CPS Community Flashcards
What length of steroid exposure is considered to put a patient at risk for clinically significant adrenal suppression?
> 2 weeks
-Need to also consider multiple short courses
What is the most common ICS scenario placing children at risk for adrenal suppression?
- High dose ICS, most commonly 500mcg of fluticasone propionate daily (or higher)
- Ciclesonide has a reduced adrenal suppression risk
Who should prescribe high dose ICS?
Canadian Thoracic Society guidelines from 2012 recommend that high-dose ICS (including doses >400 mcg of fluticasone in children) should only be used by asthma specialists
True or false. A glucocorticoid taper prevents adrenal suppression.
False. GCs should be tapered or discontinued at a rate determined by underlying condition and need to maintain disease remission. There is no evidence to support a specific approach to GC taper for the prevention of AS.
When is a first morning cortisol specific for a diagnosis of adrenal insufficiency?
When levels are =100nmol/L in most individuals w/ a N sleep/wake cycle and in whom GCs have been withheld 24-48 hours
What level of first morning cortisol may predict normal HPA axis function?
A first morning cortisol value of 350-500nmol/L
How do you replace glucocorticoid in adrenal crisis, severe illness or severe injury?
Hydrocortisone 100mg/m2 IV/IM STAT (max 100mg) then 100mg/m2/24h (max 200mg) divided Q6H or cont. inf.
Approx. STAT dosing for estimated BSA:
-Infant 25mg IV hydrocortisone
-Small child (<15kg) 50mg IV hydrocortisone
-Child or adolescent (>/=15kg) 100mg IV hydrocortisone
What is the ideal time of day to provide steroid medications?
Once-daily GC dosing should be administered in the morning, whenever possible, to minimize HPA axis suppression. This practice should be considered for all forms of GC therapy, including ICS approved for once-daily dosing. Other ICS should be administered in accordance with their approved dosing guidelines.
List the indications for asymptomatic children to be screened for adrenal suppression.
- High dose ICS for >/=3mths
- Systemic therapy for >2wks
- Swallowed ICS therapy for >1mth or ICS of any dose for >/=3mths in conjunction with CYP3A4 inhibitors
A child with a history of high dose ICS has a first morning cortisol <275nmol/L. What do you do?
Consider empiric stress dosing for up to 6-12months for asymptomatic children with a first morning cortisol<275 (vs. ACTH stim testing to confirm diagnosis)
