Chapter 6: Endocrine: Diabetes Insipidus & Corticosteroids Flashcards
High doses of corticosteroids are used to save or prolong life. Give examples of conditions they are used in (4).
- Exfoliative dermatitis
- Pemphigus
- Acute leukaemia
- Acute transplant rejection
Why should doses be kept as low as possible in chronic diseases?
To minimise side effects
Which route of administration is commonly used to treat inflammatory skin conditions?
Topical
Through which three routes are corticosteroids used in crohn’s disease and ulcerative colitis to induce remission?
- IV
- Oral
- Rectal
Which corticosteroid has the least mineral corticoid action?
Dexatmethasone
Which corticosteroid has the most mineral corticoid action?
Fludrocortisone
Put the following corticosteroids in order of increasing mineral corticoid action: Hydrocortisone, Bethamatsone, Prednisolone
Betamethasone
Predinisolone
Hydrocortisone
At which time of day should corticosteroids be given to have the greatest suppression of corticotropin release?
At night
What is the test for Cushing’s syndrome called?
Overnight dexamethasone test
What is Cushing’s syndrome?
Chronic excess glucocorticodis
Give 3 causes of Cushing’s syndrome
- Adrenal tumour
- Exogenous corticosteroids
- Excess ACTH secretion from anterior pituitary
What is a common cause of raised intracranial pressure and cerebal oedema?
Malignancy
Which corticosteroids are used to treat raised intracranial pressure and cerebal oedema? (2)
- Dexamethasone
2. Betamethasone
Are steroids used in head injury or stroke?
No
IV hydrocortisone can be used with adrenaline/epinepherine for the emergency treatment of what?
Anaphylaxis
Inhaled corticosteroids are licensed for use of which respiratory diseases? (3)
- Asthma
- COPD
- Allergic rhinitis (nasal congestion)
What is the rule of thumb to ensure side effects of corticosteroids are kept low?
What is another option (not successful in asthma)?
And a third option?
A fourth?
A fifith?
Use the lowest effective dose for a minimum time
Alternate day administration
Short-course therapy
Adding a small dose of immunosuppressive drug to reduce steroid dose required
Topical/Local application > systemic
At which time of day is the suppressive action of corticosteroids on cortisol the least?
First thing in the morning
Why are we worried about giving corticosteroids to children?
Adrenal suppression can lead to reduced growth velocity
What can we supply with ICS to those under 15? Why?
Spacer devices
Increase airway deposition and reduce orapharyngeal deposition
Which two hormones are secreted by the adrenal cortex?
- Cortisol (Glucocorticoid - some mineralcorticoid activity)
- Aldosterone (mineral corticoid)
In cortisol deficiency states (e.g. Addison’s disease), which 2 steroids are given?
- Hydrocortisone
2. Fludrocortisone
To mimic the normal diurnal rhythm of steroid secretion, how is oral hydrocortisone for the treatment of Addison’s Disease dosed?
Larger morning dose, Small evening dose
+ Fludrocortisone
What is used to treat acute adrenal insufficiency?
IV hydrocortisone
What is used to treat hypopituitarism? Are mineral corticoids required? What other additional therapy is required?
- Glucocorticoids
- Mineral corticoids not required as aldosterone can be stimulated via RAAS
- Levothyroxine and Sex hormones
What is diabetes insipidus?
A condition where too much urine is produced
What can be a fatal effect of uncontrolled diabetes insipidus?
Dehydration
What is the name of the hormone used to treat diabetes insipidus? (has two names)
Antidiuretic hormone or Vasopressin
What is the analogue of vasopressin?
Desmopressin
What are the 3 advantages of desmopressin over vasopressin?
- More potent
- Longer duration
- No vasoconstriction
Other than in diabetes insipidus, which other condition can desmopressin be used in?
Nocturnal enuresis
Other than in diabetes insipidus, which other condition can vasopressin be used in?
To control variceal bleeding in portal hypertension
In the body, what releases ADH?
Posterior pituitary
The posterior pituitary releases desmopressin and which other hormone?
Oxytocin
Which elecetrolyte imbalance does inappropriate secretion of antidiuretic hormone cause?
Hyponatreamia
If fluid restriction alone does not work, name 2 antidiuretic hormone antagonists used in SIADH
Democlocycline
Tolvaptan
What is a serious neurological event that can occur with rapid correction of hyponatreamia?
Osmotic demylination
What is the counselling advice to give to patients taking desmopression? (2)
To avoid fluid overload. To stop taking if they experience vomiting or diarrhoea
Can intranasal desmopressin be used for nocturnal enuresis?
No, increased risk of side effects
What most be measured before starting treatment with desmopressin OR tolvaptan and regularly throughout?
Baseline sodium
If plasma sodium falls below normal range, is the dose of desmopressin reduced?
No, discontinue treatment
As well as osmotic demylination, what can hyponatreamia cause?
Convulsions
High glucocorticoid activity is only an advantage when accompanied by relatively low what?
Mineralcorticoid activity
Which corticosteroid has an anti inflammatory activity which is of no clinical relevance?
Fludrocortisone
Apart from fludrocortisone, which corticosteroid has high mineralcorticoid activity making it unsuitable for long term disease prevention?
Hydrocortisone
Give 3 conditions in which hydrocortisone is used
- Adrenal replacement therapy
- Emergency treatment of some conditions (e.g. anaphylaxis)
- Topical management of inflammatory conditions
What is the most commonly used corticosteroid for disease suppression?
Prednisolone
Which 2 corticosteroids have high glucocorticoid activity and insignificant mineralcorticoid activity?
- Dexamethasone
2. Betamethasone
Which 2 corticosteroids are particularly useful in suppression of corticotropin secretion?
- Dexamethasone
2. Betamethasone
Why should steroids be avoided in active systemic infection?
Can make it worse by dampening immune response
During prolonged systemic treatment with steroids, what can occur?
Adrenal suppression
How long can adrenal suppression persist for after stopping treatment with corticosteroids?
Years
Which 3 events can abrupt withdrawal after prolonged treatment with corticosteroids cause?
- Acute adrenal insufficiency
- Hypotension
- Death
What are the signs and symptoms of adrenal suppression? (8)
- Fatigue
- Anorexia
- Nausea
- Vomiting
- Hypotension
- Hyponatreamia
- Hyperkalemia
- Hypoglycaemia
If a person is on prolonged corticosteroid treatment, in which 3 conditions do we need to increase the dose to compensate for diminished adrenocorticol response?
- Significant illness
- Trauma
- Surgical procedure
Which healthcare professional MUST know if a patient is taking corticosteroids to avoid a massive fall in blood pressure during anaesthesia or immediately post-op?
Anesthetists
What should patient on long-term corticosteroids carry with them at all times?
A steroid card
What information is contained in a steroid card? (5)
- Guidance on minimising risk
- Prescriber
- Drug
- Dosage
- Duration of treatment
What does prolonged courses of corticosteroids increase susceptibility to?
Infections
Why can serious infections (e.g. septicaemia and TB) reach an advanced stage before being recognised in patients taking corticosteroids?
Corticosteroids can make clinical presentation to infections atypical.
Which type of infections can corticosteroids exacerbate? (2)
- Fungal
2. Occular (e.g. herpes virus)
If they have never had it, which childhood condition are patients on oral or parenteral corticosteroids at high risk of?
Chicken pox
When patients on corticosteroids get chicken pox, a rash is not necessarily a prominent feature, how else can it manifest? (3)
- Pneumonia
- Hepatitis
- Disseminated intrvascular coagulation
If a patient taking corticosteroids presents to your community pharmacy with chicken pox, what is the most appropriate response?
Hospital for specialist care and urgent treatment
As well as chicken pox, which other childhood illness should patients taking corticosteroids avoid?
Measles
Patients taking high doses of systemic corticosteroids should be aware of which side effect?
Psychiatric reactions
What are they symptoms of psychiatric reactions seen in patients taking high dose systemic corticosteroids? (8)
- Euphoria
- Nightmares
- Insmonia
- Irritability
- Mood swings
- Suicidal thoughts
- Psychotic reactions
- Behavioural disturbances
As well as during treatment with corticosteroids, when else can psychiatric reactions occur?
On withdrawal
Can corticosteroids be used in pregnancy?
Yes
Why are we comfortable with using corticosteroids in pregnancy?
No convincing evidence that they increase incidence of congenital abnormalities such as cleft lip/palate
When used long term, what is a risk of corticosteroids in pregnancy?
Intra-uterine growth restrictions
What are the glucocorticoid side effects of corticosteroids? (7)
- Diabetes
- Oestoporosis (especially in the elderly, can cause hip fractures)
- Avascular necrosis of the femoral head
- Muscle wasting
- Peptic ulcerations and perforation
- Psychiatric reactions
- Increased risk infection
What are the mineralcorticoid side effects of corticosteroids? (5)
- Hypertension
- Sodium retention
- Water retention
- Potassium loss
- Calcium loss
What must be monitored annually in children taking corticosteroids?
Height
As well as adrenal suppression, what else can abrupt withdrawal of corticosteroids be associated with? (6)
- Fever
- Myalgia
- Weight loss
- Rhinitis
- Conjunctivitis
- Painful itchy skin nodules
What are the criteria for gradual withdrawal of corticosteroids? (5)
- > 40mg daily prednisolone (or =) for over 1 week
- Repeat doses in the evening
3, Over 3 weeks of treatment - Recently received repeat courses
- Taken a short course within 1 year of stopping long term
What is the first line treatment of most types of Cushing’s?
Surgical intervention
If Cushing’s cannot be treated surgically, which 2 drugs have been found to be helpful?
- Metyrapone
2. Ketoconazole
If a patient with Cushing’s is receiving a high dose of Metyrapone, what will they also need?
Cortisol replacement
What is a potentially life threatening side effect of ketoconazole?
Hepatotoxicity
Which 3 things must be monitored with ketocolazole treatment?
- ECG
- Adrenal function
- LFTs
