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Pharmacology II > Glucocorticoids > Flashcards

Glucocorticoids Flashcards

1
Q

What is the natural function of glucocorticoids?

A

The natural function of glucocorticoids is to protect glucose-dependent cerebral functions.

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2
Q

How do glucocorticoids protect glucose-dependent cerebral functions?

A
  1. Stimulating the formation of glucose by the liver
  2. Decreasing the peripheral utilization of glucose
  3. Promoting its storage as glycogen
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3
Q

The protective functions of glucocorticoids serve to?

A

These effects protect the glucose dependent tissues, the brain and heart, from starvation

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4
Q

If glucocorticoids do not perform their functions, what happens?

A
  1. Muscle wasting
  2. Delayed wound healing
  3. Thinning of the skin
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5
Q

List the Physiological roles of glucocorticoids:

A
  1. Increase gluconeogenesis
  2. Decrease protein synthesis
  3. Increase lipolysis → release of glycerol and free fatty acids
  4. Glucocorticoids during fasting contribute to the maintenance of glucose concentrations
    • ↑ the release of glucose by the liver
    • ↑ gluconeogenesis and glycogen synthase

Gluconeogenic precursors
→ amino acids and glycerol

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6
Q

Describe the effects of glucocorticoids on the development of pulmonary surfactant in the near-term fetus (lung maturation)

A

→ GCs stimulate the synthesis of surfactant proteins
→ Glucocorticoid receptor (GR) knockout mice do not survive because of lung atelectasis (partial/complete collapse of the lung)
→ prematurity with delayed development of the adrenal axis in foals has been suspected as a cause of neonatal respiratory distress syndrome

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7
Q

GCs have an ________ effect to that of insulin: ___ glucose production from amino acids (___________)

A

antagonistic, ↑, gluconeogenesis

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8
Q

GCs enhance lipolysis. GC excess may cause redistribution of ____ → stimulation of ____
and thus stimulating __________, which results in ___________.

A

fat, appetite, hyperinsulinemia, lipogenesis

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9
Q

➢ GCs inhibit bone formation by inhibiting _________ proliferation and the synthesis of bone _____ while stimulating _________ activity.

A

osteoblast, matrix, osteoclast

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10
Q

In adult dogs, 2 mg/kg __________ for 30 days reduced bone mineral density by 14%
Costa et al. 2010

A

prednisone

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11
Q

What are the cardiorespiratory effects of glucocorticoids?

➢ GCs have direct positive ___________ and ____________ actions on the heart
➢ They may induce __________ in animals and humans
➢ Increase the number and affinity of _____-___________ receptors
➢ They also increase the expression of ______-________ receptors in the vascular smooth muscle

A

➢ GCs have direct positive chronotropic and inotropic actions on the heart
➢ They may induce hypertension in animals and humans
➢ Increase the number and affinity of beta-adrenergic receptors
➢ They also increase the expression of alpha-adrenergic receptors in the vascular smooth muscle

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12
Q

How do glucocorticoids affect water and electrolyte balance?

A

GC use –> PU/PD –> Inhibition of ADH release (vasopressin, antidiuretic hormone)

GCs increase the glomerular filtration

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13
Q

Pharmacological doses of GCs stimulate the excessive production of _____ and _____ in the stomach and may cause _____ _____.

Consider also:
→Patients under ____ or
→receiving other drugs that contribute to GI damage (______)

A

acid, pepsin, peptic ulcer

stress, NSAIDs

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14
Q

GCs facilitate ____ absorption.

GCs ________ the effect of vitamin D on calcium absorption.

A

fat

antagonize

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15
Q

Pharmacological use of GCs can have what effect on the liver? Are these effects reversible?

A

Hepatomegaly and elevated liver enzyme activity.

The effects of GCs are slowly reversible
(1 to 1.5 months after therapy is discontinued)

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16
Q

Immune and hematological effects
➢ GCs results in alterations in the concentration, distribution and function of peripheral _________.
➢ ___________ production is generally unaffected by moderate dosages of GCs. An inhibition is caused only at _____ dosages and with _______-term therapy
➢ GCs inhibit ______-induced interferon synthesis
➢ GCs can induce _________ on normal lymphoid cells
➢ GCs inhibit monocyte differentiation into _________ and ___________ _________

A

➢ GCs results in alterations in the concentration, distribution and function of peripheral leukocytes
➢ AB production is generally unaffected by moderate dosages of GCs. An inhibition is caused only at high dosages and with long-term therapy
➢ GCs inhibit virus-induced interferon synthesis
➢ GCs can induce apoptosis on normal lymphoid cells
➢ GCs inhibit monocyte differentiation into macrophages and macrophage phagocytosis

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17
Q

What are the principles of rational glucocortioid therapy?

A
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18
Q

What is the physiological replacement therapy of glucocorticoids?

A

It involves use of GC in amounts like those of the naturally occurring GCs (cortisol) from the adrenal cortex
* Adrenalectomized and Addisonian dogs and cats
* It is rarely indicated in large animals
Hydrocortisone or cortisone at 0.2-1 mg/Kg day
Prednisolone or prednisone at 0.1-0.2 mg/Kg day
As a rule, animals produce approximately 1 mg/Kg of cortisol (hydrocortisone) every day

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19
Q

The effect of GC in all forms of shock may be controversial
➢ Evidence suggests GCs may lead to increased survival in _______ and _____ _______
➢ Therapy for shock should also include _____ therapy
➢ Suspected endotoxic shock should be treated with a (2)?
➢ Proponents of GCs therapy for shock point out → _____-term ( ͂ ___ h) therapy has few negative effects, and the positive effects outweigh the risks
➢ The __________ effects of GCs make their use contraindicated during chronic sepsis!

A

The effect of GC in all forms of shock may be controversial
➢ Evidence suggests GCs may lead to increased survival in hemorrhagic and septic shock
➢ Therapy for shock should also include fluid therapy
➢ Suspected endotoxic shock should be treated with a broad-spectrum antimicrobial and
fluid therapy
➢ Proponents of GCs therapy for shock point out → short-term ( ͂ 48 h) therapy has few
negative effects, and the positive effects outweigh the risks
The immunosuppressive effects of GCs make their use contraindicated during chronic sepsis!

20
Q

What are the concerns with using GCs as anti-inflammatory and anti-allergenic therapy? List examples.

A

Concerns:
→ such diseases are difficult to definitively diagnose
→ misuse of GCs is not uncommon

Examples of these uses are:
* Symptomatic treatment of pruritic dermatoses
* Allergic pulmonary disease
* Allergic gastroenteritis

21
Q

➢ Prednisolone or prednisone is most used in ______ animals
→ Induction: at 0.55 mg/Kg q 12 h given orally
→ and then maintenance: 0.55 - 2.2 mg/Kg every other (EOD)
All the dosages should be adjusted according to effect

A

➢ Prednisolone or prednisone is most used in small animals
→ Induction: at 0.55 mg/Kg q 12 h given orally
→ and then maintenance: 0.55 - 2.2 mg/Kg every other (EOD)
All the dosages should be adjusted according to effect

22
Q

What is the disadvantage of using depot products?

A

Drug dosage cannot be stopped or reduced

23
Q

List the long-acting injectable GC products.

A

Some long-acting injectable products
* Prednisolone acetate → 1 – 2 days
* Dexamethasone in propylene glycol → 1 – 7 days
* Triamcinolone → 3 – 7 days

24
Q

Immune dysregulation is likely caused by?

A

➢ Immune dysregulation: It is likely multifactorial
* Genetic factors
* Environmental triggers
Environmental triggers:
* Infectious agents
* Drugs
* Vaccines
* Neoplasia

25
Q

Immune system may be appropriately or inappropriately triggered
➢ Lymphocyte dysfunction:
→ failure of lymphocyte ________
→ generation of _______ or ___ cells toward self-antigens

The inappropriately response:
Tissue _________ and clinical __________

A

➢ Lymphocyte dysfunction:
→ failure of lymphocyte selection
→ generation of antibodies or T cells toward self-antigens
The inappropriately response
Tissue destruction and clinical disease

26
Q

List Some of the common systemic inflammatory diseases with an immune-mediated etiology in dogs and cats

What are the treatment goals?

A
  • Inflammatory bowel disease (IBD)
  • Immune-mediated hemolytic anemia (IMHA)
  • Immune-mediated thrombocytopenia (IMT)
  • Immune-mediated polyarthritis (IMPA)

Treatment goals
Induce disease remission by inhibiting inflammation and modulating
lymphocyte function while minimizing adverse drugs effects

27
Q

Glucocorticoids remain the mainstay of first line treatment of ________ and ________-mediated diseases in dogs and cats despite their long list of clinically ______ side effects

A

Glucocorticoids remain the mainstay of first line treatment of inflammatory
and immune-mediated diseases in dogs and cats despite their long list of
clinically limiting side effects

28
Q

List the GCs that act as immunosuppressive drugs.

A
  • Cyclosporine
  • Azathioprine
  • Chlorambucil
  • Mycophenolate
29
Q

It is highly recommended to use a glucocorticoid with ____-documented side effects
–> During acute illness, you should use the
_________ immunosuppressive recommended dosage until clinical signs decline
→ After that point, _________ taper the dose of GCs

A

well

→ Use highest immunosuppressive recommended dosage until clinical
signs decline
→ After that point, slowly tapering the dose of GCs

30
Q

What is important to remember when using GCs for immunosuppressive therapy?

A
  • The therapy should not be discontinued until the autoimmune disease is in remission
    for 2- 3 months (recurrence of signs)
  • If GCs provide incomplete remission, other immunosuppressant agents such as the alkylating agent cyclophosphamide may be added
31
Q

➢ GCs administration to dogs for longer than 2 weeks results in significant loss of __________ functional reserve
➢ Administration of greater than ____ mg/Kg/day of prednisolone or an equipotent dosage of a more potent drug for longer than ___ weeks should be considered chronic therapy

A _______ reduction of the dosage is indicated!

A

➢ GCs administration to dogs for longer than 2 weeks results in significant loss of adrenal functional reserve
➢ Administration of greater than 0.5 mg/Kg/day of prednisolone or an equipotent dosage of a more potent drug for longer than 2 weeks should be considered chronic therapy
A gradual reduction of the dosage is indicated!

32
Q
A
33
Q

The cellular effects of GCs are

A

dose-dependent

34
Q

At anti-inflammatory doses, GCs inhibit

A
  • Phospholipase A2
  • Release of pro-inflammatory cytokines
35
Q

At immunosuppressive doses, GCs target macrophage function by

A
  • Downregulating Fc receptor expression
  • ↓ responsiveness to antibody-sensitized cells
  • ↓ antigen processing
36
Q

Prednisone and prednisolone for immunosuppressive therapy

Prednisone is a _________ → Prednisolone
Cats achieve higher _______ concentrations when administered oral prednisolone
versus prednisone

A

Prednisone is a prodrug → Prednisolone
Cats achieve higher plasma concentrations when administered oral prednisolone
versus prednisone

37
Q

➢ Dexamethasone for immunosuppressive therapy → lacks ____________ activity

A

mineralocorticoid

The term “mineralocorticoid” is used to describe those actions of adrenal corticosteroids producing sodium and fluid retention and potassium excretion.

38
Q

➢ Budesonide for immunosuppressive therapy

A

Soft corticoid
Kind of drug that is supposed to be delivered in a place where they have to act.
Very commonly used in IBD in dogs.

Adverse reactions less if given via systemic circulation.

39
Q
  • The immune-suppressing effect of GC’s require ______ doses
  • 2 mg/Kg per day of ____________ for the treatment of IMHA
  • Initial (induction) dosage regimens employ daily doses of 2.2 to 6.6 mg/Kg/day
    (prednisolone or prednisone)
  • Initial doses generally are in the range of 2 – 4 mg/Kg/day
  • After induction period, if the patient responds favorably, the dose may be decreased by approximately _____%
  • For immune-mediated disease, maintenance doses of 1 mg/Kg are possible
A
  • The immune-suppressing effect of GC’s require high doses
  • 2 mg/Kg per day of prednisolone for the treatment of IMHA
  • Initial (induction) dosage regimens employ daily doses of 2.2 to 6.6 mg/Kg/day
    (prednisolone or prednisone)
  • Initial doses generally are in the range of 2 – 4 mg/Kg/day
  • After induction period, if the patient responds favorably, the dose may be decreased by approximately 50%
  • For immune-mediated disease, maintenance doses of 1 mg/Kg are possible
40
Q

When do you use GCs for immunosuppressive therapy?

A

Immunosuppressive therapy: Every other day therapy (EOD)
* When using an intermediate acting drug (12 – 36 hours)
* It is not supposed for GC with long duration activity
* EOD therapy will minimize, but will not prevent adrenal atrophy

41
Q

What are the side effects of using GCs for immunosuppressive therapy?

A

MAIID GO

  • Iatrogenic hyperadrenocorticism
  • Adrenal gland suppression
  • Gastrointestinal ulceration
  • Insulin resistance
  • Muscle catabolism
  • Delayed wound healing
  • Opportunistic infections
42
Q

In healthy dogs, GC treatment with prednisone (2mg/Kg/day) for 28 days
resulted in endoscopic evidence of __________ _________ after 14 days of treatment

A

gastric ulceration

43
Q

The importance of close monitoring and clinical vigilance during
steroid treatment

A
44
Q

It is important to monitor GC use in patients with:
* __________ or _____-_________ GC side effects
* Lack any clinically significant response to steroids with ___ or ____ days
- ___________ immunosuppressive drugs need consideration

A

It is important to monitor GC use in patients with:
* Intolerable or life-threatening GC side effects
* Lack any clinically significant response to steroids with 7 or 14 days
Alternative immunosuppressive drugs need consideration

45
Q

Glucocorticoid supplementation during stress
–> Animals with marginally _______ or ________ adrenal function
Situation of minor stress = 4?
Prednisolone or prednisone at 0.4 -1 mg/Kg

A

–> Animals with marginally adequate or deficient adrenal function
Situation of minor stress
* Minor surgery
* General anesthesia
* Minor illness
* Visit to the veterinarian
Prednisolone or prednisone at 0.4 -1 mg/Kg

46
Q

In severely stressful situations → ______ surgery (including adrenalectomy)
__________ ___________ can be given IM at 0.4 – 2 mg/Kg

A

major, adrenalectomy, Prednisolone acetate

47
Q
  • The anti-inflammatory dose is __ times the physiologic dose
  • The immunosuppressive doses are ________ the anti-inflammatory dose
  • Shock doses of GCs have been reported at ___ to ___ times the immunosuppressive dose
A
  • The anti-inflammatory dose is 10 times the physiologic dose
  • The immunosuppressive doses are twice the anti-inflammatory dose
  • Shock doses of GCs have been reported at 5 to 10 times the iimmunosuppressive dose

Pharmacology II (27 decks)

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