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Pharmacology II > Exam 3: Steroids > Flashcards

Exam 3: Steroids Flashcards

1
Q

List the roles of Natural Cortisol (glucocorticoid)

A
  1. Regulation of carbohydrate, fat and protein metabolism
  2. Maintenance of vascular reactivity
  3. Anti-inflammatory effects
  4. Maintenance of homeostasis during periods of stress (Emotional and Physical)
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2
Q

What increases the level of endogenous cortisol

A
  • Periods of stress
    1. (B) Surgery = most potent activator
    2. (B) Pain = important to use good pain control
    3. illness, trauma, burns, fever, hypoglycemia, emotional upset.
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3
Q

List and describe the disorders of adrenal glands

A
  1. Excessive production of cortisol
    - Cushing’s disease (primary disorder)
  2. Insufficient production of cortisol
    - Addison’s disease (primary disorder)
    • Glands do not function
      • Secondary disorder = HPA axis is suppressed due to taking glucocorticoid medications
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4
Q

Name the secondary disorder of adrenal glands

A

Medication-Induced Adrenal Insufficiency

- Taking glucocorticoid medications (exogenous steroids) suppresses the body’s own production of endogenous steroids

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5
Q

T or F, Secondary adrenal insufficiency is more common than Addison’s disease

A

True

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6
Q

What factor must be present for secondary adrenal insufficiency to produce symptoms

A
  • Condition usually does not produce symptoms unless patient is significantly stressed (or not enough circulating cortisol)
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7
Q

Can secondary adrenal insufficiency cause adrenal crisis?

A
  • Adrenal crisis is rare with secondary adrenal insufficiency
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8
Q

What is adrenal crisis

A

Severe exacerbation of patient’s symptoms

  • triggered by stress, illness, infection, surgery
  • Emergency situation and life-threatening
  • Rare with secondary adrenal insufficiency
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9
Q

Signs and symptoms of Adrenal crisis

A

(Only bolded items listed below)

  • Profuse sweating
  • Hypotension
  • Weak pulse
  • Dyspnea
  • Cyanosis
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10
Q

Name the symptoms after a patient with adrenal crisis still hasn’t received treatment or intervention and continues to decline:

A
  • Hypothermia
  • (B) Severe hypotension
  • Hypoglycemia
  • (B) Circulatory collapse (Shock)
  • Death
  • (B) ** EMS for transport and significant medical intervention required.
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11
Q

Synthetic glucocorticoid medications are indicated for what things?

A
  1. Autoimmune diseases
  2. Immunosuppressive therapy in organ transplant patients
  3. Respiratory disease management
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12
Q

List the steroid use for systemic diseases

A
  1. Replacement therapy (adrenal insufficiency, pituitary insufficiency, adrenal hyperplasia)
  2. Arthritis (rheumatoid, osteoarthritis)
  3. Rheumatic Carditis
  4. Renal diseases
  5. Collagen Diseases (lupus)
  6. Allergic diseases (anti-inflammatory effect)
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13
Q

Name the mechanism of action of Steroids

A
  1. Steroid binds to a specific receptor
  2. Steroid-receptor complex translocates into the nucleus and alters gene expression
    • Turns genes on or off
    • Regulation of many cellular processes
  3. Other effects of glucocorticoids are mediated by catecholamines
    • producing vasodilation or bronchodilation
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14
Q

Explain the mechanism by which steroids cause anti-inflammatory effects

A
  1. (B) Profound effects on number, distribution and function of peripheral leukocytes
    • Increases in concentration in neutrophils and decrease in lymphocytes, monocytes, eosinophils and basophils
  2. (B) Inhibition of phospholipase A
    • Decreases production of both prostaglandins and leukotrienes from arachidonic acid.
  3. Inhibit IL-2, migration inhibition factor and macrophage inhibition factor
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15
Q

List the effects for which steroids are used:

A
  1. anti-inflammatory action
  2. Suppression of allergic reactions
  3. also suppress the immune response (desired and undesired effect)
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16
Q

What does it mean that steroids are merely palliative rather than curative

A

They treat the symptoms rather than the underlying disease

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17
Q

Which type of steroid preparations are least likely to cause adrenal suppression

A

Topical applications least likely to cause adrenal suppression.
(Systemic steroids more likely)

Remember: the more potent the drug, the lower the dose, the higher the risk for adrenal suppression

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18
Q

Corticosteroid products are characterized how?

A

Duration of action

  • Short
  • Intermediate
  • Long
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19
Q

List the short acting drugs, their anti-inflammatory number and equivalent oral dose

A
  1. Hydrocortisone (Cortisone)
    • 1
    • 20 equi. dose
  2. prednisone (Deltasone)
    • 4
    • 5 equi. dose
  3. methylprednisolone
    • 5
    • 4 equiv. dose
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20
Q

Prednisone has what anti-inflammatory action in comparison to hydrocortisone

A

4 times the anti-inflammatory action of hydrocortisone

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21
Q

How are the equivalent doses determined?

A

Equivalent doses are based on 20 mg hydrocortisone = amount normally secreted daily by an adult without stress

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22
Q

List the intermediate-acting oral corticosteroids, their anti-inflammatory action number and equivalent oral dose

A
  1. triamcinolone
    • 5
    • 4 equi. dose
  2. prednisolone
    • 4
    • 5 equi. dose
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23
Q

List the long-acting oral corticosteroids, their anti-inflammatory action number and equivalent oral dose

A
  1. dexamethasone
    • 30
    • 0.75 equi. dose
  2. betamethasone
    • 25
    • 0.6-0.75 equi. dose
24
Q

What are the dosing considerations with steroids?

A
  • Drugs are taken in the morning
  • Alternate day therapy
  • Alternate day therapy is used for patients who must take steroids for longer than 1 month.
  • Adrenal gland functions normally on “off” day
25
Q

What is the risk of daily steroid therapy

A

Greater risk for adrenal suppression

26
Q

What is the normal adrenal output of cortisol

A

20-30 mg hydrocortisone equivalent

27
Q

What is the threshold that indicates whether a steroid may cause suppression?

A

Any medication dosage above the normal adrenal output of cortisol = 20-30 mg hydrocortisone equivalent

28
Q

Explain tapered dosing

A

Chronic steroid users “wean off” steroids in descending doses

29
Q

During stress, adrenals may secrete up to what level of hydrocortisone equivalent?

A

up to 300 mg

30
Q

Chronic steroid users should avoid what other drugs?

A

Avoid aspirin and NSAIDS!!!

- Peptic ulceration

31
Q

List the oral side effects of steroids

A
  1. Candidiasis = most common
  2. Poor wound healing = long term use
  3. Masking of oral infections = anti-inflammatory
  4. Xerostomia = inhaled and systemic steroids
32
Q

Contraindications to steroids

A
  1. Systemic fungal infections
  2. Viral infections
  3. Latent or active tuberculosis
  4. Allergy to any component of medications
33
Q

What are steroids used for in dentistry

A
  • For reduction of pain and swelling

- treatment of inflammatory pathologies of oral mucosa

34
Q

How do steroids reduce inflammation

A

Suppress migration of PMN’s

Reverse increased capillary permeability

35
Q

What is the most common route of steroid delivery in dentistry

A

Topical

36
Q

How long should high potency topical be used?

A

Use for 2 weeks only

- Anything longer needs physician consultation

37
Q

When do you apply a ointment/gel steroid?

A

Apply after brushing, eating/drinking and at bedtime

- Do not take anything by mouth for at least 30 minutes following application

38
Q

Other than applied with a cotton applicator, how can topical steroids be placed?

A

Can be placed in a mouthguard to prolong contact with lesion
- Gels adhere best

39
Q

What steroid preparation is usually used in mouthguard to prolong contact with lesion

A

triamcinolone (Kenalog in Orabase)

- Lesions should respond 7-14 days

40
Q

Name the topical steroid ointments

A
  1. fluocinonide (Lidex) = 0.5% gel
    • mild lichen Plans, recurrent aphthous stomatitis
  2. clobetasol proprionate (Temovate) = 0.5% gel
    • for oral inflammation; q-tip application
  3. betamethasone valerate (Valisone) = 0.1% gel
41
Q

Name the topical steroid rinses

A
  1. dexamethasone (Decadron) elixir
  2. prednisolone syrup
  • rinse for 30 seconds
  • expectorate
  • 2-4 times a day
42
Q

List the low potency steroid preparations

A

hydrocortisone cream 1% (OTC)

hydrocortisone cream 2.5%

43
Q

List the moderate potency steroid preparations

A

triamcinolone acetonide (0.025%, 0.1%)

44
Q

List the high potency steroid preparations

A 
tramcinolone acetonide (0.5%)
fluocinonide (Lidex) 0.05% ( gel, ointment or solution)
clobetasol (Temovate) 0.05% cream or solution
45
Q

List the types of injected steroids

A
  1. intralesional
    • used intermittently
    • no systemic complications
  2. Intra-articular
    • used at 3 week intervals to treat bone pathology
46
Q

List the oral steroids

A

methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)

prednisone (Prednisone Intensol, Sterapred)

47
Q

In what populations should you caution use of steroids?

A
  1. Avoid in pregnant/lactating women
  2. Use with extreme caution in pediatric patients
    • more susceptible to suppression with topicals
  3. Geriatric patients more susceptible to hypertension and osteoporosis side effects.
48
Q

T or F, Routine dental procedures stimulate cortisol production enough to warrant need for steroid supplementation

A

False, few dental procedures warrant use other than major surgical procedures

49
Q

When do cortisol levels show the increase? Before, during or after the procedure

A

Increase in postoperative period 1 to 5 hours after procedure has begun

  • Not before or during procedure
  • Most likely a response to pain and correlates with loss of local anesthesia
  • Improves with use of analgesics and anti-anxiety meds
50
Q

What increases risk for adrenal crisis perioperatively?

A
  1. severity of surgery
  2. drugs administered
  3. overall health of the patient
  4. extent of pain control
  5. amount of blood loss (hypotension)
  6. Fasting state (hypoglycemia)
51
Q

What blood levels represent hypotension

A

systolic BP

52
Q

What lab tests are done to check adrenal function?

A
  1. Basal plasma ACTH and cortisol levels
  2. Urine tests
  3. Stimulation tests
    • If adrenal is insufficient, implement steroid supplementation
53
Q

If a patient needing minimally invasive treatment and is on steroids comes to your office, what guidelines should you follow?

A

Patient takes usual daily dose
Schedule patient first thing in the morning
Stress reduction protocol
Monitor blood pressure

54
Q

For major invasive procedures in patients currently taking steroids, what guidelines do you follow?

A

Physician consultation
Laboratory testing
Steroid supplementation as needed

55
Q

What things can be used for anxiety control?

A

nitrous oxide
benzodiazepines (valium)
(do not alter normal plasma cortisol levels)

56
Q

List the stress protocol

A

Schedule surgeries in morning
Anxiety control
monitor blood pressure

Pharmacology II (24 decks)

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