Anti-Inflammatory Corticosteroids Flashcards

1
Q

Effects of Glucocorticoids on Carbohydrate Metabolism

A

Gluconeogenesis, increase in blood glucose leading to insulin release, and glycogen synthesis with deposition in the liver

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2
Q

Effect of excess glucocorticoids on carbohydrate metabolism

A

Diabetes-like state

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3
Q

Effect of Glucocorticoids on Protein Metabolism

A

Increased aminoacid uptake from liver and kidney, decreased protein synthesis (except in liver), result is a net transfer of AAs from muscle/bone to liver

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4
Q

Effect of excess glucocorticoids on protein metabolism

A

Muscle wasting, catabolism of skin and connective tissue

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5
Q

Effect of Glucocorticoids on Lipid Metabolism

A

Net effect is lipogenesis due to increased insulin release. There is a greater lipogenic effect in the central tissues.

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6
Q

Effect of excess glucocorticoids on lipid metabolism

A

Centripetal obesity, buffalo hump and increased abdominal fat.

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7
Q

What is the physiologic mechanism of action of mineralcorticoids?

A

Aldosterone binds cytosolic receptor, migrates to nucleus where it increased translation of specific proteins: Na-K-ATPase, sodium channels, and potassium channels.

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8
Q

Physiologic effect of mineralcorticoid

A

Increased reabsorption of sodium from renal distal tubules, and increased secretion of protons and potassium.

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9
Q

What are therapeutic doses of corticosteroids generally used for?

A

Suppress inflammatory and immune responses. Most useful if the host response is the cause of deleterious effects of the disease.

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10
Q

Anti-Inflammatory effects of glucocorticoids

A

Decreased production and action of cytokines, reduced generation of leukotrienes and prostaglandins via decreased expression of COX-2 and inhibition of Phospholipase-A2.

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11
Q

Immunosuppressive effects of glucocorticoids

A

Reduction in chronic inflammation and autoimmune reactions BUT decreased healing and protective aspects of the immune system

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12
Q

How do glucocorticoids enact their immunosuppressive effects?

A

Suppress T-cell activation, suppress cytokine production, prevent mast cells and eosinophils from releasing chemical mediators

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13
Q

Effects of glucocorticoids on vascular events

A

Decreased vasodilation, decreased fluid exudation

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14
Q

Effects of glucocorticoids on cellular events

A

Overall decrease in accumulation and activation of cells

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15
Q

Mineralocorticoid activity refers to…

A

The salt (Na+)-retaining actions at the kidney.

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16
Q

Glucocorticoid activity refers to…

A

The metabolic effects: hyperglycemia, protein wasting, and lipid redistribution.

17
Q

Compare the anti-inflammatory potency to the salt-retaining potency of cortisol (aka hydrocortisone)

A

1 : 1. i.e. Cortisol defines the potency. Just know Cortisol does both and we compare everything else to it.

18
Q

Compare the anti-inflammatory potency to the salt-retaining potency of aldosterone. (relative to cortisol)

A

0.3 : 3000 i.e. Aldosterone’s effect is essentially only salt-retaining.

19
Q

Compare the anti-inflammatory potency to the salt-retaining potency of Prednisone, Triamcinolone, and Dexamethasone. (relative to cortisol)

A

4-30 : 0-0.3 i.e. a lot of anti-inflammatory effect with little to no salt-retaining effect. Good choice to suppress immune system without mineralcorticoid activity.

20
Q

Compare the anti-inflammatory potency to the salt-retaining potency of Fludrocortisone. (relative to cortisol)

A

10 : 125-250 i.e. a lot of salt-retaining effect with little immunosuppression.

21
Q

Where is 11ß-hydroxysteroid dehydrogenase 1 (11ß-HSD1) expressed? And what reactions does it catalyze?

A

Liver. Converts cortisone to the active cortisol or prednisone to the active prednisolone. i.e. activating step.

22
Q

Where is 11ß-hydroxysteroid dehydrogenase 2 (11ß-HSD2) expressed? And what reactions does it catalyze?

A

Kidney. Converts cortisol to cortisone or prednisolone to prednisone i.e. inactivating step.

23
Q

Can you treat a pregnant woman with glucocorticoids without effect on the fetus?

A

Yes, because fetus expresses the inactivating enzyme (11(beta)-HSD2) in the kidney but does not express the activating enzyme (11(beta)-HSD1) in the liver i.e. it can convert the drug back to the prodrug. (assumption is you don’t saturate the inactivating enzyme)

24
Q

Clinical considerations for use of Cortisol (aka Hydrocortisone)

A

Common use in physiologic doses for replacement therapy and emergencies; glucocorticoid and mineralocorticoid actions [1:1]; administered orally and parenterally

25
Q

Clinical considerations for use of Prednisone

A

Most commonly used oral agent when steroid burst therapy desired; glucocorticoid and mineralocorticoid actions [13:1]; activated to prednisolone in liver. NO topical activity, not activated until first pass hepatic metabolism

26
Q

Clinical considerations for use of Methylprednisolone

A

Used if parenteral administration desired for steroid burst (no better than oral prednisone in acute exacerbations of asthma); minimal mineralocorticoid action. Oral (Medrol) and parenteral (Solu-Medrol

27
Q

Clinical considerations for use of Dexamethasone (Decadron)

A

Most potent anti-inflammatory agent, used in cerebral edema, chemotherapy-induced vomiting; no mineralocorticoid action, greatest suppression of ACTH secretion at pituitary

28
Q

Clinical considerations for use of Triamcinolone (Kenalog)

A

Potent systemic agent - excellent topical activity; no mineralocorticoid action

29
Q

What Inflammatory-type disorders are glucocorticoids used for?

A

Allergic reactions, collagen-vascular, GI disease, eye diseases, hematologic disorders, neurologic disorders, pulmonary disease, skin disorders, hypercalcemia and mountain sickness.

30
Q

What 3 categories of drugs is Rheumatoid Arthritis managed with?

A

Nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and disease modifying antirheumatic drugs (DMARDs).

31
Q

How can we minimize adverse effects of glucocorticoid therapy?

A

Alternate day schedule. Lessens growth-suppressive effects because anti-inflammatory actions outlast suppressive effect on HPA axis.

32
Q

Why is it important to terminate administration of glucocorticoids gradually?

A

If taken longer than 7-10 to 28 days, otherwise may cause severe rebound of disease or symptoms of adrenal insufficiency (adrenal crisis).

33
Q

Dosage forms of glucocorticoids

A

Oral. Most common route when systemic actions desired (also intravenous / intramuscular) Topical (skin disease). Relatively insoluble steroids, but can see systemic effects if potent steroids are applied for long periods, under occlusive dressings, or over large areas. Inhalants (asthma). Metabolized in lungs before absorption, thus decreased systemic effects. Ophthalmic (eye disease). Intra-articular (into joint for rheumatoid arthritis). Enemas (ulcerative colitis). Nasal sprays (allergic rhinitis).

34
Q

Adverse Mineralocorticoid effects of acute, short course, high dose steroids

A

Na+ and H2O retention, edema, increased BP, hypokalemia

35
Q

Adverse Glucocorticoid effects of acute, short course, high dose steroids

A

Glucose intolerance, mood changes (up or down), insomnia, GI upset

36
Q

Adverse Glucocorticoid effects expected with high dose sustained therapy (> 2 weeks) (+ short-term effects)

A

Iatrogenic Cushing’s syndrome [hyperglycemia, protein wasting (muscle), lipid deposition (weight gain) leading to diabetes-like state] Hypothalamic-pituitary-adrenal axis suppression results in insufficient response to stress; more suppression with dexamethasone and betamethasone. Also in ACTH, GH, TSH, LH, sex steroids. Mood disturbance [initial euphoria, then psychic letdown or psychosis (rarely) when dose reduced; high concentration of glucocorticoid receptors in hippocampus] Impaired wound healing, increased protein catabolism via effects on collagen and fibroblasts Increased susceptibility to infection (bacterial, viral, fungal) + short-term effects too.

37
Q

Possible Adverse effects with large cumulative doses

A

Osteoporosis via direct effect (decrease in osteoblasts, block of vitamin D3 induced osteocalcin gene) and indirect effect (decreased Ca absorption and increase in PTH release). Risk and rate of osteoporosis decreased by use of bisphosphonates (e.g., alendronate). Posterior capsular cataracts, esp. in children receiving prolonged treatment for asthma. Skin atrophy, loss of collagen support. Catabolic effects on skin and connective tissue. Growth retardation in children. Decreased growth hormone secretion and impaired action of somatomedins. Growth resumes upon discontinuation of glucocorticoids and expected height is often obtained. Peptic ulceration with higher doses via decrease in protective mucopolysaccharides, increase in histamine-induced H+ secretion, decreased immune response to H. pylori; reduce risk with antacids. Occasionally seen - avascular necrosis, myopathy, fatty liver, hirsutism

38
Q

Effects of prolonged glucocorticoid excess

A

Iatrogenic Cushing’s syndrome. Italicized effects are particularly common. Less frequent effects, related to dose and duration of therapy, are shown in parentheses.

39
Q

Functional Relationships in the HPA Axis (and select drugs)

A