Corticosteroid responsive conditions Flashcards
What are the two types of corticosteroids ?
those that have high mineralocorticoid activity (fluid retention) and those that have high glucocorticoid activity( high anti-inflammatory effects)
If corticosteroid have high mineralocorticoid activity what side effects would you expect?
fluid retention ( Na and water retention) K and Ca loss
In what conditions is fludrocortsone beneficial and why ?
Fludrocortisone has most potent mineralocorticoid activity.
In conditions where fluid retention is beneficial e.g. low BP, adrenal insufficiency due to septic shock
Anti-inflammatory effect of no clinical relevance
Why hydrocortisone is not used long term in disease suppression?
Because it has significant amount of mineralocorticoid activity which will lead to fluid retention and thats why only used for short term basis via IV in surgeries or emergencies e.g. life threatening asthma or thyrotoxicosis.
Which two steroids have negligible mineralocorticoid side effects?
Bethamethsaone, dexamethasone
Which two steroids have highest glucocorticoid activity ?
dexamethasone and bethamethasone are most potent, therefore used if fluid retention is a disadvantage e.g. HF, liver failure, renal failure
Which two steroids have significant glucocorticoid activity ?
prednisolone/prednisone
deflazcort
What are glucorticoid side effects?
Endocrine ( hyperglycaemia)
osteoporosis ( > 3 months use: prophylaxis with bisphosphonates)
muscle wasting, proximal myopathy: caution with statins
Peptic ulcers, dyspepsia: take with or after food
Psychiatric reactions: especially in high doses, paranoid state or depression with suicide risk while taking or during withdrawal, can cause mood changes like euphoria,insomina, delusion, nightmares
immunosuppression infections
adrenal suppression:risk one year after stopping
Glucocorticoids cause immunsupression that can lead to infections, so what advice you would give regarding it ?
avoid close contact to chickenpox or shingles, exposed non-immune patients need passive immunisation with varicella booster vaccine. This applies to those who are currently taking it and those who have stopped in the last 3 months.
avoid exposure to measles
What skin side effects glucorticoids can cause ?
skin thinning, purple-red strae, bruising
What eye side effects glucocorticoids can cause ?
glaucoma, cataracts
rare risk of central serous chorioretinopathy with local and systemic use
what side effects can high doses of glucocorticoids cause ?
Cushing syndrome
what CNS side effects can glucocorticoids cause ?
aggravated epilepsy, schizophrenia
what are important patient counselling points for people who are on steroids ?
risk of infections
adrenal supresion
psychiatric reactions
withdrawal of corticosteroids
How would you best advise to manage corticosteroids side effects ?
lowest effective dose
local treatment over systemic
single dose in the morning
alternate days of administration intermittently with short course
why corticosteroids are best given as single dose in the morning and on alternate days to minimise side effects?
on alternate days given to reduce adrenal suppression
given as single dose in the morning because so that not disrupt sleep and because suppressive action on cortisol secretion is least in the morning
which patient groups should avoid abrupt withdrawal of corticosteroids?
- long term use >3 weeks
- > 40 mg prednisolone per day or equivalent for more than one week
- repeat doses are taken in the evening
- recent repeated courses
- short courses within one year of stopping long term steroids
- have other causes of adrenal suppression
are corticosteroids safe during pregnancy ? should there be any monitoring?
yes generally safe, monitor fluid retention
What is Addisons disease?
low cortisol
low aldosterone
What treatment can be given for Addisons disease?
replacement with hydrocortisone and fludrocortisone
Why in Addisons disease hydrocortisone and fludrocortisone are given as combination?
low cortisol ( natural glucortcioid)- hydrocortisone is cortisol low aldosterone ( natural mineralocorticoid ): fludrocortsione which has mineralocorticoid activity
what is hypotuitarism ?
pituitary gland does not stimulate hormone secretion by target glands
why in hypotutitarism you only need hydrocortisone but not fludrocortisone?
rening-angiiotensin systemi will regulate aldosterone. however other hormones will have to be replaced: sex hormones, thyroid hormones
What is Cushing syndrome disease and what are the symptoms ?
High cortisol levels
Symptoms: skin thinning, easy bruising, redish-purple stretch marks, striae, fat deposits in the face, moon face, acne, hirsutism, amenorrhea
what are the causes of Cushing syndrome disease ?
corticosteroids: reduce dose or withdraw
tumour
what are the two drugs that can inhibit cortisol ?
metyrapone ( competitive) and ketocenazole ( potent)
what is the main risk that can lead to death when using cortisol inhibiting drugs ?
adrenal insufficiency
What are the symptoms of adrenal insufficiency ?
fatigue, anorexia, nausea, vomiting, hypotension, adrenal suppression causes hyponatraemia, hyperkalaemia, hypoglycaemia
what drug can be used to treat Cushing syndrome caused by a tumour ?
ketocenazole
why ketocenazole is rarely used ?
life-threatening hepatoxicity
what patient counselling should you give for people who are taking ketocenazole ?
report signs of liver toxicity: anorexia, abdominal pain (upper right) , dark urine, jaundice, itching, pale stools, nausea and vomiting
