Role of corticosteroids in allergic diseases

Role of Corticosteroids in Allergic
Diseases
Prof DR Dr Ariyanto Harsono SpA(K)
Prof DR Dr Ariyanto Harsono SpA(K) 1

Factors of the occurrence of
Allergy
Several factors affect the occurrence of allergy
are:
• genetic
• exposure to Allergens
• Mucosal barrier

4 Sorts of Allergens
Fruits
Milk
Eggs
Fish
Nuts
3

Alergen
APC MHC-II Th0
IL-12/ IL-1
Th-2
Th.1
IL-1 IL-2, IFN-γ
B-Cell
IL-4
IL-5
SEL PLASMASEL MEMORI
IL-6
IL-10
A
Memory Cells
ACTIVAtion of IMUNOCOMPETENCE Cells by
ANTIGENS 4

B
ACTIVATION of STRUCTURAL
CELLS
Nature Rev Immunol 2003; 3: 867-78
Neutrophil
Eosinophil
5

C
MEDIATORS RELEASE

Granule contents:
Histamine,TNF-α
Proteases, Heparin
Lipid mediators:
Prostaglandins
Leukotrienes
Cytokine production:
Specifically IL-4, IL-13

D EFFECTS of MEDIATORS RELEASE to TARGET ORGAN
Nature Rev Immunol 2004: 3:234-237
Pada Kulit:-Urticaria
-Dermatitis Atopika
-Udema Quinke
8

D EFECTS of MEDIATORS RELEASE to TARGET ORGAN
Pada Paru:-Asma
-Batuk kronik Berulang
9

D EFECTS of MEDIATORS RELEASE to TARGET Organ
Pada Hidung:-Rinitis Alergika
-Sinusitis
10

D
Pada Mata:-Conjunctivitis vernalis
11
EFECTS of MEDIATORS RELEASE to TARGET
ORGAN

D
Pada vaskuler:-Anafilaksis
12
ORGAN

D
Pada GI:-Protein loosing enteropati
-GI haemorrhage
-Eosinophilic Gastroenteritis
13
ORGAN

CE Symptoms
Oral allergy syndrome

Atopic Dermatitis

17
Urticaria

Quinke’s oedem

HSP

Fixed Skin Eruption

Serum Sickness

Steven Johnson Syndrome

Toxic Epidermal Necrolysis

Diagnosis
anamnesis
physical examination
Examination Support:
Skin test
Total IgE
Specific IgE
Prausnitz- Kustner Test
Elimination-Provocation Test

Management
General Procedure: Find the Cause, avoidance
Primary prevention
Secondary prevention
Tertiary prevention

Management
General Procedure: Find the Cause avoid
Primary prevention
Secondary prevention
Tertiary prevention

Drugs and therapy used to treat allergies can be
divided into broad groups:
• Drugs that block the activity of chemicals that are released
in the body during allergic reactions - antihistamines and
leukotriene antagonists;
• Drugs which relax the constricted muscle around the airways
of the lungs, or shrink congested tissue, or reverse the
effects of the chemicals released during allergic reactions -
bronchodilators, decongestants and epinephrine; anti
acetylchloline
• Drugs that prevent the activation of cells that are involved in
the allergic reaction - anti-allergic agents;
• Drugs which possess a more general action in reducing
inflammation - corticosteroids;
• Therapy which modifies the immune response - allergen
immunotherapy. Prof DR Dr Ariyanto Harsono SpA(K) 29

Drugs and therapy used to treat allergies can be
divided into broad groups:
• Drugs that block the activity of chemicals that are released
in the body during allergic reactions - antihistamines and
leukotriene antagonists;
• Drugs which relax the constricted muscle around the airways
of the lungs, or shrink congested tissue, or reverse the
effects of the chemicals released during allergic reactions -
bronchodilators, decongestants and epinephrine; anti
acetylchloline
• Drugs that prevent the activation of cells that are involved in
the allergic reaction - anti-allergic agents;
• Drugs which possess a more general action in reducing
inflammation - corticosteroids;
• Therapy which modifies the immune response - allergen
immunotherapy. Prof DR Dr Ariyanto Harsono SpA(K) 30

Molecular Mechanism of Cortico Steroid

All Allergy Immunology Association agreed
Cortico steroid use in the treatment of allergies
• Unless Urticaria

Mild Moderate Severe
Mild to Moderate Potency Topical Steroids
Pimecrolimus
Tacrolimus
Cyclosporine, mycophenolate
Light treatment
Treatment Strategy in AD
Emolient
Dry skin Itching and/or early sign of
inflammation
Flare
IVIG
Oral Steroids

Dermatologic Diseases
• For control of severe or incapacitating allergic
conditions (e.g., contact dermatitis, atopic
dermatitis) intractable to adequate trials of
conventional treatment.

ARIA = Allergic Rhinitis and its Impact on Asthma.
Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147.
ARIA Guidelines: Recommendations
for Management of Allergic Rhinitis
Mild
intermittent
Moderate
severe
intermittent
Mild
persistent
Moderate
severe
persistent
Immunotherapy
Allergen and irritant avoidance
Intranasal decongestant (<10 days) or oral decongestant
Second-generation nonsedating H1 antihistamine
Leukotriene receptor antagonists
Local cromone
Intra-nasal steroid
37Prof DR Dr Ariyanto Harsono SpAK

Prof. DR.Dr.Ariyanto Harsono SpA(K) 40
Management of Anaphylaxis
1. Primary treatment
• Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 ml
subcutaneously
2. Complimentary Medicine
Intended for complications:
• Seizures: diazepam, phenobarbital
• Spasm bronchi: Aminophylline 7 mg dissolved in 10-20 ml of 0.9% NaCl
followed 9 mg/kg/24 hours (divided into 3 doses)
• b-2 agonist: Ventolin nebulizer
3. Additional treatment
• Antihistamines (H1 receptor antagonist): Benadril 2 mg / kg im continued
3 mg/kg/24 hours orally (divided into 3 doses)
• H-2 receptor antagonist: Simetidine
• corticosteroids: Solukortef 4-7 mg/kg i.v.
Followed with 4-7 mg/kg/24 hours oral (divided 3 dosis)

GINA Asthma guideline

Asthma
• Used by oral inhalation for the long-term prevention of bronchospasm in patients with
asthma.
• Used orally for severe bronchial asthma intractable to conventional treatment.
• Used orally for treatment of moderate to severe acute exacerbations of asthma (oral
prednisone usually preferred). Speeds resolution of airflow obstruction and reduces rate of
relapse.
• Because onset of effects is delayed, do not use alone for emergency treatment.
• Early systemic glucocorticoid therapy particularly important for asthma exacerbations in
infants and children.
• In hospital management of an acute asthma exacerbation,
systemic adjunctive glucocorticoids if response to oral inhalation therapy is not immediate, if
oral corticosteroids were used as self-medication prior to hospitalization, or if the episode is
severe.
• For severe persistent asthma once initial control is achieved, high dosages of inhaled
corticosteroids are preferable to oral corticosteroids for maintenance because inhaled
corticosteroids have fewer systemic effects.

Conversion to Orally Inhaled Therapy in Patients Receiving
Systemic Corticosteroids
When switching from systemic corticosteroids to orally inhaled triamcinolone acetonide in
patients with asthma, asthma should be reasonably stable before initiating treatment with
the oral inhalation.
Initially, administer the aerosol concurrently with the maintenance dosage of the systemic
corticosteroid. After about 1 week, gradually withdraw systemic corticosteroid by reducing
the daily or alternate daily dosage. Generally, decrease dosage in decrements of ≤2 mg of
triamcinolone acetonide after intervals of 1–2 weeks, depending on patient response.
Death has occurred in some individuals in whom systemic corticosteroids were withdrawn
too rapidly.
During withdrawal of oral therapy, symptoms of systemic corticosteroid withdrawal may
occur, despite maintenance or even improvement in pulmonary function; continue oral
inhalation therapy but monitor for objective signs of adrenal insufficiency. If evidence of
adrenal insufficiency occurs, increase systemic corticosteroid dosage temporarily and
then continue withdrawal more slowly.
If exacerbations of asthma occur during oral inhalation therapy after systemic
corticosteroids have been withdrawn, administer short courses of systemic corticosteroids,
then taper dosage as symptoms subside. Supplemental systemic corticosteroid therapy
may also be required during periods of stress.

• Maintenance therapy with low doses of an orally inhaled corticosteroid is
preferred treatment for adults and children with mild persistent asthma (i.e.,
patients with daytime symptoms of asthma more than twice weekly but less than
once daily, and nocturnal symptoms of asthma more than twice per month).
• A long-acting β2-agonist (e.g., formoterol, salmeterol) added to low- to medium-
dose inhaled corticosteroids is the preferred therapy in patients with moderate
persistent asthma (i.e., patients with daily asthmatic symptoms); alternatively,
may increase (e.g., double) maintenance dosage of inhaled corticosteroid within
medium-dosage range in such patients.
• Orally as an adjunct to other therapy to speed resolution of all but the mildest
exacerbations of asthma when response to a short-acting inhaled β2-agonist is not
prompt or sustained after 1 hour or in those who have a history of severe
exacerbations.
• Oral glucocorticoids with minimal mineralocorticoid activity and relatively short
half-life (e.g., prednisone, prednisolone, methylprednisolone) are preferred.
• Do not use oral inhalation for the treatment of nonasthmatic bronchitis or for
relief of acute bronchospasm.

Dosage: Pediatric Patients
• Base pediatric dosage on severity of the disease and patient response rather than on strict
adherence to dosage indicated by age, body weight, or body surface area.
• Usual Dosage
• Oral
• Some clinicians recommend 0.117–1.66 mg/kg daily or 3.3–50 mg/m2
daily, administered in 4
divided doses.
• IM
• Triamcinolone acetonide in children <6 years of age: Dosage not established; insufficient
clinical experience to recommend use in this age group.
• Triamcinolone acetonide in children 6–12 years of age: Initially, 40 mg depending on the
severity of the condition. Some clinicians recommend 0.03–0.2 mg/kg or 1–6.25 mg/m2
at 1-
to 7-day intervals.
• Triamcinolone acetonide in children >12 years of age: Initially, 60 mg (using the 40-mg/mL
sterile suspension). May administer additional doses of 20–100 mg (usually 40–80 mg) when
signs and symptoms recur; some clinicians recommend administration at 6-week intervals, if
possible, to minimize HPA suppression.c
Some patients may be well controlled on doses ≤20
mg.

Asthma
Oral Inhalation
• Triamcinolone acetonide in children <6 years of age: manufacturer does not
recommended use in this age group.
• Triamcinolone acetonide in children 6–12 years of age: Initially, 100 or 200 mcg (1
or 2 sprays) 3 or 4 times daily (300–800 mcg total) or 200–400 mcg (2–4 sprays)
twice daily (400–800 mcg total); adjust dosage according to patient
response. Maximum dosage recommended by manufacturer is 1200 mcg (12
sprays) daily; some experts state that higher dosages may be used in children with
severe persistent asthma.
• Continually monitor patients for signs that indicate dosage adjustment is
necessary (e.g., remissions or exacerbations of disease and stress [surgery,
infection, trauma]). (See Conversion to Orally Inhaled Therapy in Patients
Receiving Systemic Corticosteroids under Dosage and Administration.)

Prof Dr Ariyanto Harsono dr SpAK
CURICULUM VITAE
Tempat /tgl lahir : Kediri, 3- Juli
Agama : Islam
Status Perkawinan: Menikah
Pendidikan
S-1: Lulus Dokter : FK UNAIR, 1972
S-2: Spesialis Anak : FK UNAIR, 1982
S-3: Program Pascasarjana UNAIR, 2004
Pendidikan tambahan : Sertifikat “Fellowship on Food Allergy”,
Academisch Ziekenhuis Utrecht, Nederland, 1990-1991
Jabatan sekarang : Guru Besar Ilmu Kesehatan Anak,
Dep IKA FK UNAIR/RSU Dr.Soetomo, Surabaya.
Konsultan Alergi/Imunologi: 1992

Thank You
52

Role of corticosteroids in allergic diseases

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