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Therapeutics 1 > Clinical Application Of Steroids > Flashcards

Clinical Application Of Steroids Flashcards

1
Q

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

A

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

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2
Q

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

A

-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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3
Q

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

A

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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4
Q

What disease states influence steroid clearance?

A

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

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5
Q

What medications influence steroid clearance?

A

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

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6
Q

What are the contraindications of steroid therapy?

A

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

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7
Q

Which steroids must be activated by the liver?

A

Cortisone, prednisone

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8
Q

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

A

Glucose intolerance, hyperglycemia, delayed growth in children

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9
Q

What are the gastrointestinal adverse effects of oral glucocorticoids?

A

Increased appetite, indigestion, increased gastric acid and pepsin secretion

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10
Q

What are the immune system adverse effects of oral glucocorticoids?

A

Immunosuppression, infections, delayed wound healing

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11
Q

What are the cardiovascular adverse effects of oral glucocorticoids?

A

Hypertension, edema

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12
Q

What are the ocular adverse effects of oral glucocorticoids?

A

Cataracts, glaucoma

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13
Q

What are the CNS adverse effects of oral glucocorticoids?

A

Insomnia, nervousness, psychosis (high dose)

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14
Q

Describe: Iatrogenic Cushing syndrome

A

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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15
Q

Describe: Steroid-induced Osteoporosis

A

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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16
Q

What are important counseling points for patients on oral steroids?

A

-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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17
Q

What are the monitoring parameters for someone on oral glucocorticoids?

A

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

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18
Q

What diseases are considered hypersecretory cortisol disorders?

A

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

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19
Q

How is Cushing diagnosed?

A

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

20
Q

How is Cushing Disease treated?

A

Surgery because typically etiology is tumor

21
Q

How is Cushing syndrome treated?

A

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

22
Q

What diseases are considered hyposecretory cortisol disorders?

A

-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

23
Q

What are the clinical features of adrenal insufficiency?

A

-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

24
Q

How is adrenal insufficiency diagnosed?

A

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

25
Q

What is the chronic treatment for Addison’s Disease?

A

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

26
Q

How is an acute adrenal crisis treated?

A

-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

27
Q

What are the clinical uses of steroids?

A

-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

28
Q

How are steroids used for respiratory disorders?

A

-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

29
Q

How are steroids used for systemic lupus erythematous?

A

-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

30
Q

How are steroids used for sepsis/shock?

A

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

31
Q

How are steroids used in allergic reactions?

A

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

32
Q

How are steroids used in organ transplant?

A

steroids are used liberally to prevent rejection and during transplant rejection

33
Q

What are the dermatologic uses of steroids?

A

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

34
Q

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

A

-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

35
Q

When would topical steroid vehicle, OINTMENT, be appropriate?

A

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

36
Q

When would topical steroid vehicle, CREAM, be appropriate?

A

intertriginous areas and for acute exudative inflammation

37
Q

When would topical steroid vehicle, LOTION, be appropriate?

A

can be used in hairy areas

38
Q

When would topical steroid vehicle, GEL, be appropriate?

A

useful for exudative inflammation, or on hairy area

39
Q

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

A

2-3 weeks

40
Q

What are the adverse effects of topical steroids?

A

-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

41
Q

What are important patient counseling points for topical steroids?

A

-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

42
Q

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

A

2-3 months

43
Q

Why is tapering important when attempting to discontinue steroid therapy?

A

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

44
Q

What is the typically taper schedule?

A

-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

45
Q

When are stress replacement doses required?

A

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

Therapeutics 1 (16 decks)

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