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
Why should systemic CS be used with caution in patients with ocular herpes simplex?
Risk of corneal perforation
What are the common or very common side effects of systemic CS?
- Neuro-psychiatric: Anxiety, behavioral changes, mood changes, psychosis, cognitive impairment, headache, sleep disorder
- electrolyte imbalance, fluid retention
- Subcapsular cataracts
- Cushing’s syndrome
- Fatigue
- Impaired healing
- Immune suppression and increased risk of infection
- Menstrual cycle irregularities
- Peptic ulcer
- Weight gain
What are the uncommon but important side effects of systemic CS? (19)
- Adrenal suppression
- Hypokalemia alkalosis (mineralocorticoid effect)
- Appetite increase
- Bone fracture and osteoporosis
- Osteonecrosis
- Impaired diabetic control
- Eye disorders including glaucoma, papilledema, blurred vision, chorioretinopathy
- hemorrhage
- HF
- Hyperhydrosis
- Leukocytosis
- Myopathy
- Pancreatitis
- Seizure
- Thromboembolism
- Reactivation of TB
- Vertigo
- Tendon rupture
- Growth retardation (children)
What is the concern regarding chickenpox in patients receiving systemic (oral or parenteral) corticosteroids who have NOT had chickenpox?
These patients should be regarded as being at risk of SEVERE chickenpox
Manifestations of fulminant illness include pneumonia, hepatitis and disseminated intravascular coagulation; rash is not necessarily a prominent feature
What is the treatment offered to non-immune patients receiving systemic corticosteroids (or for those who have used them within the previous 3 months) who have been exposed to chickenpox?
Passive immunization with VZIG
Confirmed chickenpox warrants specialist care and urgent treatment. Corticosteroids should not be stopped and dosage may need to be increased.
What psychiatric reactions are linked to high dose systemic corticosteroid treatment?
euphoria, insomnia, irritability, mood lability, suicidal thoughts, psychotic reactions, and behavioural disturbances
These reactions frequently subside on reducing the dose or discontinuing the corticosteroid but they may also require specific management. Patients should be advised to seek medical advice if psychiatric symptoms (especially depression and suicidal thoughts) occur and they should also be alert to the rare possibility of such reactions during withdrawal of corticosteroid treatment
What factors make psychiatric reactions more likely in patients taking high dose corticosteroids? (3)
- Previous episode of corticosteroid-induced psychosis
- Personal history of psychiatric disorder
- Family history of psychiatric disorder
Can systemic steroids be used in pregnancy?
Yes, benefits outweigh risks
CS coverage is required during labor
What are the risks associated with systemic CS use during pregnancy? (2)
- IUGR (not with short-term treatment though eg prophylactic treatment for NRDS in premie’s)
- Adrenal suppression in the neonate (resolves spontaneously after birth, rarely clinically important)
Is prednisolone safe in breastfeeding?
Yes, benefits outweigh risks
What is the guidance regarding treatment cessation in patients taking systemic corticosteroids?
The magnitude and speed of dose reduction in corticosteroid withdrawal should be determined on a case-by–case basis, taking into consideration the underlying condition that is being treated, and individual patient factors such as the likelihood of relapse and the duration of corticosteroid treatment.
What are the potential consequences of systemic CS withdrawal in adults? (10)
- acute adrenal insufficiency
- hypotension
- death
- fever
- myalgia
- arthralgia
- rhinitis
- conjunctivitis
- painful itchy skin nodules
- weight loss
Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have: (6)
- received more than 40 mg prednisolone (or equivalent) daily for more than 1 week
- been given repeat doses in the evening
- received more than 3 weeks’ treatment
- recently received repeated courses (particularly if taken for longer than 3 weeks)
- taken a short course within 1 year of stopping long-term therapy
- other possible causes of adrenal suppression
Systemic corticosteroids may be stopped abruptly in which patient populations? (3)
- In those whose disease is unlikely to relapse AND
- Who have received treatment for 3 weeks or LESS
AND - Who are not included in the patient groups that are at high risk of adrenal insufficiency
During corticosteroid withdrawal, the dose may be reduced _________ down to physiological doses and then reduced more ________. (Rapidly/Slowly)
During corticosteroid withdrawal the dose may be reduced RAPIDLY down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more SLOWLY.
Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur
What is a Steroid Emergency Card?
Cards issued to patients with adrenal insufficiency and steroid dependence for whom missed doses, illness, or surgery puts them at risk of adrenal crisis.
The card includes a management summary for the emergency treatment of adrenal crisis and can be issued by any healthcare professional managing patients with adrenal insufficiency or prescribing steroids.
A Steroid Emergency Card should be given to which groups of patients? (5)
- Those with primary adrenal insufficiency
- Those with adrenal insufficiency due to hypopituitarism requiring CS replacement
- Those taking CS at doses equivalent to or exceeding prednisolone 5 mg daily for 4 weeks or longer (across all routes of administration)
- Those taking CS at doses equivalent to or exceeding prednisolone 40 mg daily for longer than 1 week OR repeated short courses of oral CS
- Those taking a course of oral CS within 1 year of stopping long-term therapy
What are the actions of betamethasone?
Very high glucocorticoid activity and insignificant mineralocorticoid activity
What are the indications of betamethasone? (6)
- Local treatment of eye inflammation (short-term)
- Severe inflammatory skin disorders eg eczema unresponsive to less potent CS (including ears and nose)
- Psoriasis (under specialist care)
- Suppression of inflammatory and allergic disorders
- CAH
- Oral ulceration
7.
What are the contraindications for topical corticosteroids?
- Acne
- Perioral dermatitis
- Potent CS in widespread plaque psoriasis
- Rosacea
- Untreated bacterial, fungal, or viral skin lesions
Are intranasal CS safe to use after nasal surgery?
Avoid until healing has occurred
How often should topical CS preparations be applied?
No more than twice daily; once daily is often sufficient
One fingertip unit is approximately ____ mg from a tube with a standard 5 mm nozzle?
500
One fingertip unit is sufficient to cover an area that is how large?
Twice the area of a flat adult handprint (palm and fingers)
Can topical CS and emollients be applied simultaneously?
Several minutes should elapse between application
What types of drug interactions should be avoided when prescribing corticosteroids? (3)
- NSAIDs and aspirin (increased risk of GI bleed)
- Drugs that may cause hypokalemia (increased risk of torsade de pointes) ~ there are MANY
- Live vaccines including BCG and flu
What are the indications of hydrocortisone? (9)
- Thyroid storm (thyrotoxicosis) (IV)
- Adrenocortical insufficiency and adrenal crisis (IV or oral)
- Acute hypersensitivity reactions (IV)
- IBD (IV)
- Inflammatory skin disorders such as eczema, nappy rash (topical)
- Acute asthma (IV)
- Oral and perioral lesions
- Conjunctival inflammation (short term, topical)
- Severe or critical COVID-19
What is the potency of hydrocortisone cream?
Mild (0.5-2.5%)
What is the potency of betamethasone cream?
Moderate to potent (0.025% to 0.12%)
What are the indications for fludrocortisone? (3)
- Neuropathic postural hypotension
- Mineralocorticoid replacement in adrenocortical insufficiency
- Adrenocortical insufficiency resulting in septic shock (in combination with hydrocortisone)
What are the effects of methylprednisolone?
Predominantly glucocorticoid with minimal mineralocorticoid effects
What are the indications of methylprednisolone? (5)
- Suppression of inflammatory and allergic disorders
- Cerebral edema of malignancy
- Treatment of graft rejection reactions
- Treatment of MS relapse
- Joint and soft tissue inflammation (intra-articular)
Which two inflammatory conditions are ALWAYS treated with corticosteroids?
- PMR
- GCA
Relapse is common if therapy is stopped prematurely. Many patients require treatment for at least 2 years and in some patients it may be necessary to continue long-term low-dose corticosteroid treatment.
Polyarteritis nodosa and polymyositis are _________ treated with corticosteroids. (Always/usually/sometimes/never)
Usually
Is short- or long-term CS therapy preferred in the treatment of RA?
Long-term therapy should ONLY be considered after evaluating the risks and all other treatments have been considered
Short-term treatment can help rapidly decrease inflammatory symptoms
Do CS have a role in the treatment of SLE?
Yes, particularly patients with pleurisy, pericarditis, or other systemic manifestations
However, many mild cases of SLE do not require CS treatment; alternative treatment with anti-inflammatory analgesics, chloroquine or hydroxychloroquine should be considered
Is long-term CS therapy indicated in the treatment of Ankylosing Spondylitis?
No; rarely pulse doses may be needed in extremely active disease that does not respond to conventional treatment
What are the benefits of local corticosteroid injection? (5)
- Relieve pain
- Increase mobility
- Reduce deformity
- Symptomatic relief while waiting for DMARDs to take effect
Are full aseptic precautions necessary when performing intra-articular CS injections?
Yes; additionally, infected areas should be avoided
Do intra-articular CS injections have a role in the treatment of golfer’s elbow or tennis elbow?
Yes, small injection directly into the soft tissue offer relief of inflammation
Which corticosteroid is preferred for intra-articular injection?
Hydrocortisone or one of its synthetic analogues
When considering intra-articular CS injections, each joint should not usually be treated more than _______ times in one year
4
