3.4 Therapeutic Uses of Corticosteroid Medications

Question 1

Why are different corticosteroid drugs given at vastly different dosages?

Answer 1

Variations in potency/bioavailability; different purposes based on required mineralocorticoid potency etc.

Question 2

Why do we give multi-dose (over one big dose) of corticosteroids?

Answer 2

• Maintain effective levels
• Match physiological levels
• Prevent excessive spikes (esp. in setting of conditions such as diabetes, which would not benefit from huge spikes in gluconeogenesis)
• May also decrease HPA axis suppression, enabling quicker tapering

Question 3

Why is there a large difference between therapeutic and replacement levels of corticosteroids?

Answer 3

This larger dose is required to achieve the potent anti-inflammatory/immunosuppressive effects required

Question 4

What is the effect on the HPA axis of long term corticosteroid use? How does this affect cessation?

Answer 4

• Greater-than-replacement doses for 2-4 weeks or longer can suppress HPA axis
• Therefore, if withdrawn too abruptly, can lead to steroid deficiency
• The solution is to taper down dosage

Question 5

What, broadly, are the long-term side effects of corticosteroid exposure?

Answer 5

• Immunosuppression
• HPA axis suppression
• Increased bone turnover
• Increased blood glucose level
• Fat deposition (dorsal cervical fat pad, and face/”moon face”)
• Hyperpigmentation
• Proximal myopathy/weakness
• Cataracts/increased intraocular pressure
• Think skin/bruising
• Peptic ulcers
• Increased AF/clotting (both, not necessarily related)
• Premature atherosclerosis
• Mania/psychosis

Question 6

What drug starting with f is a synthetic mineralocorticoid, used in the setting of primary adrenal insufficiency?

Answer 6

Fludrocortisone

Question 7

What are the three largest clinical reasons for prescribing a corticosteroid?

Answer 7

• Immunosuppression
• Anti-inflammatory
• Lympholytic effect

Question 8

What are the main positive impacts of corticosteroids?

Answer 8

• Immunosuppression
• Anti-inflammatory
• Promote excretion of free water
• Maintain cardiac/contractility/arterial tone (prevent hypotension)
• Promote gluconeogenesis/glycogen deposition (this is how we get moon face)

Question 9

True or false: in low doses, corticosteroids may IMPROVE the immune system

Answer 9

True

Question 10

Addison’s disease vs adrenal insufficiency

Answer 10

Adrenal insufficiency encompasses all causes (primary/gland and secondary/ACTH), whereas Addison’s is just primary.

Question 11

Why don’t we give fludrocortisone in secondary adrenal insufficiency?

Answer 11

• The main drivers of aldosterone release are K+ and Angiotensin II levels
• These are unaffected by ACTH, which is what’s dysregulated in 2° AI
• Therefore, no exogenous mineralocorticoids are required

Question 12

What is stress dosing of glucocorticoids? When might it be given? Who are they most commonly given to, in terms of current dosage?

Answer 12

• Stress dosing mimics endogenous spikes in cortisol that occur in response to certain events
• These might include stress and/or illness
• Most commonly given to people on replacement dose