Corticosteroids

Question 1

When is it appropriate to use corticosteroids with COVID 19 patients

Answer 1

in severely ill patients

Question 2

hydrocortisone dose for minor procedure

Answer 2

25 mg IV

Question 3

hydrocortisone dose for moderate procedure

Answer 3

50-75 mg IV, taper over 1-2 days

Question 4

hydrocortisone dose for major procedure

Answer 4

100-150 mg IV, taper over 1-2 days

Question 5

Who should get perioperative steroid replacement

Answer 5

1. pharmacologic doses of glucocorticoids greater than 5mg of prednisone equivalent per day
2. period of treatment with corticosteroids was for 2-3weeks or longer
3. treatment occurred during immediate 12 months before surgery

Question 6

Acute use side effects

Answer 6

hyperglycemia, delayed wound healing, infection, cancer recurrence, CNS disturbances, GI disturbances

Question 7

Chronic use side effects

Answer 7

HPA axis suppression, corticosteroid supplementation, electrolyte and metabolic changes, CNS dysfunction, peptic ulcer disease, skeletal muscle myopathy

Question 8

drug interactions with corticosteroids

Answer 8

enzyme inhibition: ketoconazole/fluconazole (antifungals), etomidate/metapyrone (11 beta hydro.)
accelerate metabolism: phenytoin, rifampin, phenobarbital, ephedrine

Question 9

What does the hypothalamus do?

Answer 9

produces hormones (CRH), regulates body temp, daily physiological cycles of melatonin and cortisol, controlling appetite, managing sexual behavior, and managing emotional responses

Question 10

Which hormones does the anterior pituitary gland release?

Answer 10

ACTH, TSH, FSH, LH, GH, PRL

Question 11

Which zone in the adrenal cortex releases aldosterone?

Answer 11

zona glomerulosa

Question 12

Which zone in the adrenal cortex releases cortisol?

Answer 12

zona fasiculata

Question 13

Which zone in the adrenal cortex releases sex hormones?

Answer 13

zona reticularis

Question 14

Which hormones does the adrenal medulla release?

Answer 14

epi and norepi

Question 15

What are the actions of cortisol?

Answer 15

carbohydrate metabolism (gluconeogenesis), increases protein catabolism, inhibits insulin from shuttling into cells, mobilize free fatty acids, suppress pro-inflammatory cytokines, suppress immune system

Question 16

How does cortisol influence the HPA axis?

Answer 16

Negative feedback loop to the anterior pituitary from releasing ACTH and the hypothalamus from releasing CRH

Question 17

What time are maximal concentrations of cortisol at?

Answer 17

08:00

Question 18

What time are minimal concentrations of cortisol at?

Answer 18

midnight

Question 19

normal production of cortisol

Answer 19

15-30 mg/day

Question 20

How does a minor procedure affect cortisol production?

Answer 20

increases up to 50 mg/day; returns to baseline within 24 hours

Question 21

How does a moderate procedure affect cortisol production?

Answer 21

increases up to 75-100 mg/day; returns to baseline by day 5

Question 22

How does a major procedure affect cortisol production?

Answer 22

increases up to 200 mg/day; return to baseline by 5 usually

Question 23

What causes Cushing’s Syndrome

Answer 23

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

Question 24

What are some symptoms of cushing’s syndrome?

Answer 24

thin extremities and skin, hyperglycemia, moon face, personality changes, Na+ and H20 retention, osteoporosis

Question 25

What disease is a primary adrenocortical insufficiency?

Answer 25

addison’s disease

Question 26

What causes secondary adrenal insufficiency?

Answer 26

TBI, ischemic/hemorrhagic lesions of hypothalamic-pituitary axis, chronic glucocorticoid treatment (3-4weeks)

Question 27

Signs and symptoms of adrenal crisis

Answer 27

hypotension, acute abdominal symptoms, n/v, AMS, fatigue, fever, lab abnormalities

Question 28

What kind of lab abnormalities would you see in adrenal crisis?

Answer 28

hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia

Question 29

What can cause adrenal crisis?

Answer 29

interruption of glucocorticoid intake, infections, surgery, gastroenteritis, stress

Question 30

Interventions to fix adrenal crisis

Answer 30

0.9% NS 1-3L over 6-12 h

100 mg hydrocortisone

Question 31

classifications of corticosteroids

Answer 31

1. mineralocorticoid effect - reabsorption of Na+ in exchange for K+ in renal distal tubules
2. glucocorticoid effect - antiinflammatory properties

Question 32

MOA of corticosteroids

Answer 32

stimulate changes in transcription of 456 DNA, changes to synthesis of proteins, target cells that contain 11-beta hydroxysteroid dehydrogenase

Question 33

PK of corticosteroids

Answer 33

antacids interfere with oral absorption, highly protein bound, readily crosses placenta, elimination half time 1.5-3 h, mostly conjugated in liver

Question 34

Uses of corticosteroids

Answer 34

adrenal insufficiency, asthma (not rescue), cerebral edema, preop antiemetic, postop analgesia, immunosuppression, post intubation laryngeal edema, prolong regional blocks

Question 35

Hydrocortisone

Answer 35

cortisol, short acting

Question 36

Hydrocortisone dose, elimination 1/2 time, DOA

Answer 36

20 mg, 1.5-3h, 8-12h

Question 37

Prednisolone

Answer 37

sole replacement therapy in adrenocortical insufficiency

Question 38

Prednisolone dose, elimination 1/2 time, DOA

Answer 38

5mg, 2-4h, 12-36 h

Question 39

Prednisone

Answer 39

rapidly converted to prednisolone after absorption from GI tract

Question 40

Prednisone dose, elimination 1/2 time, DOA

Answer 40

5 mg, 2-4 h, 12-36 h

Question 41

Methylprednisolone

Answer 41

used to produce intense glucocorticoid affect

Question 42

Methylprednisolone dose, elimination 1/2 time, DOA

Answer 42

4mg, 2-4 h, 12-36 h

Question 43

Dexamethasone

Answer 43

has multiple uses

Question 44

Dexamethasone dose, elimination 1/2 time, DOA

Answer 44

0.75mg, 3.5-5h, 36-54h