Lecture 33/34

Question 1

relieve pain/distressing symptoms principles

Answer 1

start with lower dose
gradually reduce dose until worsening symptoms
substitute with other medications (like NSAIDs)

Question 1

implications of glucocorticoid administration

Answer 1

do not administer unless absolutely indicated or more conservative measures have failed
prescribe the lowest dose to achieve the desired effects for shortest duration possible

Question 2

symptoms gets worse when reducing dose

Answer 2

go back to the lowest acceptable dose to try and find a happy medium
try and reduce later

Question 3

treat life threatening conditions principles

Answer 3

initial dose must be high
no benefits observed quickly, double or triple the dose
reserve high dose, long therapy for life threatening doses

Question 4

physiologic dose

Answer 4

replacement dose, once a day
hydrocortisone - 20mg
prednisone - 5 to 7.5mg
methylprednisolone - 4 mg
dexamethasone - 0.75mg

Question 5

pharmacologic dose

Answer 5

any dose greater than physiologic dose

Question 6

maintenance or low pharmacologic dose

Answer 6

prednisone 5 to 15 mg per day

Question 7

moderate pharmacologic dose

Answer 7

prednisone 0.5 mg per kg per day

Question 8

high pharmacologic dose

Answer 8

prednisone 1-3 mg per kg per day

Question 9

massive pharmacologic dose

Answer 9

prednisone 15-30 mg per kg per day

Question 10

20mg of hydrocortisone is equal to

Answer 10

cortisone - 25 mg
prednisone - 5 mg
methylprednisolone - 4mg
dexamethasone - 0.75mg

Question 11

clinical presentation of Cushing’s syndrome

Answer 11

redistribution of body fat (central obesity - 80%)
moon faces (80%)
thick neck (buffalo hump and supraclavicular fat accumulation - 80%)
muscle wasting and weakness (steroid myopathy - 70%)
easy bruising (50%)

Question 12

cyp450 3a4 inhibitors

Answer 12

protease inhibitors
antifungals
split dose of glucocorticoid in half if necessary concurrent admin

Question 13

cyp450 3a4 inducer

Answer 13

phenytoin
rifampin
barbiturates
carbamazepine
double dose of glucocorticoids if necessary concurrent admin

Question 14

treatment strategy to prevent Cushing’s syndrome

Answer 14

give lowest glucocorticoid dose and shortest possible duration
use admin routes that minimize systemic absorption (like inhalation or topical)
avoid concurrent administrations of drugs that inhibit/induce steroid metabolism
gradually taper the dose
supplement with extra dose of steroid during periods of physiologic stress

Question 15

gradually taper the dose

Answer 15

prednisone 20mg (or equivalent) daily given in the morning –> every other day in the morning –> reach equivalent physiologic dose –> stop

Question 16

recovery period

Answer 16

up to a year for HPA axis recovering after steroid discontinuation
may need extra dose of steroid during periods of physiologic stress - surgery or emergency treatment

Question 17

adrenal insufficiency

Answer 17

inability of the adrenal gland to produce adequate amount of cortisol to regulate normal body functions in time of stress
long term usage of steroids make adrenal glands get lazy

Question 18

signs of adrenal insufficiency (addison’s disease)

Answer 18

bronze pigmentation of skin
changes in distribution of body hair
weakness
weight loss

Question 19

key monitoring parameters

Answer 19

subjective well-being of the patient in primary and secondary disease
resolution of hypotension, dizziness, dehydrations, hyponatremia, and hyperkalemia
monitor for adverse reactions of steroid (under-replacement and over-replacement)
maintenance of normal weight
blood pressure
electrolytes regression of clinical features
adjust dose accordingly as needed

Question 20

signs of under-replacement

Answer 20

weight loss
fatigue
nausea
myalgia
lack of energy

Question 21

signs of over-replacement

Answer 21

weight gain
central obesity
stretch marks
osteopenia/osteoporosis
impaired glucose tolerance
high blood pressure

Question 22

appropriate education for adrenal insufficiency

Answer 22

take with meals or milk
do not stop therapy without seeking healthcare provider’s advice
increase the dose of glucocorticoid during excessive physiologic stress
how to administer parenteral glucocorticoid if unable to immediately access medical care during an emergency
need to wear or carry identification
cause of adrenal insufficiency, including drug-induced etiologies
how to recognize the clinical manifestations
how to prevent an acute adrenal crisis

Question 23

physiologic stress

Answer 23

presence of fever
invasive dental procedure
invasive diagnostic procedures
surgery

Question 24

traditional replacement for adults

Answer 24

15 to 25 mg of hydrocortisone per day OR 20 to 35 mg of cortisone per day

Question 25

alternative replacement for adults

Answer 25

prednisone 3 to 5 mg per day
may be given to patients with reduced adherence

Question 26

treatment strategies

Answer 26

traditional replacement for adults
dosing regimen for short-acting steroids
glucocorticoid replacement for acute adrenal crisis

Question 27

TID dosing

Answer 27

give 2/3 of dosing in the morning between 6-8am
give 1/3 of dosing in the early afternoon roughly 2 hours after lunch
can decrease adherence
delivering at night causes insomnia

Question 28

glucocorticoid replacement for acute adrenal crisis

Answer 28

1) administer 100mg of HC IV
2) administer 200mg per day of HC as continuous infusion for 24 hours
3) when stable, reduce dose to 100mg per day of HC the following day
4) taper to maintenance therapy by day 4 or 5
5) add mineralocorticoid therapy as required
6) maintain or increase the dose to 200-400mg per day if complications persist or occur

Question 29

systemic glucocorticoid interactions

Answer 29

undergo metabolism by cyp450 3A4, cyp340, and other transformations in the liver
substrates of p-glycoprotein membrane efflux transporters
meds may alter serum concentration