Pharmaceutical care issues associated with steroids

Question 1

Are steroids either completely glucocorticoids or mineralcorticoids?

Answer 1

No each steroid has a varying degree of glucocorticoid and mineralcorticoid activity and potency and hence impacts the prescribing decisions for certain conditions.

Question 2

Which steroids require replacement in Addison’s disease?

Answer 2

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).

Question 3

What are the main indications of glucocorticoids?

Answer 3

Anti-inflammatory and immunosuppression

Question 4

What are some examples of glucocorticoids?

Answer 4

Prednisolone
Prednisone
Beclometasone
Hydrocortisone
Betamethasone
Dexamethasone

Question 5

What are some conditions in which glucorticoid therapy is used?

Answer 5

Asthma
Inflammatory bowel disease
Eczema
Post transplant
Rheumatoid arthritis
Chemotherapy allergies

Question 6

What are the adverse effects associated with topical use of steroids?

Answer 6

Skin thinning
Skin infection
Acne
Folliculitis
Stretch marks

Question 7

What are the adverse effects associated with inhaled use of steroids?

Answer 7

Hoarseness
Throat irritation
Oral thrush
Dysphonia

(systemic effects can occur with high doses)

Question 8

What is a counselling point for topical use steroids?

Answer 8

Ensure the steroid cream is used sparingly.

Question 9

What is a counselling point for inhaled use steroids?

Answer 9

Rinse mouth/brush teeth after using inhaled steroids or use spacer device

Question 10

What is the main adverse effect associated with systemically used steroids?

Answer 10

Adrenal suppression

Question 11

When does adrenal suppression occur?

Answer 11

After long term therapy due to exogenous steroid medicating halts production of endogenous steroids.

Question 12

Is reduced endogenous steroid production reversible?

Answer 12

Yes but it cannot be restarted quickly therefore a decreasing titrated dose regime of the exogenous steroids is appropriate.

Question 13

What happens if there is abrupt withdrawal of the exogenous steroids?

Answer 13

Causes acute adrenal insufficiency and can result in hypotension, confusion, coma and death

Question 14

What prescribing decisions should be made for somebody on long-term steroids during illness, trauma or surgery?

Answer 14

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).

Question 15

What is the purpose of the steroid treatment card?

Answer 15

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.

Question 16

When is the gradual withdrawal of steroids required?

Answer 16

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

Question 17

What does the dose withdrawal of steroids entail?

Answer 17

Can decrease the dose fairly rapidly until about the physiological dose (7.5mg) and then decrease slowly.

Question 18

When can you stop steroid treatment abruptly?

Answer 18

If the disease is unlikely to relapse AND the treatment is less than 3 weeks and not in one of the groups above.

Question 19

How does steroids increase the risk of infection?

Answer 19

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.

Question 20

What advice is given about infection prevention?

Answer 20

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.

Question 21

What are some of the psychiatric reactions associated with high dose steroid use?

Answer 21

Steroids act directly on the brain and can cause:
Euphoria
Nightmares
Insomia
Irritability
Mood lability
Suicidial thoughts
Psychotic reactions (especially history of mental illness)

Question 22

What is the appropriate management if a patient has psychotic adverse effects?

Answer 22

Dose reduction or withdrawal or if severe may need appropriate anti-pyschotic therapy

Question 23

What are some of the other side effects associated with mineralocorticoid activity?

Answer 23

Hypertension, sodium and water retention, weight gain, potassium loss and calcium loss (electrolyte inbalance)

Question 24

What are some of the other side effects associated with glucocorticoid activity?

Answer 24

Diabetes and glucose intolerance
Osteoporosis
GI disturbances
Cushing’s syndrome
Growth suppression in children

Question 25

What should you advise if a patient with diabetes is put on steroid therapy?

Answer 25

They should monitor their blood glucose levels closely as their insulin requirements may change dramatically

Question 26

If a patient is at risk of osteoporosis and they are put on long-term therapy of steroids what should you do?

Answer 26

Osteoporosis prophylatics (biphosphonates)

Question 27

What advice can you give for the GI side effects?

Answer 27

May be put on PPIs?

Question 28

How do steroids cause growth suppression in children?

Answer 28

They reduce the growth hormone

Question 29

What is the role of the pharmacist in the management of steroids?

Answer 29

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