Corticosteroids Flashcards
Give 3 examples of inhaled corticosteroids?
- Beclomethasone
- Budesonide
- Fluticasone
How can systemic corticosteroids be administered?
- IV
- Oral
Give 3 examples of systemic corticosteroids
- Prednisolone
- Dexamethasone
- Hydrocortisone
What is mechanism of action of steroids?
Reduce inflammation by causing up regulation of anti-inflammatory mediators
What effect do steroids have on the respiratory system
Dilates airway and reduces mucosal inflammation and mucus production
How do steroids exert their effects on the respiratory system?
Binding to steroid receptors and mimicing the action of cortisol
What are the potential routes of delivery of steroids?
- PO
- IV
- Inhaled/nebulised
- Topical application
What are the indications for the use of corticosteroids?
- Management of obstructive airway disease
- Exacerbation of asthma or COPD
- Anaphylaxis
- Suppression of inflammatory and allergic disease
- Inflammatory bowel disease
- Nasal polyps
What mode of delivery is used when steroids are used in the management of obstructive airway disease?
Inhaled
What mode of delivery is used when steroids are used for exacerbation of asthma/COPD?
Systemic
What steroid is used in the management of inflammatory bowel disease?
IV hydrocortisone
What is the role of steroids in nasal polyps?
Steroid nasal sprays can help shrink nasal polyps
Can steroids be used in pregnancy?
Systemic steroids are contraindicated, but inhaled steroids can be taken as normal in pregnancy and breastfeeding
Why are systemic steroids contraindicated in pregnancy?
Risk of IUGR
What monitoring is required with systemic steroids?
BP measurement and blood glucose prior to treatment, and intermittently throughout treatment
Why should you monitor BP and BG during treatment for systemic steroids?
To monitor cardiovascular and metabolic effects of steroids
What drugs can steroids interact with?
- NSAIDs
- Anti-hypertensives
- Anti-diabetic drugs
- Warfarin
What happens when NSAIDs are taken with steroids?
Increased risk of peptic ulceration and bleeding
What happens when anti-hypertensives are taken with steroids?
Reduced hypotensive effect
What happens when anti-diabetic drugs are taken with steroids?
Steroids antagonise the anti-diabetic effects of these medications
What happens when warfarin is taken with steroids?
Steroids can increase or decrease anticoagulant effect
What are the side effects of inhaled corticosteroids?
- Oral candidiasis
- Voice hoarseness
- Growth suppression in children
What pneumonic can be used to remember the side effects of corticosteroids?
CORTICOSTEROIDS
What are the side effects of systemic corticosteroids?
- Cushing’s syndrome
- Osteoporosis
- Retardation of growth
- Thin skin, easy bruising
- Immunosuppression
- Cataracts and glaucoma
- Oedema
- Suppression of HPA axis
- Truncal obesity
- Emotional disturbances
- Rise in BP
- Oesophageal and peptic ulceration
- Increased hair growth (hirsutism)
- Diabetes mellitus
- Striae
What needs to be considered when thinking about the side effects of corticosteroids?
Not all corticosteroids have the same side effects
What prophylaxis do patients on long term steroids require?
- Osteoporosis prophylaxis with bisphosphonates
- Gastric ulceration prophylaxis with PPI
What is central serous chorioretinopathy?
A retinal disorder that has been linked to the systemic use of corticosteroids
What recent discovery has been made regarding central serous chorioretinopathy?
It has been reported to occur after local administration of corticosteroids via inhaled and intranasal, epidural, intra-articular, topical dermal, and periocular routes
What is recommended due to the possibility of central serous chorioretinopathy with the use of steroids?
Patients should be advised to report any blurred vision or other visual disturbance with corticosteroid treatment given by any route
What should be done if a patient on steroids presents with visual problems?
Consider referral to an ophthalmologist
What patient counselling is required with inhaled corticosteroids?
- In depth counselling about full side effects
- Inhaler technique
- Indication for each inhaler
- Preventing oral thrush
What counselling needs to be given regarding side effects with inhaled corticosteroids?
Explain common side effects and discuss risks, including cardiovascular, metabolic, and psychological changes, and the benefits of treatment. Ask patients to report any visual changes
What counselling needs to be given regarding inhaler technique with inhaled corticosteroids?
Educate patient on appropriate inhaler technique, and review inhaler technique at follow up
What can you consider prescribing to make the use of steroid inhalers easier?
A spacer, or a breath-actuated inhaler
When might you want to prescribe something to make the use of steroid inhalers easier?
If it is the first time the patient is being prescribed an inhaler, or if the patient is struggling with using their inhaler
What counselling needs to be given regarding the indication for each inhaler with inhaled corticosteroids?
Ensure the patient knows when to use each type of inhaler if prescribed multiple inhalers, i.e. preventer and reliever therapy
What counselling needs to be given regarding preventing oral thrush with inhaled corticosteroids?
Warn patients to gargle with water after using inhaler to prevent oral candidiasis
What patient counselling is required with systemic corticosteroids?
- In-depth counselling about full side-effects
- PPI and bisphosphonates
- Compliance and withdrawal
- Steroid treatment card
- Sick day rules
What counselling needs to be given regarding side-effects with systemic corticosteroids?
- Common side effects
- Risks, including cardiovascular, metabolic, and psychological changes
- Benefits of treatment
- Report visual changes
What counselling needs to be given regarding PPI and bisphosphonates with systemic corticosteroids?
Explain the reason for co-prescribing bisphosphonates and a PPI, and emphasise the importance of compliance to avoid adverse effects with long term steroid treatment
What counselling needs to be given regarding compliance and withdrawal with systemic corticosteroids?
It is important the patient does not stop taking the steroids unless advised by their doctor
How should withdrawal of steroids be done?
It should be gradual, and determined on a case-by-case basis
What can abrupt withdrawal of steroids potentially cause?
- Adrenal insufficiency
- Hypotension
- Death
What counselling needs to be given regarding a steroid treatment card with systemic corticosteroids?
Patient should be given a steroid treatment card to carry, which contained details of prescriber, drug, dose, and duration
What counselling needs to be given regarding sick day rules with systemic corticosteroids?
All patients and their partners should receive regular crisis prevention training including verification of steroid emergency card/bracelet and instruction on stress-related glucocorticoid dose adjustment
What are the sick day rules for systemic corticosteroids, regarding intercurrent illness?
Generally, hydrocortisone should be doubled during intercurrent illness, such as a respiratory infection or fever, until clinical recovery. GI infections may require parenteral hydrocortisone administration
What are the sick day rules for systemic corticosteroids, regarding access to acute medical care?
Preferably all patients, but particularly patients living or travelling in areas with limited access to acute medical care, should receive a hydrocortisone emergency self-injection kit
What are the sick day rules for systemic corticosteroids, regarding serious illness?
For major surgery, trauma, delivery, and diseases requiring intensive care unit monitoring, patients should receive IV administration
