Corticosteroids Flashcards
What is the role of corticosteroids in the management of psoriasis?
Should be avoided or used only under specialist supervision
What are the different types of steroids? (3)
- Mineralocorticoid (aldosterone, 11-deoxycorticosterone)
- Glucocorticoid (cortisol, corticosterone)
- Sex hormones (androgen, progestogen, estrogen)
Which synthetic corticosteroid is used for its potent mineralocorticoid activity?
Fludrocortisone
May be used to treat postural hypotension in autonomic neuropathy
What are the naturally synthesized mineralocorticoids? (2)
- Aldosterone (most potent)
2. Deoxycorticosterone (much weaker)
What are the naturally synthesized glucocorticoids? (2)
- Cortisol
2. Corticosterone
Which synthetic corticosteroid are used for their potent glucocorticoid activity? ()
- Dexamethasone
- Betamethasone
Very little mineralocorticoid activity; suitable for suppressing corticotropin in CAH
When should glucocorticoids be given in order to provide the greatest HPA axis suppression?
At night
Eg dexamethasone for treatment of CAH, dexamethasone suppression test for diagnosis of Cushing’s
In most individuals a single dose of dexamethasone at night, is sufficient to inhibit corticotropin secretion for _________.
24 hours
This is the basis of the ‘overnight dexamethasone suppression test’ for diagnosing Cushing’s syndrome.
Which type of corticosteroids would be preferred for use in patients with potential to suffer from water retention?
Corticosteroids with little to no mineralocorticoid activity eg betamethasone and dexamethasone
In which cases of raised ICP/cerebral edema can corticosteroid administration be beneficial?
When caused by malignancy
However, a corticosteroid should not be used for the management of head injury or stroke because it is unlikely to be of benefit and may even be harmful.
Do corticosteroids have a role in the management of increased ICP/cerebral edema caused by trauma or stroke?
No, only malignancy
In the management of head injury or stroke they are unlikely to be of benefit and may even be harmful.
What is the preferred corticosteroid in cases of acute hypersensitivity reactions?
Hydrocortisone IV
What are the mineralocorticoid side effects of corticosteroids? (5)
- HTN
- Na retention
- Water retention
- K loss
- Ca loss
(Think about the effects of aldosterone)
Most marked with fludrocortisone but significant with hydrocortisone, corticotropin, and tetracosactide
Occur only slightly with betamethasone and dexamethasone, methylprednisolone, prednisolone, and triamcinolon
What are the glucocorticoid side effects of corticosteroids? (6)
- DM
- Osteoporosis
- Avascular necrosis of the femoral head
- Muscle wasting (proximal myopathy)
- Peptic ulcers and perforation
- Psychiatric reactions (psychosis)
How are side-effects of corticosteroids minimized? (2)
- By using the lowest effective dose for the minimum period possible
- Whenever possible, local treatment with creams, intra-articular injections, inhalations, eye-drops, or enemas should be used in preference to systemic treatment
The suppressive action of a corticosteroid on cortisol secretion is least when it is given as a single dose in the ___________.
Morning
In an attempt to reduce pituitary-adrenal suppression further, the total dose for two days can sometimes be taken as a single dose on alternate days; pituitary-adrenal suppression can also be reduced by means of intermittent therapy with short courses
(Risk of adrenal suppression leading to adrenal insufficiency, adrenal crisis)
Do inhaled corticosteroids have significant systemic effects?
Yes, but significantly fewer than oral
How do corticosteroids cause adrenal insufficiency and adrenal crisis?
By providing negative feedback to the hypothalamic-pituitary-adrenal axis
(In the presence of exogenous steroids the adrenals shut down; when exogenous drugs are discontinued, they are inactive so no endogenous steroid :( make take some time to get adrenals back online…)
Who is at risk of adrenal crisis? (2)
Patients who are STEROID DEPENDENT:
- Primary adrenal insufficiency (Addison’s disease, CAH, HPA damage from tumors or surgery)
- Secondary adrenal insufficiency (patients who take oral, inhaled, or topical steroids for other medical conditions)
https://www.england.nhs.uk/wp-content/uploads/2020/08/NPSA-Emergency-Steroid-Card-FINAL-2.3.pdf
What are the triggers of adrenal crisis in patients with adrenal insufficiency? (3)
- Acute illness
- Trauma
- Surgery
In these cases, patients need an INCREASED dose of steroid
https://www.england.nhs.uk/wp-content/uploads/2020/08/NPSA-Emergency-Steroid-Card-FINAL-2.3.pdf
What are the signs and symptoms of adrenal crisis? (15)
- Abdominal pain or flank pain
- Confusion, LOC, or coma
- Dehydration
- Dizziness or lightheadedness
- Fatigue, severe weakness
- Headache
- High fever
- Loss of appetite
- Hypotension
- Hypoglycemia
- N/V
- Tachycardia
- Tachypnea
- Unusual and excessive sweating on face or palms
- Slow, sluggish movement
What are the main indications of prednisolone? (15)
Predominantly glucocorticoid effects with minimal mineralocorticoid effects
- COPD acute exacerbation (oral)
- Mild to severe croup (before transfer to hospital) (oral)
- Acute asthma (oral)
- Suppression of inflammatory and allergic disorders (oral)
- ITP (oral)
- IBD (oral or rectal suppository/enema)
- MG (oral)
- RA (oral)
- PMR (oral)
- GCA (oral)
- Polyarteritis nodosa (oral)
- Polymyosotis (oral)
- SLE (oral)
- Moderate-severe Pneumocystis pneumonia in patients with HIV (oral)
What are the contraindications to use of systemic corticosteroids? (2)
- Systemic infection (unless specific therapy given)
2. Avoid live virus vaccines in those receiving immunosuppressive doses (serum antibody response diminished)
Why should systemic corticosteroids be used with caution in patients with congestive HF?
Risk of fluid retention from mineralocorticoid effects
Why should systemic CS be used with caution in diabetic patients?
Hyperglycemia caused by glucocorticoid effects
Why should systemic CS be used with caution in patients with untreated or active infection, diverticulitis, or recent bowel anastomosis?
Increased risk of disseminated infection due to immunosuppressive effects of CS
**also impaired wound healing in bowel anastomosis
Why should systemic CS be used with caution in children, post-menopausal women, and the elderly?
Risk of osteoporosis