Corticosteroids

Question 1

Example of mineralocorticoid and the effects it exerts

Answer 1

Fludrocrotisone
High fluid retention and low anti-inflammatory

Question 2

What is fludrocortisone used to treat?

Answer 2

Postural hypotension

Question 3

Mineralocorticoid side effects

Answer 3

Sodium and water retention = hypertension
Potassium loss = hypokalaemia
Calcium loss = hypocalcaemia
Negligible with high potency glucocorticoids: betamethasone and dexamethasone

Question 4

Examples of glucocorticoids and the effects they exert

Answer 4

Dexamethasone, betamethasone, prednisolone, prednisone and deflazacort

High anti-inflammatory effects and low fluid retention

Question 5

Glucocorticoid side effects

Answer 5

Diabetes
Osteoporosis = osteoporotic fractures
Avascular necrosis of the femoral head and muscle wasting
Gastric ulceration and perforation

Question 6

MHRA warning associated with corticosteroids

Answer 6

Rare risk of central serous chorioretinopathy with local as well as systemic administration

Report blurred vision or other visual disturbances

Question 7

How to manage corticoidsteroids side effects?

Answer 7

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

Question 8

Corticosteroid side effects

Answer 8

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

Question 9

When would gradual withdrawal be necessary?

Answer 9

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

Question 10

Topical steroid potencies

Answer 10

Mild: hydrocortisone
Moderate: clobetasone, betamethasone 0.025%
Potent: betamethasone 0.1%
Very potent: clobetasol

Question 11

What causes adrenal insufficiency?

Answer 11

Addison’s disease or congenital adrenal hyperplasia

Question 12

Adrenal insufficiency treatment

Answer 12

Hydrocortisone (most similar to cortisol)
Prednisolone
Dexamethasone (rarely)

Primary adrenal insufficiency treated with fludrocortisone as well

Question 13

Complications of adrenal insufficiency

Answer 13

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)

Question 14

How to manage patient with adrenal suppression and has significant illness, trauma or surgical procedure?

Answer 14

Should increase corticosteroid dose temporarily or temporary reintroduction if already stopped

Question 15

Consequence of abrupt steroid withdrawal

Answer 15

Acute adrenal insufficiency, hypotension or death

Question 16

What makes hydrocortisone unsuitable for disease suppression on a long-term basis?

Answer 16

The relatively high mineralocorticoid activity which results in fluid retention

Question 17

Management of Cushing’s syndrome

Answer 17

Metyrapone
Ketoconazole

Question 18

Endogenous causes of Cushing’s syndrome

Answer 18

Adrenocorticotrophic hormone (ACTH)-secreting pituitary tumours (Cushing’s disease)

Cortisol-secreting adrenal tumours

Ectopic ACTH-secreting tumours

Question 19

Counselling for patient with adrenal insufficiency

Answer 19

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

Question 20

How to manage glucocorticoid dose in patients with adrenal insufficiency who are unwell with moderate intercurrent illness (fever or infection requiring abx)?

Answer 20

Double daily dose

Question 21

How to manage patients with adrenal insufficiency on long-acting hydrocortisone during an intercurrent illness?

Answer 21

Switch to short-acting, more rapidly absorbed preparations

Question 22

How to manage patients with adrenal insufficiency with severe intercurrent illness (persistent vomiting)?

Answer 22

IM or IV hydrocortisone

Question 23

When are patients with adrenal insufficiency at a higher risk of glucocorticoid deficiency?

Answer 23

If they are vomiting or have diarrhoea

Question 24

What should a patient with established adrenal insufficiency be provided with?

Answer 24

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

Question 25

Treatment of adrenal crisis

Answer 25

Hydrocortisone

Rehydration using sodium chloride

Question 26

Treatment of adrenal crisis in patients usually on fludrocortisone?

Answer 26

High-dose hydrocortisone