Managing Steriods In Practise Flashcards
What can steroids be used for?
A) to suppress inflammatory process
B) steroid replacement where body doesn’t make enough
Give an example of steroids being used to suppress an inflammatory process
Oral prednisone for a chest infection
What’s the difference between glucocorticoid and mineralocorticoid activity?
Glucocorticoid- regulate carbohydrate, protein and fat metabolism. It is an anti-inflammatory immunosuppressant
Mineralocorticoid- regulates fluid and electrolyte levels
What drug would you use for a chest infection and why?
A glucocorticoid based drug as it has higher anti inflammatory action unlike mineralocorticoids
Give examples of conditions where steroid replacement therapy is needed
Addisons disease
Hypopituitarism (pituitary tumour)
Congenital adrenal hyperplasia
What does the adrenal cortex secrete?
Cortisol (glucocorticoid activity)
Aldosterone (mineralocorticoid)
What drug is used to replace cortisol in s Teri I’d replacement therapy?
Hydrocortisone
Tablets 15-40mg, 2-3 times a day
Larger dose given in morning
Eg. 10mg OM, 5mg LT, 5mg TT
What drug replaces aldosterone in steroid replacement therapy?
Fludrocortisone
Used when adrenal cortex is destroyed (addisons)
Also used in HPoT due to fluid retaining properties
50-300mcg daily in morning
What is the symptoms of adrenal insufficiency?
Hint acronym
A ppetite loss, unintentional weight loss, abdominal pain
D iscolouration of the skin
D ehydration
I ncreased thirst and polyuria
S alt cravings
O ligomenorrhoea
N o energy/ fatigue/ low mood
S ore/ weakness in muscles or joints
What is adrenal crisis?
The adrenal glands can’t cope with the extra corticosteroids needed hence life threatening symptoms can develop
Name 3 symptoms of adrenal crisis
Severe vomiting and diarrhoea—-> dehydration
Abdominal pain
Severe muscle weakness/ cramps
Severe drowsiness and fatigue
Pyrexia
Dizziness, low BP
Confusion
Limb and back pain
Delirium or loss of consciousness
How is adrenal crisis treated?
IV fluids or steroids
All steroid dependant patients need to be issued a steroid emergency card, what patients does this include?
Patients on LT prednisolone 5mg daily
Addisons
Hypothalamopituitary dysfunction
What happens to the dose of steroid if the patient is ill, injured or undergoes strenuous exercise?
- Generally, double the dose of hydrocortisone if fever or on antibiotics until recovered
- Vomiting is dangerous, patients may use emergency hydrocortisone injection & seek medical attention
- Up to double doses with extra fluid intake for strenuous events such as marathon
Why is hydrocortisone acetate not used in an emergency injection situation? What drugs are used instead?
It has a delayed onset so no good for emergency
Hydrocortisone sodium phosphate 100mg or hydrocortisone sodium succinate 100mg are used instead
What drug and usual dose is used for an inflammatory disease?
Oral prednisolone
30mg daily (6x5mg tabs, take all together in morning)
May be short course then stopped abruptly but can be long course
What are the desirable properties for glucocorticoid therapy?
High glucocorticoid activity
Relatively low mineralocorticoid activity
What are some side effects of long term steroid use?
Mood and behaviour changes eg. Confusion, irritability, delusions and suicidal thoughts
Increased susceptibility to infections
Suppression of normal adrenal function
What is classed as long term steroid treatment?
> 3 weeks
How does adrenal crisis occur?
Chronic deficiency conditions
Cessation of LT steroids/ rapid dose decrease
Infection, trauma, surgery etc
Name 3 side effects of short term steroid use and long term steroid use
ST- insomnia (take steroids in morning), mood disturbances and GI disturbances
LT- short course + increased susceptibility to infection, osteoporosis, adrenal suppression, cushingiod state, diabetes, skin changes (thinning, easy bruising), GI ulceration, hypokalaemia, growth retardation and fluid retention
A rare condition can occur when on corticosteroids where patients are encouraged to report and visual disturbances, what is the condition?
Chorioretinopathy
A retinal disorder
What are the contra indications of steroids?
Systemic infection (unless specific therapy given)
Avoid live virus vaccines
Name 3 cautions of steriod therapy
Children
Elderly
Chronic heart failure
Peptic ulcer
Epilepsy
Diabetes
Pregnancy
How do you minimise the side effects of steroids?
Morning dose to avoid insomnia
Minimise duration of course
Consider local application where possible
Alternate day dosing
Can steroids worsen or improve blood glucose control?
Worsen
Steroid induced hyperglycaemia
Steroid induced diabetes
Name the drug interactions with steroids
No major ones
NSAIDs can increase GI ulcer risk & so can steroids
Enzyme inducers may reduce serum conc of oral corticosteroids eg. Phenytoin and carbamazepine
Cholestyramine causes inhibition of GI absorption of oral corticosteroids with cholestyramine and other binding agents so doses should be separated from steriod
When should steroids be tapered down to avoid adrenal crisis?
Over 3 weeks at any dose
>40mg prednisolone or equivalent for more than 1 week
Multiple recent repeated courses
Short course within a year of stopping long course
Been given repeated doses in evening
How do you taper down steroids?
Decreasing the steriod dosage by the equivalent of 2.5mg of prednisolone every 3-7 days until physiologic dosage (7.5mg of prednisolone) is reached
Then more gradual reduction of 0.5-1mg every 2-4 weeks should be considered
List 3 withdrawal symptoms of steroids
Fatigue
Weight loss
Abdominal pain
Nausea
Vomiting
Headaches
Fever
Dizziness
Confusion
Loss of consciousness
(Note all of these are symptoms of adrenal insufficiency)
Give an example of a long, intermediate and short acting steroid
Long- dexamethasone, betamethasone
Intermediate- prednisolone
Short- cortisone, cortisol
Why is a topical steroid not recommended if the person has an infection eg infected eczema?
Because it will spread the infection
(Unless they are on antibiotics for the infection already)
What would the potency be like if the skin was thin?
Milder steroid would be prescribed
Name a mild, moderate, potent and very potent steroid
Mild- hydrocortisone
Moderate- clobetasone, betamethasone
Potent- beclomethasone, betamethasone dipropionate
Very potent- clobetasol
Describe the application of topical steroids
Apply thinly
Finger tip application- enough for twice size of adult palm
No more than twice daily
Use least potent formulation that is effective
Avoid prolonged use on face & keep away from eyes
Caution in children during pregnancy
Suppression of pituitary adrenal axis and Cushing syndrome can occur with prolonged use in large area
Name 3 side effects of topical steroids
Thinning of skin (LT)
Contact dermatitis
Perioral dermatitis
Acne, worsening of acne rosacea
Depigmentation
Increased hair growth
Spread/ worsening of infection
Is a ISC card required for clinic modulite <800mcg and Qvar <400mcg?
No
What needs to be checked before a patients dose of steroid is increased?
Patient adherence
Inhaler technique (consider spacer)
Smoking cessation
How is IBD treated? What route of administration?
Rectal route using enemas or suppositories
