糖皮质激素在感染相关急症，如何使用？

2020-06-17 高丽丽医学之声

糖皮质激素是一类基本结构为类固醇（甾体），有抗过敏、抗炎、抗毒、抗休克、抑制免疫应答、抑制气道高反应性等作用的药物，临床可用于感染相关疾病等的治疗。

糖皮质激素是一类基本结构为类固醇（甾体），有抗过敏、抗炎、抗毒、抗休克、抑制免疫应答、抑制气道高反应性等作用的药物，临床可用于感染相关疾病等的治疗。

糖皮质激素对病原微生物并无抑制作用，但其有抗毒作用，即可提高机体对有害刺激的应激能力或耐受力，减轻细菌内毒素对机体的损害，减轻中毒、组织破坏、渗出，进而迅速缓解严重症状，使机体度过危险期，并缓解毒血症症状，也可减少内热源的释放，对感染毒血症的高热有退热作用，临床可用于严重急性感染，如中毒性感染或同时伴有休克，包括中毒性菌痢、爆发型流行性脑膜炎、重症伤寒、中毒性肺炎、爆发型肝炎、猩红热、脓毒症等，一般感染不用。但是，糖皮质激素可抑制炎症反应和免疫反应，降低机体防御功能，致机体抵抗力下降，反而有可能使潜在的感染病灶（如化脓性病灶）活动和扩散，即易感性增大，或加重现有的感染和诱发潜伏性感染，其抗炎作用可掩盖症状直至感染发展至晚期，因而抗微生物治疗未能控制的细菌感染者禁用。那么，糖皮质激素在感染相关急症中如何使用呢？

糖皮质激素包括内源性的可的松和氢化可的松，及外源性的泼尼松（强的松）、泼尼松龙（强的松龙）、甲泼尼龙（甲基强的松龙）、倍他米松和地塞米松等。

糖皮质激素的分类

分类	药物	等效剂量（mg）	血浆半衰期（min）	作用持续时间（h）	HPA轴抑制时间（24h）
短效	氢化可的松	20	90	8 -12	1.25-1.50
短效	可的松	25	30	8 -12	1.25-1.50
中效	泼尼松	5	60	12-36	1.25-1.50
	泼尼松龙	5	200	12-36	1.25-1.50
	甲泼尼龙	4	180	12-36	1.25-1.50
	曲安西龙	4	＞200	12-36	1.25-1.50
长效	地塞米松	0.75	100-300	36-54	2.75
长效	倍他米松	0.60	100-300	36-54	3.25

注：①可的松、泼尼松需在肝内转化为氢化可的松和泼尼松龙才有生物活性，故严重肝功能不全者宜用氢化可的松或泼尼松龙。② HPA轴：下丘脑-垂体-肾上腺轴

糖皮质激素在感染相关急症中的使用

疾病	《糖皮质激素急诊应用专家共识》（2020年）推荐
慢性阻塞性肺疾病急性加重（AECOPD）	①推荐所有 AECOPD 者使用全身性糖皮质激素。 ②泼尼松40-60mg 1次/d，治疗持续时间为5-7d。疗程结束时，若已明显恢复可直接停用糖皮质激素，而不是逐渐减量至停药。
社区获得性肺炎（CAP）（普通成人）	①糖皮质激素用于CAP 辅助治疗有争议，若有证据^[1]表明CAP者的宿主炎症反应过度或失调，建议辅助使用。糖皮质激素避免用于有重度不良事件危险因素的CAP 者，如近期消化道出血、糖尿病控制不良或重度免疫功能受损者。若已知CAP 者由流感病毒或真菌如曲真菌引起，糖皮质激素使用需慎重。 ②若辅助使用糖皮质激素，疗程为5d：若不能口服，静脉使用甲泼尼龙0.5mg/kg，1次/12h；若能口服，使用口服泼尼松50mg/d。
社区获得性肺炎（CAP）（普通成人）	注：证据定义为脓毒症或需FiO₂>50%的呼吸衰竭伴≥1项以下特征：代谢性酸中毒（动脉血pH值<7.3）、乳酸>4 mmol/L、C反应蛋白>150 mg/L。
急性细菌性脑膜炎（ABM）	①对怀疑急性细菌性脑膜炎者，开始抗生素治疗前或首剂抗生素后的短时间内可使用地塞米松辅助治疗，一旦病原学确定不是肺炎链球菌感染应立即停用。若无病原学证据，临床表现及脑脊液检查又像是链球菌感染时，应使用糖皮质激素治疗。对耐药肺炎链球菌，仍建议使用地塞米松减轻炎症。但地塞米松辅助治疗不用于已接受抗生素治疗的成人，因其不太可能改善结局。 ②免疫正常者，使用首剂抗生素稍前或在其同时，应开始使用地塞米松。推荐静脉地塞米松0.15mg/(kg·d) ，1次/6h，持续4d。
病毒性心肌炎（VM）	①对严重的暴发性心肌炎可尝试使用糖皮质激素，以改善左室收缩功能，但不推荐对所有病毒性心肌炎常规使用糖皮质激素。 ②氢化可的松5-10mg/(kg·d) 或泼尼松1-2mg/(kg·d)，疗程2- 4周，后逐渐减量。
结核性脑膜炎（TBM ）	①推荐对TBM者使用糖皮质激素辅助治疗。HIV阴性TBM者无论病情轻重，都应接受糖皮质激素辅助治疗。 ②地塞米松成人0.3-0.4mg/(kg·d) ，持续2周，后在第3周0.2mg/(kg·d) ，第4周0.1 mg/(kg·d) ，此后4mg/d，且每周将日剂量减少1mg，总疗程约8周。泼尼松成人60 mg/d。初始剂量治疗2周后，在接下来的6周期间逐渐减量至停药，即每周将日剂量减少10 mg，总疗程约8周。
脓毒性休克	①对成人严重脓毒性休克者（给予充分液体复苏和血管加压药物后，收缩压<90 mmHg仍持续＞1h），建议视情况静脉使用糖皮质激素。不应根据ACTH 刺激试验的结果选用糖皮质激素治疗的对象，应根据临床情况使用。 ②通常静脉氢化可的松200-300 mg/d，分次给药（50mg/次，1次/6h；或100mg/次，1次/8h）或连续输注。给予5-7d的治疗，并根据临床反应逐渐减量至最终停药。

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2020-07-03 sunlong28

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2020-07-01 sunlong28

阅读

133 0
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2020-06-18 heli0118

#皮质激素#

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