Corticosteroid responsive conditions Flashcards
Corticosteroids can be used for
replacement therapy when there is an insufficiency or they can be used in the treatment of disease.
The adrenal cortex (in healthy individuals) secretes
• CORTISOL (glucocorticoid) and ALDOSTERONE (mineralocorticoid).
In replacement therapy,
•hydrocortisone is used to replace cortisol and fludrocortisone is used to replace aldosterone.
In glucocorticoid therapy of other diseases, hydrocortisone is
• rarely used since it also has mineralocorticoid activity which can lead to fluid retention. However, it is still useful for topical treatments.
Betamethasone and Dexamethasone have
• HIGHER GLUCOCORTICOID (=anti-inflammatory) and lower mineralocorticoid activity than Prednisolone making them a better drug for high-dose therapy. However, Prednisolone remains the drug of choice for most oral corticosteroid treatments since it has a larger margin of safety.
If oral corticosteroids are used, they should be
taken in the morning, so they don’t suppress the natural adrenal activity which is most active at NIGHT. (corticosteroids supress cortisol secretion).
Long-term treatment can lead to
• adrenal atrophy, abrupt withdrawal can lead to adrenal deficiency which may lead to hypotension or death. Withdrawal is also linked with cold and flu-like symptoms, itching and weight loss.
Patients should also be advised to
• stay clear of people with chickenpox, shingles or measles due to immunosuppression.
Steroids should also be used in caution in children due to
• possible growth restrictions.
Corticosteroids and anticoagulants
Corticosteroids may enhance the anticoagulant effects of warfarin at high doses; they may reduce anticoagulant effects at lower doses.
Mineralocorticoid side-effects
(most likely with fludrocortisone – most potent) include hypertension, sodium + water retention, and the loss of potassium and calcium. Aldosterone is a mineralocorticoid involved in the rennin- angiotensin system – hence increased sodium and decreased potassium and hydrogen ions
Glucocorticoid side-effects
include diabetes, osteoporosis (>3m use: prophylaxis with bisphosphonate), muscle wasting, psychiatric reactions; also, potentially peptic ulceration (take with/after food). High doses cause avascular necrosis of femoral head. Hydrocortisone is a glucocorticoid; it has anti- inflammatory + immunosuppressive effects (hence ulceration); they increase blood glucose levels (hence diabetes) and mobilise calcium (hence osteoporosis).
Side effects can be minimised by
using the lowest effective dose for the minimum time period.
Glucocorticoid and Mineralocorticoid activity
When comparing the potencies of corticosteroids in terms of their anti-inflammatory (glucocorticoid) effects it should be noted that high glucocorticoid activity in itself is of no advantage unless it is accompanied by relatively low mineralocorticoid activity.
• The high mineralocorticoid activity of Hydrocortisone
resulting in fluid retention, makes it unsuitable for long-term use. Thus, it is used on a short-term basis by I.V. injection for the emergency management of some conditions. The relatively moderate anti-inflammatory potency of hydrocortisone makes it a useful topical corticosteroid for inflammatory skin conditions because side effects are less marked.
Prednisolone and Prednisone have
• predominantly glucocorticoid activity. Prednisolone is the corticosteroid most commonly used by mouth for long-term disease suppression.
Betamethasone and Dexamethasone have
• a long duration of action and along with their lack of mineralocorticoid activity, they are suitable for conditions which require suppression of corticotropin secretion (e.g. congenital adrenal hyperplasia)
MHRA: Corticosteroids
Rare risk of central serous chorioretinopathy with local + systemic use. Report any blurred vision or other visual disturbances.
Adrenal suppression
- During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy (wasting) develops and can persist for years after stopping.
- Abrupt withdrawal after a prolonged period can lead to acute adrenal insuffiency, hypotension or death.
- To compensate for adrenal suppression caused by prolonged treatment… any significant intercurrent illness, trauma or surgical procedure requires a temporary increase in corticosteroid dose (or if already stopped, a temporary reintroduction of corticosteroid treatment).
Corticosteroids (systemic) Side effects mnemonic
ACHING BOSOM: Adrenal suppression/appetite larger, Cushing’s syndrome/cataracts, Hyperglycaemia/ Hyperlipidaemia, Infections/ insomnia, Nervous system (psychiatric reactions), Glaucoma/GI ulcers,
BP increased, Osteoporosis, Skin thinning, Obesity, Muscle wasting
Psychiatric reactions with Corticosteroids (systemic)
- High doses can cause psychiatric reactions (glucocorticoid side effect) including euphoria, insomnia nightmares, irritability and behavioural changes. These reactions frequently subside on reducing the dose or discontinuing the corticosteroid, but they may also require specific management.
- Thus, they should be used in caution in patients with a history of psychiatric problems.
- Patients should seek medical attention if they become depressed or have suicidal thoughts.
Abrupt withdrawal can lead to
to adrenal deficiency which may lead to hypotension or death. Withdrawal is also linked with cold and flu-like symptoms, itching and weight loss.
- However, systemic corticosteroids can be abruptly stopped in those whose disease is unlikely to relapse and have received treatment for 3 weeks or less and who are not included in the patient groups above.
- High-dose steroid treatment can suddenly be brought down to 7.5 mg prednisolone daily (or equivalent), as this is equal to the natural adrenal levels, and then decreased gradually
Gradual withdrawal by titration is needed if patients have any one of the following:
- Taking more than 40mg prednisolone for more than a week
- Taking evening doses
- Received more than 3 weeks treatment at any dose.
MHRA: Methylprednisolone (Solu-Medrone 40mg):
Contains lactose: DO NOT use is patients with cow’s milk allergy
