can have a serious or even fatal course in non-immune patients taking corticosteroids; other herpes infection (herpes simplex) may also disseminate in immunosuppressed individuals. In corticosteroid-treated patients who have not had these diseases or are nonimmune, avoid exposure of these people to these viral infections. If a corticosteroid-treated patient is exposed to varicella, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If varicella develops, consider treatment with antiviral. If a corticosteroid-treated patient is exposed to measles, prophylaxis with immunoglobulin (IG) may be indicated. Hepatitis B exacerbation/reactivation can occur in patients who are hepatitis B virus carriers treated with immunosuppressive dosages of corticosteroids, including methylprednisolone. Reactivation can also occur infrequently in corticosteroid-treated people who appear to have resolved hepatitis B infection. Screen patients for hepatitis B infection before initiating immunosuppressive (e.g., prolonged) treatment with systemic corticosteroids. For individuals who show evidence of hepatitis B infection, consult providers with expertise in managing hepatitis B regarding monitoring and consideration for hepatitis B antiviral therapy. Systemic methylprednisolone use is generally contraindicated in the presence of a systemic fungal infection. Corticosteroids, including methylprednisolone, may exacerbate systemic fungal infections; therefore, avoid corticosteroid use in the presence of a fungal infection unless a corticosteroid is needed to control drug reactions. If a fungal infection develops during chronic corticosteroid therapy, corticosteroid withdrawal or dosage reduction is recommended. Depot methylprednisolone acetate injection is contraindicated for use in systemic fungal infections, except when administered as an intra-articular injection for localized joint conditions. Corticosteroids, including methylprednisolone, may activate latent amebiasis. Latent or active amebiasis should be ruled out before initiating methylprednisolone in people who have spent time in the tropics or have unexplained diarrhea. Corticosteroids, including methylprednisolone, should be used with great care in the presence of known or suspected Strongyloides (threadworm) helminth infection. Corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia. In selected patients from strongyloidiasis endemic areas who need systemic corticosteroids, consider administering prophylactic treatment. Also avoid corticosteroids, including methylprednisolone, in people with cerebral malaria. 30015] [41361] [41362]

      Patients should be instructed to notify their physician immediately if signs of infection or injury occur, both during treatment or up to 12 months following cessation of therapy with methylprednisolone. Dosages should be adjusted, or glucocorticoid therapy reintroduced, if required. If surgery is needed, patients should advise the attending physician of the corticosteroid they have received within the last 12 months and the disease for which they were being treated. Identification cards that include the name of the patient's disease, the currently administered type and dose of corticosteroid, and the patient's physician should be carried with the patient at all times.

      Corticosteroid therapy has been associated with left ventricular free-wall rupture in patients with recent myocardial infarction and methylprednisolone should therefore be used cautiously in these patients.

      Use methylprednisolone with caution in patients with heart failure, hypertension, or renal disease as this can cause an exacerbation of their condition. Systemic corticosteroids can cause edema and weight gain.[30015] [41361] [41362]

      Use cautiously in patients with glaucoma, cataracts, or other types of visual disturbance. Corticosteroids may cause cataracts and increased ocular pressure and may exacerbate glaucoma with long-term administration. Systemic corticosteroids may produce posterior subcapsular cataracts and glaucoma with possible damage to the optic nerves. Periodically assess patients receiving corticosteroids chronically for cataract formation. If systemic methylprednisolone is administered for more than 6 weeks, monitor intraocular pressure. Prolonged use of corticosteroids may enhance the establishment of a secondary ocular infection due to fungi or viruses.[30015] [41361] [41362]

      Use with caution in patients with diabetes mellitus. Systemic corticosteroids, such as methylprednisolone, may decrease glucose tolerance, produce hyperglycemia, and aggravate or precipitate diabetes mellitus. This may especially occur in patients predisposed to diabetes mellitus. When corticosteroid therapy is necessary in patients with diabetes mellitus, changes in insulin, oral antidiabetic agent dosage, and/or diet may be required.[30015] [41361] [41362]

      Methylprednisolone should be used with caution in patients with myasthenia gravis who are being treated with anticholinesterase agents (see Interactions). Muscle weakness can be transiently increased during the initiation of glucocorticoid therapy in patients with myasthenia gravis, necessitating respiratory support.

      Systemic corticosteroids should be used with caution in patients with active or latent peptic ulcer disease, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since steroids may increase the risk of a gastrointestinal (GI) perforation. Signs of peritoneal irritation following GI perforation in patients receiving corticosteroids may be minimal or absent. Corticosteroids should not be used in patients where there is a possibility of impending GI perforation, abscess, or pyogenic infection. There is an enhanced effect due to decreased metabolism of corticosteroids in patients with severe hepatic disease with cirrhosis.[30015] [41361] [41362]

      Glucocorticoids rarely can increase blood coagulability and cause intravascular thrombosis, thrombophlebitis, and thromboembolism. Therefore, methylprednisolone should be used with caution in patients with coagulopathy and/or thromboembolic disease. It is important to note that corticosteroid use via intramuscular administration for immune thrombocytopenic purpura (ITP) is contraindicated, though intravascular and oral administration of methylprednisolone are utilized for this condition.[41361] [41362]

      There are no adequate or well controlled studies of the use of methylprednisolone in pregnant women. Complications, including cleft palate, stillbirth, and premature abortion, have been reported when corticosteroids were administered during pregnancy in animals. If these drugs must be used during pregnancy, the potential risks should be discussed with the patient. Babies born to women receiving large doses of corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency, and appropriate therapy should be initiated, if necessary. Corticosteroids have been shown to impair fertility in male rats.[41361] [41362] Under certain circumstances, methylprednisolone may be considered for use in the pregnant patient (e.g., severe asthma exacerbation); poorly-controlled asthma and exacerbations generally present a greater risk to the mother and fetus than do needed asthma treatments.[64807] The American College of Obstetricians and Gynecologists (ACOG) include methylprednisolone as a last-line treatment option for nausea and vomiting of pregnancy in patients who have failed other therapies and suggest a limited duration of use for this purpose in responding patients.[66066]

      Methylprednisolone is compatible with breast-feeding. Amounts of methylprednisolone in breast milk are low, with a relative infant dose of 0.46% to 3.15%. No infant adverse effects have been reported with maternal methylprednisolone use, even with intravenous doses of up to 1 gram daily. At higher daily methylprednisolone doses, avoidance of breast-feeding during times of peak milk concentrations (usually until 3 to 4 hours following a dose) can help limit infant exposure. Medium to large doses of corticosteroids and intra-articular injections have been associated with a temporary decrease in milk supply.[70364] [70365] There are reports of breast-feeding in 3 infants who were breast-fed from birth during maternal use of methylprednisolone (6 to 8 mg PO daily) with no reported adverse effects up to 3 months.[33727] [33728] In 1 of the reports, 2 babies had normal blood cell counts, no increase in infections, and above average growth rates.[33728]

      Chronic systemic corticosteroid use can promote the development of osteopenia and osteoporosis in people of any age. Chronic systemic corticosteroid use can promote the development of osteopenia and osteoporosis in people of any age. Vertebral compression fractures, aseptic necrosis of femoral and humeral heads, and pathologic fractures of long bones, increased bone resorption, and protein catabolism can occur. Pediatric-specific issues should be considered prior to treatment initiation with systemic corticosteroids, such as methylprednisolone. The potential for growth inhibition should be monitored during prolonged therapy in pediatric patients, and the potential for growth effects should be weighed against the clinical benefit obtained and the availability of other treatment alternatives. Administration of corticosteroids to pediatric patients should be limited to the least amount compatible with an effective therapeutic regimen. Pediatric patients may be more susceptible to developing systemic toxicity; adrenal suppression and increased intracranial pressure have been reported with the use and/or withdrawal of various corticosteroid formulations in young patients. Further, children receiving corticosteroids are immunosuppressed and are therefore more susceptible to infection. Normally innocuous infections can become fatal in children receiving systemic corticosteroids, so care should be taken to avoid exposure to patients with infectious diseases, particularly those with chicken pox or measles.[30015] [41361] [41362] [51792] [58998]

      Glucocorticoids can produce or aggravate Cushing's syndrome, thus methylprednisolone should be avoided in patients with Cushing's disease.

      Pharmacologic doses of methylprednisolone administered for prolonged periods may result in hypothalamic-pituitary-adrenal (HPA) suppression. Acute adrenal insufficiency and even death may occur following abrupt discontinuation. Withdrawal from prolonged oral corticosteroid therapy should be gradual; HPA suppression can last for up to 12 months following cessation of therapy, and patients may need supplemental corticosteroid treatment during periods of physiologic stress, such as surgery, acute blood loss, or infection, even after the drug has been discontinued. Also, a non-HPA withdrawal syndrome may occur following abrupt discontinuation of corticosteroid therapy, and is apparently unrelated to adrenocortical insufficiency. These effects are thought to be due to the sudden change in glucocorticoid concentration rather than to low corticosteroid levels (see Adverse Reactions).

      Hypertrophic cardiomyopathy may develop after parenteral administration of methylprednisolone to premature neonates, therefore appropriate diagnostic evaluation and monitoring of cardiac function and structure should be performed.[41361] Several commercial formulations of methylprednisolone injection contain benzyl alcohol; formulations preserved with benzyl alcohol are contraindicated for use in premature neonates and should be used with caution in neonates. Administration of benzyl alcohol to neonates can result in 'gasping syndrome,' which is a potentially fatal condition characterized by metabolic acidosis and CNS, respiratory, circulatory, and renal dysfunction; it is also characterized by high concentrations of benzyl alcohol and its metabolites in the blood and urine. While the minimum amount of benzyl alcohol at which toxicity may occur is not known, 'gasping syndrome' has been associated with benzyl alcohol dosages greater than 99 mg/kg/day in neonates and low-birth-weight neonates. Additional symptoms may include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic failure, renal failure, hypotension, bradycardia, and cardiovascular collapse. Rare cases of death, primarily in premature neonates, have been reported. Furthermore, an increased incidence of kernicterus, especially in small, premature neonates has been reported. Practitioners administering this and other medications containing benzyl alcohol should consider the combined daily metabolic load of benzyl alcohol from all sources. Premature neonates, neonates with a low birth weight, and patients who receive a high dose may be more likely to develop benzyl alcohol toxicity.[41361] [41362]

       

      Methylprednisolone is contraindicated in patients with a hypersensitivity to the drug or any of its components.[30015] [41361] [41362] True corticosteroid hypersensitivity reactions are rare; however, serious hypersensitivity reactions have been reported.[55730] While a hypersensitivity reaction could be to a specific salt of the corticosteroid, administer any form of methylprednisolone with extreme caution in patients who have demonstrated a prior hypersensitivity reaction to methylprednisolone. It is possible, though also rare, that such patients will display cross-hypersensitivity to other corticosteroids. It is advisable that patients who have a hypersensitivity reaction to any corticosteroid undergo skin testing, which, although not a conclusive predictor, may help to determine if hypersensitivity to another corticosteroid exists. Carefully monitor such patients during and after the administration of any corticosteroid.[27616] Some methylprednisolone sodium succinate injection presentations (i.e., Solu-Medrol brand, 40 mg injection) contains lactose monohydrate produced from cow's milk and are contraindicated in patients with a known or suspected hypersensitivity to cow's milk (milk protein hypersensitivity), milk components, or other dairy products.[41361]

      Additional monitoring and/or periodic methylprednisolone dosage adjustments may been needed in patients with thyroid disease, as corticosteroid metabolic clearance is affected by thyroid function. Patients with hyperthyroidism have an increased rate of methylprednisolone elimination and may have a less than expected drug-effect; while those with hypothyroidism have decreased corticosteroid clearance and can have an exaggerated drug response.[30015] [41361] [41362]

      Use systemic corticosteroids with caution in the geriatric adult; the risks and benefits of therapy should be considered for any individual patient, particularly with chronic use. According to the Beers Criteria, systemic corticosteroids are considered potentially inappropriate medications (PIMs) for use in geriatric patients with delirium or at high risk for delirium; avoid when possible in these patient populations due to the possibility of new-onset delirium or exacerbation of the current condition. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of chronic obstructive pulmonary disease (COPD) but should be prescribed in the lowest effective dose and for the shortest possible duration.[63923]

      Corticosteroid therapy such as methylprednisolone usually does not contraindicate vaccination with live-virus vaccines when such therapy is of short-term (< 2 weeks); low to moderate dose; long-term alternate day treatment with short-acting preparations; maintenance physiologic doses (replacement therapy); or via topical administration (skin or eye), by aerosol, or by intra-articular, bursal or tendon injection. The immunosuppressive effects of steroid treatment differ, but many clinicians consider a dose equivalent to either 2 mg/kg/day or 20 mg/day of prednisone as sufficiently immunosuppressive to raise concern about the safety of immunization with live-virus vaccines. In general, patients with severe immunosuppression due to large doses of corticosteroids should not receive vaccination with live-virus vaccines. When cancer chemotherapy or immunosuppressive therapy is being considered (e.g., for patients with Hodgkin's disease or organ transplantation), vaccination should precede the initiation of chemotherapy or immunotherapy by >= 2 weeks. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy. In patients who have received high-dose, systemic corticosteroids for >= 2 weeks, it is recommended to wait at least 3 months after discontinuation of therapy before administering a live-virus vaccine.

      Results from one multicenter, randomized, placebo-controlled study with methylprednisolone hemisuccinate, an IV corticosteroid, showed an increase in early (at 2 weeks) and late (at 6 months) mortality in patients with head trauma who were determined not to have other clear indications for corticosteroid treatment. High doses of systemic corticosteroids, including methylprednisolone, should not be used for the treatment of traumatic brain injury.[41361]

      Tumor lysis syndrome (TLS) has been reported in patients with neoplastic disease, including hematological malignancies and solid tumors, following the use of systemic corticosteroids alone or in combination with other chemotherapeutic agents. Patients at high risk of TLS, such as patients with tumors that have a high proliferative rate, high tumor burden and high sensitivity to cytotoxic agents, should be monitored closely and appropriate precautions should be taken.[30015] [41362] [41361]

      An increased incidence of scleroderma renal crisis has been observed with the use of corticosteroids, including methylprednisolone, in people with scleroderma.[30015] [41361] [41362]

      Kaposi's sarcoma has been reported to occur in individuals during systemic corticosteroid therapy, such as methylprednisolone, most often for chronic conditions. Discontinuation of corticosteroids may result in clinical improvement of Kaposi's sarcoma.[30015] [41361] [41362]

      Revision Date: 07/16/2024, 03:02:57 PM

      References

      27616 - Butani L. Corticosteroid-induced hypersensitivity reactions. Ann Allergy Asthma Immunol 2002;89(5):439-445.30015 - Medrol (methylprednisolone) tablet package insert. New York, NY: Pfizer; Pharmacia and Upjohn Company LLC; 2024 June33727 - Coulam CB, Moyer TP, Jiang N-S, et al. Breast-feeding after renal transplantation. Transplant Proc 1982;13:605-9.33728 - Grekas DM, Vasiliou SS, Lazarides AN. Immunosuppresive therapy and breast-feeding after renal transplantation. Nephron 1984;37:68. Letter.41361 - Solu-Medrol (methylprednisolone sodium succinate for injection) package insert. New York, NY: Pharmacia and Upjohn Co; 2024 June41362 - Depo-Medrol (methylprednisolone acetate for injection, suspension) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 Dec.51792 - Patradoon-Ho P, Gunasekera H, Ryan MM. Inhaled corticosteroids, adrenal suppression and benign intracranial hypertension. Med J Aust 2006;185:279-28055730 - Nahum A, Garty BZ, Marcus N, et al. Severe hypersensitivity reactions to corticosteroids in children. Pediatr Emerg Care 2009;25:339-341.57053 - Food and Drug Administration (US FDA) Drug Medwatch-FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. Retrieved April 23, 2014. Available on the World Wide Web at http://www.fda.gov/downloads/Drugs/DrugSafety/UCM394286.pdf.58998 - Neville BG, Wilson J. Benign intracranial hypertension following corticosteroid withdrawal in childhood. Br Med J 1970;3:554-556.63923 - 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71:2052-208164807 - Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2020. Available from: http://www.ginasthma.org. Accessed May 20th, 2020.66066 - American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 189: Nausea and vomiting of pregnancy. Obstet Gynecol 2018;131:15-30. Reaffirmed 2019.70364 - Drugs and Lactation Database (LactMed) [e-book]. Bethesda (MD): National Institute of Child Health and Human Development; 2006- . Available from: https://www.ncbi.nlm.nih.gov/books/NBK501922/. Accessed February 21, 2024.70365 - Hales TW, Krutsch K. Hale’s Medications and Mother’s Milk. 20th ed.[e-book]. New York City: Springer Publishing; 2023. Available from: https://www.halesmeds.com/. Accessed February 21, 2024.

      Mechanism of Action

      Glucocorticoids are naturally occurring hormones that prevent or suppress inflammation and immune responses when administered at pharmacological doses. At the molecular level, unbound glucocorticoids readily cross cell membranes and bind with high affinity to specific cytoplasmic receptors. This binding induces a response by modifying transcription and, ultimately, protein synthesis to achieve the steroid's intended action. Such actions can include: inhibition of leukocyte infiltration at the site of inflammation, interference in the function of mediators of inflammatory response, and suppression of humoral immune responses. Some of the net effects include reduction in edema or scar tissue as well as a general suppression in immune response. The degree of clinical effect is normally related to the dose administered. The antiinflammatory actions of corticosteroids are thought to involve phospholipase A2 inhibitory proteins, collectively called lipocortins. Lipocortins, in turn, control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of the precursor molecule arachidonic acid. Likewise, the numerous adverse effects related to corticosteroid use are usually related to the dose administered and the duration of therapy.

      Revision Date: 07/16/2024, 03:02:57 PM

      References

      Pharmacokinetics

      Methylprednisolone is administered orally; methylprednisolone sodium succinate solution is administered by IM and IV injection, and by IV infusion; methylprednisolone acetate suspension is administered by IM, intra-articular, intralesional, or soft tissue injection. The onset and duration of action of parenteral methylprednisolone are dependent on the route of administration, the site of administration, and, if the drug is administered by intra-articular or IM injection, the extent of the local blood supply. As with other corticosteroids, once in systemic circulation, methylprednisolone is quickly distributed into the kidneys, intestines, skin, liver, and muscle. Corticosteroids distribute into breast milk and cross the placenta. Methylprednisolone is metabolized by the liver to inactive metabolites. These inactive metabolites, as well as a small portion of unchanged drug, are excreted in the urine. The biological half-life of methylprednisolone is 18 to 36 hours.[41361][41362][30943]

       

      Affected cytochrome P450 isoenzymes and drug transporters: CYP3A4

      Methylprednisolone is a substrate of both CYP3A4, and may exhibit drug interactions with CYP3A4 inducers or inhibitors.[41361]

      Route-Specific Pharmacokinetics

      Oral Route

      Methylprednisolone is rapidly absorbed following an oral dose. Peak effects following oral administration occur within 1—2 hours.

      Intravenous Route

      Following IV administration of methylprednisolone sodium succinate, effects occur within 1 hour and excretion is almost complete within 12 hours. Repeat dosing is needed every 4 to 6 hours if continuously high plasma levels of methylprednisolone are required.[41361]

      Intramuscular Route

      Systemic absorption is rapid following IM administration of methylprednisolone sodium succinate.[41361]

      Other Route(s)

      Intra-articular Route

      Absorption of methylprednisolone from an intra-articular injection site can be very slow, continuing over about 7 days.

      Revision Date: 07/16/2024, 03:02:57 PM

      References

      30943 - Schimmer B, Parker K. Adrenocorticotropic hormone; adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormones. In: Hardman JG, Limbird LE, Molinoff PB, et al., eds. Goodman and Gilman's the Pharmacological Basis of Therapeutics, 10th edition. New York: McGraw Hill, 2001;1649-1674.41361 - Solu-Medrol (methylprednisolone sodium succinate for injection) package insert. New York, NY: Pharmacia and Upjohn Co; 2024 June41362 - Depo-Medrol (methylprednisolone acetate for injection, suspension) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 Dec.

      Pregnancy/Breast-feeding

      pregnancy

      There are no adequate or well controlled studies of the use of methylprednisolone in pregnant women. Complications, including cleft palate, stillbirth, and premature abortion, have been reported when corticosteroids were administered during pregnancy in animals. If these drugs must be used during pregnancy, the potential risks should be discussed with the patient. Babies born to women receiving large doses of corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency, and appropriate therapy should be initiated, if necessary. Corticosteroids have been shown to impair fertility in male rats.[41361] [41362] Under certain circumstances, methylprednisolone may be considered for use in the pregnant patient (e.g., severe asthma exacerbation); poorly-controlled asthma and exacerbations generally present a greater risk to the mother and fetus than do needed asthma treatments.[64807] The American College of Obstetricians and Gynecologists (ACOG) include methylprednisolone as a last-line treatment option for nausea and vomiting of pregnancy in patients who have failed other therapies and suggest a limited duration of use for this purpose in responding patients.[66066]

      breast-feeding

      Methylprednisolone is compatible with breast-feeding. Amounts of methylprednisolone in breast milk are low, with a relative infant dose of 0.46% to 3.15%. No infant adverse effects have been reported with maternal methylprednisolone use, even with intravenous doses of up to 1 gram daily. At higher daily methylprednisolone doses, avoidance of breast-feeding during times of peak milk concentrations (usually until 3 to 4 hours following a dose) can help limit infant exposure. Medium to large doses of corticosteroids and intra-articular injections have been associated with a temporary decrease in milk supply.[70364] [70365] There are reports of breast-feeding in 3 infants who were breast-fed from birth during maternal use of methylprednisolone (6 to 8 mg PO daily) with no reported adverse effects up to 3 months.[33727] [33728] In 1 of the reports, 2 babies had normal blood cell counts, no increase in infections, and above average growth rates.[33728]

      Revision Date: 07/16/2024, 03:02:57 PM

      References

      33727 - Coulam CB, Moyer TP, Jiang N-S, et al. Breast-feeding after renal transplantation. Transplant Proc 1982;13:605-9.33728 - Grekas DM, Vasiliou SS, Lazarides AN. Immunosuppresive therapy and breast-feeding after renal transplantation. Nephron 1984;37:68. Letter.41361 - Solu-Medrol (methylprednisolone sodium succinate for injection) package insert. New York, NY: Pharmacia and Upjohn Co; 2024 June41362 - Depo-Medrol (methylprednisolone acetate for injection, suspension) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 Dec.64807 - Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) 2020. Available from: http://www.ginasthma.org. Accessed May 20th, 2020.66066 - American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 189: Nausea and vomiting of pregnancy. Obstet Gynecol 2018;131:15-30. Reaffirmed 2019.70364 - Drugs and Lactation Database (LactMed) [e-book]. Bethesda (MD): National Institute of Child Health and Human Development; 2006- . Available from: https://www.ncbi.nlm.nih.gov/books/NBK501922/. Accessed February 21, 2024.70365 - Hales TW, Krutsch K. Hale’s Medications and Mother’s Milk. 20th ed.[e-book]. New York City: Springer Publishing; 2023. Available from: https://www.halesmeds.com/. Accessed February 21, 2024.

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      • Sulindac
      • Sumatriptan; Naproxen
      • Telmisartan; Hydrochlorothiazide, HCTZ
      • Testosterone
      • Thiazide diuretics
      • Thiazolidinediones
      • Tick-Borne Encephalitis Vaccine
      • Tirzepatide
      • Tolmetin
      • Torsemide
      • Triamterene; Hydrochlorothiazide, HCTZ
      • Tuberculin Purified Protein Derivative, PPD
      • Tucatinib
      • Valsartan; Hydrochlorothiazide, HCTZ
      • Vecuronium
      • Voriconazole
      • Vorinostat
      • Warfarin

      Level 4 (Minor)

      • Amiloride
      • Aminolevulinic Acid
      • Amoxicillin; Clarithromycin; Omeprazole
      • Azathioprine
      • Basiliximab
      • Bexarotene
      • Bortezomib
      • Carmustine, BCNU
      • Chlorambucil
      • Cladribine
      • Clarithromycin
      • Clofarabine
      • Econazole
      • Erythromycin
      • Estramustine
      • Fludarabine
      • Hydroxyurea
      • Ibritumomab Tiuxetan
      • Interferon Alfa-2b
      • Isoniazid, INH
      • Isotretinoin
      • Lansoprazole; Amoxicillin; Clarithromycin
      • Levomefolate
      • Lomustine, CCNU
      • Mercaptopurine, 6-MP
      • Methoxsalen
      • Mitoxantrone
      • Nelarabine
      • Oritavancin
      • Pentostatin
      • Photosensitizing agents (topical)
      • Potassium-sparing diuretics
      • Purine analogs
      • Spironolactone
      • Thioguanine, 6-TG
      • Tretinoin, ATRA
      • Triamterene
      • Vonoprazan; Amoxicillin; Clarithromycin
      • Zafirlukast
      Abatacept: (Moderate) Concomitant use of immunosuppressives, as well as long-term corticosteroids, may potentially increase the risk of serious infection in abatacept treated patients. Advise patients taking abatacept to seek immediate medical advice if they develop signs and symptoms suggestive of infection. [8565] Acarbose: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Acetaminophen; Aspirin: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Acetaminophen; Aspirin; diphenhydrAMINE: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Acetaminophen; Chlorpheniramine; Phenylephrine : (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Acetaminophen; Dextromethorphan; guaiFENesin; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Acetaminophen; Dextromethorphan; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Acetaminophen; guaiFENesin; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Acetaminophen; Ibuprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Acetaminophen; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] acetaZOLAMIDE: (Moderate) Corticosteroids may increase the risk of hypokalemia if used concurrently with acetazolamide. Hypokalemia may be especially severe with prolonged use of corticotropin, ACTH. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy. [26417] [28267] Adagrasib: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with adagrasib. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and adagrasib is a strong CYP3A inhibitor. Other strong CYP3A inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [41361] [68325] Aldesleukin, IL-2: (Major) Avoid coadministration of corticosteroids with aldesleukin. Corticosteroids can be immunosuppressive. Aldesleukin is an interleukin-2 lymphocyte growth factor which induces lymphokine-activated killer (LAK) cells, natural killer (NK) cells, and interferon gamma production. Concomitant use may reduce the efficacy of aldesleukin. [41853] Alemtuzumab: (Moderate) Concomitant use of alemtuzumab with immunosuppressant doses of corticosteroids may increase the risk of immunosuppression. Monitor patients carefully for signs and symptoms of infection. [58461] Aliskiren; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Alogliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Alogliptin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] Alogliptin; Pioglitazone: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Alpha-glucosidase Inhibitors: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Amifampridine: (Moderate) Carefully consider the need for concomitant treatment with systemic corticosteroids and amifampridine, as coadministration may increase the risk of seizures. If coadministration occurs, closely monitor patients for seizure activity. Seizures have been observed in patients without a history of seizures taking amifampridine at recommended doses. Systemic corticosteroids may increase the risk of seizures in some patients. [45339] [63790] aMILoride: (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] aMILoride; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Aminolevulinic Acid: (Minor) Corticosteroids administered prior to or concomitantly with photosensitizing agents used in photodynamic therapy may decrease the efficacy of the treatment. [6625] Aminosalicylate sodium, Aminosalicylic acid: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] amLODIPine; Celecoxib: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] amLODIPine; Valsartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Amoxicillin; Clarithromycin; Omeprazole: (Minor) Postmarketing reports of interactions with coadministration of clarithromycin and methylprednisolone have been noted. Clarithromycin is a CYP3A4 inhibitor and may decrease the clearance of methylprednisolone if coadministered. [28238] [30016] Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum electrolytes and cardiac function during concomitant use. Corticosteroids have potassium-wasting effects and may potentiate hypokalemia during amphotericin B therapy and increase the risk for cardiac dysfunction. There have been cases reported in which concomitant use of amphotericin B and systemic corticosteroids was followed by cardiac enlargement and congestive heart failure. [26417] [35434] [35435] [45579] [54049] Amphotericin B liposomal (LAmB): (Moderate) Monitor serum electrolytes and cardiac function during concomitant use. Corticosteroids have potassium-wasting effects and may potentiate hypokalemia during amphotericin B therapy and increase the risk for cardiac dysfunction. There have been cases reported in which concomitant use of amphotericin B and systemic corticosteroids was followed by cardiac enlargement and congestive heart failure. [26417] [35434] [35435] [45579] [54049] Amphotericin B: (Moderate) Monitor serum electrolytes and cardiac function during concomitant use. Corticosteroids have potassium-wasting effects and may potentiate hypokalemia during amphotericin B therapy and increase the risk for cardiac dysfunction. There have been cases reported in which concomitant use of amphotericin B and systemic corticosteroids was followed by cardiac enlargement and congestive heart failure. [26417] [35434] [35435] [45579] [54049] Anthrax Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Antithymocyte Globulin: (Moderate) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [6303] [7714] Aprepitant, Fosaprepitant: (Moderate) When coadministered with a single dose of fosaprepitant 150 mg IV, reduce the dose of intravenous methylprednisolone by 25% or oral methylprednisolone by 50% on days 1 and 2 for patients receiving highly emetogenic chemotherapy (HEC) and on day 1 for patients receiving moderately emetogenic chemotherapy (MEC); the manufacturer also makes a general recommendation of a 25% (IV) or 50% (PO) methylprednisolone dose reduction (time frame not specified) when coadministered with an oral aprepitant regimen (125 mg/80 mg/80 mg). Methylprednisolone is a CYP3A4 substrate. Aprepitant, when administered as a 3-day oral regimen (125 mg/80 mg/80 mg), is a moderate CYP3A4 inhibitor and inducer and may increase plasma concentrations of methylprednisolone. A 3-day regimen of oral aprepitant (125 mg/80 mg/80 mg) increased the AUC of methylprednisolone (125 mg IV/40 mg PO/40 mg PO) by 1.34-fold on day 1 and by 2.5-fold on day 3; the effect of other aprepitant, fosaprepitant doses on methylprednisolone pharmacokinetics has not been reported. However, a 5-day oral aprepitant regimen increased the AUC of another CYP3A4 substrate, midazolam (single dose), by 2.3-fold on day 1 and by 3.3-fold on day 5. As a single 125 mg or 40 mg oral dose, the inhibitory effect of aprepitant on CYP3A4 is weak, with the AUC of midazolam increased by 1.5-fold and 1.2-fold, respectively. After administration, fosaprepitant is rapidly converted to aprepitant and shares many of the same drug interactions. However, as a single 150 mg intravenous dose, fosaprepitant only weakly inhibits CYP3A4 for a duration of 2 days; there is no evidence of CYP3A4 induction. Fosaprepitant 150 mg IV as a single dose increased the AUC of midazolam (given on days 1 and 4) by approximately 1.8-fold on day 1; there was no effect on day 4. Less than a 2-fold increase in the midazolam AUC is not considered clinically important. [30676] [40027] Arsenic Trioxide: (Moderate) Caution is advisable during concurrent use of arsenic trioxide and corticosteroids as electrolyte imbalance caused by corticosteroids may increase the risk of QT prolongation with arsenic trioxide. [26417] [59438] Articaine; EPINEPHrine: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and epinephrine use due to risk for additive hypokalemia; potassium supplementation may be necessary. Corticosteroids may potentiate the hypokalemic effects of epinephrine. [26417] [56575] Asparaginase Erwinia chrysanthemi: (Moderate) Concomitant use of L-asparaginase with corticosteroids can result in additive hyperglycemia. L-Asparaginase transiently inhibits insulin production contributing to hyperglycemia seen during concurrent corticosteroid therapy. Insulin therapy may be required in some cases. Administration of L-asparaginase after rather than before corticosteroids reportedly has produced fewer hypersensitivity reactions. [55362] Aspirin, ASA: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Butalbital; Caffeine: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Butalbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Caffeine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Caffeine; Orphenadrine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Dipyridamole: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; Omeprazole: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Aspirin, ASA; oxyCODONE: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Atazanavir: (Moderate) Coadministration of methylprednisolone with atazanavir may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome and adrenal suppression. Methylprednisolone is a CYP3A4 substrate; atazanavir is a strong inhibitor of CYP3A4. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [28142] [30676] [34482] [58000] Atazanavir; Cobicistat: (Moderate) Coadministration of methylprednisolone with atazanavir may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome and adrenal suppression. Methylprednisolone is a CYP3A4 substrate; atazanavir is a strong inhibitor of CYP3A4. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [28142] [30676] [34482] [58000] (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] Atenolol; Chlorthalidone: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Atracurium: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] azaTHIOprine: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [4710] [7714] Azilsartan; Chlorthalidone: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Bacillus Calmette-Guerin Vaccine, BCG: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Basiliximab: (Minor) Because systemically administered corticosteroids have immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives. [4746] Benazepril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Benzoic Acid; Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Bexagliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Bexarotene: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents, such as bexarotene. [30943] Bismuth Subsalicylate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Bismuth Subsalicylate; metroNIDAZOLE; Tetracycline: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Bisoprolol; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Bortezomib: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Brompheniramine; Dextromethorphan; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Brompheniramine; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Bumetanide: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and loop diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and loop diuretics cause increased renal potassium loss. [26417] [28429] [29779] BUPivacaine; EPINEPHrine: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and epinephrine use due to risk for additive hypokalemia; potassium supplementation may be necessary. Corticosteroids may potentiate the hypokalemic effects of epinephrine. [26417] [56575] BUPivacaine; Meloxicam: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] buPROPion: (Moderate) Monitor for seizure activity during concomitant bupropion and corticosteroid use. Bupropion is associated with a dose-related seizure risk; concomitant use of other medications that lower the seizure threshold, such as systemic corticosteroids, increases the seizure risk. [44094] buPROPion; Naltrexone: (Moderate) Monitor for seizure activity during concomitant bupropion and corticosteroid use. Bupropion is associated with a dose-related seizure risk; concomitant use of other medications that lower the seizure threshold, such as systemic corticosteroids, increases the seizure risk. [44094] Butalbital; Acetaminophen: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Butalbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] Butalbital; Acetaminophen; Caffeine: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Butalbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] Butalbital; Acetaminophen; Caffeine; Codeine: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Butalbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] Butalbital; Aspirin; Caffeine; Codeine: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Butalbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Caffeine; Sodium Benzoate: (Moderate) Corticosteroids may cause protein breakdown, which could lead to elevated blood ammonia concentrations, especially in patients with an impaired ability to form urea. Corticosteroids should be used with caution in patients receiving treatment for hyperammonemia. [8083] Canagliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Canagliflozin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Candesartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Captopril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] carBAMazepine: (Moderate) Hepatic microsomal enzyme inducers, including carbamazepine, can increase the metabolism of methylprednisolone. Dosage adjustments may be necessary, and closer monitoring of clinical and/or adverse effects is warranted when carbamazepine is used with methylprednisolone. [41237] Carmustine, BCNU: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [5946] [7714] [7944] Celecoxib: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Celecoxib; Tramadol: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Ceritinib: (Moderate) Monitor for steroid-related adverse reactions if coadministration of ceritinib with methylprednisolone is necessary, due to increased methylprednisolone exposure; Cushings syndrome and adrenal suppression could potentially occur with long-term use. Ceritinib is a strong CYP3A4 inhibitor and methylprednisolone is a CYP3A4 substrate. Another strong CYP3A4 inhibitor has been reported to decrease the metabolism of certain corticosteroids by up to 60%, leading to increased risk of corticosteroid side effects. [30016] [57094] Certolizumab pegol: (Moderate) The safety and efficacy of certolizumab in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with certolizumab may be at a greater risk of developing an infection. Many of the serious infections occurred in patients on immunosuppressive therapy who received certolizumab. [10783] Chikungunya Vaccine, Live: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Chlorambucil: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [4757] [7714] Chlorothiazide: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Chlorpheniramine; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Chlorthalidone: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Cholera Vaccine: (Moderate) Patients receiving immunosuppressant medications may have a diminished response to the live cholera vaccine. When feasible, administer indicated vaccines prior to initiating immunosuppressant medications. Counsel patients receiving immunosuppressant medications about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to cholera bacteria after receiving the vaccine. High-dose corticosteroid therapy may impair immune function and is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. [60092] [60871] [65107] Cholestyramine: (Moderate) The absorption of oral corticosteroids, such as methylprednisolone, may be reduced during concurrent administration with cholestyramine. In a study of 10 healthy subjects, reductions in plasma cortisol concentrations and delays in peak concentrations were observed when cholestyramine 4 g was given prior to a single dose of another corticosteroid. When given with cholestyramine, the AUC of the corticosteroid decreased by approximately one-third and time to peak plasma cortisol concentrations was reached 50 +/- 22 minutes later than controls. It is recommended that other drugs be taken at least 1 hour before or 4 to 6 hours after cholestyramine (or as great an interval as possible) to avoid absorption interference. [30288] [41362] [61778] Choline Salicylate; Magnesium Salicylate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Ciprofloxacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Cisatracurium: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] Cladribine: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] Clarithromycin: (Minor) Postmarketing reports of interactions with coadministration of clarithromycin and methylprednisolone have been noted. Clarithromycin is a CYP3A4 inhibitor and may decrease the clearance of methylprednisolone if coadministered. [28238] [30016] Clofarabine: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7557] [7714] Cobicistat: (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] Codeine; Phenylephrine; Promethazine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Conjugated Estrogens: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Conjugated Estrogens; Bazedoxifene: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Conjugated Estrogens; medroxyPROGESTERone: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] cycloSPORINE: (Moderate) Convulsions have been reported during concurrent use of cyclosporine and high dose methylprednisolone. In addition, mutual inhibition of metabolism occurs with concurrent use of cyclosporine and methylprednisolone; therefore, the potential for adverse events associated with either drug may be increased. Coadministration should be approached with caution. [36319] [41361] Dapagliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Dapagliflozin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Dapagliflozin; sAXagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Darunavir: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with darunavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and darunavir is a strong CYP3A inhibitor. Other strong CYP3A inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [32432] [41361] Darunavir; Cobicistat: (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with darunavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and darunavir is a strong CYP3A inhibitor. Other strong CYP3A inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [32432] [41361] Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with darunavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and darunavir is a strong CYP3A inhibitor. Other strong CYP3A inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [32432] [41361] Deferasirox: (Moderate) Because gastric ulceration and GI bleeding have been reported in patients taking deferasirox, use caution when coadministering with other drugs known to increase the risk of peptic ulcers or gastric hemorrhage including corticosteroids. [31807] Delafloxacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Dengue Tetravalent Vaccine, Live: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to the dengue virus vaccine. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [64100] [65107] Denosumab: (Moderate) The safety and efficacy of denosumab use in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with denosumab may be at a greater risk of developing an infection. [40862] Desmopressin: (Major) Desmopressin is contraindicated with concomitant inhaled or systemic corticosteroid use due to an increased risk of hyponatremia. Desmopressin can be started or resumed 3 days or 5 half-lives after the corticosteroid is discontinued, whichever is longer. [42295] [61806] Desogestrel; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Dexbrompheniramine; Dextromethorphan; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Dextromethorphan; buPROPion: (Moderate) Monitor for seizure activity during concomitant bupropion and corticosteroid use. Bupropion is associated with a dose-related seizure risk; concomitant use of other medications that lower the seizure threshold, such as systemic corticosteroids, increases the seizure risk. [44094] Dextromethorphan; diphenhydrAMINE; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Dextromethorphan; guaiFENesin; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Diclofenac: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Diclofenac; miSOPROStol: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Dienogest; Estradiol valerate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Diflunisal: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] dilTIAZem: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with diltiazem. Concurrent use has been observed to increase methylprednisolone peak exposure, overall exposure, and half-life by 1.6-, 2.6-, and 1.9-fold, respectively. [28920] Dipeptidyl Peptidase-4 Inhibitors: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] diphenhydrAMINE; Ibuprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] diphenhydrAMINE; Naproxen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] diphenhydrAMINE; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Diphtheria Toxoid, Tetanus Toxoid, Acellular Pertussis Vaccine, DTaP; Haemophilus influenzae type b Conjugate Vaccine; Hepatitis B Vaccine, Recombinant; Inactivated Poliovirus Vaccine, IPV: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Diphtheria Toxoid, Tetanus Toxoid, Acellular Pertussis Vaccine, DTaP; Haemophilus influenzae type b Conjugate Vaccine; Inactivated Poliovirus Vaccine, IPV: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Diphtheria Toxoid, Tetanus Toxoid, Acellular Pertussis Vaccine, DTaP; Hepatitis B Vaccine, Recombinant; Inactivated Poliovirus Vaccine, IPV : (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Diphtheria Toxoid, Tetanus Toxoid, Acellular Pertussis Vaccine, DTaP; Inactivated Poliovirus Vaccine, IPV: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Diphtheria Toxoid; Tetanus Toxoid Adsorbed, DT, Td: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Diphtheria/Tetanus Toxoids; Pertussis Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Dofetilide: (Major) Corticosteroids can cause increases in blood pressure, sodium and water retention, and hypokalemia, predisposing patients to interactions with certain other medications. Corticosteroid-induced hypokalemia could also enhance the proarrhythmic effects of dofetilide. [49489] Dronedarone: (Moderate) Coadministration of methylprednisolone with dronedarone may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome and adrenal suppression. Monitor closely. Methylprednisolone is a CYP3A4 substrate and dronedarone is an inhibitor of CYP3A4. [30015] [36101] droPERidol: (Moderate) Caution is advised when using droperidol in combination with corticosteroids which may lead to electrolyte abnormalities, especially hypokalemia or hypomagnesemia, as such abnormalities may increase the risk for QT prolongation or cardiac arrhythmias. [5468] Drospirenone; Estetrol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Drospirenone; Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Drospirenone; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Drospirenone; Ethinyl Estradiol; Levomefolate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] (Minor) L-methylfolate and methylprednisolone should be used together cautiously. Plasma concentrations of L-methylfolate may be reduced when used concomitantly with methylprednisolone. Monitor patients for decreased efficacy of L-methylfolate if these agents are used together. [35581] [42117] Dulaglutide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Echinacea: (Moderate) Echinacea possesses immunostimulatory activity and may theoretically reduce the response to immunosuppressant drugs like corticosteroids. For some patients who are using corticosteroids for serious illness, such as cancer or organ transplant, this potential interaction may result in the preferable avoidance of Echinacea. Although documentation is lacking, coadministration of echinacea with immunosuppressants is not recommended by some resources. [25398] [32073] [61902] [61905] Econazole: (Minor) In vitro studies indicate that corticosteroids inhibit the antifungal activity of econazole against C. albicans in a concentration-dependent manner. When the concentration of the corticosteroid was equal to or greater than that of econazole on a weight basis, the antifungal activity of econazole was substantially inhibited. When the corticosteroid concentration was one-tenth that of econazole, no inhibition of antifungal activity was observed. [6968] Elagolix; Estradiol; Norethindrone acetate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Coadministration of methylprednisolone with cobicistat may cause elevated methylprednisolone serum concentrations, potentially resulting in Cushing's syndrome or adrenal suppression. Cobicistat is a CYP3A4 inhibitor, while methylprednisolone is a CYP3A4 substrate. Corticosteroids, such as beclomethasone and prednisolone, whose concentrations are less affected by strong CYP3A4 inhibitors, should be considered, especially for long-term use. [30015] [41361] [41362] [51664] [58000] [58763] Empagliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Empagliflozin; Linagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Empagliflozin; Linagliptin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Empagliflozin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Enalapril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Encorafenib: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with encorafenib; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and encorafenib is a strong CYP3A inducer. [41361] [63317] Enzalutamide: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with enzalutamide; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and enzalutamide is a strong CYP3A4 inducer. [41361] [51727] ePHEDrine: (Moderate) Ephedrine may enhance the metabolic clearance of corticosteroids. Decreased blood concentrations and lessened physiologic activity may necessitate an increase in corticosteroid dosage. [8844] ePHEDrine; guaiFENesin: (Moderate) Ephedrine may enhance the metabolic clearance of corticosteroids. Decreased blood concentrations and lessened physiologic activity may necessitate an increase in corticosteroid dosage. [8844] EPINEPHrine: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and epinephrine use due to risk for additive hypokalemia; potassium supplementation may be necessary. Corticosteroids may potentiate the hypokalemic effects of epinephrine. [26417] [56575] Eprosartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Erlotinib: (Moderate) Monitor for symptoms of gastrointestinal (GI) perforation (e.g., severe abdominal pain, fever, nausea, and vomiting) if coadministration of erlotinib with methylprednisolone is necessary. Permanently discontinue erlotinib in patients who develop GI perforation. The pooled incidence of GI perforation clinical trials of erlotinib ranged from 0.1% to 0.4%, including fatal cases; patients receiving concomitant methylprednisolone may be at increased risk. [30555] Ertugliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Ertugliflozin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Ertugliflozin; SITagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Erythromycin: (Minor) Erythromycin decreases the clearance of methylprednisolone. The clinical implications of these pharmacokinetic interactions are uncertain, but some studies have used the interaction to dose-reduce methylprednisolone in acutely asthmatic patients without compromising steroid efficacy. [6764] Esterified Estrogens: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Esterified Estrogens; methylTESTOSTERone: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estradiol; Levonorgestrel: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estradiol; Norethindrone: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estradiol; Norgestimate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estradiol; Progesterone: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estramustine: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [4744] [7714] Estrogens: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Estropipate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Ethacrynic Acid: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and loop diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and loop diuretics cause increased renal potassium loss. [26417] [28429] [29779] Ethinyl Estradiol; Norelgestromin: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Ethinyl Estradiol; Norethindrone Acetate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Ethinyl Estradiol; Norgestrel: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Ethynodiol Diacetate; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Etodolac: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Etonogestrel; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Etravirine: (Moderate) Monitor for decreased efficacy of methylprednisolone if coadministration with etravirine is necessary; plasma concentrations of methylprednisolone may decrease. Methylprednisolone is a CYP3A substrate and etravirine induces CYP3A. [33718] [41361] Exenatide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Fenoprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Fludarabine: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] Flurbiprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Fosamprenavir: (Moderate) Concomitant use of methylprednisolone and fosamprenavir may result in altered methylprednisolone plasma concentrations. Monitor closely. Methylprednisolone is a substrate of CYP3A4. Amprenavir, the active metabolite of fosamprenavir, is a potent inhibitor of CYP3A4, but may also induce this enzyme to some degree. The net effect is likely increased methylprednisolone exposure. [29012] [30015] Fosinopril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Fosphenytoin: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with fosphenytoin; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and fosphenytoin is a strong CYP3A inducer. [41239] [41361] Furosemide: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and loop diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and loop diuretics cause increased renal potassium loss. [26417] [28429] [29779] Gallium Ga 68 Dotatate: (Moderate) Repeated administration of high corticosteroid doses prior to gallium Ga 68 dotatate may result in false negative imaging. High-dose corticosteroid therapy is generally defined as at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. Corticosteroids can down-regulate somatostatin subtype 2 receptors: thereby, interfering with binding of gallium Ga 68 dotatate to malignant cells that overexpress these receptors. [60852] Gemifloxacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Glimepiride: (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] glipiZIDE: (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] glipiZIDE; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] glyBURIDE: (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] glyBURIDE; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Glycerol Phenylbutyrate: (Moderate) Corticosteroids may induce elevated blood ammonia concentrations. Corticosteroids should be used with caution in patients receiving glycerol phenylbutyrate. Monitor ammonia concentrations closely. [53022] Golimumab: (Moderate) The safety and efficacy of golimumab in patients with immunosuppression have not been evaluated. Patients receiving immunosuppressives along with golimumab may be at a greater risk of developing an infection. [35501] Grapefruit juice: (Moderate) Grapefruit juice may enhance steroid effects if taken with oral methylprednisolone. Grapefruit juice contains a compound that inhibits CYP3A4 in enterocytes; decreased methylprednisolone metabolism is the probable mechanism. Methylprednisolone peak concentrations and AUC increased and the half-life of methylprednisolone was prolonged in one study of the interaction. The clinical significance of the interaction is uncertain. Patients should be advised to not significantly alter their grapefruit juice ingestion. [6770] guaiFENesin; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Haemophilus influenzae type b Conjugate Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Haloperidol: (Moderate) Caution is advisable during concurrent use of haloperidol and corticosteroids as electrolyte imbalance caused by corticosteroids may increase the risk of QT prolongation with haloperidol. [28307] Hemin: (Moderate) Hemin works by inhibiting aminolevulinic acid synthetase. Corticosteroids increase the activity of this enzyme should not be used with hemin. [6702] Hepatitis A Vaccine, Inactivated: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Hepatitis A Vaccine, Inactivated; Hepatitis B Vaccine, Recombinant: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Hepatitis B Vaccine, Recombinant: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Human Papillomavirus 9-Valent Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] hydroCHLOROthiazide, HCTZ; Moexipril: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] HYDROcodone; Ibuprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Hydroxyurea: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Hylan G-F 20: (Major) The safety and efficacy of hylan G-F 20 given concomitantly with other intra-articular injectables have not been established. Other intra-articular injections may include intra-articular steroids (betamethasone, dexamethasone, hydrocortisone, prednisolone, methylprednisolone, and triamcinolone). [45238] [45239] Hyoscyamine; Methenamine; Methylene Blue; Phenyl Salicylate; Sodium Biphosphate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Ibritumomab Tiuxetan: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Ibuprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Ibuprofen; Famotidine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Ibuprofen; oxyCODONE: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Ibuprofen; Pseudoephedrine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Idelalisib: (Major) Avoid concomitant use of idelalisib, a strong CYP3A inhibitor, with methylprednisolone, a CYP3A substrate, as methylprednisolone toxicities may be significantly increased. The AUC of a sensitive CYP3A substrate was increased 5.4-fold when coadministered with idelalisib. [41361] [57675] Incretin Mimetics: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Indapamide: (Moderate) Additive hypokalemia may occur when indapamide is coadministered with other drugs with a significant risk of hypokalemia such as systemic corticosteroids. Coadminister with caution and careful monitoring. [26417] Indomethacin: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Inebilizumab: (Moderate) Concomitant usage of inebilizumab with immunosuppressant drugs, including systemic corticosteroids, may increase the risk of infection. Consider the risk of additive immune system effects when coadministering therapies that cause immunosuppression with inebilizumab. [65576] inFLIXimab: (Moderate) Many serious infections during infliximab therapy have occurred in patients who received concurrent immunosuppressives that, in addition to their underlying Crohn's disease or rheumatoid arthritis, predisposed patients to infections. The impact of concurrent infliximab therapy and immunosuppression on the development of malignancies is unknown. In clinical trials, the use of concomitant immunosuppressant agents appeared to reduce the frequency of antibodies to infliximab and appeared to reduce infusion reactions. [27994] Influenza Virus Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Insulin Aspart: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Aspart; Insulin Aspart Protamine: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Degludec: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Degludec; Liraglutide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Detemir: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Glargine: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Glargine; Lixisenatide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Glulisine: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Lispro: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin Lispro; Insulin Lispro Protamine: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulin, Inhaled: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Insulins: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Interferon Alfa-2b: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Intranasal Influenza Vaccine: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Iohexol: (Major) Serious adverse events, including death, have been observed during intrathecal administration of both corticosteroids (i.e., methylprednisolone) and radiopaque contrast agents (i.e., iohexol); therefore, concurrent use of these medications via the intrathecal route is contraindicated. Cases of cortical blindness, stroke, spinal cord infarction, paralysis, seizures, nerve injury, brain edema, and death have been temporally associated (i.e., within minutes to 48 hours after injection) with epidural administration of injectable corticosteroids. In addition, patients inadvertently administered iohexol formulations not indicated for intrathecal use have experienced seizures, convulsions, cerebral hemorrhages, brain edema, and death. Administering these medications together via the intrathecal route may increase the risk for serious adverse events. [28963] [57053] Iopamidol: (Contraindicated) Because both intrathecal corticosteroids (i.e., methylprednisolone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated. [5442] Irbesartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Isavuconazonium: (Moderate) Concomitant use of isavuconazonium with methylprednisolone may result in increased serum concentrations of methylprednisolone. Methylprednisolone is a substrate of CYP3A4 and isavuconazole, the active moiety of isavuconazonium, is an inhibitor of CYP3A4. Caution and close monitoring for adverse effects, such as corticosteroid-related adverse effects, are advised if these drugs are used together. [30015] [41361] [41362] [59042] Isoniazid, INH: (Minor) Corticosteroids, such as methylprednisolone, may decrease serum concentrations of isoniazid. Isoniazid serum concentrations decreased by 25% and 40% in slow and rapid acetylators, respectively, when isoniazid (10 mg/kg) was co-administered with another corticosteroid. The exact mechanism of action of the interaction is unknown. The decrease in plasma concentrations may be caused by enhanced acetylation or renal clearance of isoniazid or by an increase in total body water. [29847] [41362] Isoniazid, INH; Pyrazinamide, PZA; rifAMPin: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with rifampin; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and rifampin is a strong CYP3A4 inducer. [30314] [41361] (Minor) Corticosteroids, such as methylprednisolone, may decrease serum concentrations of isoniazid. Isoniazid serum concentrations decreased by 25% and 40% in slow and rapid acetylators, respectively, when isoniazid (10 mg/kg) was co-administered with another corticosteroid. The exact mechanism of action of the interaction is unknown. The decrease in plasma concentrations may be caused by enhanced acetylation or renal clearance of isoniazid or by an increase in total body water. [29847] [41362] Isoniazid, INH; rifAMPin: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with rifampin; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and rifampin is a strong CYP3A4 inducer. [30314] [41361] (Minor) Corticosteroids, such as methylprednisolone, may decrease serum concentrations of isoniazid. Isoniazid serum concentrations decreased by 25% and 40% in slow and rapid acetylators, respectively, when isoniazid (10 mg/kg) was co-administered with another corticosteroid. The exact mechanism of action of the interaction is unknown. The decrease in plasma concentrations may be caused by enhanced acetylation or renal clearance of isoniazid or by an increase in total body water. [29847] [41362] Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Isoproterenol: (Moderate) The risk of cardiac toxicity with isoproterenol in asthma patients appears to be increased with the coadministration of corticosteroids. Intravenous infusions of isoproterenol in refractory asthmatic children at rates of 0.05 to 2.7 mcg/kg/min have caused clinical deterioration, myocardial infarction (necrosis), congestive heart failure and death. [28004] ISOtretinoin: (Minor) Both isotretinoin and corticosteroids can cause osteoporosis during chronic use. Patients receiving systemic corticosteroids should receive isotretinoin therapy with caution. [5283] Itraconazole: (Moderate) Itraconazole may inhibit the metabolism of methylprednisolone via hepatic CYP3A4 inhibition. Several published reports note that itraconazole decreases the clearance and increases the elimination half-life of methylprednisolone, resulting in increased exposure to methylprednisolone. The interaction can result in enhanced adrenal suppression. [27983] [40233] Japanese Encephalitis Virus Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Ketoconazole: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with ketoconazole. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and ketoconazole is a strong CYP3A4 inhibitor. Ketoconazole has been reported to decrease the metabolism of certain corticosteroids by up to 60%. [27982] [41361] [67231] Ketoprofen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Ketorolac: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Lansoprazole; Amoxicillin; Clarithromycin: (Minor) Postmarketing reports of interactions with coadministration of clarithromycin and methylprednisolone have been noted. Clarithromycin is a CYP3A4 inhibitor and may decrease the clearance of methylprednisolone if coadministered. [28238] [30016] Letermovir: (Moderate) An increase in the plasma concentration of methylprednisolone may occur if given with letermovir. In patients who are also receiving treatment with cyclosporine, the magnitude of this interaction may be amplified. Methylprednisolone is a CYP3A4 substrate. Letermovir is a moderate CYP3A4 inhibitor; however, when given with cyclosporine, the combined effect on CYP3A4 substrates may be similar to a strong CYP3A4 inhibitor. In a drug interaction study, concurrent administration of certain corticosteroids with another potent CYP3A4 inhibitor significantly decreased the corticosteroid metabolism (up to 60% reduction). [30016] [62611] levoFLOXacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Levoketoconazole: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with ketoconazole. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and ketoconazole is a strong CYP3A4 inhibitor. Ketoconazole has been reported to decrease the metabolism of certain corticosteroids by up to 60%. [27982] [41361] [67231] Levomefolate: (Minor) L-methylfolate and methylprednisolone should be used together cautiously. Plasma concentrations of L-methylfolate may be reduced when used concomitantly with methylprednisolone. Monitor patients for decreased efficacy of L-methylfolate if these agents are used together. [35581] [42117] Levonorgestrel; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Lidocaine; EPINEPHrine: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and epinephrine use due to risk for additive hypokalemia; potassium supplementation may be necessary. Corticosteroids may potentiate the hypokalemic effects of epinephrine. [26417] [56575] Linagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Linagliptin; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] Liraglutide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Lisinopril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Live Vaccines: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Lixisenatide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Lomustine, CCNU: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [5946] [7714] [7944] Lonafarnib: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with lonafarnib. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and lonafarnib is a strong CYP3A4 inhibitor. Other strong CYP3A4 inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [41361] [66129] Lonapegsomatropin: (Moderate) Corticosteroids can retard bone growth and therefore, can inhibit the growth-promoting effects of somatropin. If corticosteroid therapy is required, the corticosteroid dose should be carefully adjusted. [6807] Loop diuretics: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and loop diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and loop diuretics cause increased renal potassium loss. [26417] [28429] [29779] Lopinavir; Ritonavir: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with ritonavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and ritonavir is a strong CYP3A4 inhibitor. Other strong CYP3A4 inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [30015] [47165] [58664] Losartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Lumacaftor; Ivacaftor: (Moderate) Lumacaftor; ivacaftor may reduce the efficacy of methylprednisolone by decreasing systemic exposure of the corticosteroid. If used together, a higher systemic corticosteroid dose may be required to obtain the desired therapeutic effect. Methylprednisolone is a CYP3A4 substrate. Lumacaftor is a strong CYP3A inducer. [30015] [59891] Lumacaftor; Ivacaftor: (Moderate) Lumacaftor; ivacaftor may reduce the efficacy of methylprednisolone by decreasing systemic exposure of the corticosteroid. If used together, a higher systemic corticosteroid dose may be required to obtain the desired therapeutic effect. Methylprednisolone is a CYP3A4 substrate. Lumacaftor is a strong CYP3A inducer. [30015] [59891] Lutetium Lu 177 dotatate: (Major) Avoid repeated administration of high doses of glucocorticoids during treatment with lutetium Lu 177 dotatate due to the risk of decreased efficacy of lutetium Lu 177 dotatate. Lutetium Lu 177 dotatate binds to somatostatin receptors, with the highest affinity for subtype 2 somatostatin receptors (SSTR2); glucocorticoids can induce down-regulation of SSTR2. [62824] Macimorelin: (Major) Avoid use of macimorelin with drugs that directly affect pituitary growth hormone secretion, such as corticosteroids. Healthcare providers are advised to discontinue corticosteroid therapy and observe a sufficient washout period before administering macimorelin. Use of these medications together may impact the accuracy of the macimorelin growth hormone test. [62723] Magnesium Salicylate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Mannitol: (Moderate) Corticosteroids may accentuate the electrolyte loss associated with diuretic therapy resulting in hypokalemia. Also, corticotropin may cause calcium loss and sodium and fluid retention. Mannitol itself can cause hypernatremia. Close monitoring of electrolytes should occur in patients receiving these drugs concomitantly. [6524] Measles Virus; Mumps Virus; Rubella Virus; Varicella Virus Vaccine, Live: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Measles/Mumps/Rubella Vaccines, MMR: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Mecasermin, Recombinant, rh-IGF-1: (Moderate) Additional monitoring may be required when coadministering systemic or inhaled corticosteroids and mecasermin, recombinant, rh-IGF-1. In animal studies, corticosteroids impair the growth-stimulating effects of growth hormone (GH) through interference with the physiological stimulation of epiphyseal chondrocyte proliferation exerted by GH and IGF-1. Dexamethasone administration on long bone tissue in vitro resulted in a decrease of local synthesis of IGF-1. Similar counteractive effects are expected in humans. If systemic or inhaled glucocorticoid therapy is required, the steroid dose should be carefully adjusted and growth rate monitored. [8314] [8315] Meclofenamate Sodium: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Mefenamic Acid: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Meglitinides: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Meloxicam: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Meningococcal Group B Vaccine (3 strain): (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Meningococcal Group B Vaccine (4 strain): (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Meningococcal Groups A, B, C, W, and Y Vaccine (5 valent): (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Meningococcal Groups A, C, W, and Y Vaccine (4 valent): (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Mercaptopurine, 6-MP: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] metFORMIN; Repaglinide: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] metFORMIN; sAXagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] metFORMIN; SITagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] methazolAMIDE: (Moderate) Corticosteroids may increase the risk of hypokalemia if used concurrently with methazolamide. Hypokalemia may be especially severe with prolonged use of corticotropin, ACTH. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy. The chronic use of corticosteroids may augment calcium excretion with methazolamide leading to increased risk for hypocalcemia and/or osteoporosis. [5023] Methenamine; Sodium Salicylate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Methoxsalen: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] metOLazone: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Metoprolol; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] metyraPONE: (Contraindicated) Medications which affect pituitary or adrenocortical function, including all corticosteroid therapy, should be discontinued prior to and during testing with metyrapone. Patients taking inadvertent doses of corticosteroids on the test day may exhibit abnormally high basal plasma cortisol levels and a decreased response to the test. [33528] Micafungin: (Moderate) Leukopenia, neutropenia, anemia, and thrombocytopenia have been associated with micafungin. Patients who are taking immunosuppressives such as the corticosteroids with micafungin concomitantly may have additive risks for infection or other side effects. In a pharmacokinetic trial, micafungin had no effect on the pharmacokinetics of prednisolone. Acute intravascular hemolysis and hemoglobinuria was seen in a healthy volunteer during infusion of micafungin (200 mg) and oral prednisolone (20 mg). This reaction was transient, and the subject did not develop significant anemia. [44913] miFEPRIStone: (Major) Mifepristone for termination of pregnancy is contraindicated in patients on long-term corticosteroid therapy and mifepristone for Cushing's disease or other chronic conditions is contraindicated in patients who require concomitant treatment with systemic corticosteroids for life-saving purposes, such as serious medical conditions or illnesses (e.g., immunosuppression after organ transplantation). For other situations where corticosteroids are used for treating non-life threatening conditions, mifepristone may lead to reduced corticosteroid efficacy and exacerbation or deterioration of such conditions. This is because mifepristone exhibits antiglucocorticoid activity that may antagonize corticosteroid therapy and the stabilization of the underlying corticosteroid-treated illness. Mifepristone may also cause adrenal insufficiency, so patients receiving corticosteroids for non life-threatening illness require close monitoring. Because serum cortisol levels remain elevated and may even increase during treatment with mifepristone, serum cortisol levels do not provide an accurate assessment of hypoadrenalism. Patients should be closely monitored for signs and symptoms of adrenal insufficiency, If adrenal insufficiency occurs, stop mifepristone treatment and administer systemic glucocorticoids without delay; high doses may be needed to treat these events. Factors considered in deciding on the duration of glucocorticoid treatment should include the long half-life of mifepristone (85 hours). [28003] [48697] Miglitol: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Mitotane: (Moderate) Use caution if mitotane and methylprednisolone are used concomitantly, and monitor for decreased efficacy of methylprednisolone and a possible change in dosage requirements. Mitotane is a strong CYP3A4 inducer and methylprednisolone is a CYP3A4 substrate; coadministration may result in decreased plasma concentrations of methylprednisolone. [34482] [41934] mitoXANTRONE: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Moxifloxacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Nabumetone: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Naproxen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Naproxen; Esomeprazole: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Naproxen; Pseudoephedrine: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Natalizumab: (Major) Ordinarily, patients receiving chronic immunosuppressant therapy should not be treated with natalizumab. Treatment recommendations for combined corticosteroid therapy are dependent on the underlying indication for natalizumab therapy. Corticosteroids should be tapered in those patients with Crohn's disease who are on chronic corticosteroids when they start natalizumab therapy, as soon as a therapeutic benefit has occurred. If the patient cannot discontinue systemic corticosteroids within 6 months, discontinue natalizumab. The concomitant use of natalizumab and corticosteroids may further increase the risk of serious infections, including progressive multifocal leukoencephalopathy, over the risk observed with use of natalizumab alone. In multiple sclerosis (MS) clinical trials, an increase in infections was seen in patients concurrently receiving short courses of corticosteroids. However, the increase in infections in natalizumab-treated patients who received steroids was similar to the increase in placebo-treated patients who received steroids. Short courses of steroid use during natalizumab, such as when they are needed for MS relapse treatment, appear to be acceptable for use concurrently. [30470] [62264] Nateglinide: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Nefazodone: (Moderate) It appears that nefazodone inhibits the metabolism of methylprednisolone. In addition, concomitant nefazodone prolongs the duration of methylprednisolone induced cortisol suppression. If nefazodone and methylprednisolone are to be coadministered, care should be taken with regards to the potential for prolonged corticosteroid exposure. [4591] Nelarabine: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Neostigmine: (Moderate) Concomitant use of anticholinesterase agents, such as neostigmine, and systemic corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating systemic corticosteroid therapy. [29779] [30015] [30028] [31123] [54891] [56146] [64165] Neostigmine; Glycopyrrolate: (Moderate) Concomitant use of anticholinesterase agents, such as neostigmine, and systemic corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating systemic corticosteroid therapy. [29779] [30015] [30028] [31123] [54891] [56146] [64165] Neuromuscular blockers: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] Nirmatrelvir; Ritonavir: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with ritonavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and ritonavir is a strong CYP3A4 inhibitor. Other strong CYP3A4 inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [30015] [47165] [58664] Non-Live Vaccines: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Nonsteroidal antiinflammatory drugs: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Norethindrone; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Norgestimate; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Ocrelizumab: (Moderate) Ocrelizumab has not been studied in combination with other immunosuppressive or immune modulating therapies used for the treatment of multiple sclerosis, including immunosuppressant doses of corticosteroids. Concomitant use of ocrelizumab with any of these therapies may increase the risk of immunosuppression. Monitor patients carefully for signs and symptoms of infection. [61838] Ofatumumab: (Moderate) Concomitant use of ofatumumab with corticosteroids may increase the risk of immunosuppression. Monitor patients carefully for signs and symptoms of infection. Ofatumumab has not been studied in combination with other immunosuppressive or immune modulating therapies used for the treatment of multiple sclerosis, including immunosuppressant doses of corticosteroids. [65850] Ofloxacin: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Olmesartan; amLODIPine; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Olmesartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Oritavancin: (Minor) Methylprednisolone is metabolized by CYP3A4; oritavancin is a weak CYP3A4 inducer. Plasma concentrations and efficacy of methylprednisolone may be reduced if these drugs are administered concurrently. [30676] [57741] Oxaprozin: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Oxymetholone: (Moderate) Concomitant use of oxymetholone with corticosteroids or corticotropin, ACTH may cause increased edema. Manage edema with diuretic and/or digitalis therapy. [48342] Ozanimod: (Moderate) Concomitant use of ozanimod with methylprednisolone may increase the risk of immunosuppression. Monitor patients carefully for signs and symptoms of infection. In clinical studies for ulcerative colitis, the use of systemic corticosteroids did not appear to influence safety or efficacy of ozanimod. [65169] Pancuronium: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] PAZOPanib: (Moderate) Pazopanib is a weak inhibitor of CYP3A4. Coadministration of pazopanib and methylprednisolone, a CYP3A4 substrate, may cause an increase in systemic concentrations of methylprednisolone. Use caution when administering these drugs concomitantly. In addition, concomitant administration may predispose the patient to over-immunosuppression resulting in an increased risk for the development of severe infections. [30676] [37098] [7714] Pegaspargase: (Moderate) Monitor for an increase in glucocorticoid-related adverse reactions such as hyperglycemia and osteonecrosis during concomitant use of pegaspargase and glucocorticoids. [61310] Peginterferon Alfa-2a: (Moderate) Additive myelosuppressive effects may be seen when alpha interferons are given concurrently with other myelosuppressive agents, such as antineoplastic agents or immunosuppressives. [29421] penicillAMINE: (Major) Agents such as immunosuppressives have adverse reactions similar to those of penicillamine. Concomitant use of penicillamine with these agents is contraindicated because of the increased risk of developing severe hematologic and renal toxicity. [5567] Pentostatin: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] PHENobarbital: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Phenobarbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] PHENobarbital; Hyoscyamine; Atropine; Scopolamine: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Phenobarbital is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Phenytoin: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with phenytoin; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and phenytoin is a strong CYP3A inducer. [41239] [41361] Photosensitizing agents (topical): (Minor) Corticosteroids administered prior to or concomitantly with photosensitizing agents used in photodynamic therapy may decrease the efficacy of the treatment. [6625] PHYSostigmine: (Moderate) Concomitant use of anticholinesterase agents, such as physostigmine, and systemic corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, withdraw anticholinesterase inhibitors at least 24 hours before initiating corticosteroid therapy. [29779] [30015] [30028] [31123] [56146] [64165] Pimozide: (Moderate) According to the manufacturer of pimozide, the drug should not be coadministered with drugs known to cause electrolyte imbalances, such as high-dose, systemic corticosteroid therapy. Pimozide is associated with a well-established risk of QT prolongation and torsade de pointes (TdP), and electrolyte imbalances (e.g., hypokalemia, hypocalcemia, hypomagnesemia) may increase the risk of life-threatening arrhythmias. Pimozide is contraindicated in patients with known hypokalemia or hypomagnesemia. Topical corticosteroids are less likely to interact. [28225] [43463] Pioglitazone: (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Pioglitazone; Glimepiride: (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Pioglitazone; metFORMIN: (Moderate) Monitor blood glucose during concomitant corticosteroid and metformin use; a metformin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [28550] [30585] [51002] [51324] [62853] (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Piroxicam: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Pneumococcal Vaccine, Polyvalent: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Ponesimod: (Moderate) Monitor for signs and symptoms of infection. Additive immune suppression may result from concomitant use of ponesimod and high-dose corticosteroid therapy which may extend the duration or severity of immune suppression. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. [66527] Posaconazole: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with posaconazole. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A substrate and posaconazole is a strong CYP3A inhibitor. Other strong CYP3A inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [32723] [34464] [34465] [41361] Potassium-sparing diuretics: (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Pramlintide: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Prasterone, Dehydroepiandrosterone, DHEA (Dietary Supplements): (Moderate) Corticosteroids blunt the adrenal secretion of endogenous DHEA and DHEAS, resulting in reduced DHEA and DHEAS serum concentrations. [2460] Prasterone, Dehydroepiandrosterone, DHEA (FDA-approved): (Moderate) Corticosteroids blunt the adrenal secretion of endogenous DHEA and DHEAS, resulting in reduced DHEA and DHEAS serum concentrations. [2460] Prilocaine; EPINEPHrine: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and epinephrine use due to risk for additive hypokalemia; potassium supplementation may be necessary. Corticosteroids may potentiate the hypokalemic effects of epinephrine. [26417] [56575] Primidone: (Moderate) Coadministration may result in decreased exposure to methylprednisolone. Primidone is a CYP3A4 inducer; methylprednisolone is a CYP3A4 substrate. Monitor for decreased response to methylprednisolone during concurrent use. [28001] Promethazine; Phenylephrine: (Moderate) The therapeutic effect of phenylephrine may be increased in patient receiving corticosteroids, such as hydrocortisone. Monitor patients for increased pressor effect if these agents are administered concomitantly. [54374] [57578] Propranolol: (Moderate) Monitor blood sugar during concomitant corticosteroid and propranolol use due to risk for hypoglycemia. Concurrent use may increase risk of hypoglycemia because of loss of the counter-regulatory cortisol response. [56853] Propylthiouracil, PTU: (Moderate) The metabolism of corticosteroids is increased in hyperthyroidism and decreased in hypothyroidism. Dosage adjustments may be necessary when initiating, changing or discontinuing thyroid hormones or antithyroid agents. [6763] Purine analogs: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] pyRIDostigmine: (Moderate) Concomitant use of anticholinesterase agents, such as pyridostigmine, and corticosteroids may produce severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy. [29779] [30015] [30028] [31123] [34253] [56146] [64002] [64165] Quinapril; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Quinolones: (Moderate) Quinolones have been associated with an increased risk of tendon rupture requiring surgical repair or resulting in prolonged disability; this risk is further increased in those receiving concomitant corticosteroids. Discontinue quinolone therapy at the first sign of tendon inflammation or tendon pain, as these are symptoms that may precede rupture of the tendon. [28423] [28424] [28764] [29818] [30738] [62028] [65562] Rabies Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Regular Insulin: (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Regular Insulin; Isophane Insulin (NPH): (Moderate) Monitor blood glucose during concomitant corticosteroid and insulin use; an insulin dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Relugolix; Estradiol; Norethindrone acetate: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Repaglinide: (Moderate) Monitor patients receiving antidiabetic agents closely for worsening glycemic control when corticosteroids are instituted and for signs of hypoglycemia when corticosteroids are discontinued. Systemic and inhaled corticosteroids are known to increase blood glucose and worsen glycemic control in patients taking antidiabetic agents. The main risk factors for impaired glucose tolerance due to corticosteroids are the dose of steroid and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [62853] Respiratory Syncytial Virus Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] rifAMPin: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with rifampin; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and rifampin is a strong CYP3A4 inducer. [30314] [41361] Rifapentine: (Moderate) Monitor for decreased corticosteroid efficacy if methylprednisolone is used with rifapentine; a dosage increase may be necessary. Concurrent use may decrease the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and rifapentine is a strong CYP3A4 inducer. [41361] [65685] Rilonacept: (Moderate) Patients receiving immunosuppressives along with rilonacept may be at a greater risk of developing an infection. [10690] Ritonavir: (Moderate) Monitor for corticosteroid-related adverse events if methylprednisolone is used with ritonavir. Concurrent use may increase the exposure of methylprednisolone. Methylprednisolone is a CYP3A4 substrate and ritonavir is a strong CYP3A4 inhibitor. Other strong CYP3A4 inhibitors have been reported to decrease the metabolism of certain corticosteroids by up to 60%. [30015] [47165] [58664] riTUXimab: (Moderate) Rituximab and corticosteroids are commonly used together; however, monitor the patient for immunosuppression and signs and symptoms of infection during combined chronic therapy. [30943] [49773] [56233] riTUXimab; Hyaluronidase: (Moderate) Rituximab and corticosteroids are commonly used together; however, monitor the patient for immunosuppression and signs and symptoms of infection during combined chronic therapy. [30943] [49773] [56233] Rocuronium: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] Rosiglitazone: (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Rotavirus Vaccine: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Salicylates: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Salsalate: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and salicylate use. Concomitant use increases the risk of GI bleeding. In patients receiving concomitant corticosteroids and chronic use of salicylates, withdrawal of corticosteroids may result in salicylism because corticosteroids enhance renal clearance of salicylates and their withdrawal is followed by return to normal rates of renal clearance. [24574] [28502] Saquinavir: (Moderate) Saquinavir may inhibit CYP3A4 metabolism of methylprednisolone, resulting in increased plasma methylprednisolone concentrations and reduced serum cortisol concentrations. There have been reports of clinically significant drug interactions in patients receiving ritonavir with other corticosteroids, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Similar results are expected with saquinavir. Consider using an alternative treatment to methylprednisolone, such as a corticosteroid not metabolized by CYP3A4 (i.e., beclomethasone or prednisolone). If corticosteroid therapy is to be discontinued, consider tapering the dose over a period of time to decrease the potential for withdrawal. [28995] [30015] Sargramostim, GM-CSF: (Major) Avoid the concomitant use of sargramostim and systemic corticosteroid agents due to the risk of additive myeloproliferative effects. If coadministration of these drugs is required, frequently monitor patients for clinical and laboratory signs of excess myeloproliferative effects (e.g., leukocytosis). Sargramostim is a recombinant human granulocyte-macrophage colony-stimulating factor that works by promoting proliferation and differentiation of hematopoietic progenitor cells. [61087] SARS-CoV-2 (COVID-19) vaccines: (Moderate) Patients receiving corticosteroids in greater than physiologic doses may have a diminished response to the SARS-CoV-2 virus vaccine. Counsel patients receiving corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) Adenovirus Vector Vaccine: (Moderate) Patients receiving corticosteroids in greater than physiologic doses may have a diminished response to the SARS-CoV-2 virus vaccine. Counsel patients receiving corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) mRNA Vaccine: (Moderate) Patients receiving corticosteroids in greater than physiologic doses may have a diminished response to the SARS-CoV-2 virus vaccine. Counsel patients receiving corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] SARS-CoV-2 Virus (COVID-19) Recombinant Spike Protein Nanoparticle Vaccine: (Moderate) Patients receiving corticosteroids in greater than physiologic doses may have a diminished response to the SARS-CoV-2 virus vaccine. Counsel patients receiving corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure to SARS-CoV-2 virus after receiving the vaccine. [65107] [66080] sAXagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Segesterone Acetate; Ethinyl Estradiol: (Moderate) Monitor for corticosteroid-related adverse events if corticosteroids are used with estrogens. Concurrent use may increase the exposure of corticosteroids. Estrogens may decrease the hepatic clearance of corticosteroids thereby increasing their effect. [29779] [54049] Semaglutide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] SGLT2 Inhibitors: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Siponimod: (Moderate) Monitor patients carefully for signs and symptoms of infection during coadministration of siponimod and methylprednisolone. Concomitant use may increase the risk of immunosuppression. Siponimod has not been studied in combination with other immunosuppressive therapies used for the treatment of multiple sclerosis, including immunosuppressant doses of corticosteroids. [64031] SITagliptin: (Moderate) Monitor blood glucose during concomitant corticosteroid and dipeptidyl peptidase-4 (DPP-4) inhibitor use; a DPP-4 dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Smallpox and Monkeypox Vaccine, Live, Nonreplicating: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Smallpox Vaccine, Vaccinia Vaccine: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Sodium Benzoate; Sodium Phenylacetate: (Moderate) Corticosteroids may cause protein breakdown, which could lead to elevated blood ammonia concentrations, especially in patients with an impaired ability to form urea. Corticosteroids should be used with caution in patients receiving treatment for hyperammonemia. [8083] Sodium Phenylbutyrate: (Moderate) The concurrent use of corticosteroids with sodium phenylbutyrate may increase plasma ammonia levels (hyperammonemia) by causing the breakdown of body protein. Patients with urea cycle disorders being treated with sodium phenylbutyrate usually should not receive regular treatment with corticosteroids. [57685] Sodium Phenylbutyrate; Taurursodiol: (Moderate) The concurrent use of corticosteroids with sodium phenylbutyrate may increase plasma ammonia levels (hyperammonemia) by causing the breakdown of body protein. Patients with urea cycle disorders being treated with sodium phenylbutyrate usually should not receive regular treatment with corticosteroids. [57685] Somapacitan: (Moderate) Patients treated with glucocorticoid replacement for hypoadrenalism may require an increase in their maintenance or stress steroid doses following initiation of somapacitan. Monitor for signs/symptoms of reduced serum cortisol concentrations. Growth hormone (GH) inhibits 11betaHSD-1. Consequently, patients with untreated GH deficiency have relative increases in 11betaHSD-1 and serum cortisol. The initiation of somapacitan may result in inhibition of 11betaHSD-1 and reduced serum cortisol concentrations. [65878] Somatrogon: (Moderate) Monitor for a decrease in serum cortisol concentrations and corticosteroid efficacy during concurrent use of corticosteroids and somatrogon. Patients treated with glucocorticoid replacement for hypoadrenalism may require an increase in their maintenance or stress steroid doses following initiation of somatrogon. Additionally, supraphysiologic glucocorticoid treatment may attenuate the growth promoting effects of somatrogon. Carefully adjust glucocorticoid replacement dosing to avoid hypoadrenalism and an inhibitory effect on growth. [69144] Somatropin, rh-GH: (Moderate) Corticosteroids can retard bone growth and therefore, can inhibit the growth-promoting effects of somatropin. If corticosteroid therapy is required, the corticosteroid dose should be carefully adjusted. [6807] Sotagliflozin: (Moderate) Monitor blood glucose during concomitant corticosteroid and SGLT2 inhibitor use; a SGLT2 inhibitor dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Spironolactone: (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Spironolactone; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Succinylcholine: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] Sulfonylureas: (Moderate) Monitor blood glucose during concomitant corticosteroid and sulfonylurea use; a sulfonylurea dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Sulindac: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] SUMAtriptan; Naproxen: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Tacrolimus: (Major) Patients receiving tacrolimus and systemic corticosteroids concomitantly should be carefully monitored for alterations in tacrolimus whole blood concentrations. According to the manufacturer of tacrolimus, methylprednisolone may increase tacrolimus blood concentrations. The mechanism of the interaction is unclear. Tacrolimus is a CYP3A4 substrate, but methylprednisolone does not appear to have an inhibitory effect on CYP3A4 activity. For example, the pharmacokinetics and pharmacodynamics of the CYP3A4 substrate triazolam were determined in a three-phase cross-over study; the three treatment periods were placebo, methylprednisolone 32 mg PO 1 hour before triazolam 0.25 mg PO, and methylprednisolone 8 mg PO daily for 9 days before triazolam 0.25 mg PO. The single methylprednisolone dose did not significantly affect CYP3A4 activity. Methylprednisolone receipt for 9 days led to slightly reduced maximum triazolam concentrations, which may have been due to an inducing effect on the CYP3A4-mediated first-pass metabolism of triazolam. [11365] [28611] Telmisartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Testosterone: (Moderate) Monitor for fluid retention during concurrent corticosteroid and testosterone use. Concurrent use may result in increased fluid retention. [33698] Thiazide diuretics: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Thiazolidinediones: (Moderate) Monitor blood glucose during concomitant corticosteroid and thiazolidinedione use; a thiazolidinedione dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Thioguanine, 6-TG: (Minor) Concurrent use of purine analogs with other agents which cause bone marrow or immune suppression such as other antineoplastic agents or immunosuppressives may result in additive effects. [5504] Tick-Borne Encephalitis Vaccine: (Moderate) Patients receiving high-dose corticosteroid therapy may have a diminished response to vaccines. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 2 weeks after discontinuation. If vaccine administration is necessary, consider revaccination following restoration of immune competence. Counsel patients receiving high-dose corticosteroids about the possibility of a diminished vaccine response and to continue to follow precautions to avoid exposure after receiving the vaccine. [60092] [65107] Tirzepatide: (Moderate) Monitor blood glucose during concomitant corticosteroid and incretin mimetic use; an incretin mimetic dose adjustment may be necessary. Corticosteroids may increase blood glucose concentrations. Risk factors for impaired glucose tolerance due to corticosteroids include the corticosteroid dose and duration of treatment. Corticosteroids stimulate hepatic glucose production and inhibit peripheral glucose uptake into muscle and fatty tissues, producing insulin resistance. Decreased insulin production may occur in the pancreas due to a direct effect on pancreatic beta cells. [28032] [30585] [51002] [51324] [62853] Tolmetin: (Moderate) Monitor for gastrointestinal toxicity during concurrent corticosteroid and nonsteroidal antiinflammatory drug (NSAID) use. Concomitant use increases the risk of GI bleeding. [24574] [29611] [35893] Torsemide: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and loop diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and loop diuretics cause increased renal potassium loss. [26417] [28429] [29779] Tretinoin, ATRA: (Minor) Because systemically administered corticosteroids exhibit immunosuppressive effects when given in high doses and/or for extended periods, additive effects may be seen with other immunosuppressives or antineoplastic agents. [7714] Triamterene: (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Triamterene; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] (Minor) The manufacturer of spironolactone lists corticosteroids as a potential drug that interacts with spironolactone. Intensified electrolyte depletion, particularly hypokalemia, may occur. However, potassium-sparing diuretics such as spironolactone do not induce hypokalemia. In fact, hypokalemia is one of the indications for potassium-sparing diuretic therapy. Therefore, drugs that induce potassium loss, such as corticosteroids, could counter the hyperkalemic effects of potassium-sparing diuretics. [26417] [29016] [30011] Tuberculin Purified Protein Derivative, PPD: (Moderate) Immunosuppressives may decrease the immunological response to tuberculin purified protein derivative, PPD. This suppressed reactivity can persist for up to 6 weeks after treatment discontinuation. Consider deferring the skin test until completion of the immunosuppressive therapy. [43298] [43299] Tucatinib: (Moderate) Monitor for steroid-related adverse reactions if coadministration of methylprednisolone with tucatinib is necessary, due to increased methylprednisolone exposure; Cushings syndrome and adrenal suppression could potentially occur with long-term use. Methylprednisolone is a CYP3A4 substrate and tucatinib is a strong CYP3A4 inhibitor. Another strong CYP3A4 inhibitor has been reported to decrease the metabolism of certain corticosteroids by up to 60%, leading to increased risk of corticosteroid side effects. [30015] [30016] [65295] Typhoid Vaccine: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Valsartan; hydroCHLOROthiazide, HCTZ: (Moderate) Monitor potassium concentrations during concomitant corticosteroid and thiazide diuretic use due to risk for additive hypokalemia; potassium supplementation may be necessary. Both corticosteroids and thiazide diuretics cause increased renal potassium loss. [26417] [29779] Varicella-Zoster Virus Vaccine, Live: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Vecuronium: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years. [41361] [41961] [42031] [43319] [54278] [60760] [61750] [61937] Vigabatrin: (Major) Vigabatrin should not be used with corticosteroids, which are associated with serious ophthalmic effects (e.g., retinopathy or glaucoma) unless the benefit of treatment clearly outweighs the risks. [36250] Vonoprazan; Amoxicillin; Clarithromycin: (Minor) Postmarketing reports of interactions with coadministration of clarithromycin and methylprednisolone have been noted. Clarithromycin is a CYP3A4 inhibitor and may decrease the clearance of methylprednisolone if coadministered. [28238] [30016] Voriconazole: (Moderate) Monitor for potential adrenal dysfunction with concomitant use of voriconazole and methylprednisolone. In patients taking corticosteroids, voriconazole-associated CYP3A4 inhibition of their metabolism may lead to corticosteroid excess and adrenal suppression. Corticosteroid exposure is likely to be increased. Voriconazole is a strong CYP3A4 inhibitor, and methylprednisolone is a CYP3A4 substrate. [28158] [30015] [34447] Vorinostat: (Moderate) Use vorinostat and corticosteroids together with caution; the risk of QT prolongation and arrhythmias may be increased if electrolyte abnormalities occur. Corticosteroids may cause electrolyte imbalances; hypomagnesemia, hypokalemia, or hypocalcemia and may increase the risk of QT prolongation with vorinostat. Frequently monitor serum electrolytes if concomitant use of these drugs is necessary. [26417] [32789] Warfarin: (Moderate) Monitor the INR if warfarin is administered with corticosteroids. The effect of corticosteroids on warfarin is variable. There are reports of enhanced as well as diminished effects of anticoagulants when given concurrently with corticosteroids; however, limited published data exist, and the mechanism of the interaction is not well described. High-dose corticosteroids appear to pose a greater risk for increased anticoagulant effect. In addition, corticosteroids have been associated with a risk of peptic ulcer and gastrointestinal bleeding. [28549] [29779] Yellow Fever Vaccine, Live: (Contraindicated) Avoid the administration of live virus vaccines with high-dose corticosteroid therapy and for at least 1 month following treatment. High-dose corticosteroid therapy is generally defined as a dose of at least 20 mg/day of prednisone or equivalent (or 2 mg/kg/day for patients weighing less than 10 kg) for at least 14 consecutive days. When feasible, administer indicated live virus vaccines at least 4 weeks before planned high-dose corticosteroid therapy or wait at least 1 month after discontinuation. Patients with altered immunocompetence may be at increased risk for severe adverse reactions due to uninhibited growth of the attenuated live virus. Additionally, vaccine efficacy may be diminished in patients receiving any supraphysiologic dose of corticosteroid. [60092] [65107] Zafirlukast: (Minor) Zafirlukast inhibits the CYP3A4 isoenzymes and should be used cautiously in patients stabilized on drugs metabolized by CYP3A4, such as corticosteroids. [4718] [4948]
      Revision Date: 07/16/2024, 03:02:57 PM

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      Monitoring Parameters

      • blood glucose
      • blood pressure
      • growth rate
      • pulmonary function tests (PFTs)
      • serum potassium
      • weight

      US Drug Names

      • A-Methapred
      • Depmedalone-40
      • Depmedalone-80
      • Depo-Medrol
      • Medrol
      • Medrol Dosepak
      • Solu-Medrol
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