Corticosteroids Flashcards
Example of mineralocorticoid and the effects it exerts
Fludrocrotisone
High fluid retention and low anti-inflammatory
What is fludrocortisone used to treat?
Postural hypotension
Mineralocorticoid side effects
Sodium and water retention = hypertension
Potassium loss = hypokalaemia
Calcium loss = hypocalcaemia
Negligible with high potency glucocorticoids: betamethasone and dexamethasone
Examples of glucocorticoids and the effects they exert
Dexamethasone, betamethasone, prednisolone, prednisone and deflazacort
High anti-inflammatory effects and low fluid retention
Glucocorticoid side effects
Diabetes
Osteoporosis = osteoporotic fractures
Avascular necrosis of the femoral head and muscle wasting
Gastric ulceration and perforation
MHRA warning associated with corticosteroids
Rare risk of central serous chorioretinopathy with local as well as systemic administration
Report blurred vision or other visual disturbances
How to manage corticoidsteroids side effects?
Minimised by using the lowest effective dose
Minimum possible duration
Give single dose in the morning
Take total dose for two days as a single dose on alternate days
Intermittent therapy with short courses
Use local/topical treatment over systemic
Gradual withdrawal
Corticosteroid side effects
Psychiatric: insomnia, irritability, suicidal ideation
Adrenal suppression (can last years after treatment cessation)
Infection (as immunosuppressant)
Chickenpox ?
Insomnia
Skin thinning
Hyperglycaemia
Cushing’s syndrome
Hypertension
Peptic ulcer
Hypokalaemia
Stunted growth
When would gradual withdrawal be necessary?
More than 40mg prednisolone (or equivalent) daily for >1 week
Repeat evening doses
> 3 weeks treatment
Recently received repeated courses
Taken a short course within 1 year of stopping long-term therapy
Other possible causes of adrenal suppression
All entitled patients to be given a steroid card
Topical steroid potencies
Mild: hydrocortisone
Moderate: clobetasone, betamethasone 0.025%
Potent: betamethasone 0.1%
Very potent: clobetasol
What causes adrenal insufficiency?
Addison’s disease or congenital adrenal hyperplasia
Adrenal insufficiency treatment
Hydrocortisone (most similar to cortisol)
Prednisolone
Dexamethasone (rarely)
Primary adrenal insufficiency treated with fludrocortisone as well
Complications of adrenal insufficiency
Severe dehydration, hypovolaemic shock, altered consciousness, seizures, stroke, or cardiac arrest = death if untreated
Medical emergency – treat with hydrocortisone (brining water back into body treating hypotension)
How to manage patient with adrenal suppression and has significant illness, trauma or surgical procedure?
Should increase corticosteroid dose temporarily or temporary reintroduction if already stopped
Consequence of abrupt steroid withdrawal
Acute adrenal insufficiency, hypotension or death
What makes hydrocortisone unsuitable for disease suppression on a long-term basis?
The relatively high mineralocorticoid activity which results in fluid retention
Management of Cushing’s syndrome
Metyrapone
Ketoconazole
Endogenous causes of Cushing’s syndrome
Adrenocorticotrophic hormone (ACTH)-secreting pituitary tumours (Cushing’s disease)
Cortisol-secreting adrenal tumours
Ectopic ACTH-secreting tumours
Counselling for patient with adrenal insufficiency
Stress glucocorticoid dose i.e., increased dose during times of stress (surgical or invasive procedures) to prevent adrenal crisis
This is to maintain cortisol levels as close to the physiological concentration as possible
Sick day rules
How to manage glucocorticoid dose in patients with adrenal insufficiency who are unwell with moderate intercurrent illness (fever or infection requiring abx)?
Double daily dose
How to manage patients with adrenal insufficiency on long-acting hydrocortisone during an intercurrent illness?
Switch to short-acting, more rapidly absorbed preparations
How to manage patients with adrenal insufficiency with severe intercurrent illness (persistent vomiting)?
IM or IV hydrocortisone
When are patients with adrenal insufficiency at a higher risk of glucocorticoid deficiency?
If they are vomiting or have diarrhoea
What should a patient with established adrenal insufficiency be provided with?
An emergency hydrocortisone injection kit
Their family/carers should be trained in the administration of iM hydrocortisone and advised to go to hospital if vomiting or diarrhoea illness persist
