Glucocorticoids_PHARM

Question 1

Adrenal Cortex
Physiological Effect

Answer 1

1. sex hormones
   - androgens
   - estrogens
2. mineralcorticoids
   - aldosterone
3. glucocorticoids
   - cortisol

Question 2

Physiological effect of cortisol

Answer 2

1. glucose
   - increase BG
   - glycogen
2. breakdown lipids, muscle
   - make glucose out of lipids, a.a
   - dyslipidemia
3. vasoconstriction, decreased vascular permeability, water/sodium retention, potassium excretion
4. Immunosupression
   - decrease lymphocytes, monocytes, basophils, eosinophils
   - decrease prostaglandins
5. neonatal respiratory maturation
6. Breakdown bone
   - increase osteoclasts, decrease osteoblasts, decrease GI absorption calcium, increase PTH

Question 3

Cortisol
MOA

Answer 3

Transcription factor
binds nuclear receptor
complex binds promotor and results in DNA transcription

• anti-inflammatory (inhibition cytokines, histamine, prostaglandins)
• immunosupressant (inhibition T cells, lymphocytes, monocytes, basophils, eosinophils; proliferation, infiltration)

Question 4

Cortisol
Pharmacological effect

Answer 4

• hyperglycemia
• hypernatremia, water retention
• hypokalemia, dysrhythmias
• striae
• breakdown lipids, muscle, myopathy
• glaucoma
• GI bleeds (lack of prostaglandins)
• immunosupression
• infection, activation latent infections
• psychosis, depression (long term low dose), mania, anxiety (short term, high dose), delirium, psychosis

Question 5

Indication
Corticosteroids

Answer 5

Autoimmune diseases, inflammatory diseases, organ transplants, cancer, pain/nausea
- RA, ALS, SLE
- IBD
- Allergies
- Asthma
- Dermatologic: psoriasis
- neonatal respiratory distress syndrome

Question 6

SE
Cortisol

Answer 6

duration vs. dosage of treatment

cushingoid syndrome
- hypernatremia, water retention
- hypokalemia
- hyperglycemia
- triglyceridemia
- hypertension
- osteoporosis
- skin striae
- infections
- poor wound healing
- GI bleeds
- Kidney disease
- psychogenic

*greater in older people

Question 7

Corticosteroid and adrenal supression

Answer 7

Duration vs. Dosage
- > 3 weeks duration
- weaning required
- stress dosing required

Question 8

Prophylactic prescriptions with corticosteroids

Answer 8

Bones
- calcium
- vitamin D
- bone mineral density scan
- Bisphosphonate (inhibits osteoclasts), calcitonin (inhibits osteoclasts), teriparatide (new bone formatioN), estrogen therapy

GI
- PPI
- H2 receptor blocker
- dont coprescribe alcohol, smoking, NSAIDs

Infection
- screen for latent infections (HIV, TB)
- prophylaxis Abx treatment
- Vaccinations prior to prescription up to date

hyperglycemia
- monitor BG
- increase insulin

Fluid and electrolytes
- limit sodium in diet
- increase potassium in diet (potatoes, bananas, beans, oranges, etc.)

Growth supression
- monitor growth chart

depression
- anti-depressant
- weaning

anxiety, mania
- anti-psychotic, anxiety

adrenal supression
- alternate day dosing (every other day)

Cataracts and glaucoma
- opthalmolostic monitoring

Question 9

Contraindications/precautions
glucocorticoids

Answer 9

live vaccinations, latent infections, immunosupression

NSAIDs, alcohol, smoking

pregnancy, breastfeeding

diabetics

osteoporosis

glaucoma, cataracts

infants, children

psychological depression, anxiety, depression

GI disorders

CVD disorders

Question 10

Route of administration

Answer 10

Oral
- systemic effects
- higher SE

Intranasal, topical, inhaled
- local effect
- lower SE

Question 11

Glucocorticoid activity/potency
Low, medium, high
list

Answer 11

Low
- hydrocortisone
- cortisone
*highest mineralcorticoid activity (retention sodium and water)

Medium
- prednisolone
- prednisone
- methylprednisone

High
- dexamethasone
- betamethaxone

Question 12

Baseline laboratory data before starting glucocorticoids

Answer 12

CBC
- RBC, WBC diff (infection)

Lytes
- Sodium, potassium, fluid

lipid pannel
- TG

BG, A1C
- glycemia

TB, HIV, etc.
- latent infections

Vaccination status
- give vaccines, live

BMD
- bone mineral density
- DEXA scan

eyes
- cataracts, glaucoma

Psych
- depression, anxiety, psychosis

GI
- bleeds, NSAIDs, smoking, alcohol

Question 13

glucocorticoid withdrawal syndrome

Answer 13

cause
- adrenal insufficiency

symptoms
- hypotension, hypoglycemia, myalgias, fatigue

taper
- taper if duration > 2 weeks
- taper over 7 days

Question 14

Patient education

Answer 14

• administer in morning (natural release)
• take with food (prevention GI distress)
• don’t d/c , withdrawal, life threatening (wean, stress dosing)
• signs of infection, risk of infection (fever, malaise)
• fluid retention
• hypokalemia (muscle weakness, irregular pulse, cramping)
• cataracts, glaucoma (vision. blurred, HA)
• GI bleeding (bloody stool, black, tarry)
• psychological symptoms (anxiety, depression, psychosis)
• no live vaccinations
• laboratory monitoring:
• CBC, lytes, lipid pannel, glucose pannel, BMD, opthalmology, TB/HIV, height/weight, BP, BMI

Question 15

Laboratory monitoring with glucocorticoids

Answer 15

• CBC (pancytopenia)
• electrolytes (Na, K)
• lipid pannel (TG)
• glucose (hyperglycemia)
• BMD (OP)
• opthalmology (Cataracts glaucoma)
• TB, HIV (latent infections)
• BMI, BP (every visit; HTN, water retention)
• height (every 6 months; growth supression)

1 month
6 months
every year there after

Question 16

Precautions glucocorticoids
infants
children
pregnancy
breastfeeding
elderly

Answer 16

infants/children
- growth supression
- OP

pregnancy
- teratogenic - cleft lip, hypoadrenalism
- inhaled/topical preferred
- hydrocortisone preferred

breastfeeding
- contraindicated

elderly
- increase SE observed