Corticosteroid Responsive Conditions

Question 1

The adrenal cortex secretes which compounds?

Answer 1

Hydrocortisone (cortisol) and aldosterone.

Question 2

What activity does hydrocortisone (cortisol) have?

Answer 2

Glucocorticoid activity and some mineralocorticoid activity.

Question 3

What activity does aldosterone have?

Answer 3

Mineralocorticoid activity.

Question 4

What are glucocorticoids?

Answer 4

Any of a group of corticosteroids (e.g. hydrocortisone) which are involved in the metabolism of carbohydrates, proteins, and fats and have anti-inflammatory activity.

Question 5

What are mineralocorticoids?

Answer 5

Mineralocorticoids are produced in the adrenal cortex and influence salt and water balances (electrolyte balance and fluid balance).

Question 6

In deficiencies of corticosteroids (e.g. Addison’s disease). how is physiological replacement best achieved?

Answer 6

By use of a combination of oral hydrocortisone and the mineralocorticoid fludrocortisone acetate. Hydrocortisone alone does not provide sufficient mineralocorticoid activity for complete replacement.

Question 7

How is corticosteroid replacement therapy given in terms of dosage?

Answer 7

Replacement therapy is given in two doses, one larger in the morning and one smaller in the evening. This is to mimic the normal rhythm of cortisol secretion.

Question 8

How is acute adrenocortical insufficiency treated?

Answer 8

By administration of IV hydrocortisone every 6 to 8 hours.

Question 9

How is oral hydrocortisone used in the treatment of hypopituitarism?

Answer 9

Only hydrocortisone is given as a mineralocorticoid is not required due to the remaining function of the adrenal glands.

Question 10

Alongside oral hydrocortisone, what other therapy may be required for the treatment of hypopituitarism?

Answer 10

Replacement therapy with levothyroxine and sex hormones, as indicated by the pattern of hormone deficiency.

Question 11

When comparing corticosteroids, what is important to take into account?

Answer 11

High glucocorticoid activity (anti-inflammatory) in itself is of no advantage unless it is accompanied by relatively low mineralocorticoid activity. E.g. the mineralocorticoid activity of fludrocortisone is so high that its anti-inflammatory activity is of no clinical relevance.

Question 12

Describe the duration of action of betamethasone and dexamethasone.

Answer 12

Long duration.

Question 13

Describe the corticosteroid activity of betamethasone and dexamethasone.

Answer 13

Very high glucocorticoid activity, insignificant mineralocorticoid activity.

Question 14

When is the use of betamethasone and dexamethasone most appropriate?

Answer 14

High dose therapy in conditions where fluid retention would be a disadvantage.

Question 15

What is the corticosteroid most commonly used by mouth for disease suppression?

Answer 15

Prednisolone.

Question 16

Describe the corticosteroid activity of prednisolone and prednisone.

Answer 16

Predominantly glucocorticoid.

Question 17

Which drug is derived from prednisolone and has a high glucocorticoid activity?

Answer 17

Deflazacort.

Question 18

What characteristic of hydrocortisone makes it unsuitable for use in long-term disease suppression?

Answer 18

The mineralocorticoid activity and associated fluid retention.

Question 19

Although it is unsuitable for long-term disease suppression, what therapy can oral hydrocortisone be used for?

Answer 19

Adrenal replacement therapy.

Question 20

Where are corticosteroids produced?

Answer 20

The adrenal cortex.

Question 21

Describe the physiological effects of glucocorticoids.

Answer 21

They have an effect on carb, fat, and protein metabolism. They have anti-inflammatory, immunosuppressive, antiproliferative and vasoconstrictive effects.

Question 22

Describe the physiological effects of mineralocorticoids.

Answer 22

They are primarily involved in the regulation of electrolyte and water balance.

Question 23

With which corticosteroid are mineralocorticoid side effects most marked with?

Answer 23

Fludrocortisone.

Question 24

Which corticosteroids show significant mineralocorticoid side effects?

Answer 24

Hydrocortisone, corticotropin, and tetracosactide.

Question 25

Which corticosteroids show negligible mineralocorticoid side effects?

Answer 25

The high potency glucocorticoids such as betamethasone and dexamethasone.

Question 26

Which corticosteroids show slight mineralocorticoid side effects?

Answer 26

Methylprednisolone, prednisolone, and triamcinolone.

Question 27

Give some mineralocorticoid side effects.

Answer 27

Hypertension, sodium retention, water retention, potassium loss, calcium loss.

Question 28

Give some glucocorticoid side effects.

Answer 28

Diabetes, osteoporosis (especially in the elderly), avascular necrosis of the femoral head (high doses), proximal myopathy, peptic ulceration (weak link), psychiatric reactions, Cushing’s syndrome (high doses), weight gain/increased appetite.

Question 29

When a patient is on corticosteroid therapy, what warning signs should be reported to the doctor?

Answer 29

Paradoxical bronchospasm, uncontrolled asthma, adrenal suppression, frequent courses of antibiotics and/or corticosteroids, immunosuppression, psychiatric reactions.

Question 30

How long after withdrawal of long-term corticosteroid therapy can adrenal atrophy persist for?

Answer 30

Years after treatment.

Question 31

What can acute adrenal suppression lead to? What are the signs of this?

Answer 31

Hypotension or death. Signs include: fever, nausea, vomiting, weight loss, fatigue, headache, muscular weakness. Can occur after abrupt withdrawal of prolonged treatment.

Question 32

In which patients should gradual reduction of corticosteroid therapy be considered?

Answer 32

Patients who have received more than 40mg prednisolone (or equivalent) daily for more than one week. Patients who have been given repeat evening doses of corticosteroids. Patients who have received treatment for more than three weeks.

Question 33

Which psychiatric symptoms would one want to report to the doctor when using corticosteroids?

Answer 33

Aggravation of epilepsy or schizophrenia, euphoria, suicidal thoughts, nightmares, depression, insomnia. These usually subside upon dose reduction.

Question 34

What monitoring is required when a patient is on corticosteroid therapy?

Answer 34

Blood pressure, blood lipids, serum potassium, body weight and height in children and adolescents (growth can be suppressed), bone mineral density, blood glucose, eye exam (for IOP and cataracts), signs of adrenal suppression.

Question 35

How should pregnant women with fluid retention from corticosteroid use be monitored?

Answer 35

Closely.

Question 36

The metabolism of corticosteroids is accelerated by which drugs?

Answer 36

Carbamazepine, phenobarbital, phenytoin, rifamycins.

Question 37

What effect may corticosteroids have on coumarins?

Answer 37

They may induce or enhance the anticoagulant effect of coumarins.

Question 38

What effect can high dose corticosteroids have on the administration of vaccines?

Answer 38

They may impair immune response to vaccines. Avoid concomitant use with live vaccines.

Question 39

What effect can corticosteroids have when used with NSAIDs (including aspirin)?

Answer 39

They may mask the gastrointestinal effects of NSAIDS and aspirin. Avoid concomitant use if possible and consider gastroprotection.

Question 40

When given with other drugs which can lower serum potassium levels, what effect can corticosteroids have?

Answer 40

Severe hypokalaemia can be seen.

Question 41

How are the effects of antihypertensive and oral hypoglycaemic drugs affected by the use of corticosteroids?

Answer 41

Their effects are antagonised.