Endocrine: Steroid conditions

Question 1

If high glucocorticoid activity - what are the effects?

Answer 1

Most anti-inflammatory effects

Dex, Beta, Pred, deflazacort

Question 2

If high mineralocorticoid activity - what are the effects? Give drug examples

Answer 2

fluid retention - Sodium and water retention (Hypertension) and K+ and Ca loss
fludrocortisone, hydrocortisone (but not as much) , corticotrophin

Question 3

Which steroid has highest mineralocorticoid activity?

Answer 3

Fludrocortisone

Question 4

What are the highest potency glucocorticoids? but what is most commonly used?

Answer 4

Dexamethasone
Betamethasone

Most common is prednisolone (significant potency)

Question 5

What is the adrenal replacement therapy for addisons disease? How are these given?

Answer 5

Hydrocortisone and fludrocortisone

Hydrocortisone is given in 2 doses - larger in morning and smaller in evening to mimix natural cortisol secretion

Question 6

What is the replacement for hypopituitism?

Answer 6

Where the pituitary gland does not stimulate hormone secretion - only need to replace with Hydrocortisone (not fludro because RAAS regulates aldosterone)

Reeplace sex hormones and thyroid too e.g. levo

Question 7

What is a NHS improvement patient safety alert for steroids?

Answer 7

Steroid emergency card to support early recognition and treatment of adrenal crisis

Question 8

What is the treatment for acute adrenal crisis

Answer 8

IV hydrocortisone - rapid acting

Question 9

What is the acronym to remember glucocorticoid (corticosteroid) side effects?

Answer 9

ACHING BOSOM

Question 10

IDENTIFY corticosteroid S/E using the acronym aching bosom

Answer 10

A:adrenal suppression, abrupt withdrawal rxn, apetite
C: cushing syndrome, cataracts
H: hyperglycaemia, hyperlipidaemia
I: infections, insomnia
N: nervous system,psychiatric reactions
G:glaucoma, GI ulcer

B: blood pressure increase (HTN)
O: osteoporosis
S: skin thinning
O:obesity
M:muscle wasting

Question 11

What are the effects of glucocorticoids on musculoskeletal?

Answer 11

Osteoporosis
Avascular necrosis of femoral head
Fracture risk

Question 12

If using corticosteroids for?3 months what is used as prophylaxis for osteoporosis?

Answer 12

Bisphosphonates

Question 13

What are the GI effects of corticosteroids and counselling?

Answer 13

Peptic/GI ulcers and dyspepsia

Take with food

Question 14

What is the psychiatric risk of corticosteroids?

Answer 14

Paranoia or depression - report

Question 15

What is the risk of infection when patients taking corticosteroids?

Answer 15

Immunosuppression- increased infection but atypical presentations e.g. not detected until advanced stages e.g. TB/septicaemia, amoebiasis, may not present with typical rash in chickenpox/shingles etc

Question 16

What is the advice to patients regarding chickenpox in corticosteroid use and for 3 months after?

Answer 16

Avoid exposure /close contact

Question 17

If a patient is non-immune to chickenpox and needs CCS, what is done?

Answer 17

Passive immunisation with varicella zoster immnunoglobulin

Question 18

What is advice regarding vaccinations for patients on CCS

Answer 18

Avoid live vaccines e.g. influenza, MMR, BCG, Varicella, yellow fever

Question 19

What are the symptoms of adrenal suppression and when can they occur

Answer 19

1 year after stopping
fatigue, anorexia, nausea, vomiting, SEVERE HYPOTENSION
Hyperkalaemia, Hyponatraemia

Question 20

During stress/trauma/illness, what changes are needed to steroids and why?

Answer 20

During stress etc cortisol levels rise but this doesn’t occur in people on steroids due to adrenal suppression - so because there is diminished adrenal cortex action- need to increase doses of steroids

Question 21

What is the MHRA warning for steroids regarding eyes?

Answer 21

Chorioretinopathy - local and systemic - blurred vision and visual disturbances

Question 22

With high doses of steroids what can occur? what are symptoms?

Answer 22

Cushing syndrome - moon face, striae, acne, hirutism - usually reversible - need to tape down the steroid to withdraw

Question 23

As per MHRA warning, what steroid injection should not be used in patientss with a cows milk allergy?

Answer 23

Methylprednisolone injection (solu-medrone 40mg) - contains lactose

Question 24

What situations would you avoid abrupt withdrawal of steroids?

Answer 24

Long term >3weeks
>40mg pred daily or equivalent 
Repeat doses in evening
addisons
short course within 1 year of stopping long term 
recent repeated courses

Question 25

What is treatment for cushings syndrome caused by tumour?

Answer 25

Ketoconazole or metyrapone (cortisol inhibitor)