Corticosteroids

Question 1

Give examples of mineralocorticoids

Answer 1

Fludrocortisone - MOST POTENT
- Use: neuropathic postural hypotension, septic shock

Significant w hydrocortisone
- Use: acute hypersensitivity, adrenocorticol insufficiency
- Not used LT bc it will cause fluid retention

Question 1

What is the MOA of corticosteroids?

Answer 1

• Synthetic version of hormones made by adrenal glands
• Aldosterone (mineral corticoid)
• Cortisol (glucocorticoid)

Question 2

Give examples of glucocorticoids

Answer 2

Dexamethasone + betamethasone - MOST POTENT
- Use: if fluid retention is disadvantage eg HF
- palliative: anorexia, raised intracranial pressure

Prednisolone - significant
- Use: asthma, COPD, eczema, IBD

Question 3

Side effect: mineralocorticoid effects

Answer 3

• Na + fluid retention: HPT + oedema
• K excretion: hypOkalaemia

Question 4

Side effect: endocrine

Answer 4

• Diabetes
• Cushing’s syndrome
• Growth failure in children (Monitor: height + weight)

Question 5

Side effect: MSK

Answer 5

Muscle wasting
- Caution: statins, myasthenia gravis

Osteoporosis
- High risk: prevention w bisphosphonate

Question 6

Side effect: GI

Answer 6

Peptic ulcer

GI irritation + bleed
- Counsel: take w food

Question 7

Side effect: CNS

Answer 7

Psychiatric reactions
- Counsel: report psychiatric symptoms (suicidal thoughts)

Insomnia
- Counsel: take in the morning

Question 8

Side effect: skin

Answer 8

• Skin thinning
• Purple-red striae
• Bruising

Question 9

Side effect: eye

Answer 9

• MHRA: corticosteroids: central serous chorioretinopathy (report blurred vision + visual disturbance)
• Glaucoma
• Cataracts

Question 10

Side effect: infections

Answer 10

• Counsel: avoid measles, chickenpox
• CI: systemic infections, live vaccines
• Caution: ocular HSV (corneal perforation)

Question 11

Side effect: adrenal suppression

Answer 11

Counsel:

• Avoid abrupt w/drawal if >3w
• Mention steroid for any treatment (or stopped <1 y)
• Sick day rules: fever: higher dose. If vomiting: extra dose. Persists: hospital
• NHS patient safety alert: steroid emergency care

Question 12

How to manage side effects?

Answer 12

• Lowest effective dose for minimum period
• Single dose in morning
• Admin on alt days
• Intermittent short courses
• Local route

Question 13

When do you require a steroid card/need to avoid abrupt withdrawal?

Answer 13

• 3+ weeks

Avoid abrupt w/drawal:
- 3w use
- 40mg daily for 1+ week (prednisolone)
- Repeat doses in evening
- Repeated course
- <1Y of stopping (short course)
- Other causes of adrenal suppression (addisons)

Question 14

What are the interactions of steroids?

Answer 14

• Enzyme inhibitor (clarithromycin, azoles) → toxicity
• Enzyme inducer (carbamazepine, phenytoin, rifampacin) → therapeutic failure
• NSAIDs → GI bleed
• Drugs that cause hypokalaemia inc risk of torsade de pointes: B2 agonist, corticosteroids, loop + thiazide diuretic

Question 15

MHRA: hydrocortisone

Answer 15

• Muco-adhesive buccal tabs: not for adrenal insufficiency in children
• Alkindi: acute adrenal insufficiency in children when switching tablet to granules (Counsel: observe for symptoms in first week + take action (inc dose))

Question 16

MHRA: methylprednisolone

Answer 16

Injectable med containing lactose

• Do not use in patients w cow milk allergy
• If symptoms worsen or new allergic symptom occurs, stop + treat