Corticosteroids

Question 1

Example of a Corticosteroid

Answer 1

Prednisolone

Question 2

How do Corticosteroids work?

Answer 2

These corticosteroids exert mainly glucocorticoid effects. They bind to cytosolic glucocorticoid receptors, which then translocate to the nucleus and bind to glucocorticoid-response elements, which regulate gene expression. Corticosteroids are most commonly prescribed to modify the immune response. They upregulate anti-inflammatory genes and downregulate pro-inflammatory genes (e.g. cytokines, tumour necrosis factor alpha). Direct actions on inflammatory cells include suppression of circulating monocytes and eosinophils. Their metabolic effects include increased gluconeogenesis from increased circulating amino and fatty acids, released by catabolism (breakdown) of muscle and fat. These drugs also have mineralocorticoid effects, stimulating Na+ and water retention and K+ excretion in the renal tubule.

Question 3

Indications for corticosteroids

Answer 3

To treat allergic or inflammatory disorders, e.g. anaphylaxis, asthma.

Suppression of autoimmune disease, e.g. inflammatory bowel disease, inflammatory arthritis.

In the treatment of some cancers as part of chemotherapy or to reduce tumour-associated swelling.

Hormone replacement in adrenal insufficiency or hypopituitarism.

Question 4

Contraindications of corticosteroids

Answer 4

Caution in people with infection and in children (in whom they can suppress growth).

Question 5

Side effects of corticosteroids

Answer 5

Immunosuppression increases the risk and severity of infection and alters the host response.

Metabolic effects include diabetes mellitus and osteoporosis. Increased catabolism causes proximal muscle weakness, skin thinning with easy bruising and gastritis.

Mood and behavioural changes include insomnia, confusion, psychosis and suicidal ideas.

Hypertension, hypokalaemia and oedema can result from mineralocorticoid actions.

Question 6

Interactions of corticosteroids

Answer 6

Corticosteroids increase the risk of peptic ulceration and gastrointestinal bleeding when used with NSAIDs and enhance hypokalaemia in patients taking β2-agonists, theophylline, loop or thiazide diuretics. Their efficacy may be reduced by cytochrome P450 inducers (e.g. phenytoin, carbamazepine, rifampicin). Corticosteroids reduce the immune response to vaccines.

Question 7

Elimination of corticosteroids

Answer 7

Renal

Question 8

Patient information on corticosteroids

Answer 8

Once daily corticosteroid treatment should be taken in the morning, to mimic the natural circadian rhythm and reduce insomnia.

Explain that treatment should suppress the underlying disease process and that the patient will usually start to feel better within 1–2 days. For patients who require prolonged treatment, warn them not to stop treatment suddenly, as this could make them very unwell. Give them a steroid card to carry with them at all times and show if they need treatment. Discuss the benefits and risks of steroids, including longer-term risks of osteoporosis, bone fractures and diabetes so that your patient can make an informed decision about taking treatment.