Methylprednisolone

Methylprednisolone Tablets are indicated in the following conditions:

Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the first choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy mineralocorticoid supplementation is of particular importance).

Congenital adrenal hyperplasia

Nonsuppurative thyroiditis

Hypercalcemia associated with cancer

As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in:

Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy)

Ankylosing spondylitis

Acute and subacute bursitis

Synovitis of osteoarthritis

Acute nonspecific tenosynovitis

Post-traumatic osteoarthritis

Psoriatic arthritis

Epicondylitis

Acute gouty arthritis

During an exacerbation or as maintenance therapy in selected cases of:

Systemic lupus erythematosus

Systemic dermatomyositis (polymyositis)

Acute rheumatic carditis

Bullous dermatitis herpetiformis

Severe erythema multiforme (Stevens-Johnson syndrome)

Severe seborrheic dermatitis

Exfoliative dermatitis

Mycosis fungoides

Pemphigus

Severe psoriasis

Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment:

Seasonal or perennial allergic rhinitis

Drug hypersensitivity reactions

Serum sickness

Contact dermatitis

Bronchial asthma

Atopic dermatitis

Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as:

Allergic corneal marginal ulcers

Herpes zoster ophthalmicus

Anterior segment inflammation

Diffuse posterior uveitis and choroiditis

Sympathetic ophthalmia

Keratitis

Optic neuritis

Allergic conjunctivitis

Chorioretinitis

Iritis and iridocyclitis

Symptomatic sarcoidosis

Berylliosis

Loeffler’s syndrome not manageable by other means

Fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy

Aspiration pneumonitis

Idiopathic thrombocytopenic purpura in adults

Secondary thrombocytopenia in adults

Acquired (autoimmune) hemolytic anemia

Erythroblastopenia (RBC anemia)

Congenital (erythroid) hypoplastic anemia

For palliative management of:

Leukemias and lymphomas in adults

Acute leukemia of childhood

To induce a diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus.

To tide the patient over a critical period of the disease in:

Ulcerative colitis

Regional enteritis

Acute exacerbations of multiple sclerosis

Tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy.

Trichinosis with neurologic or myocardial involvement.

The initial dosage of Methylprednisolone Tablets may vary from 4 mg to 48 mg of methylprednisolone per day depending on the specific disease entity being treated. In situations of less severity lower doses will generally suffice, while in selected patients higher initial doses may be required. The initial dosage should be maintained or adjusted until a satisfactory response is noted. If after a reasonable period of time there is a lack of satisfactory clinical response, Methylprednisolone should be discontinued and the patient transferred to other appropriate therapy.

The rationale for this treatment schedule is based on two major premises: (a) the anti-inflammatory or therapeutic effect of corticoids persists longer than their physical presence and metabolic effects and (b) administration of the corticosteroid every other morning allows for reestablishment of more nearly normal hypothalamic-pituitary-adrenal (HPA) activity on the off-steroid day.

A brief review of the HPA physiology may be helpful in understanding this rationale. Acting primarily through the hypothalamus a fall in free cortisol stimulates the pituitary gland to produce increasing amounts of corticotropin (ACTH) while a rise in free cortisol inhibits ACTH secretion. Normally the HPA system is characterized by diurnal (circadian) rhythm. Serum levels of ACTH rise from a low point about 10 pm to a peak level about 6 am. Increasing levels of ACTH stimulate adrenal cortical activity resulting in a rise in plasma cortisol with maximal levels occurring between 2 am and 8 am. This rise in cortisol dampens ACTH production and in turn adrenal cortical activity. There is a gradual fall in plasma corticoids during the day with lowest levels occurring about midnight.

The diurnal rhythm of the HPA axis is lost in Cushing's disease, a syndrome of adrenal cortical hyperfunction characterized by obesity with centripetal fat distribution, thinning of the skin with easy bruisability, muscle wasting with weakness, hypertension, latent diabetes, osteoporosis, electrolyte imbalance, etc. The same clinical findings of hyperadrenocorticism may be noted during long-term pharmacologic dose corticoid therapy administered in conventional daily divided doses. It would appear, then, that a disturbance in the diurnal cycle with maintenance of elevated corticoid values during the night may play a significant role in the development of undesirable corticoid effects. Escape from these constantly elevated plasma levels for even short periods of time may be instrumental in protecting against undesirable pharmacologic effects.

During conventional pharmacologic dose corticosteroid therapy, ACTH production is inhibited with subsequent suppression of cortisol production by the adrenal cortex. Recovery time for normal HPA activity is variable depending upon the dose and duration of treatment. During this time the patient is vulnerable to any stressful situation. Although it has been shown that there is considerably less adrenal suppression following a single morning dose of prednisolone (10 mg) as opposed to a quarter of that dose administered every six hours, there is evidence that some suppressive effect on adrenal activity may be carried over into the following day when pharmacologic doses are used. Further, it has been shown that a single dose of certain corticosteroids will produce adrenal cortical suppression for two or more days. Other corticoids, including methylprednisolone, hydrocortisone, prednisone, and prednisolone, are considered to be short acting (producing adrenal cortical suppression for 1
^1/4to 1
^1/2days following a single dose) and thus are recommended for alternate day therapy.

The following should be kept in mind when considering alternate day therapy:

• 1) Basic principles and indications for corticosteroid therapy should apply. The benefits of ADT should not encourage the indiscriminate use of steroids.
• 2) ADT is a therapeutic technique primarily designed for patients in whom long-term pharmacologic corticoid therapy is anticipated.
• 3) In less severe disease processes in which corticoid therapy is indicated, it may be possible to initiate treatment with ADT. More severe disease states usually will require daily divided high dose therapy for initial control of the disease process. The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases. It is important to keep the period of initial suppressive dose as brief as possible particularly when subsequent use of alternate day therapy is intended.
• Once control has been established, two courses are available: (a) change to ADT and then gradually reduce the amount of corticoid given every other day or (b) following control of the disease process reduce the daily dose of corticoid to the lowest effective level as rapidly as possible and then change over to an alternate day schedule. Theoretically, course (a) may be preferable.
• 4) Because of the advantages of ADT, it may be desirable to try patients on this form of therapy who
• have been on daily corticoids for long periods of time (e.g., patients with rheumatoid arthritis). Since
• these patients may already have a suppressed HPA axis, establishing them on ADT may be difficult
• and not always successful. However, it is recommended that regular attempts be made to change
• them over. It may be helpful to triple or even quadruple the daily maintenance dose and administer
• this every other day rather than just doubling the daily dose if difficulty is encountered. Once the
• patient is again controlled, an attempt should be made to reduce this dose to a minimum.
• 5) As indicated above, certain corticosteroids, because of their prolonged suppressive effect on adrenal
• activity, are not recommended for alternate day therapy (e.g., dexamethasone and betamethasone).
• 6) The maximal activity of the adrenal cortex is between 2 am and 8 am, and it is minimal between 4
• pm and midnight. Exogenous corticosteroids suppress adrenocortical activity the least, when given
• at the time of maximal activity (am).
• 7) In using ADT it is important, as in all therapeutic situations to individualize and tailor the therapy to
• each patient. Complete control of symptoms will not be possible in all patients. An explanation of the
• benefits of ADT will help the patient to understand and tolerate the possible flare-up in symptoms
• which may occur in the latter part of the off-steroid day. Other symptomatic therapy may be added
• or increased at this time if needed.
• 8) In the event of an acute flare-up of the disease process, it may be necessary to return to a full
• suppressive daily divided corticoid dose for control. Once control is again established alternate day
• therapy may be reinstituted.
• 9) Although many of the undesirable features of corticosteroid therapy can be minimized by ADT, as in
• any therapeutic situation, the physician must carefully weigh the benefit-risk ratio for each patient in
• whom corticoid therapy is being considered.

• Sodium retention
• Congestive heart failure in susceptible patients
• Hypertension
• Fluid retention
• Potassium loss
• Hypokalemic alkalosis

• Muscle weakness
• Loss of muscle mass
• Steroid myopathy
• Osteoporosis
• Vertebral compression fractures
• Aseptic necrosis of femoral and humeral heads
• Pathologic fracture of long bones

• Peptic ulcer with possible perforation and hemorrhage
• Pancreatitis
• Abdominal distention
• Ulcerative esophagitis

• Impaired wound healing
• Petechiae and ecchymoses
• May suppress reactions to skin tests
• Thin fragile skin
• Facial erythema
• Increased sweating

• Increased intracranial pressure with papilledema (pseudo-tumor cerebri) usually after treatment
• Convulsions
• Vertigo
• Headache

• Development of Cushingoid state
• Suppression of growth in children
• Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness
• Menstrual irregularities
• Decreased carbohydrate tolerance
• Manifestations of latent diabetes mellitus
• Increased requirements of insulin or oral hypoglycemic agents in diabetics

• Posterior subcapsular cataracts
• Increased intraocular pressure
• Glaucoma
• Exophthalmos

Negative nitrogen balance due to protein catabolism

The following additional reactions have been reported following oral as well as parenteral therapy:

Urticaria and other allergic, anaphylactic or hypersensitivity reactions.

Methylprednisolone Tablets, USP contain methylprednisolone which is a glucocorticoid. Glucocorticoids are adrenocortical steroids, both naturally occurring and synthetic, which are readily absorbed from the gastrointestinal tract. Methylprednisolone occurs as a white to practically white, odorless, crystalline powder. It is sparingly soluble in alcohol, in dioxane, and in methanol, slightly soluble in acetone, and in chloroform, and very slightly soluble in ether. It is practically insoluble in water.

The chemical name for methylprednisolone is pregna-1,4-diene-3,20-dione, 11, 17, 21-trihydroxy-6- methyl-,(6α,11β)- and the molecular weight is 374.48. The structural formula is represented below:

C
₂₂H
₃₀O
₅

Methylprednisolone Tablets, USP for oral administration, are available as scored tablets in the following strength: 4 mg, 8 mg, 16 mg, and 32 mg. In addition each tablet contains the following inactive ingredients: colloidal silicon dioxide, lactose anhydrous (4 mg and 8 mg), lactose monohydrate (16 mg and 32 mg), magnesium stearate, microcrystalline cellulose, pregelatinized starch, sodium lauryl sulfate and sodium starch glycolate.

Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. Their synthetic analogs are primarily used for their potent anti-inflammatory effects in disorders of many organ systems.

Glucocorticoids cause profound and varied metabolic effects. In addition, they modify the body's immune responses to diverse stimuli.