Pharmaceutical care issues associated with steroids Flashcards
Are steroids either completely glucocorticoids or mineralcorticoids?
No each steroid has a varying degree of glucocorticoid and mineralcorticoid activity and potency and hence impacts the prescribing decisions for certain conditions.
Which steroids require replacement in Addison’s disease?
As there is a deficiency in both cortisol (glucocorticoid) and aldosterone (mineralcorticoid) steroid replacement therapy for both types of steroids are required, normally hydrocortisone (replacing cortisol) and fludrocortisone (replacing aldosterone).
What are the main indications of glucocorticoids?
Anti-inflammatory and immunosuppression
What are some examples of glucocorticoids?
Prednisolone
Prednisone
Beclometasone
Hydrocortisone
Betamethasone
Dexamethasone
What are some conditions in which glucorticoid therapy is used?
Asthma
Inflammatory bowel disease
Eczema
Post transplant
Rheumatoid arthritis
Chemotherapy allergies
What are the adverse effects associated with topical use of steroids?
Skin thinning
Skin infection
Acne
Folliculitis
Stretch marks
What are the adverse effects associated with inhaled use of steroids?
Hoarseness
Throat irritation
Oral thrush
Dysphonia
(systemic effects can occur with high doses)
What is a counselling point for topical use steroids?
Ensure the steroid cream is used sparingly.
What is a counselling point for inhaled use steroids?
Rinse mouth/brush teeth after using inhaled steroids or use spacer device
What is the main adverse effect associated with systemically used steroids?
Adrenal suppression
When does adrenal suppression occur?
After long term therapy due to exogenous steroid medicating halts production of endogenous steroids.
Is reduced endogenous steroid production reversible?
Yes but it cannot be restarted quickly therefore a decreasing titrated dose regime of the exogenous steroids is appropriate.
What happens if there is abrupt withdrawal of the exogenous steroids?
Causes acute adrenal insufficiency and can result in hypotension, confusion, coma and death
What prescribing decisions should be made for somebody on long-term steroids during illness, trauma or surgery?
Normally endogenous steroid production increases during these times of stress therefore this needs to be replicated with exogenous steroids and is known as the sick day rules where the exogenous steroid dose is doubled.
May also need to switch the form (oral to IV).
What is the purpose of the steroid treatment card?
A Steroid Treatment Card (blue) carries a series of instructions for the patient and informs healthcare professionals of the details of the steroids prescribed and prevent a sudden withdrawal of the medication.
Also tells them what to do in the cases of illness infection etc.
When is the gradual withdrawal of steroids required?
Greater than 40mg Prednisolone once daily for one week
Any dose greater than 3 weeks
Recently received repeated short doses
Require a short course within one year of stopping treatment
What does the dose withdrawal of steroids entail?
Can decrease the dose fairly rapidly until about the physiological dose (7.5mg) and then decrease slowly.
When can you stop steroid treatment abruptly?
If the disease is unlikely to relapse AND the treatment is less than 3 weeks and not in one of the groups above.
How does steroids increase the risk of infection?
Steroids have an immuno-suppressive action and therefore increase the risk of infection development. Furthermore they can cause an atypical presentation of the infection, for example symptoms only present once the infection has become advanced as it suppresses the normal response.
What advice is given about infection prevention?
If they have not had chicken pox they should avoid anybody with chicken pox, shingles or measles and if they do come into contact they should seek medical advice immediately due to the complications of developing the viruses as they are immuno-suppressed.
What are some of the psychiatric reactions associated with high dose steroid use?
Steroids act directly on the brain and can cause:
Euphoria
Nightmares
Insomia
Irritability
Mood lability
Suicidial thoughts
Psychotic reactions (especially history of mental illness)
What is the appropriate management if a patient has psychotic adverse effects?
Dose reduction or withdrawal or if severe may need appropriate anti-pyschotic therapy
What are some of the other side effects associated with mineralocorticoid activity?
Hypertension, sodium and water retention, weight gain, potassium loss and calcium loss (electrolyte inbalance)
What are some of the other side effects associated with glucocorticoid activity?
Diabetes and glucose intolerance
Osteoporosis
GI disturbances
Cushing’s syndrome
Growth suppression in children
What should you advise if a patient with diabetes is put on steroid therapy?
They should monitor their blood glucose levels closely as their insulin requirements may change dramatically
If a patient is at risk of osteoporosis and they are put on long-term therapy of steroids what should you do?
Osteoporosis prophylatics (biphosphonates)
What advice can you give for the GI side effects?
May be put on PPIs?
How do steroids cause growth suppression in children?
They reduce the growth hormone
What is the role of the pharmacist in the management of steroids?
Promote the lowest dose of steroids for the shortest time
Ensure gradual withdrawal when appropriate
Advise on increased dose requirements during illness, trauma and surgery
Supply a steroid card
Counsel on side effects
Ensure prophylactic treatment when appropriate
