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Evaluation of rational use of glucocorticoid drugs

I. Overview

Glucocorticoids are a metabolically regulating hormone secreted by the most mid-layer bundle of the adrenal cortex. The secretion of glucocorticoids in the body is mainly regulated by the hypothalamus – the pituitary front algeum – the adrenal cortical axis. The adrenal corticosteroid-releasing hormone (corticoropin hormone, CRH) secreted by the hypothalamus brain enters the pituitary front alsteria to promote the secretion ofadrenal cortico hormone (adrenocorticohormone, ACTH), which promotes the secretion of cortisol. In turn, increased concentration sprenoglum in the blood can inhibit the secretion of CRH and ACTH in the pre-clotic and pituitary lobes to reduce the secretion of glucocorticoids,and the increase inACTH levels also inhibits the secretion of CRHin the hypothalamus, a negative feedback process that ensures the balance ofglucocorticoid content in the body. The secretion of endogenous glucocorticoids has circadian rhythm, the lowest content at midnight and the highest in the morning. In addition, the body in the state of stress, endogenous corticosteroid secretion will surge to the usual 10 times. Glucocorticoids are widely used in clinical practice and are mainly used in anti-inflammatory, anti-toxic, anti-shock and immunosuppressive applications involving a number of clinical specialties. The application of glucocorticoids should be very careful, the correct and reasonable application of glucocorticoids is the key to improve their efficacy and reduce adverse reactions. Its correct and reasonable application mainly depends on the following two aspects: First, whether the treatment adaptation certificate is accurate, and second, the variety and the choice of the drug treatment program is correct and reasonable.

1. Pharmacological effects of glucocorticoids

Anti-inflammatory effect, immunosuppressive effect, antitoxin effect, anti-shock effect, affect the hematopoietic system, central excitatory effect, other: promote the secretion of stomach acid; inhibit the secretion of pineal melatonin; reduce the intake and removal and transformation of iodine ions in the thyroid gland.

2. Evidence of glucocorticoid adaptation

Endocrine system diseases, rheumatic and autoimmune diseases, respiratory diseases, blood system diseases, kidney system diseases, severe infections or inflammatory reactions, severe illness (shock), allomic organ transplants, allergic diseases, neurological damage: tendon end disease, tendonitis, etc.

Prevention and treatment of certain inflammatory reaction sequelae: the application of glucocorticoids can prevent the occurrence of certain inflammatory reaction sequelae and post-operative reactive inflammation, such as tissue adhesion, scarring and so on.

Implementation of the programme

  1. Sampling criteria: prescriptions contain intravenous or oral prescriptions for glucocorticoid drugs;
  2. Sampling frequency: 1 time / month;
  3. Sample time: 1st month to the end of the month;
  4. Sampling method: random sampling or full sampling;
  5. Comment method: Comments on the patient’s prescription or medication prescription, according to the “glucocorticoid drug review prescription specification smetric reference index” requirements content review.

Fourth, the key points of the review

Review Criteria

  1. Adaptation certificate is not suitable;
  2. The selection of medicines is not appropriate;
  3. Inappropriate dosage forms or routes of administration;
  4. Usage, dosage is not suitable;
  5. Joint drug use is not suitable or has a contraindication;
  6. Repeated administration of medicine;
  7. Physicians over-authority to use glucocorticoids;
  8. Other medications are not suitable.
Commentary Rules Adaptation certificate is not suitable;

Key points of review

Prescription drugs do not correspond to clinical diagnosis;Glucocorticoids have a pharmacological effect to suppress autoimmune diseases, but are not applicable to all treatments for autoimmune diseases such as chronic lymphocytic thyroiditis  (Bridgewood disease),type 1 diabetes, and common psoriasis. Cases of abuse of glucocorticoids;It is routinely used as an antidote to lower body temperature;Used to prevent infusion reactions;Abuse of chronic diseases;Local treatment abuse.For example, the upper respiratory tract infection is febrile and only dexamethasone is used to deheat the fever.See the medicine instructions.
Commentary Rules The selection of medicines is not appropriate;

Key points of review

Drug indications are suitable, but banned by special groups;Children Long-term application of glucocorticoids in children should be more strictly grasp of adaptation certificates and appropriate selection of treatment methods. The treatment of glucocorticoids should be determined based on age, weight (better surface area), severity of the disease, and the child’s response to treatment. More attention should be paid to closely observe adverse reactions to avoid or reduce the effects of glucocorticoids on the growth and development of children. Pregnant women People who use glucocorticoids in large doses should not be pregnant. Pregnant women use glucocorticoids with caution. In special cases, clinicians can decide the use of glucocorticoids according to the situation, such as chronic adrenal corticosande and congenital adrenal corticosis patients should adhere to alternative treatment of glucocorticoids during pregnancy, severe pregnancy herpes, pregnancy-like herpes can also be considered for use of glucocorticoids. Lactating women The use of physiological or maintenance doses of glucocorticoids in lactating women generally has no significant adverse effects on infants. However, lactating women should not breastfeed when receiving moderate doses of glucocorticoids for medium-range treatment stoics to avoid adverse effects of glucocorticoids secreted by breast milk on infants. The choice of medicine does not match the sex and age of the patient;The patient has a history of drug-contraindications;Non-use of glycocorticoid drugs with a history of: Allergies to glucocorticoid drugs; severe history of mental illness; epilepsy; active peptic ulcers; recent gastrointestinal surgery; fractures; trauma repair period; herpes simplex keratitis, conjunctivitis and ulcerative keratitis, corneal ulcers; severe hypertension; severe diabetes; uncontrolled infections (e.g. chickenpox, fungal infections); active tuberculosis More severe osteoporosis; early pregnancy and childbirth; common psoriasis. However, if there is a need to use glucocorticoid drugs to control the disease, to save the patient’s life, if the above-mentioned situation, can actively treat the primary disease, closely monitor the above-mentioned changes in the disease at the same time, the careful use of glucocorticoid drugs. Careful use of glucocorticoids: Patients with Cushing syndrome, atherosclerosis, intestinal disease or chronic malnutrition, as well as patients with recent post-surgery procedures, are treated with caution. Acute heart failure, diabetes, psychotic tendencies, glaucoma, hyperlipidemia, hypertension, severe muscle weakness, severe osteoporosis, peptic ulcer disease, pregnant and lactating women should be used with caution, infectious diseases must be combined with effective antimicrobial drugs, viral infection patients should be used with caution;   The glucocorticoid varieties were not correctly selected according to the characteristics of different diseases and various glucocorticoids.According to the time of action classification: can be divided into short-acting, medium-effect and long-lasting three categories. Short-acting drugs such as hydrogenated pine and cosin, the effect time is more than 812 ~hours, the medium-effect drugs such as pernison, pernitson, meta-polyester, the effect time is more than 1236 ~hours, long-acting drugs such as dexamethasone, pentami pine, the effect time is more than 3654 ~hours.
Commentary Rules Inappropriate dosage forms or routes of administration;

Key points of review

The dosage type is not suitable;The route of administration is not appropriate.Failure to use the medicine in accordance with the instructions;Local administration should be given with systemic administration.Patients with acute adrenal insufficiency only apply hormone oral therapy.
Commentary Rules Usage, dosage is not suitable;

Key points of review

The course of treatment is too long or too short;Course. Different diseases of glucocorticoid treatment, generally can be divided into the following cases:Impact therapy: The course of treatment is less than 5 days. It is suitable for the rescue of critically ill patients, such as outbreak infection, anaphylactic shock, severe asthma continuity, allergic larynx edema, lupus encephalopathy, severe herpes skin disease, severe drug rash, acute nephritis, etc. Impact therapy must be combined with other effective treatment measures, can be quickly discontinued, if not effective in most cases can not be repeated impact treatment in a short period of time. Short-range treatment: Treatment for less than 1 month, including stress therapy. Suitable for infectious or allergic diseases such as tuberculosis meningitis and pleurisy, peeling dermatitis or acute rejection of organ transplants. Short-range treatment should be accompanied by other effective treatment measures and the discontinuation of medicine should be gradually reduced to discontinuation. Medium-range treatment: within 3 months of the course of treatment. It is suitable for diseases with long courses and multiple organ-affected diseases, such as rheumatic fever. After effective reduction to maintainthe dose, the discontinuation needs to gradually decrease. Long-term treatment: The course of treatment is greater than 3 months. It is suitable for the prevention and treatment of rejection reaction after organ transplantation and recurrent and multi-organ fatigue of chronic autoimmune diseases, such as systemic lupus erythematosus, hemolytic anemia, systemic vasculitis, nodule disease, herpes skin disease, etc. Maintenance therapy may be given daily or every other day, and the drug should be gradually transferred to the next day after the treatment. Life-long replacement therapy: suitable for primary or secondary chronic adrenal cortical degenerative disease, and appropriate dose increase in various stress situations.Unreasonable frequency of administration;The time of administration is not suitable;Time medicationIf corticosteroids should be used 1 morning or the next morning 1 time, the effect is better. The dose of the drug is too large or insufficient;Drug dose: Physiological dose and pharmacological dose of glucocorticoids have different effects, should be selected according to different therapeutic purposes. It is generally believed that the dose of administration (in the case of pernisson) can be divided into the following situations:Long-term maintenance dose:2.515.0 mg/d;~small dose:<0.5mg· kg-1· d-1;0.51.0 mg~ kg-1 d-1;1.0 mg kg-1 d-1;7.530.0 mg~ kg-1 d-1 The opt-in is not suitable;The solute capacity is not suitable;Different adaptation certificate usage is not suitable;The method of drug suspension is not suitable;The reduction of glucocorticoids should be treated individually under the premise of close lycincorticoid reaction, and attention should be paid to the possible discontinuation reaction and anti-jumping phenomenon.Special reasons need to adjust the amount of dosage but not adjust the dosage;The use of oversized doses of glucocorticoids and “shock therapy” is used.
Commentary Rules Joint drug use is not suitable or has a contraindication;

Key points of review

the drug of the same kind of drug, the drug of the same mechanism of action;The use of combination drugs without the need for joint drug use;When the drug is used, it can have a physical and chemical reaction such as turbidity, precipitation, gas generation and discoloration, such as abnormal appearance;Drug dispensing increases side effects or toxicity, causing serious adverse reactions;Drug matching makes the therapeutic effect over-enhanced, beyond the body’s ability to tolerate, can also cause adverse reactions, and even harm patients;Drug dispensing reduces the therapeutic effect or the stability of the drug.   Drugs not associated with glucocorticoiddrugs: (1) Potassium diuretics: These drugs are mainly stitine, bumetani, torasemi, chlorpyrifos, pyridoxamine, hydrochlorpyrifos, carbonicacid inhibitors, etc. Glucocorticoids, in combination with these potassium-in-the-urea drugs, can lead to severe low blood potassium, and glucocorticoids’ sodium retention reduces the diuretic effects of diuretic drugs. (2) Antifungal drugs: Sexcin B is a drug against deep tissue fungal infection in the human body, combined with glucocorticoid drugs, can lead to or aggravate low blood potassium, so that fungal lesions spread, but also cause liver damage. Ketoconazole and isoconazole inhibit the elimination of glucocorticoids in the body, antifungal drugs can inhibit the metabolism of glucocorticoids in the liver, and may inhibit endogenous adrenal corticocorticoid function, adverse reactions. (3) Anti-epileptic drugs: such as sodium phenytotoin, barbiturates, etc. These drugs are liver drug enzyme inducers, which can promote the excretion of glucocorticoid drugs in the liver, so that the efficacy of glucocorticoid drugs reduced. (4) Antibacterial drugs: aminoglycoside drugs, such as co-use with glucocorticoids, will also lead to reduced role of glucocorticoids, because aminoglycoside serottoin, etc. is also a liver drug enzyme inducer, can also make glucocorticoids in the liver metabolism accelerated. Chloramphenicol can increase the effectiveness of glucocorticoids, chloramphenicol is a liver drug enzyme inhibitor that inhibits the metabolism of glucocorticoids in the liver. In addition, glucocorticoids can increase the excretion of methazole from the body, which is associated with liver drug enzymes. (5) Anti-inflammatory anti-inflammatory analgesics: aspirin, pyridine, dichlorofen, ibuprofen, ketone-lofen, psilocyandin and other anti-inflammatory analgesics and glucocorticoids, easy to lead to digestive ulcers and other complications. Glucocorticoids can accelerate the elimination of salicylic acid and reduce its efficacy, which can increase toxicity to the liver in combination with acetaminophen. (6) Sugar-lowering drugs: glycocorticoids can promote sugar isogenesis, reduce the intake and use of glucose in peripheral tissues, thus raising blood sugar, reducing the role of oral hypoglycemic drugs or insulin. (7) Strong heart glycoside: glycocorticoids and strong heart glycoside co-use, can increase the occurrence of meldonium toxicity and arrhythmia, the cause of glucocorticoids water sodium retention and potassium excretion. (8) Protein assimilation hormones: such as metatestosterone, metazole, dazole, acetaminophen, testosterone, protein assimilating hormones and glucocorticoids, can increase the incidence of edema, induce or aggravate acne.
Commentary Rules Repeated administration of medicine;

Key points of review

A drug with the same ingredient but a different generic name is prescribed;A combination of compound preparations containing the same main ingredients;Pharmacologically the same drugs are reused.
Commentary Rules Physicians over-authority to use glucocorticoids;

Key points of review

Impact therapy needs to be decided by a physician qualified to serve in the professional and technical positions above the attending physician;Long-term glucocorticoid treatment programs should be formulated by the relevant subject physician and above qualified for professional and technical positions. The long-term treatment plan for congenital adrenal cortical hyperplasia requires the decision of the doctor who qualifies for the professional and technical position sitfort of the primary physician of the tertiary hospital’s endocrinology. Follow-up and dose adjustment may be decided by the endocrinologist above the professional professional position of professional qualifications of the physician;In emergency situations, clinicians may use glucocorticoids above the authority listed in the preceding article, but only for 3 days and strictly document the treatment process. :: Guidelines for clinical application ofglucocorticoid drugs
Commentary Rules Other medications are not suitable.
Other than the above-mentioned review rules are not suitable for medication.

Work forms

Review Form: Glucocorticoid Prescription / Medical Advice Review Worksheet

Annex

1. Commonly used glucocorticoid drugs (slightly)

2. Schedule The intensity, efficacy and equivalent dose ratio of commonly used glucocorticoids

Category Drug Affinity for glucocorticoid receptors Water salt metabolism (ratio) Sugar metabolism (ratio) Anti-inflammatory effects (ratio) Equivalent dose(mg) Plasma half-life(min) Duration of action(h)
Short-term effects Hydrogenated pine 1.00 1.0 1.0 1.0 20.00 90 8-12
Can’t be loose 0.01 0.8 0.8 0.8 25.00 30 8-12
Medium effect Ponisson 0.05 0.8 4.0 3.5 5.00 60 12-36
Pune pine dragon 2.20 0.8 4.0 4.0 5.00 200 12-36
Armor-splash nylon 11.90 0.5 5.0 5.0 4.00 180 12-36
Qu Anxilong 1.90 0 5.0 5.0 4.00 >200 12-36
Long Dexamison 7.10 0 20.0-30.0 30.0 0.75 100-300 36-54
Double Tamson 5.40 0 20.0-30.0 25.0-35.0 0.60 100-300 36-54

Note: The ratios of water salt metabolism, sugar metabolism and  anti-inflammatory effect in the table were measured with hydrocortisone as the standard, and the equivalent dose was based on hydrogenated pine.

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