Solu-MEDROL


methylprednisolone

Medrol, Medrone (UK)

methylprednisolone acetate

Depo-Medrol, Depo-Medrone (UK), Unimed (CA)

methylprednisolone sodium succinate

A-Methapred, Solu-Medrol, Solu-Medrone (UK)

Pharmacologic class: Glucocorticoid

Therapeutic class: Antiasthmatic, anti-inflammatory (steroidal), immunosuppressant

Pregnancy risk category C

Action

Unclear. Reduces inflammation and prevents edema by stabilizing membranes and reducing permeability of leukocytic cells. Suppresses immune system by interfering with antigen-antibody interactions of macrophages and T cells.

Availability

Solution for injection: 40 mg, 125 mg, 500 mg, 1 g, 2 g

Suspension for injection: 20 mg/ml, 40 mg/ml, 80 mg/ml

Tablets: 2 mg, 4 mg, 8 mg, 16 mg, 24 mg, 32 mg

Indications and dosages

➣ Diseases and disorders of endocrine system, collagen, skin, eye, GI tract, respiratory system, or hematologic system; neoplastic diseases; allergies; edema; multiple sclerosis; tuberculous meningitis; trichinosis; rheumatic disorders; osteoarthritis; bursitis; localized inflammatory lesions

Adults: Methylprednisolone-4 to 160 mg P.O. daily in four divided doses, depending on disease or disorder.

Acetate-40 to 120 mg I.M., or 4 to 80 mg by intra-articular or soft-tissue injection, or 20 to 60 mg by intralesional injection (depending on type, size, and location of inflammation); may be repeated at 1 to 5 weeks.

Sodium succinate high-dose therapy-30 mg/kg I.V. over at least 30 minutes. May be repeated q 4 to 6 hours for 48 hours.

Off-label uses

• Lupus nephritis

• Pneumocystis jiroveci pneumonia in AIDS patients

Contraindications

• Hypersensitivity to drug or its component

• Systemic fungal infections

• Use in premature infants (with sodium succinate form, which contains benzyl alcohol)

Precautions

Use cautiously in:

• cardiovascular, hepatic, renal, or GI disease; active untreated infections; thromboembolitic tendency; idiopathic thrombocytopenic purpura; osteoporosis; myasthenia gravis; hypothyroidism; glaucoma; ocular herpes simplex; vaccinia or varicella; seizure disorders; metastatic cancer

• pregnant or breastfeeding patients

• children.

Administration

• As needed and prescribed, give prophylactic antacids to prevent peptic ulcers in patients receiving high doses.

• When methylprednisolone acetate is substituted for oral form, know that I.M. dosage should equal oral dosage and should be given once daily.

• Know that methylprednisolone acetate is not for I.V. use. It may be given I.M. or by intra-articular, intralesional, or soft-tissue injection.

• Be aware that methylprednisolone sodium succinate may be given I.M. or I.V. Reconstitute with bacteriostatic water for injection containing 0.9% benzyl alcohol, per manufacturer's instructions.

• In long-term methylprednisolone therapy, alternate-day therapy should be considered.

• For direct I.V. injection, inject each 500-mg dose over 2 to 3 minutes or more. For I.V. infusion, further dilute in compatible I.V. solution (such as 5% dextrose, 0.9% sodium chloride, or 5% dextrose in 0.9% sodium chloride injection) and give over 10 to 20 minutes.

• Maintain patient on lowest effective dosage, to minimize adverse effects.

Adverse reactions

CNS: headache, restlessness, nervousness, depression, euphoria, personality changes, psychoses, vertigo, paresthesias, insomnia, adhesive arachnoiditis, conus medullaris syndrome, increased intracranial pressure, seizures, meningitis

CV: hypotension, hypertension, arrhythmias, heart failure, shock, fat embolism, thrombophlebitis, thromboembolism

EENT: cataracts, glaucoma, increased intraocular pressure, nasal irritation, nasal septum perforation, sneezing, epistaxis, nasopharyngeal or oropharyngeal fungal infection, dysphonia, hoarseness, throat irritation

GI: nausea, vomiting, abdominal distention, rectal bleeding, dry mouth, anorexia, esophageal candidiasis, esophageal ulcer, peptic ulcer, pancreatitis

GU: amenorrhea, irregular menses

Respiratory: cough, wheezing, bronchospasm

Metabolic: decreased growth (in children), reduced carbohydrate tolerance, diabetes mellitus, hyperglycemia, sodium and fluid retention, hypokalemia, hypocalcemia, cushingoid state (with long-term use), hypothalamic-pituitary-adrenal suppression (with systemic use beyond 5 days), adrenal suppression (with long-term, high-dose use), acute adrenal insufficiency (with abrupt withdrawal)

Musculoskeletal: muscle wasting, osteoporosis, osteonecrosis, tendon rupture, aseptic joint necrosis, muscle pain and weakness, steroid myopathy, spontaneous fractures (with long-term use)

Skin: facial edema, rash, pruritus, urticaria, contact dermatitis, acne, decreased wound healing, bruising, hirsutism, thin and fragile skin, petechiae, purpura, striae, subcutaneous fat atrophy, skin atrophy, acneiform lesions, angioedema

Other: anosmia, bad taste, increased appetite, weight gain (with long-term use), Churg-Strauss syndrome, increased susceptibility to infection, aggravation or masking of infections, impaired wound healing, atrophy at injection site, local pain and burning, irritation, hypersensitivity reaction

Interactions

Drug-drug. Amphotericin B, mezlocillin, piperacillin, thiazide and loop diuretics, ticarcillin: additive hypokalemia

Fluoroquinolones: increased risk of tendon rupture

Isoniazid, phenobarbital, phenytoin, rifampin: decreased methylprednisolone efficacy

Ketoconazole: decreased methylprednisolone clearance

Live-virus vaccines: decreased antibody response to vaccine, increased risk of adverse reactions

Nonsteroidal anti-inflammatory drugs: increased risk of adverse GI effects

Oral anticoagulants: altered anticoagulant requirement

Drug-diagnostic tests. Calcium, potassium, thyroxine, triiodothyronine: decreased levels

Cholesterol, glucose: increased levels

Nitroblue tetrazolium test for bacterial infection: false-negative result

Drug-herbs. Echinacea: increased immune stimulation

Ginseng: immunomodulation

Drug-behaviors. Alcohol use: increased risk of gastric irritation and ulcers

Patient monitoring

• Monitor fluid and electrolyte balance, weight, and blood pressure.

• With long-term or high-dose use, assess for cushingoid effects, such as moon face, central obesity, acne, abdominal striae, hypertension, osteoporosis, myopathy, hyperglycemia, fluid and electrolyte imbalances, and increased susceptibility to infection.

See Check for signs and symptoms of steroid-induced psychosis (delirium, euphoria, insomnia, mood swings, personality changes, and depression).

• Monitor growth and development in children on prolonged therapy.

• Know that therapy beyond 6 months increases risk of osteoporosis. Obtain baseline bone density mass, and provide teaching about lifestyle factors (such as weight-bearing exercise, proper diet, moderation of alcohol intake, and smoking cessation) and possible need for calcium, vitamin D, or bisphosphonate therapy.

• With long-term use, withdraw drug gradually.

See After dosage reduction or drug withdrawal, monitor patient for signs and symptoms of adrenal insufficiency.

Patient teaching

• Tell patient to take with food to minimize GI upset.

• Advise patient on chronic therapy to have periodic eye exams and to carry medical identification that states he's taking drug.

• Inform patient that drug increases risk for infection. Urge him to avoid exposure to people with infections such as measles and chickenpox. Tell him to contact prescriber if exposure occurs.

• Advise patient to report unusual weight gain, swelling, muscle weakness, black tarry stools, vomiting of blood, menstrual irregularities, sore throat, fever, or infection.

See Tell patient to immediately report signs or symptoms of adrenal insufficiency (including fatigue, appetite loss, nausea, vomiting, diarrhea, weight loss, weakness, and dizziness) after dosage reduction or drug withdrawal.

• Advise diabetic patient to monitor blood glucose level carefully.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

methylPREDNISolone

(meth-ill-pred-niss-oh-lone) methylprednisolone,

A-Methapred

(trade name),

Depo-Medrol

(trade name),

Medrol

(trade name),

Solu-MEDROL

(trade name)

Classification

Therapeutic: anti inflammatories steroidal
Pharmacologic: corticosteroids
Pregnancy Category: C

Indications

Used systemically and locally in a wide variety of chronic diseases including:
  • Inflammatory,
  • Allergic,
  • Hematologic,
  • Neoplastic,
  • Autoimmune disorders,
  • Immunosuppresant.
May be suitable for alternate-day dosing in the management of chronic illness.Replacement therapy in adrenal insufficiency.Adjunctive therapy of hypercalcemia.Management of acute spinal cord injury.Adjunctive management of nausea and vomiting from chemotherapy.

Action

Suppresses inflammation and the normal immune response.Has numerous intense metabolic effects (see Adverse Reactions and Side Effects).Suppresses adrenal function at chronic doses of 4 mg/day.Has negligible mineralocorticoid activity.

Therapeutic effects

Suppression of inflammation and modification of the normal immune response.Replacement therapy in adrenal insufficiency.

Pharmacokinetics

Absorption: Well absorbed after oral administration. Succinate salt is rapidly absorbed after IM administration. Acetate salt is slowly but completely absorbed after IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete.Distribution: Widely distributed, crosses the placenta, and probably enters breast milk.Metabolism and Excretion: Metabolized mostly by the liver.Half-life: >3.5 hr (plasma), 18–36 hr (tissue); adrenal suppression lasts 1.25–1.5 days.

Time/action profile (anti-inflammatory activity)

ROUTEONSETPEAKDURATION
POunknown1–2 hr1.25–1.5 days
IM (acetate)6–48 hr4–8 days1–4 wk
IM, IV (succinate)rapidunknownunknown

Contraindications/Precautions

Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis); Lactation: Avoid chronic use; Known alcohol, bisulfite, or tartrazine hypersensitivity or intolerance (some products contain these and should be avoided in susceptible patients); Administration of live virus vaccines.Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Pediatric: Chronic use will result in ↓ growth; use lowest possible dose for shortest period of time; Stress (surgery, infections); supplemental doses may be needed; Potential infections may mask signs (fever, inflammation); Obstetric: Safety not established; Pediatric: Neonates (avoid use of benzyl alcohol containing injectable preparations, use preservative-free formulations).

Adverse Reactions/Side Effects

Adverse reactions/side effects are much more common with high-dose/long-term therapy

Central nervous system

  • depression (most frequent)
  • euphoria (most frequent)
  • headache
  • ↑ intracranial pressure (children only)
  • personality changes
  • psychoses
  • restlessness

Ear, Eye, Nose, Throat

  • cataracts
  • ↑ intraocular pressure

Cardiovascular

  • hypertension (most frequent)

Gastrointestinal

  • peptic ulceration (life-threatening)
  • anorexia (most frequent)
  • nausea (most frequent)
  • vomiting

Dermatologic

  • acne (most frequent)
  • ↓ wound healing (most frequent)
  • ecchymoses (most frequent)
  • fragility (most frequent)
  • hirsutism (most frequent)
  • petechiae (most frequent)

Endocrinologic

  • adrenal suppression (most frequent)
  • hyperglycemia

Fluid and Electrolyte

  • fluid retention (long-term high doses)
  • hypokalemia
  • hypokalemic alkalosis

Hematologic

  • thromboembolism (life-threatening)
  • thrombophlebitis

Metabolic

  • weight gain
  • weight loss

Musculoskeletal

  • muscle wasting (most frequent)
  • osteoporosis (most frequent)
  • avascular necrosis of joints
  • muscle pain

Miscellaneous

  • cushingoid appearance (moon face, buffalo hump) (most frequent)
  • ↑ susceptibility to infection

Interactions

Drug-Drug interaction

Additive hypokalemia withthiazide and loopdiuretics, amphotericin B, piperacillin, or ticarcillin.Hypokalemia may ↑ the risk of digoxin toxicity.May ↑ requirement for insulins or oral hypoglycemic agents.Phenytoin,phenobarbital, and rifampin stimulate metabolism; may ↓ effectiveness.Oral contraceptives may ↓ metabolism.↑ risk of adverse GI effects with NSAIDs (includingaspirin ).At chronic doses that suppress adrenal function, may ↓ the antibody response to and ↑ the risk of adverse reactions from live-virus vaccines.May ↑ serum concentrations of cyclosporine and tacrolimus.May ↑ the risk of tendon rupture fromfluoroquinolones.

Route/Dosage

Oral (Adults) Multiple sclerosis—160 mg/day for 7 days, then 64 mg every other day for 1 mo. Other uses—2–60 mg/day as a single dose or in 2–4 divided doses. Asthma exacerbations—120–180 mg/day in divided doses 3–4 times/day for 48 hr, then 60–80 mg/day divided twice daily.Oral (Children) Anti-inflammatory/Immunosuppressive— 0.5–1.7 mg/kg/day or 5–25 mg/m2/day in divided doses q 6–12 hr. Asthma exacerbations—1 mg/kg q 6 hr for 48 hr, then 1–2 mg/kg/day (maximum: 60 mg/day) divided twice daily.Intramuscular Intravenous (Adults) Most uses: methylprednisolone sodium succinate—40–250 mg q 4–6 hr. High-dose “pulse” therapy: methylprednisolone sodium succinate—30 mg/kg IV q 4–6 hr for up to 72 hr. Multiple sclerosis: methylprednisolone sodium succinate—160 mg/day for 7 days, then 64 mg every other day for 1 mo. Adjunctive therapy ofPneumocystis jirovecii pneumonia in AIDS patients: methylprednisolone sodium succinate—30 mg twice daily for 5 days, then 30 mg once daily for 5 days, 15 mg once daily for 10 days. Acute spinal cord injury: methylprednisolone sodium succinate—30 mg/kg over 15 min initially, followed 45 min later with 5.4 mg/kg/hr for 23 hr (unlabeled).Intramuscular Intravenous (Children) Anti-inflammatory/Immunosuppressive— 0.5–1.7 mg/kg/day or 5–25 mg/m2/day in divided doses q 6–12 hr Acute spinal cord injury: methylprednisolone sodium succinate—30 mg/kg over 15 min initially, then 45 min later initiate continuous infusion of 5.4 mg/kg/hr for 23 hr (unlabeled). Staus asthmaticus—2 mg/kg/dose, then 0.5–1 mg/kg/dose q 6 hr. Lupus nephritis—30 mg/kg IV every other day for 6 doses.Intramuscular (Adults) Methylprednisolone acetate—40–120 mg daily, weekly, or every 2 wk.

Availability (generic available)

Tablets: 4 mg, 8 mg, 16 mg, 32 mg Powder for injection (sodium succinate): 40 mg, 125 mg, 500 mg, 1 g, 2 g Suspension for injection (acetate): 20 mg/mL, 40 mg/mL, 80 mg/mL

Nursing implications

Nursing assessment

  • Indicated for many conditions. Assess involved systems before and periodically during therapy.
  • Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness) before and periodically during therapy.
  • Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional if these occur.
  • Children should have periodic evaluations of growth.
  • Lab Test Considerations: Monitor serum electrolytes and glucose. May cause hyperglycemia, especially in persons with diabetes. May cause hypokalemia. Patients on prolonged therapy should routinely have hematologic values, serum electrolytes, and serum and urine glucose evaluated. May ↓ WBC counts. May ↓ serum potassium and calcium and increase serum sodium concentrations.
    • Guaiac test stools. Promptly report presence of guaiac-positive stools.
    • May ↑ serum cholesterol and lipid values. May ↓ uptake of thyroid 123I or 131I.
    • Suppresses reactions to allergy skin tests.
    • Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy.

Potential Nursing Diagnoses

Risk for infection (Side Effects)
Disturbed body image (Side Effects)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)

Implementation

  • Do not confuse Solu-Medrol (methylprednisolone) with Solu-Cortef (hydrocortisone) or Depo-Medrol (methylprednisolone).
  • If dose is ordered daily or every other day, administer in the morning to coincide with the body's normal secretion of cortisol.
  • Periods of stress, such as surgery, may require supplemental systemic corticosteroids.
  • Oral: Administer with meals to minimize GI irritation, do not administer with grapefruit juice.
    • Tablets may be crushed and administered with food or fluids for patients with difficulty swallowing.
  • Intramuscular: Shake suspension well before drawing up. IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix. Do not administer acetate suspensions IV.
  • Intravenous Administration
  • pH: 3.5–7.0.
  • Reconstitute with provided solution (Act-O-Vials, Univials, ADD-Vantage vials) or 2 mL of bacteriostatic water (with benzyl alcohol) for injection. Use preservative-free diluent for use in neonates. Concentration: Maximum of 125 mg/mL.
  • Rate: Low dose (≤1.8 mg/kg or ≤125 mg/dose): May be administered direct IV push over 3–15 min.
  • Intermittent/Continuous Infusion: Diluent: May be diluted further in D5W, 0.9% NaCl, or D5/0.9% NaCl. Concentration: 2.5–20 mg/mL.
  • Rate: Moderate dose (≥2 mg/kg or 250 mg/dose): give over 15–30 min; High dose (15 mg/kg or ≥500 mg/dose): give over 30 min; Doses > 15 mg/kg or ≥1 g: give over 1 hour
  • Y-Site Compatibility: acyclovir, alfentanil, alprostadil, amifostine, amikacin, aminocaproic acid, aminophylline, amiodarone, amphotericin B cholesteryl, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, cefotetan, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisplatin, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, dobutamine, dopamine, doripenem, doxacurium, doxorubicin liposome, enalaprilat, ephedrine, epinephrine, epoetin alfa, eptifibatide, ertapenem, erythromycin, etoposide, famotidine, fentanyl, fluconazole, fludarabine, fluorouracil, folic acid, fosaprepitant, furosemide, gentamicin, glycopyrrolate, granisetron, hetastarch, hydromorphone, ifosfamide, imipenem/cilastatin, insulin, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, mannitol, mechlorethamine, melphalan, metaraminol, methotrexate, methoxamine, methyldopate, metoclopramide, metoprolol, metronidazole, milrinone, morphine, multivitamin, nafcillin, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, oxaliplatin, oxytocin, pamidronate, pancuronium, papaverine, pemetrexed, penicillin G, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium acetate, procainamide, prochlorperazine, propranolol, ranitidine, remifentanil, rituximab, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tirofiban, tobramycin, tolazoline, topotecan, trastuzumab, vancomycin, vasopressin, verapamil, vincristine, voriconazole, zoledronic acid
  • Y-Site Incompatibility: alemtuzumab, allopurinol, amphotericin B colloidal, ampicillin/sulbactam, amsacrine, calcium chloride, calcium gluconate, caspofungin, cefotaxime, cefoxitin, ciprofloxacin, dantrolene, diazepam, diazoxide, diphenhydramine, docetaxel, doxycycline, epirubicin, etoposide phosphate, fenoldopam, filgrastim, ganciclovir, gemcitabine, haloperidol, hydralazine, idarubicin, irinotecan, magnesium sulfate, mitoxantrone, nalbuphine, paclitaxel, palonosetron, pantoprazole, papaverine, pentamidine, pentazocine, phenytoin, promethazine, propofol, protamine, pyridoxine, quinapristin/dalfopristin, rocuronium, sargramostim, thiamine, trimethoprim/sulfamethoxazole, vecuronium, vinorelbine

Patient/Family Teaching

  • Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.
    • Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately.
    • Caution patient to avoid vaccinations without first consulting health care professional.
    • Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur. Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes.
    • Advise patient to notify health care professional of medication regimen before treatment or surgery.
    • Discuss possible effects on body image. Explore coping mechanisms.
    • Instruct patient to inform health care professional if symptoms of underlying disease return or worsen.
    • Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history.
    • Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.
  • Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see ). Alcohol should be avoided during therapy.

Evaluation/Desired Outcomes

  • Decrease in presenting symptoms with minimal systemic side effects.
  • Suppression of the inflammatory and immune responses in autoimmune disorders, allergic reactions, and neoplasms.
  • Management of symptoms in adrenal insufficiency.