Clinical Application Of Steroids Flashcards by Kathryn Cannaday

What are the general principles of corticosteroid dosing with life-threatening conditions?

Large dose initially, if no response, double or triple the dose

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What are the general principles of corticosteroid dosing in chronic conditions?

-start with small dose, then gradually increase until tolerable relief is achieved
-start with high dose to resolve symptoms, then gradually decrease dose until tolerable relief is maintained

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What disease states should be taken into consideration before corticosteroid initiation?

History of: diabetes, HTN, cardiovascular disease, peptic ulcer disease, psychological disorders, or preexsiting osteoporosis- BECAUSE these diseases could be made worse by taking steroids

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What disease states influence steroid clearance?

-hyperthyroidism INCREASE clearance
-liver disease, age, pregnancy, hypothyroidism, anorexia nervosa, and protein-calorie malnutrition REDUCE clearance

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What medications influence steroid clearance?

-phenytoin, phenobarbital, rifampin INCREASES clearance
-estrogen REDUCES clearance

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What are the contraindications of steroid therapy?

Active systemic fungal infection, active tuberculosis, active infection (relative), and glaucoma (relative)

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Which steroids must be activated by the liver?

Cortisone, prednisone

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What are the endocrine and metabolic adverse effects of oral glucocorticoids?

Glucose intolerance, hyperglycemia, delayed growth in children

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What are the gastrointestinal adverse effects of oral glucocorticoids?

Increased appetite, indigestion, increased gastric acid and pepsin secretion

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What are the immune system adverse effects of oral glucocorticoids?

Immunosuppression, infections, delayed wound healing

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What are the cardiovascular adverse effects of oral glucocorticoids?

Hypertension, edema

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What are the ocular adverse effects of oral glucocorticoids?

Cataracts, glaucoma

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What are the CNS adverse effects of oral glucocorticoids?

Insomnia, nervousness, psychosis (high dose)

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Describe: Iatrogenic Cushing syndrome

Adverse effect of oral glucocorticoids associated with treatment with high dose for 2-3 weeks. Patients experience body habitual alterations such as, rounding of the face (moon facies), redistribution of fat to the face and trunk, thin and atrophic kin

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Describe: Steroid-induced Osteoporosis

Patients at risk if on oral glucocorticoids for more than 2 weeks, risk increases with dose, bone mineral density (BMD) must be obtained at baseline and every 6-12 months for 2 years, calcium, vitamin D, and bisphosphonate can be given for prevention

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What are important counseling points for patients on oral steroids?

-NEVER discontinue therapy with consulting PCP for risk of adrenal crisis which is life threatening
-take with food if GI upset occurs
-dose increase may be required in times of stress or emergency

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What are the monitoring parameters for someone on oral glucocorticoids?

Blood pressure, weight, glucose, electrolytes, eye exam, bone mineral density, growth and development (children and adolescents)

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What diseases are considered hypersecretory cortisol disorders?

-cushing disease= ACTH excess by pituitary
-Cushing syndrome= cortisol excess by adrenal

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How is Cushing diagnosed?

24h urine free cortisol, 2-3x normal, discover underlying etiology

How is Cushing Disease treated?

Surgery because typically etiology is tumor

How is Cushing syndrome treated?

Surgery if due to adrenal adenoma, if not then pharmaceutical therapy

What diseases are considered hyposecretory cortisol disorders?

-primary adrenal insufficiency (Addison’s Disease), categorized by > 90% destruction of adrenal gland caused by autoimmune, HIV, TB, cancer
-secondary adrenal insufficiency (disorder of the HPA system) caused by hypopituitarism or rapid withdrawal of glucocorticoids

What are the clinical features of adrenal insufficiency?

-flu-like syndrome with fatigue, malaise, nausea, anorexia, abdominal pain, arthralgia, and postural dizziness
-progressive symptoms (depends on severity): vomiting, fever, hypotension, shock
-increased skin pigmentation (primary) and vitiligo (secondary)
-labs: hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, eosinophilia
-hemodynamic instability and dependency on catecholamines despite control of infection

How is adrenal insufficiency diagnosed?

-cortisol level (random or free)
-ACTH stimulation test

What is the chronic treatment for Addison's Disease?

*this is the only disease that steroids "cure"* prednisone 5mg/day + fludrocortisone 0.05-0.2 mg/day

How is an acute adrenal crisis treated?

-hydrocortisone 100mg IV push STAT, then continuous infusion of 10 mg/hr or 50 mg IV q6h for 1st 24h -fluid replacement with D5NS to maintain blood pressure -day 2 reduce IV dose to 100 mg in divided doses -once stable, hydrocortisone 25mg q6-8h for 48h then taper

What are the clinical uses of steroids?

-addison's disease/adrenal insufficiency -respiratory disease -rheumatoid arthritis -systemic lupus erythematous -sepsis/shock -allergic reactions/anaphylaxis -organ transplant -pneumocystis jiroveci pneumonia (PCP) -dermatologic uses

How are steroids used for respiratory disorders?

-asthma: inhaled corticosteroids preferred in patients with persistent asthma, oral reserved for severe asthma -COPD: inhaled corticosteroids are added to B2 agonists for high risk patients -exacerbations: give bursts of oral steroids (5-7 days), but IV can be given for severe airway obstruction

How are steroids used for systemic lupus erythematous?

-acute flares: prednisone 1 mg/kg/day up to 60mg -mild disease: prednisone 10 mg/day for 4-6 weeks, maintenance therapy with ADT dosing for chronic therapy

How are steroids used for sepsis/shock?

*controversial with mixed data* could be used if pt failed fluids and vasopressors

How are steroids used in allergic reactions?

-mild: medrol DosePak or prednisone DosePak -severe: hydrocortisone 500mg IV or methylprednisolone 125mg x1, along with supportive therapy

How are steroids used in organ transplant?

steroids are used liberally to prevent rejection and during transplant rejection

What are the dermatologic uses of steroids?

-psoriasis -vitiligo -atopic dermatitis -radiation-induced dermatitis -eczema -lichen sclerosis *lots of off-label uses as well*

What are the rules for steroid potency when treating dermatologic conditions?

-low-to-medium potency agents are usually effective for treating thin, acute, inflammatory skin lesions -high to ultra high potency agents are often required for treating chronic, hyperkeratotic, or lichenified lesions -for face and intertriginous areas, used low potency agent (high potency could be used for a SHORT duration) -for palms of hands or soles of feet use high or ultra high potency agents

When would topical steroid vehicle, OINTMENT, be appropriate?

dry, thick, hyperkeratotic areas (should not be used in hairy or intertriginous areas)

When would topical steroid vehicle, CREAM, be appropriate?

intertriginous areas and for acute exudative inflammation

When would topical steroid vehicle, LOTION, be appropriate?

can be used in hairy areas

When would topical steroid vehicle, GEL, be appropriate?

useful for exudative inflammation, or on hairy area

How long can high or ultra high potency topical steroids be used?

2-3 weeks

What are the adverse effects of topical steroids?

-percutaneous absorption -skin atrophy -rebound papular dermatitis after medium-high potency -striae formation -systemic absorption can occur in high and ultra-high potency so SE of oral corticosteroids

What are important patient counseling points for topical steroids?

-apply sparingly and only to areas of skin affected by the skin disease -apply only as often as prescribed (daily or BID) -once disease is under control, application may be reduced or discontinued -wash hands after each application

How long does it take for the HPA axis (pituitary and adrenal) to become responsive after chronic steroid therapy?

2-3 months

Why is tapering important when attempting to discontinue steroid therapy?

if dose is reduced too quickly, acute or chronic adrenal insufficiency could occur

What is the typically taper schedule?

-step one (consolidation): convert multiple daily doses to once daily in the morning -step two (rapid taper): decrease dose by 2.5-5 mg prednisone every 3-7 days until physiologic dose reached (5 mg/day of prednisone) -step three (slow taper): decrease by 1 mg prednisone or equivalent per week *if symptoms worsen then increase dose until symptoms resolve*

When are stress replacement doses required?

in patients that are on more than 5 mg prednisone or equivalent or have been off of steroids for <3 months, dose should be doubled in times of physical stress (illness or injury) and even more for surgery