Chen's Corticosteroid Lecture Flashcards
What are the equivalent doses?
Hydrocortisone _____ = Cortisone _____ = Prednisone ______ = Methylprednisolone _____ = Dexamethasone ______
20 mg; 25 mg; 5 mg; 4 mg; 0.75 mg
which glucocorticoid drug is most like the body’s natural steroid produced
hydrocortisone
which steroid has the most mineralcorticoid action
fludrocortisone
For the steroid drugs: if there is more potent GC activity - there is a (shorter or longer) duration of action
LONGER!
For Steroid Drugs there are two kinds of dosing: _________ or _________
Physiologic; Pharmacologic
The physiologic dose of hydrocortisone is: ______/day
20 mg
The physiologic dose of prednisone is: __________/day
5 - 7.5 mg
The physiologic dose of dexamethasone is: ______________/day
0.75 mg
The physiologic dose of methylprednisolone is: ____________ /day
4 mg
A pharmacologic dose of prednisone is anything greater than ________
physiologic dose
Why should steroids be dosed in the morning (before 9 AM)?
- mimics natural circadian rhythm
- pituitary is less sensitive to steroid during this time
Intra-articular dosing of steroids: has (slow or fast) absorption and (short or long) duration of action
fast; long
Longer or shorter acting steroids improve adherence?
Longer (duh, bc won’t have to take the steroid as often!)
Using steroids for Anti-inflammatory means:
- use a steroid with (min or max) effect of mineralcorticoids
- want length of action of steroid is best? (short, intermediate, long)
MIN!; intermediate (therefore not too much dosing and too long not needed…)
List possible complications of Corticosteroid Therapy
infections; myopathy; osteoneocrosis; osteoporosis; psychiatric sx; Fluid and salt retention; metabolic changes; gastric ulcer; cataract; CV Risk
How to manage an infection due to Corticosteroid Therapy:
treat infection; rinse mouth after inhaled steroid
what are the psychiatric symptoms of corticosteroid therapy
- nervousness/anxiety
- insomnia
- mood swings/depression/personality changes
- poor concentration/ memory
- overy psychosis/hallucination
How to manage fluid and salt retention that can come from Corticosteroid Therapy
- treat edema & HTN
- reduce Na+ intake
- Supplement with K+ if needed
How to manage metabolic changes that come from Corticosteroid Therapy
diet; hypoglycemia agents; insulin
what are things to monitor for gastric ulcer complications from Corticosteroid Therapy
- burning pain/heartburn
- black/dark stools
- vomiting blood
- weight loss
- bloating
how to manage a gastric ulcer complication that results from Corticosteroid Therapy
- prevent (prophylaxis) w/ PPI or H2 receptor antagonists
- AVOID large doses of antacids
What things must be monitored while a pt is on Corticosteroid Therapy - related to CV risk
- BP
- Cholesterol
- HR
- Edema
how to manage osteoporosis when resulting from Corticosteroid Therapy
- supplement Ca2+ and vit. D
- weight bearing exercises
- avoid smoking
- treat w/ bisphosphonates
Cushings syndrome occurs because there is (too much or too little) cortisol in the body
too MUCH
T or F: Not all forms of steroid with glucocorticoid activity can cause Cushings
FALSE - all forms w/ GC activity can cause Cushings
What are some non corticosteroids that have glucocorticoid activity - aka should be warned about Cushings
- Megestrol (Megace)
- Depo-Provera
Treatment Goals of Cushings Syndrome
- Reverse hypercortisolism
- reduce exogenous glucocorticoid administration
- Manage co-associated co-morbidities (large increase in mortality in CV disease)
- minimize long term complications
When to start Glucocorticoid Withdrawal?
- max desired therapeutic benefit has been attained
- inadequate therapeutic benefit has been obtained
- side effects are too serious/uncontrollable (HTN, osteoporosis, Cushing’s Syndrome)
NEVER STOP A CORTICOSTEROID IMMEDIATELY - Especially if pt was getting dose > __________ for long term (aka > _________)
7.5 mg/day; 3 weeks
When tapering off of corticosteroids: How to PREVENT adrenal Crisis:
- asses the pts risk for adrenal insufficiency
- gradually taper dose til at about prednisone _____ mg daily - give in AM
- then move to dosing of EVERY OTHER day
20;
Steroid Tapering: Can stop steroid when it reaches a \_\_\_\_\_\_\_\_ dose: which would be Hydrocortisone \_\_\_\_\_\_ Prednisone \_\_\_\_\_\_\_\_ Dexamethasone \_\_\_\_\_\_\_
physiologic; 20 mg/day; 5 - 7.5 mg/day; 0.75 mg/day
What kinds of drugs should be avoided to help prevent the development of hypocortisolism
(want to avoid CYP3A4 INDUCERS - bc inducers will increase the metabolism of cortisol and lead to hypocortisolism)
CYP3a4 inducers are: phenytoin, rifampin, barbiturates, carbamazepine
what drugs are CYP3a4 inducers
phenytoin, rifampin, barbiturates, carbamazepine
if a CYP3a4 inducer is present whilst using glucocorticoids - should you decrease or increase the dose of glucocorticoids
INCREASE dose
Ways to prevent hypercortisolism -
- give ________ GC dose and for the ______ amount of time
lowest;shortest
Ways to prevent hypercortisolism -
- give GC dose via administration routes that (decrease or increase) systemic absorption and what are examples of that
DECREASE; inhalation and topical
Ways to prevent hypercortisolism -
Give GC treatment (every day/ every other day/ twice a day)
every OTHER day
Ways to prevent hypercortisolism -
avoid GC doses with CYP3a4 (inducers or inhibitors)
inhibitors! CYP3a4 inhibitors will lead to too much GC in the body since the inhibitors are preventing the metabolism of GC
Examples of CYP3a4 inhibitors
protease inhibitors (drugs that end in -avir), antifungals
if a CYP3a4 inhibitor is being used while on GC dose - how should you change the GC dose to prevent possible drug interactions
DECREASE the dose - to prevent hypercortisolism
Counseling Points for GC Therapy:
let pt be aware of potential side effects: like ______ disturbances, ______ and _____ wound healing
visual; brusiing; delayed
primary adrenal insufficiency occurs at the ______ in the body
adrenal gland
what are causes of primary adrenal insufficiency
Main reason is Addison’s Disease; drugs and some infections can cause this too
what is the common cause for secondary adrenal insufficiency
EXOGENOUS steroid level/dose is too high
what is the common cause for tertiary adrenal insufficiency
EXOGENOUS steroid level/dose is too high
Primary/Secondary/Tertiary Adrenal Insufficiency - which one(s) need MINERALCORTICOID supplementation
ONLY primary - because adrenal gland will make MC; 2 and 3 don’t affect MC making….
Primary/Secondary/Tertiary Adrenal Insufficiency - which one(s) need lifelong supplementation
PRIMARY ONLY - 2 and 3 are usually due to too high of dose - just adjust dose until HPA adjusts
Cushings or Addisons Disease? “Pt looks great (aka Tan) but feels awful”
Addisons! (Pt pigmentation and weakness is addisions disease)
Weakness and Fatigue ar signs of Cushings or Addisons?
Addisons! (Remember cortisol is used in morning to help get you around…. lack of cortisol = tiredness - addisons has lack of cortisol….)
Treatment Goals of Adrenal Insufficiency:
- to mimic endogenous secretion of GC via ________
- replace both _________ and _______ deficiencies
- manage symptoms of adrenal insufficiency and prevent adrenal crisis
GC replacement therapy; GC; MC
Typical Dosing Regimen for Short Acting Steroid - using for Chronic Adrenal Insufficiency
Give 2/3 of dose in AM ( 6 - 8 am)
Give 1/3 of dose in early afternoon (2 - 4 pm)
Traditional Replacement for Adults with Chronic Adrenal Insufficiency
____________ at ____ mg/day
or
___________ at ____ mg/day
Hydrocortisone; 15 - 25; Cortisone; 20 - 35
If adrenal insufficient pt is going under stressful situation (infection/ surgery/fever) - what should happen to their GC dose?
INCREASE IT! body needs more steroid to compensate for the stress on the body
Adrenal insufficient patients should wear ________
a medical alert bracelet/ necklace
5 S’s of adrenal crisis management
steroids; salt; sugar; support; search
(support is fluid/hydration)
(search is for underlying cause)
What are signs of over replacement of steroids/HYPERcortisolism
- weight gain
- stretch marks
- impaired glucose tolerance
- High BP
- Central/trunkal obesity
