Corticosteroid responsive conditions

Question 1

What are the two types of corticosteroids ?

Answer 1

those that have high mineralocorticoid activity (fluid retention) and those that have high glucocorticoid activity( high anti-inflammatory effects)

Question 2

If corticosteroid have high mineralocorticoid activity what side effects would you expect?

Answer 2

fluid retention ( Na and water retention)
K and Ca loss

Question 3

In what conditions is fludrocortsone beneficial and why ?

Answer 3

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

Question 4

Why hydrocortisone is not used long term in disease suppression?

Answer 4

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.

Question 5

Which two steroids have negligible mineralocorticoid side effects?

Answer 5

Bethamethsaone, dexamethasone

Question 6

Which two steroids have highest glucocorticoid activity ?

Answer 6

dexamethasone and bethamethasone are most potent, therefore used if fluid retention is a disadvantage e.g. HF, liver failure, renal failure

Question 7

Which two steroids have significant glucocorticoid activity ?

Answer 7

prednisolone/prednisone

deflazcort

Question 8

What are glucorticoid side effects?

Answer 8

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

Question 9

Glucocorticoids cause immunsupression that can lead to infections, so what advice you would give regarding it ?

Answer 9

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

Question 10

What skin side effects glucorticoids can cause ?

Answer 10

skin thinning, purple-red strae, bruising

Question 11

What eye side effects glucocorticoids can cause ?

Answer 11

glaucoma, cataracts

rare risk of central serous chorioretinopathy with local and systemic use

Question 12

what side effects can high doses of glucocorticoids cause ?

Answer 12

Cushing syndrome

Question 13

what CNS side effects can glucocorticoids cause ?

Answer 13

aggravated epilepsy, schizophrenia

Question 14

what are important patient counselling points for people who are on steroids ?

Answer 14

risk of infections
adrenal supresion
psychiatric reactions
withdrawal of corticosteroids

Question 15

How would you best advise to manage corticosteroids side effects ?

Answer 15

lowest effective dose
local treatment over systemic
single dose in the morning
alternate days of administration intermittently with short course

Question 16

why corticosteroids are best given as single dose in the morning and on alternate days to minimise side effects?

Answer 16

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

Question 17

which patient groups should avoid abrupt withdrawal of corticosteroids?

Answer 17

• 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

Question 18

are corticosteroids safe during pregnancy ? should there be any monitoring?

Answer 18

yes generally safe, monitor fluid retention

Question 19

What is Addisons disease?

Answer 19

low cortisol

low aldosterone

Question 20

What treatment can be given for Addisons disease?

Answer 20

replacement with hydrocortisone and fludrocortisone

Question 21

Why in Addisons disease hydrocortisone and fludrocortisone are given as combination?

Answer 21

low cortisol ( natural glucortcioid)- hydrocortisone is cortisol
low aldosterone ( natural mineralocorticoid ): fludrocortsione which has mineralocorticoid activity

Question 22

what is hypotuitarism ?

Answer 22

pituitary gland does not stimulate hormone secretion by target glands

Question 23

why in hypotutitarism you only need hydrocortisone but not fludrocortisone?

Answer 23

rening-angiiotensin systemi will regulate aldosterone. however other hormones will have to be replaced: sex hormones, thyroid hormones

Question 24

What is Cushing syndrome disease and what are the symptoms ?

Answer 24

High cortisol levels
Symptoms: skin thinning, easy bruising, redish-purple stretch marks, striae, fat deposits in the face, moon face, acne, hirsutism, amenorrhea

Question 25

what are the causes of Cushing syndrome disease ?

Answer 25

corticosteroids: reduce dose or withdraw

tumour

Question 26

what are the two drugs that can inhibit cortisol ?

Answer 26

metyrapone ( competitive) and ketocenazole ( potent)

Question 27

what is the main risk that can lead to death when using cortisol inhibiting drugs ?

Answer 27

adrenal insufficiency

Question 28

What are the symptoms of adrenal insufficiency ?

Answer 28

fatigue, anorexia, nausea, vomiting, hypotension, adrenal suppression causes hyponatraemia, hyperkalaemia, hypoglycaemia

Question 29

what drug can be used to treat Cushing syndrome caused by a tumour ?

Answer 29

ketocenazole

Question 30

why ketocenazole is rarely used ?

Answer 30

life-threatening hepatoxicity

Question 31

what patient counselling should you give for people who are taking ketocenazole ?

Answer 31

report signs of liver toxicity: anorexia, abdominal pain (upper right) , dark urine, jaundice, itching, pale stools, nausea and vomiting