Adrenocorticosteriods

Question 1

Moving on to the Adverse Effects of Glucocorticoids. The major undesirable effects are the result of their hormonal actions, which lead to a Cushing’s like syndrome. What are the metabolic effects of glucocorticoids?

Answer 1

Rounding, puffiness, fat deposition, and plethora usually appear
Fat tends to be redistributed from the extremities to the trunk, the back of the neck and the supraclavicular fossae.
Increased growth of fine hair over the face, thighs and trunk
Breakdown of protein and diversion of AA to glucose production increase the need for insulin leads to
–weight gain, visceral fat deposition, myopathy and muscle wasting, thinning of the skin with striae and bruising, hyperglycemia and eventually osteoporosis, diabetes, and aseptic necrosis of the hip

Question 2

Other serious adverse effects of glucocorticoids include?

Answer 2

Peptic ulcers
Hypomania or acute psychosis
Depression (long term or long acting steroids)
Increased intraocular pressure is common
Glaucoma may be induced
Benign intracranial hypertension
bacterial and mycotic infections are masked

Question 3

When corticosteroids are administered for more than 2 weeks what happens?

Answer 3

Adrenal suppression may occur
–if tx extends over weeks to months, the patients should be given appropriate supplementary therapy at times of minor stress such as accidental trauma or surgery

Question 4

How should corticosteroid dosage be reduced?

Answer 4

Tapered Slowly
–reduction process should be quite slow
May take 2-12 months for the hypothalamic-pituitary -adrenal axis to function acceptably and cortisol levels may not return to normal for another 6-9 months

Question 5

What happens if dosage is reduced too rapidly?

Answer 5

Symptoms of the disorder in which they were using glucocorticoids for may reappear or increase in intensity.
–even with patients without an underlying disorder may develop symptoms with rapid reductions in corticosteroid levels
Symptoms: anorexia, nausea, vomiting, weight loss, lethargy, headache, fever, joint or muscle pain, and postural hypotension.
These symptoms appear either glucocorticoid deficiency or in the presence of normal or elevated plasma cortical levels indicating dependence

Question 6

Patients receiving glucocorticoids must be monitored carefully for the development of what?

Answer 6

Hyperglycemia
Sodium retention with edema 
HTN
Hypokalmeia 
Peptic Ulcer 
Osteoporosis
Hidden Infectiond

Question 7

How can K loss and effects on bone be prevented in patients on chronic glucocorticoids?

Answer 7

Giving patient K, Ca and vitamin D supplements

Question 8

The last set of drugs will go over the Antagonist of Adrenocortical Agents. First up is a mineralocorticoid antagonist called Spironolactone, what are features of this drug?

Answer 8

Reverses many of the manifestation of aldosteronism
–establish dx and ameliorating the signs and symptoms when surgical removal is delayed
AE: hyperkalemia, cardiac arrhythmia, menstrual abnormalities, gynecomastia, sedation, headache, GI disturbances, and skin rashes

Question 9

Next are the synthesis inhibitors and Glucocorticoid Antagonists. First up is Aminogluthemide. What is the MOA and use of this drug?

Answer 9

Blocks the conversion of cholesterol and pregnenolone and causes a reduction in the synthesis of all hormonally active steroids
–tx of adrenal cancer along with hydrocortisone or dexamethasone

Question 10

Next ketoconazole, an antifungal imidazole derivative is a potent and rather non selective inhibitor of adrenal and gonadal steroid synthesis. Effects only seen at high doses. What is it used for?

Answer 10

Tx of patients with Cushings Syndrome due to several causes.
Tx of prostate cancer

Question 11

Next Metyrapone, a selective inhibitor of steroid 11-hydroxylation, interfering with cortisol and corticosteroid synthesis. What are the uses of this drug?

Answer 11

Only adrenal mediation that can be administered to pregnant women with Cushing’s Syndrome
AE: salt and water retention and hirsutism resulting from diversion of the 11-deoxycortisol precursor to androgen synthesis

Question 12

Lastly is Mifepristone, which is a pharmacologic antagonist at the steroid receptor. High doses of mifepristone do what?

Answer 12

Exert anti-glucocorticoid activity by blocking the glucocorticoid receptor.
–only recommended for inoperable patients with ectopic ACTH secretion or adrenal carcinoma who have failed to respond to other therapeutic manipulations