Steroids

Question 1

Fludrocortisone: Indications

Answer 1

(Florinef)

Indications for Use

• Replacement therapy for adrenocortical insufficiency (Addison’s Disease)
• Salt-losing syndrome

Unlabeled:
- Severe orthostatic hypotension

Question 2

Fludrocortisone: MOA

Answer 2

(Florinef)

• Mimics the action of aldosterone

Mechanism of Action (MOA):
- Facilitates Na+ resorption –> Increase in BP

Question 3

Fludrocortisone: Dose and AE

Answer 3

(Florinef)

Dose:
0.1-0.2mg PO daily

AE:
Fluid imbalance, hypokalemia, edema, ↑BP, CHF

Question 4

Topical Glucocorticoids (Choice of Potency)

Answer 4

Low: thin skin, acute inflammatory lesions

Medium or High: chronic, hyperkeratotic, lichenified lesions

Question 5

Topical: Choice of Vehicle

Answer 5

Ointment: thick lichenified lesions; enhances penetration of drug
Creams: acute and subacute dermatoses; moist skin and intertriginous areas
Solutions, gels & sprays: scalp, where non-oil based vehicles is needed

Question 6

Topical: Duration of Therapy

Answer 6

Medium-high to very high:

Question 7

Topical: Adverse Effects

Answer 7

• Skin atrophy
• Acne
• Abnormal pigmentation
• Purpura (purple rash)
• Delayed skin healing
• Photosensitivity
• Infection

Question 8

Glucocorticoids Once-Daily Dosing (taper rule)

Answer 8

Indicated for maintenance therapy or control of active disease

Mimics normal cycle = Administer in the morning

May require taper if patient received therapy for >2weeks at doses >20mg/day

Question 9

Alternate-Day Therapy (indication)

Answer 9

Indicated for non-symptomatic manifestations of mild-moderate disease

Minimizes the HPA axis suppression

Not recommended for initial therapy = For patients whom require long term therapy

Question 10

Conversion to Alternate-Day Therapy (QD to QOD dosing)

Answer 10

(1) determine the minimum effective QD dose
(2) optimum QOD dose is 2.5-3x the minimal daily dose (GENERALLY)

Conversion from QD to QOD
Requires gradually ↑ in “on” day dose with concurrent ↓ in “off” day dose

Question 11

Discontinuation of Therapy

Answer 11

Short-term (

Question 12

Glucocorticoids Contraindications

Answer 12

Live Vaccines
* CDC recommendations state ≤20mg/day of prednisone for more than 2 weeks

• Systemic Fungal Infections
• Hypersensitivity

Question 13

prednisone (Delayed-Release Tablets)

Answer 13

(RAYOS)
“Chronotherapy”
- Cytokines increase at night, peak early morning in RA

Prednisone inside an inactive shell
- Shell breaks not pH dependent

When taken w/food: Releases prednisone approx. 4 hours after administration

Do not crush/chew/split; administer at bedtime Approximately 10pm

Question 14

Dosing During Stressful Events

Answer 14

Risk of adrenal insufficiency may last up to 12 months after therapy

Empiric supplementation in patients with severe medical illnesses, major trauma or surgery

• ** Oral Prednisone for minor procedures
• ** IV Hydrocortisone for major or severe illnesses

Question 15

Glucocorticoids Monitoring

Answer 15

Labs: Including glucose, electrolytes, WBC
Stool test for occult blood loss
DEXA 
Growth and development
Cushingoid symptoms
Blood pressure
Ophthalmologic exams

Question 16

Glucocorticoids Patient Counseling

Answer 16

Take in the morning with food
Never stop therapy abruptly!
Patient should be aware of side effects

Missed doses:
QD: Take as soon as remember (skip if close to the next dose)

QOD: Take as soon as remember if that morning, if not, skip that day and take the next morning

Question 17

Glucocorticoid-Induced Osteoporosis

Answer 17

Occurs within first 6-12 months of therapy
↓Bone formation and ↑ bone resorption
Prednisone doses b/w 5-7.5mg daily*