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Table 6 Major drug interactions with systemic GCs[1, 8]

From: A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy

Interacting drug class Effect Recommendation/comment
Anticonvulsants (e.g., carbamazepine, phenobarbital, phenytoin) • ↓ GC exposure and efficacy; may persist for weeks following discontinuation of anticonvulsant • Closely monitor outcomes of concomitant use
• GC dose alterations may be required
Anticoagulants (e.g., warfarin) • May ↑ anticoagulant effects of warfarin and ↑ risk of GI bleeding • Monitor INR closely
• Significant alteration in warfarin dose will likely be required within 3–7 days of GC initiation
Antifungals (e.g., itraconazole, ketoconazole) • ↑ GC exposure and toxicity • Monitor concurrent use for signs of GC overdose (fluid retention, hypertension, hyperglycemia)
• Dose alteration of methylprednisolone and dexamethasone may be needed (prednisone and prednisolone not affected to a clinically relevant degree by this interaction)
Antidiabetic agents • GC initiation can lead to glucose dysregulation, thereby counteracting the effects of antidiabetic drugs • ↑ frequency of BG monitoring when initiating GC therapy
• Adjust antidiabetic therapy based on BG results
Antibiotics (macrolides) (e.g., clarithromycin) • ↑ GC exposure and toxicity • Monitor concurrent use for signs of GC overdose (fluid retention, hypertension, hyperglycemia)
• Dose alteration of methylprednisolone and dexamethasone may be needed (prednisone and prednisolone not affected to a clinically relevant degree by this interaction)
Antivirals (e.g., atazanavir, indinavir, ritonavir, saquinavir) • ↑ GC exposure and toxicity • Monitor concurrent use for signs of GC overdose (fluid retention, hypertension, hyperglycemia)
• Dexamethasone may ↑ levels of indinavir and saquinavir • Dose alteration of methylprednisolone and dexamethasone may be needed (prednisone and prednisolone not affected to a clinically relevant degree by this interaction)
  • Monitor antiviral efficacy of indinavir and saquinavir if patient is taking dexamethasone
Anti-infectives (e.g., efavirenz, nevirapine, rifampin) • ↓ GC exposure and efficacy; may persist for weeks following discontinuation of anti-infective • Closely monitor outcomes, especially in transplant recipients
• ↑ GC dose accordingly
Diuretics, potassium wasting (e.g., furosemide, HCTZ) • GCs may ↑ kaliuretic effects of these diuretics • Monitor potassium levels to determine whether alteration of diuretic therapy and/or potassium supplementation is needed
Live vaccines • Immunization with live vaccines while taking immunosuppressive GC doses (40 mg/day of prednisolone [or equivalent] for > 7 days) may increase risk of both generalized and life-threatening infections • Postpone live vaccines for at least 3 months after high-dose GC therapy is discontinued
NSAIDS • May ↑ risk of GI ulcers when given concomitantly with corticosteroids • Consider use of PPI if person is at risk of GI ulcers
  1. GC glucocorticoid, INR international normalized ratio, BG blood glucose, GI gastrointestinal, HCTZ hydrochlorothiazide, PPI proton pump inhibitor, NSAIDS non-steroidal anti-inflammatory drugs.