corticosteroids Flashcards
1
Q
use of CCs in psoriasis
A
should be avoided or only used under specialist supervision
2
Q
primary example of mineralocorticoid
A
aldosterone
3
Q
Main function, MOA, Effects on Body and Regulation of mineralocorticoids (primary example: aldosterone)
A
Main Functions: Regulate electrolyte and water balance.
Mechanism of Action: Act on the kidneys to increase the reabsorption of sodium and water, while promoting the excretion of potassium.
Effects on the Body: Helps maintain blood pressure and fluid balance.
Regulation: Primarily regulated by the renin-angiotensin-aldosterone system (RAAS) and potassium levels.
4
Q
primary example of glucocorticoid
A
cortisol
5
Q
Main function of GCs
A
Main Functions: Influence carbohydrate, protein, and fat metabolism; suppress the immune system; reduce inflammation.
6
Q
which drug can be used to treat postural hypotension in autonomic neuropathy and why
A
mineralocorticoid activity of fludrocortisone
- increases BP by reabsorption of water and sodium
- SE include oedema
7
Q
why is dexamethasone and betamethasone suitable for suppressing corticotropin secretion in congenital adrenal hyperplasia
A
have little if any mineralocorticoid action and have a long duration of action
dose should be tailored to clinical response and by measurement of adrenal androgens and 17-hydroxyprogesterone.
as with all GCs, their suppressive action on the hypothalamic- pituitary-adrenal axis is greatest and most prolonged when they are given at night.
by reducing ACTH levels, they help lower the production of adrenal androgens, which are often elevated in CAH.
8
Q
When is the suppressive action on the HPA axis greatest for GCs e.g. dexameth, beta
A
In common with all glucocorticoids their suppressive action on the hypothalamic- pituitary-adrenal axis is greatest and most prolonged when they are given at night.
9
Q
How to diagnose Cushing’s syndrome
A
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.
Negative test = low cortisol in morning blood test, indicating HPA axis is functioning normally
Positive test for Cushing’s syndrome = high cortisol
10
Q
name 2 CCs that are appropriate for conditions where water retention would be a disadvantage
A
betamethasone
dexamethasone
11
Q
which ccs should be avoided for management of septic shock
A
high dose ccs
but there is evidence that admin of lower doses of HC and fludrocortisone is of benefit in adrenal insufficiency resulting from septic shock
12
Q
5 side effects of mineralocorticoids
A
- hypertension
- sodium retention
- water retention
- potassium loss
- calcium loss
13
Q
mineralocorticoid side effects are most marked with this drug
A
fludrocortisone
14
Q
mineralocorticoid side effects are most marked with fludrocortisone, but are significant with the following 3 drugs
A
HC, corticotropin, tetracosactide
15
Q
there are negligible mineralocorticoid actions with the high potency GCs betamethasone and dexamethasone, but they do occur slightly with the following three drugs
A
methylprednisolone, prednisolone, and triamcinolone.
16
Q
6 SE of glucocorticoids
A
- diabetes
- osteoporosis (danger esp in elderly as can result in osteoporotic fractures e.g. hip or vertebrae)
- high doses associated with avascular necrosis of femoral head
- muscle wasting
- CC therapy weakly linked with peptic ulcers and perforation
- psychiatric reactions
17
Q
main way to manage side effects of CCs
A
- use lowest effective dose for minimum period possible
18
Q
suppressive action of a CC on cortisol secretion is least when it is….
A
given as a single dose in the morning
19
Q
In an attempt to reduce pituitary-adrenal suppression further, what can you do regarding adminsitration of CCs?
A
total dose for two days can sometimes be taken as a single dose on alternate days; alternate-day administration has not been very successful in the management of asthma.
20
Q
side effects of CCs - MHRA advice on rare risk of central serous chorioretinopathy with local and systemic administration
A
- retinal disorder linked to systemic use of CCs, and local aswell
- pt to report any blurred vision and other visual disturbances with CC treatment
- consider referral to ophthalmologist for elevation of possible causes if a pt presents with vision problems
21
Q
glucocorticoid suppression action on hypothalamic-pituitary-adrenal axis is greatest and most prolonged when they are given…
A
at night
22
Q
in most individuals a single dose of …… at night is sufficient to inhibit corticotropin secretion for 24h
A
dexamethasone
23
Q
overnight dexamethasone suppression test for diagnosing Cushing’s syndrome
A
- finds out if there is excess amount of cortisol in body
- after measuring baseline cortisol, dexamethasone is given with the intention of suppressing cortisol
- if it does not suppress after taking dexamethasone at night, it means there is too much cortisol production aka Cushing’s syndrome
24
Q
why is dexamethasone given to pt to diagnose cushings syndrome
A
In most individuals a single dose of dexamethasone at night, is sufficient to inhibit corticotropin secretion for 24 hours
therefore if cortisol has not reduced, it means they have the syndrome
25
should a CC be used for management of head injury or stroke
no - unlikely to be of benefit and may even be harmful
26
can a cc be used in the management of raised intracranial pressure or cerebral oedema that occurs as a result of malignancy (see Prescribing in palliative care).
yes
prescribing in palliative care: A corticosteroid (such as dexamethasone) can provide temporary symptomatic relief from pain (or headaches) due to raised intracranial pressure from cerebral oedema.
27
how does adrenal insufficiency occur
as a result of inadequate production of steroid hormones in adrenal cortex
28
what are the two main groups of steroid hormones produced by the adrenal cortex and what primarily regulates their production?
- GCs (e.g. cortisol) - production largely regulation by HPA
- MCs (e.g. aldosterone) - production largely regulated by renin-angiotensin system
29
symptoms of adrenal insufficiency can be mild, non-specific, and may include
fatigue, gastrointestinal upset, anorexia, weight loss, musculoskeletal symptoms, salt cravings, and dizziness or syncope due to hypotension.
30
classifications of adrenal insufficiency
- primary
- secondary
- tertiary
31
primary adrenal insufficiency results from disorders that affect the ........ e.g. ........
adrenal cortex e.g. Addison' disease, congenital adrenal hyperplasia
32
secondary adrenal insufficiency results from disorders of the .... e.g. ......
anterior pituitary gland e.g. pituitary tumour or subarachnoid haemorrhage
33
tertiary adrenal insufficiency results from disorders of the ..... e.g. .....
hypothalamus e.g. HPA axis suppression
34
Some drugs can also cause adrenal insufficiency. for example the systemic use of ..... is most common cause due to suppression of the HPA axis
GC
| this is an example of tertiary adrenal insufficiency (hypothalamic)
35
what is the most common cause of adrenal insufficiency and how?
systemic use of GC due to suppression of HPA axis
36
if GC are stopped or decreased too quickly after prolonged, .....
endogenous glucocorticoid production may not be sufficient to meet the body’s needs. this could result in adrenal crisis (acute adrenal insufficiency)
37
life threatening symptoms of adrenal crisis
- severe dehydration
- hypotension
- hypovalaemic shock
- altered consciousness
- seizures
- stroke
- cardiac arrest
- if untreated can lead to death or permanent disability
38
what should pt with adrenal insufficiency and steroid dependence who are at risk of adrenal crisis be provided with and why?
A patient-held Steroid Emergency Card (different to steroid treatment card)
It aims to support healthcare staff with the early recognition of patients at risk of adrenal crisis and the emergency treatment of adrenal crisis. All eligible patients should be issued a Steroid Emergency Card. Providers that treat patients with acute physical illness or trauma, or who may require emergency treatment, elective surgery, or other invasive procedures, should establish processes to check for risk of adrenal crisis and confirm if the patient has a Steroid Emergency Card.
39
adrenal crisis can occur in pt particular during times of increased need e.g. ...... as pt are unable to mount a stress response buy increasing endogenous GC production
surgery
infection
trauma
40
treatment of adrenal insufficiency
physiological glucocorticoid replacement with mainly hydrocortisone (most similar to cortisol), prednisolone, or rarely dexamethasone.
41
pt with primary adrenal insufficiency usually also require mineralocorticoid replacement with .... due to aldosterone deficiency
fludrocortisone
## Footnote
think - makes sense because primary = from adrenal cortex. adrenal cortex produces both GC and MC so would also need MC replacement
42
Some patients, usually those with secondary or tertiary adrenal insufficiency, including treatment with exogenous steroids or other drugs (such as some antifungals and antiretroviral medication), may have a suboptimal cortisol response but.....
do not require maintenance GC treatment
43
advice to give pt with adrenal insufficiency/ at risk of it on the importance of stress GC doses
- advice all pt with adrenal insufficiency & pt at risk of adrenal insufficiency on the important of stress GC doses (aka increases doses) to prevent adrenal crisis during times of stress
- times of stress: e.g. surgical or invasive procedures
-this maintains cortisol levels as close to physiological conc as possible
- pt with adrenal insufficiency who do not usually require maintenance GC (e.g. mostly if secondary or tertiary adrenal insufficiency) should still be aware of the likely need for GC replacement during times of stress
44
sick day rules for pt with adrenal insufficiency and intercurrent illness
- unwell with moderate intercurrent illness (e.g. fever and infection requiring abx), generally double the daily GC dose
- if on long acting HC prep, switch to short acting, more rapidly absorbed preps during intercurrent illness
- for severe intercurrent illness (e.g. persistent vomiting from GI viral illness), give IM or IV HC
45
pt with adrenal insufficiency and have vomiting or diarrhoea
- higher risk of GC deficiency
- for pt with established adrenal insufficiency, provide HC emergency injection kit and train in administration of IM HC and advise to go to hospitality vomiting or diarrhoea
46
management of adrenal crisis
- medical emergency
- treat immediately, esp pregnant women
- initiate investigations once pt clinically stable
- no adverse consequences of initiating a life saving bolus dose of HC treatment
- treatment involves prompt GC replacement with HC and rehydration using crystalloid fluid (e.g. sodium chloride 0.9%)
- for pt on fludrocortisone, high dose HC has sufficient mineralocorticoids effect to cover this
47
prompt treatment of adrenal crisis involves
prompt glucocorticoid replacement with hydrocortisone, and rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%). For patients usually on fludrocortisone, high-dose hydrocortisone has sufficient mineralocorticoid effect to cover this.
48
Particular care is required in patients with diabetes insipidus and adrenal insufficiency related to hypothalamic-pituitary disease who are treated with desmopressin because..
they are at risk of uncontrolled diabetes insipidus if doses of desmopressin are omitted, or hyponatraemia if excess fluid is given.
49
high GC activity in itself is of no advantage unless it is accompanies by...
relatively low MC activity
50
the mineralocorticoid activity of this drug is so high that its anti inflammatory activity is of no clinical relevance
fludrocortisone
51
why is HC unsuitable for disease suppression on a long term basis
- high MC activity and resulting fluid retention
52
why is HC useful topical CC for management of inflammatory skin conditions
moderate anti inflammatory potency
side effects, topical and systemic, are less marked
53
what is the CC most commonly used PO for long term disease suppression
prednisolone
54
prednisolone has predominantly .... activity
GC
55
these two drugs have very high GC activity and insignificant MC activity
betamethasone and dexamethasone
56
what two drugs are suitable for high-dose therapy in conditions where fluid retention would be a disadvantage because they have very high glucocorticoid activity in conjunction with insignificant mineralocorticoid activity
betamethasone and dexamethasone
57
which two drugs are suitable for conditions which require suppression of corticotropin (corticotrophin) secretion (e.g. congenital adrenal hyperplasia) and why
Betamethasone and dexamethasone because they have a long duration of action and lack of mineralcortcoid activity
58
deflazacort is derives from .... and has high.... activity
high glucocorticoid activity; it is derived from prednisolone.
59
who should be issued a steroid emergency card
pt with adrenal insufficiency and steroid dependence who are at risk of adrenal crisis
60
why should systemic CCs be used with caution n pt who have recently had an MI
rupture reported
61
common SE of systemic CCs
- anixety, mood disorders, sleep disorders, psychotic disorders
- abnormal behaviour
- catarct
- cognitive impairment
- Cushing's syndrome
- electrolyte imbalance
- fluid retention
- GI discomfort
- healing discomfort
- hirsuitism
- increased risk of infection
- menstrual cycle irregulariites
- osteoporosis
- peptic ulcer
- weight gain
- grown retardation common in children
62
adrenal suppression with corticosteroids
- how does this happen
- effect of abrupt withdrawal
- when will doses need increasing
- prolonged therapy, esp systemic - adrenal atrophy develops and can persist for years after stopping
- abrupt withdrawal after prolonged period can lead to adrenal crisis, hypotension or death
- to compensate for diminished adrenocortical response caused by prolonged CC treatment, any significant intercurrent illness, trauma or surgery requires temporary increase in CC dose, or if already stopped, a temporary reintroduction of CC treatment
63
increased risk of infection with CCs
- prolonged courses increase susceptibility to infections and severity of infections
- clinical presentation of infection may be atypical
- serious infections e.g. TB and septicaemia may reach advanced stage before being recognised
- some infections may be exaggerated e.g. amoebiasis, fungal, viral ocular
64
risk of severe chickenpox - some pt taking CCs
- unless they have had chickenpox, pt receiving oral or parenteral CCs for purposes other than replacement should be regarded as being at risk of severe chickenpox
- manifestations of fulminant illness include pneumonia, hepatitis and disseminated intravascular coagulation
-- rash isn't necessarily a prominent feature
- passive immunisation with VZ immunoglobulin is needed for exposed no n immune pt receiving systemic CCs or for those who have used them within past 3 months
- confirmed chickenpox = specialist care an urgent treatment
- do not stop CCs, dosage may need to be increased
65
measles and corticosteroids
- pt taking CCs should be advised to take particular care to avoid exposure to measles
- seek immediate medical advice if exposure occurs
- prophylaxis with IM normal immunoglobulin may be needed
66
CCs and psychiatric reactions
- systemic esp high doses are linked to psychiatric reactions
- includes euphoria, insomnia, irritability, mood lability, suicidal thoughts, psychotic reactions, behavioural disturbances
- freq subside on reduced dose or discontinuation
- may require specific management
- seek medical advice
- possibility of such reactions during withdrawal of CC
- prescribe with care in pt predisposed to psychiatric reactions, P or FHx, or previously suffered from CC induced psychosis
67
monitoring requirements or all systemic CC
- before starting and then at regular intervals during course of long term treatment
- BP
- body weight
- BMI
- height in children and teens
- HbA1c
- triglycerides
- potassium
- eye exam for glaucoma and cataract
- the following depending on clinical judgement - osteoporosis risk, falls risk, adrenal suppression
68
what affects can systemic CCs have on lab tests
May suppress skin test reactions.
69
max amount of times a day that topical CCs should be applied
max BD, OD often sufficient
70
Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:
- >40mg prednisolone (or equivalent) daily for more than 1 week
- repeat doses in evening
- >3 weeks treatment
- recently received repeat courses, esp 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
71
pt must gradually withdraw systemic CCs if they have received
more than 40mg prednisolone (or equivalent) daily for more than 1 week
72
Systemic corticosteroids may be stopped abruptly 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 described above. (i.e. not more than 40mg prednisone daily for >1 week, no repeat doses in evening, not recently received repeated courses, esp if taken for longer than 3 weeks, etc)
73
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.
74
one fingertip unit is the distance from....
tip of the adult index finger to the first crease)
75
one fingertip unit is sufficient to cover an area...
that is twice that of the flat adult handprint (palm and fingers)
76
how long to leave between application of topical corticosteroids and emollients.
several mins
77
which drug has equal MC and GC activity
HC
78
choice of steroid formulation - cream or ointment?
- Water-miscible corticosteroid creams are suitable for moist or weeping lesions
- ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required
79
potency of topical HC 0.1-2.5%
mild
80
potency of topical betamethasone, clobetasone (eumovate)
moderate
81
potency of topical betamethasone dipiroprionate 0.025%, betamethasone valerate 0.1%, betnovate, diprosone, elocon, mometasone 0.1%, HC butyrate
potent
82
explain how mineralocorticoids cause high BP as a side effect
sodium and water retention raises BP
83
Gc or Mc - which one is the anti inflammatory effect
glucocorticoid activity gives anti inflammatory effect
84
in which conditions is fluid retention beneficial, thus treatment with fludrocortisone is given
postural hypotension or shock which are characterised by a low blood pressure
85
why is HC unsuitable long term as an anti inflammatory
Significant mineralocorticoid activity
Moderate glucocorticoid anti-inflammatory activity
As an anti-inflammatory, hydrocortisone is unsuitable long term because it will cause fluid retention
86
Why can CCs cause insomnia and how would this effect be avoided
CCs can cause insomnia as they mimic cortisol which is the body's natural wake hormone
Counsel patients to take doses in the morning and not at night
87
When do you need to carry a blue steroid card?
Systemic CC >3 weeks
High doses e.g. >40mg pred
Or high dose CC inhaler
88
MHRA HYDROCOIRTISONE - HC buccal tablets have been used off label to teat adrenal insufficiency in children
DO NOT DO THIS
Should only be used for mouth ulcers because absorption is different to oral formulations
This means there may not sufficient dose
89
MHRA HYDROCOIRTISONE - switching from tabs to granules
Switching from HC tabs to granules (Alkindi) = risk of acute adrenal insufficiency in children
Counsel: observe for symptoms adrenal insufficiency in first week and take action e.g. increase dose or seek immediate medical advice
90
Prednisolone interactions
- drugs that increase risk of GI bleeds e.g. blood thinners, antidepressants, aspirin, NSAIDs
- drugs that cause hypokalaemia increase risk of TDP e.g. antipsychotics, amiodarone, SABAs, theophylline, diuretics, digoxin toxicity, macrocodes, sSRIs
- inhibitors (sick faces.com) increase EXPOSURE to prednisolone - monitor
- inducers decrease levels
- live vaccines - risk of serious generalised infection
- digoxin toxicity - caution
- increases AC effect of warfarin, monitor
91
MHRA advice about methylprednisolone injections and lactose intolerant
Solu-Medrone 40mg: methylprednisolone injections contain lactose: serious hypersensitivity in pt with cow's milk allergy
e.g. bronchospasms, anaphylaxis
If symptoms worsen or new allergic symptoms occur, stop and treat
Newer forms in lactose-free, ensure NOT TO CONFUSE! Take care when dispensing
92
what is and how does cushings syndrome occur
it is when you have too much cortisol in body
results from chronic exposure to excess cortisone
it is usually iatrogenic (caused by medical examination or treatment - i.e. GC treatment)
93
what does iatrogenic mean
illness caused by medical examination or treatment
for example Cushing's syndrome is usually iatrogenic from GC treatment
94
most common cause of Cushing's syndrome
exogenous CC use
usually from long term, high dose use of cortisol like GCs which are used to treat conditions like asthma, lupus, RA
95
endogenous causes of Cushing's syndrome include (3)
Adrenocorticoptrphinc homrone (ACTH)-secreting pitruatry tumorus (Cushing's disease)
Cortisol-secreting adrenal tumours
Rare: ectopic ACTH-secreting tumours
96
most types of endogenous Cushing's syndrome are treated...
surgically or with cortisol-inhibiting drugs
97
3 drugs licensed for Cushing's syndrome
ketoconazole (endogenous CS)
metyrapone (management of CS specialist supervision in hospital)
osilodrostat (endogenous CS)
98
symptoms of Cushing's syndrome varies but people who have had high levels for a long period of time are likely to have clear signs e.g.
- weight gain
- moon face
- thin arms and legs
- fatty hump between shoulders
- increased fat around base of neck
- easy bruising
- weak muscles
- wide purple stretch marks
99
Chilren with cushing's syndrome tend to have (2)
Delayed growth
Obesity
100
Women with Cushing 's syndrome may have (2)
Excess facial hair, and on neck, chest, abdomen, thights
Irregular/cessation of periods
101
men with Cushing 's syndrome may have (3)
Decreased feritltiy
Lowered interest in sex
ED
102
complications of Cushing's syndrome
Heart attack and stroke
DVT - lungs and legs
Infections
Bone loss and fractures
Hypercholesterolemia
Hypertension
Depression and other mood disorders
Memory loss
Trouble concentrating
Insulin resistance and prediabetes
T2D
103
tests for diagnosis of Cushing's syndrome (4)
- 24 hour urinary free cortisol test - if cortisol higher than normal, indicated Cushing's syndrome
- late night cortisol test - cortisol production normally drops just after falling asleep, but not in Cushing's syndrome
- low dose dexamethasone suppression test - low dose taken, then a blood test is taken to see if cortisol levels have dropped
- dexamethasone-CRH test - usually a followup test to confirm whether excess cortisol is caused by Cushing's or not
104
which anti fungal drug is used in the treatment of endogenous Cushing's disease
ketoconazole
105
important patient and carer advice for oral ketoconazole
Recognise signs of liver disorder
Discontinue treatment seek prompt meiedcal attention if sypmomes such as anorexia, n/v, fatigue, jaundice, adominal pain, dark urine
Recognise signs of adrenal insufficency
Dizziness and sonolence may affect performance of silled atsks (e..g driving)
