Exam 3: Steroids Flashcards
List the roles of Natural Cortisol (glucocorticoid)
- Regulation of carbohydrate, fat and protein metabolism
- Maintenance of vascular reactivity
- Anti-inflammatory effects
- Maintenance of homeostasis during periods of stress (Emotional and Physical)
What increases the level of endogenous cortisol
- Periods of stress
- (B) Surgery = most potent activator
- (B) Pain = important to use good pain control
- illness, trauma, burns, fever, hypoglycemia, emotional upset.
List and describe the disorders of adrenal glands
- Excessive production of cortisol
- Cushing’s disease (primary disorder) - Insufficient production of cortisol
- Addison’s disease (primary disorder)- Glands do not function
- Secondary disorder = HPA axis is suppressed due to taking glucocorticoid medications
- Glands do not function
Name the secondary disorder of adrenal glands
Medication-Induced Adrenal Insufficiency
- Taking glucocorticoid medications (exogenous steroids) suppresses the body’s own production of endogenous steroids
T or F, Secondary adrenal insufficiency is more common than Addison’s disease
True
What factor must be present for secondary adrenal insufficiency to produce symptoms
- Condition usually does not produce symptoms unless patient is significantly stressed (or not enough circulating cortisol)
Can secondary adrenal insufficiency cause adrenal crisis?
- Adrenal crisis is rare with secondary adrenal insufficiency
What is adrenal crisis
Severe exacerbation of patient’s symptoms
- triggered by stress, illness, infection, surgery
- Emergency situation and life-threatening
- Rare with secondary adrenal insufficiency
Signs and symptoms of Adrenal crisis
(Only bolded items listed below)
- Profuse sweating
- Hypotension
- Weak pulse
- Dyspnea
- Cyanosis
Name the symptoms after a patient with adrenal crisis still hasn’t received treatment or intervention and continues to decline:
- Hypothermia
- (B) Severe hypotension
- Hypoglycemia
- (B) Circulatory collapse (Shock)
- Death
- (B) ** EMS for transport and significant medical intervention required.
Synthetic glucocorticoid medications are indicated for what things?
- Autoimmune diseases
- Immunosuppressive therapy in organ transplant patients
- Respiratory disease management
List the steroid use for systemic diseases
- Replacement therapy (adrenal insufficiency, pituitary insufficiency, adrenal hyperplasia)
- Arthritis (rheumatoid, osteoarthritis)
- Rheumatic Carditis
- Renal diseases
- Collagen Diseases (lupus)
- Allergic diseases (anti-inflammatory effect)
Name the mechanism of action of Steroids
- Steroid binds to a specific receptor
- Steroid-receptor complex translocates into the nucleus and alters gene expression
- Turns genes on or off
- Regulation of many cellular processes
- Other effects of glucocorticoids are mediated by catecholamines
- producing vasodilation or bronchodilation
Explain the mechanism by which steroids cause anti-inflammatory effects
- (B) Profound effects on number, distribution and function of peripheral leukocytes
- Increases in concentration in neutrophils and decrease in lymphocytes, monocytes, eosinophils and basophils
- (B) Inhibition of phospholipase A
- Decreases production of both prostaglandins and leukotrienes from arachidonic acid.
- Inhibit IL-2, migration inhibition factor and macrophage inhibition factor
List the effects for which steroids are used:
- anti-inflammatory action
- Suppression of allergic reactions
- also suppress the immune response (desired and undesired effect)
What does it mean that steroids are merely palliative rather than curative
They treat the symptoms rather than the underlying disease
Which type of steroid preparations are least likely to cause adrenal suppression
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
Corticosteroid products are characterized how?
Duration of action
- Short
- Intermediate
- Long
List the short acting drugs, their anti-inflammatory number and equivalent oral dose
- Hydrocortisone (Cortisone)
- 1
- 20 equi. dose
- prednisone (Deltasone)
- 4
- 5 equi. dose
- methylprednisolone
- 5
- 4 equiv. dose
Prednisone has what anti-inflammatory action in comparison to hydrocortisone
4 times the anti-inflammatory action of hydrocortisone
How are the equivalent doses determined?
Equivalent doses are based on 20 mg hydrocortisone = amount normally secreted daily by an adult without stress
List the intermediate-acting oral corticosteroids, their anti-inflammatory action number and equivalent oral dose
- triamcinolone
- 5
- 4 equi. dose
- prednisolone
- 4
- 5 equi. dose
List the long-acting oral corticosteroids, their anti-inflammatory action number and equivalent oral dose
- dexamethasone
- 30
- 0.75 equi. dose
- betamethasone
- 25
- 0.6-0.75 equi. dose
What are the dosing considerations with steroids?
- 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
What is the risk of daily steroid therapy
Greater risk for adrenal suppression
What is the normal adrenal output of cortisol
20-30 mg hydrocortisone equivalent
What is the threshold that indicates whether a steroid may cause suppression?
Any medication dosage above the normal adrenal output of cortisol = 20-30 mg hydrocortisone equivalent
Explain tapered dosing
Chronic steroid users “wean off” steroids in descending doses
During stress, adrenals may secrete up to what level of hydrocortisone equivalent?
up to 300 mg
Chronic steroid users should avoid what other drugs?
Avoid aspirin and NSAIDS!!!
- Peptic ulceration
List the oral side effects of steroids
- Candidiasis = most common
- Poor wound healing = long term use
- Masking of oral infections = anti-inflammatory
- Xerostomia = inhaled and systemic steroids
Contraindications to steroids
- Systemic fungal infections
- Viral infections
- Latent or active tuberculosis
- Allergy to any component of medications
What are steroids used for in dentistry
- For reduction of pain and swelling
- treatment of inflammatory pathologies of oral mucosa
How do steroids reduce inflammation
Suppress migration of PMN’s
Reverse increased capillary permeability
What is the most common route of steroid delivery in dentistry
Topical
How long should high potency topical be used?
Use for 2 weeks only
- Anything longer needs physician consultation
When do you apply a ointment/gel steroid?
Apply after brushing, eating/drinking and at bedtime
- Do not take anything by mouth for at least 30 minutes following application
Other than applied with a cotton applicator, how can topical steroids be placed?
Can be placed in a mouthguard to prolong contact with lesion
- Gels adhere best
What steroid preparation is usually used in mouthguard to prolong contact with lesion
triamcinolone (Kenalog in Orabase)
- Lesions should respond 7-14 days
Name the topical steroid ointments
- fluocinonide (Lidex) = 0.5% gel
- mild lichen Plans, recurrent aphthous stomatitis
- clobetasol proprionate (Temovate) = 0.5% gel
- for oral inflammation; q-tip application
- betamethasone valerate (Valisone) = 0.1% gel
Name the topical steroid rinses
- dexamethasone (Decadron) elixir
- prednisolone syrup
- rinse for 30 seconds
- expectorate
- 2-4 times a day
List the low potency steroid preparations
hydrocortisone cream 1% (OTC)
hydrocortisone cream 2.5%
List the moderate potency steroid preparations
triamcinolone acetonide (0.025%, 0.1%)
List the high potency steroid preparations
tramcinolone acetonide (0.5%) fluocinonide (Lidex) 0.05% ( gel, ointment or solution) clobetasol (Temovate) 0.05% cream or solution
List the types of injected steroids
- intralesional
- used intermittently
- no systemic complications
- Intra-articular
- used at 3 week intervals to treat bone pathology
List the oral steroids
methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
prednisone (Prednisone Intensol, Sterapred)
In what populations should you caution use of steroids?
- Avoid in pregnant/lactating women
- Use with extreme caution in pediatric patients
- more susceptible to suppression with topicals
- Geriatric patients more susceptible to hypertension and osteoporosis side effects.
T or F, Routine dental procedures stimulate cortisol production enough to warrant need for steroid supplementation
False, few dental procedures warrant use other than major surgical procedures
When do cortisol levels show the increase? Before, during or after the procedure
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
What increases risk for adrenal crisis perioperatively?
- severity of surgery
- drugs administered
- overall health of the patient
- extent of pain control
- amount of blood loss (hypotension)
- Fasting state (hypoglycemia)
What blood levels represent hypotension
systolic BP
What lab tests are done to check adrenal function?
- Basal plasma ACTH and cortisol levels
- Urine tests
- Stimulation tests
- If adrenal is insufficient, implement steroid supplementation
If a patient needing minimally invasive treatment and is on steroids comes to your office, what guidelines should you follow?
Patient takes usual daily dose
Schedule patient first thing in the morning
Stress reduction protocol
Monitor blood pressure
For major invasive procedures in patients currently taking steroids, what guidelines do you follow?
Physician consultation
Laboratory testing
Steroid supplementation as needed
What things can be used for anxiety control?
nitrous oxide
benzodiazepines (valium)
(do not alter normal plasma cortisol levels)
List the stress protocol
Schedule surgeries in morning
Anxiety control
monitor blood pressure
