Corticosteroids Flashcards
When is it appropriate to use corticosteroids with COVID 19 patients
in severely ill patients
hydrocortisone dose for minor procedure
25 mg IV
hydrocortisone dose for moderate procedure
50-75 mg IV, taper over 1-2 days
hydrocortisone dose for major procedure
100-150 mg IV, taper over 1-2 days
Who should get perioperative steroid replacement
- pharmacologic doses of glucocorticoids greater than 5mg of prednisone equivalent per day
- period of treatment with corticosteroids was for 2-3weeks or longer
- treatment occurred during immediate 12 months before surgery
Acute use side effects
hyperglycemia, delayed wound healing, infection, cancer recurrence, CNS disturbances, GI disturbances
Chronic use side effects
HPA axis suppression, corticosteroid supplementation, electrolyte and metabolic changes, CNS dysfunction, peptic ulcer disease, skeletal muscle myopathy
drug interactions with corticosteroids
enzyme inhibition: ketoconazole/fluconazole (antifungals), etomidate/metapyrone (11 beta hydro.)
accelerate metabolism: phenytoin, rifampin, phenobarbital, ephedrine
What does the hypothalamus do?
produces hormones (CRH), regulates body temp, daily physiological cycles of melatonin and cortisol, controlling appetite, managing sexual behavior, and managing emotional responses
Which hormones does the anterior pituitary gland release?
ACTH, TSH, FSH, LH, GH, PRL
Which zone in the adrenal cortex releases aldosterone?
zona glomerulosa
Which zone in the adrenal cortex releases cortisol?
zona fasiculata
Which zone in the adrenal cortex releases sex hormones?
zona reticularis
Which hormones does the adrenal medulla release?
epi and norepi
What are the actions of cortisol?
carbohydrate metabolism (gluconeogenesis), increases protein catabolism, inhibits insulin from shuttling into cells, mobilize free fatty acids, suppress pro-inflammatory cytokines, suppress immune system
How does cortisol influence the HPA axis?
Negative feedback loop to the anterior pituitary from releasing ACTH and the hypothalamus from releasing CRH
What time are maximal concentrations of cortisol at?
08:00
What time are minimal concentrations of cortisol at?
midnight
normal production of cortisol
15-30 mg/day
How does a minor procedure affect cortisol production?
increases up to 50 mg/day; returns to baseline within 24 hours
How does a moderate procedure affect cortisol production?
increases up to 75-100 mg/day; returns to baseline by day 5
How does a major procedure affect cortisol production?
increases up to 200 mg/day; return to baseline by 5 usually
What causes Cushing’s Syndrome
overuse of corticosteroids, tumors of pituitary gland, ectopic adrenocorticotropic hormone releasing tumors in lungs, pancreas, or thyroid, adrenal gland abnormality or tumor, familial cushing’s syndrome
What are some symptoms of cushing’s syndrome?
thin extremities and skin, hyperglycemia, moon face, personality changes, Na+ and H20 retention, osteoporosis
What disease is a primary adrenocortical insufficiency?
addison’s disease
What causes secondary adrenal insufficiency?
TBI, ischemic/hemorrhagic lesions of hypothalamic-pituitary axis, chronic glucocorticoid treatment (3-4weeks)
Signs and symptoms of adrenal crisis
hypotension, acute abdominal symptoms, n/v, AMS, fatigue, fever, lab abnormalities
What kind of lab abnormalities would you see in adrenal crisis?
hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia
What can cause adrenal crisis?
interruption of glucocorticoid intake, infections, surgery, gastroenteritis, stress
Interventions to fix adrenal crisis
0.9% NS 1-3L over 6-12 h
100 mg hydrocortisone
classifications of corticosteroids
- mineralocorticoid effect - reabsorption of Na+ in exchange for K+ in renal distal tubules
- glucocorticoid effect - antiinflammatory properties
MOA of corticosteroids
stimulate changes in transcription of 456 DNA, changes to synthesis of proteins, target cells that contain 11-beta hydroxysteroid dehydrogenase
PK of corticosteroids
antacids interfere with oral absorption, highly protein bound, readily crosses placenta, elimination half time 1.5-3 h, mostly conjugated in liver
Uses of corticosteroids
adrenal insufficiency, asthma (not rescue), cerebral edema, preop antiemetic, postop analgesia, immunosuppression, post intubation laryngeal edema, prolong regional blocks
Hydrocortisone
cortisol, short acting
Hydrocortisone dose, elimination 1/2 time, DOA
20 mg, 1.5-3h, 8-12h
Prednisolone
sole replacement therapy in adrenocortical insufficiency
Prednisolone dose, elimination 1/2 time, DOA
5mg, 2-4h, 12-36 h
Prednisone
rapidly converted to prednisolone after absorption from GI tract
Prednisone dose, elimination 1/2 time, DOA
5 mg, 2-4 h, 12-36 h
Methylprednisolone
used to produce intense glucocorticoid affect
Methylprednisolone dose, elimination 1/2 time, DOA
4mg, 2-4 h, 12-36 h
Dexamethasone
has multiple uses
Dexamethasone dose, elimination 1/2 time, DOA
0.75mg, 3.5-5h, 36-54h
