Steroids

Question 1

What are some functions of natural cortisol (glucocorticoid)?

Answer 1

maintain vascular reactivity, cause anti-inflammatory effects, maintain homeostasis during periods of stress and regulate carbohydrate, fat and protein metabolism

Question 2

What are two major stressors that increase levels of endogenous cortisol?

Answer 2

surgery (most potent activator) and pain (thus the importance of using good pain control)-other stressors include illness, trauma, burns, fever, hypoglycemia, emotional upset

Question 3

Identify indications for use for corticosteroids in medicine and dentistry.

Answer 3

autoimmune diseases, immunosuppressive therapy in organ transplant patients, respiratory disease management

Question 4

What are some examples of steroid use for systemic disease?

Answer 4

replacement therapy (adrenal insufficiency, pituitary insufficiency, adrenal hyperplasia), arthritis (rheumatoid, osteoarthritis), rheumatic carditis, renal disease, collagen disease, allergic disease (anti-inflammatory effect)

Question 5

Mechanism of action of steroids

Answer 5

anti-inflammatory effects, effect on #, distribution and function of peripheral leukocytes, inhibition of phopholipase A (decreases production of both prostaglandins and leukotrienes from arachidonic acid)

Question 6

Discuss side effects associated with chronic use of corticosteroid medications.

Answer 6

Systemic steroids are more likely to cause adrenal suppression. Additional problems may include insomnia, peptic ulceration, osteoporosis, hyperglycemia, cataract formation, glaucoma, growth suppression, redistribution of fat, delayed wound healing.

Question 7

How are corticosteroid products characterized?

Answer 7

Characterized by duration of action (short, intermediate, long): agents are given values in relation to those of hydrocortisone (arbitrarily assigned value of 1)

Question 8

What are three short-acting oral corticosteroids?

Answer 8

hydrocortisone (Cortisol), prednisone (Deltasone), methylprednisolone (Medrol)

Question 9

What are three intermediate-acting oral corticosteroids?

Answer 9

triamcinolone (often used in ointments prescribed for aphthous ulcers), prednisolone

Question 10

What are three long-acting oral corticosteroids?

Answer 10

dexamethasone, betamethasone

Question 11

What are equivalent doses of corticosteroids?

Answer 11

Equivalent doses are based on 20 mg hydrocortisone = amount normally secreted by an adult without stress in a day

Question 12

Describe some dosing considerations with steroids

Answer 12

alternate day therapy is used for patients who must take steroids for longer than 1 month, daily therapy poses greater risk for adrenal suppression, any medication dosage that exceeds this amount may cause suppression

Question 13

What are contraindications to steroids?

Answer 13

systemic fungal infections, viral infections (ex. Herpes), latent or active TB, allergy to component of medications

Question 14

Based upon their side effect profile, identify patients in whom corticosteroids must be used with caution.

Answer 14

pregnant/lactating women (category C drugs), pediatric patients (more susceptible to suppression), geriatric patients (more susceptible to hypertension and osteoporosis side effects)

Question 15

Cushing’s disease

Answer 15

Primary disorder of adrenal glands resulting in an excessive production of cortisol

Question 16

Addison’s disease

Answer 16

Primary disorder of adrenal glands resulting in an insufficient production of cortisol

Question 17

Distinguish between the 2 etiologies of adrenal insufficiency.

Answer 17

(1) Addison’s disease (primary disorder) wherein the adrenal glands do not function (2) secondary disorder = HPA axis suppressed due to taking glucocorticoid medications

Question 18

Medication-induced adrenal insufficiency

Answer 18

A secondary disorder wherein glucocorticoid medications (exogenous steroids) suppress the body’s own production of endogenous steroids. This is more common than Addison’s disease and is associated with chronic steroid use and does not usually produce symptoms unless the patient is significantly stressed (or does not have enough circulating cortisol)

Question 19

What are five key signs and symptoms of adrenal crisis?

Answer 19

profuse sweating, hypotension, weak pulse, dyspnea, cyanosis

Question 20

What severe effects may occur to patients suffering from adrenal crisis who do not receive emergency assistance?

Answer 20

severe hypotension, circulatory collapse (shock), hypothermia, hypoglycemia, death

Question 21

What are the appropriate treatment interventions used to manage adrenal crisis?

Answer 21

Call 911 (EMS transport and medical intervention is required), elevate feet above head, IV glucocorticoids, fluid and electrolyte replacement, administration of vasopressors (epi)

Question 22

What patients are more at risk for adrenal crisis?

Answer 22

Pediatric patients (extreme caution must be used because children are more susceptible to suppression with topicals and even 5 mg may limit growth)

Question 23

What are characteristics of topical corticosteriod medications?

Answer 23

topical administration is the most common route in dentistry (high potentcy drugs limited to 2 weeks only), ointments/gels applied directly to lesions with cotton-tip, and rinses are used 2 to 4 times a day for 30 seconds each rinse

Question 24

What are characteristics of systemic corticosteriod medications?

Answer 24

oral steroids may be used before, during and after oral surgery to reduce swelling and pain postoperatively and to treat oral lesions.

Question 25

What are two preparations of oral steroids?

Answer 25

methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol) and prednisone (Prednisone Intensol, Sterapred)

Question 26

What are the indications for topical corticosteroid medications when used in dentistry?

Answer 26

for reduction of pain and swelling (after major oral surgery) and treatment of inflammatory pathologies of oral mucosa

Question 27

What are examples of topical steroid ointments used in dentistry?

Answer 27

*triamcinolone (Kenalog in Orabase), fluocinonide (Lidex), clobetasol proprionate (Temovate), betamethasone valerate (Valisone)

Question 28

What are examples of topical steroid rinses used in dentistry?

Answer 28

dexamethasone (Decadron) elixir or prednisolone syrup

Question 29

What are the indications for systemic corticosteroid medications when used in dentistry?

Answer 29

reduce swelling and pain after major surgery and treatment of inflammatory conditions. Topical administration is the most common route in dentistry.

Question 30

Discuss the decision-making strategies used to determine whether a dental patient requires supplemental steroids prior to receiving dental treatment.

Answer 30

No supplementation is necessary for routine dental procedures (this applies to patients currently taking steroids, those with a history of regular steroid use and those currently useing topical or inhaled steroids). For invasive oral surgical procedures, laboratory testing and physician consulations may be involved.

Question 31

What are oral side effects of steroid use?

Answer 31

*candidiasis (most common), poor wound healing (with long-term use), masking of oral infections, xerostomia

Question 32

What is the rationale for the “rule of two’s”?

Answer 32

Adrenal suppression occurs rapidly and may persist for 2 years following as little as 2 weeks of steroid therapy. Stress response returns after 2 weeks (normal HPA axis function). Therefore, providers should wait 2 weeks after steroids are discontinued prior to initiating any invasive procedure to ensure that the HPA axis is functioning properly

Question 33

What can providers do to improve treatment outcomes for patients currently taking steroids (in regards to diagnostic and minimally invasive procedures)?

Answer 33

schedule the patient early in the morning, follow stress reduction protocol, monitor blood pressure and inform the patient to take his/her usual daily dose of steroids

Question 34

What are some examples of stress reduction protocol?

Answer 34

schedule surgeries in the morning, control anxiety (nitrous oxide, benzodiazepines-Valium), monitor blood pressure, keep surgeries as short as possible, use methods to reduce blood loss.

Question 35

What are typical target dosages of hydrocortisone per day for minor oral/periodontal surgeries and major oral surgery involving general anethesia?

Answer 35

25 mg and 50-100 mg hydrocortisone per day, respectively