Corticosteroids (systemic)

Question 1

What are they indicated for?

Answer 1

Allergic or inflammatory disorders e.g. anaphylaxis, asthma, COPD

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

Reduce tissue damage due to excessive inflammation in infections bacterial meningitis, COVID-19 and croup

Hormone replacement in adrenal insufficiency or hypopituitarism

Question 2

How do they work?

Answer 2

They upregulate anti-inflammatory genes and downregulate pro-inflammatory genes

Question 3

What side effects can occur with mineralocorticoids?

Answer 3

Hypertension, hypokalaemia, and oedema

Question 4

What can occur with sudden withdrawal of steroids?

Answer 4

adrenal crisis with cardiovascular collapse

Question 5

What are the warnings of these drugs?

Answer 5

Caution in people with infection and children

Question 6

What drugs interact with this drug class?

Answer 6

NSAIDs increased risk of peptic ulceration
β2-agonists, theophylline, loop or thiazide diuretics increased risk of hypokalaemia
Cytochrome P450 inducers reduced efficacy
Vaccines reduced benefit to immune response

Question 7

What steroids are used for replacement therapy ?

Answer 7

Hydrocortisone
fludrocortisone

This is because the steroids that the body secretes cortisol (glucocorticoid) and aldosterone (mineralocorticoid)

Question 8

Why is hydrocortisone rarely used for non replacement therapy?

Answer 8

It has little mineralocorticoid activity which can lead to fluid retention.

Question 9

Why should steroids be taken in the morning?

Answer 9

So they don’t surprise the natural activity which is most active at night.

Corticosteroids surpress cortisol.

Question 10

What are side effects of Mineralocorticoids?

Answer 10

(Aldosterone)

hypertension
sodium and water retention (aldosterone is a mineralocorticoid therefore is involved in RAS )
Loss of potassium and calcium

Question 11

What are side effects of glucocorticoids?

Answer 11

(Hydrocortisone)

Diabetes
osteoporosis
peptic ulcers

It has anti-inflammatory effects and immunosupressive effects so increases the BG and mobilise calcium (hence osteoporosis)

Question 12

What drugs have high glucocorticoid activity?

Answer 12

Prednisolone/prednisone- used fior long term disease suppression
Betamethasone- very high but low mineralocorticoid activity.
Dexamethasone

Question 13

What is the MHRA warning of all corticosteroids?

Answer 13

rare risk of central serous chorioretinopathy with local as well as systemic administration (August 2017)

Question 14

What can high dose/prolonged use of steroids lead to?

Answer 14

Adrenal suppression

Psychiatric reactions - more common in glucocorticoids
( euphoria , nightmares and behavioural changes)

Question 15

When would gradual reduction in dose need to be done ?

Answer 15

Gradually by titration if;

taking more than 40mg >1 week
taking evening doses

Received more than 3 weeks treatment at any dose.

Question 16

how should doses be titrated?

Answer 16

If high dose can be brought down to 7.5mg prednisolone daily or equivalent as this is equal to natural adrenal levels and then decreased gradually.

Question 17

What is patient and carer advice?

Answer 17

Immunosupression
Prolonged courses can lead to increased risk of infection

Adrenal suppression
If given for longer than 3 weeks must not be stopped abruptly

Mood and behavioural changes
high doses can alter mood and behaviour early in treatment- can also occur when being withdrawn