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Pharm 2 > Steroids > Flashcards

Steroids Flashcards

1
Q

Where are mineralocorticoids produce in the adrenal cortex?

A

Zona glomerulus (outer layer)

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2
Q

Where are glucocorticoids produce in the adrenal cortex?

A

Zona fascicule (middle layer)

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3
Q

Where are weak androgens produced in the adrenal cortex?

A

Zona reticularis (inner layer)

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4
Q

What is cortisol?

A

Hormone produced in the adrenal cortex

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5
Q

When is cortisol released?

A

stimulation of the H-P-A axis due to stresss

also upon waking up

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6
Q

What does cortisol do?

A

It initiates a series of metabolic effects directed at relieving the damaging nature of the stress response

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7
Q

What are the effects of cortisol throughout the body?

A

Carbohydrate, Protein, Fat metabolism

Fluid and electrolyte balance

CV, CNS, Immune, Endocrine, Renal stability

Inhibition of inflammatory, allergic response

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8
Q

What does cortisol do at the cellular level?

A

Partakes in RNA transcription which affects protein metabolism

this is why steroids take several hours to work

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9
Q

What are the effects of aldosterone?

A
  • Increase K excretion
  • Increase Na retention
  • Increase water retention, increase blood volume
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10
Q

When causes aldosterone to be secreted?

A
  • Increased K+
  • Decreased Na+
  • Decreased BP/Fluid volume
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11
Q

T/F

Secretory rates of CRH, ACTH, and cortisol are high in the morning and low in the late eveing

A

True

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12
Q

Should higher does of the steroids be taken in the AM or PM?

A

AM, to correlate with circadian rhythm (unless you work night shift)

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13
Q

Primary adrenocortical insufficiency is also known as ____

A

Addison’s disease

Adrenals do not secrete cortisol or aldosterone

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14
Q

Do you need give mineralocortocids or glucocorticoids for addison’s disease?

A

Both

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15
Q

What is secondary adrenocortical insufficiency related to?

A

Due to chronic steroid use and suppression (negative feedback loop) of the H-P-A axis…like COPD

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16
Q

Why is aldosterone secretion maintained with secondary adrenocortical insufficiency?

A

b/c it does not affect mineralocorticoids

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17
Q

Do you need give mineralocortocids or glucocorticoids for secondary adrenocortical insufficiency?

A

Glucocortocoid only

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18
Q

What are the physiological effects of steroids?

A
  • Increased cardiac output
  • Increased respiratory rate
  • Increased gluconeogenesis
  • Decreased inflammation
  • Decreased immune response
  • Inhibition of digestion
  • Enhanced analgesia
  • Redistribution of CNS blood flow
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19
Q

Steroids are classified according to their ____

A

potencies

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20
Q

What is the effect of glucocorticoids?

A

anti-inflammatory response

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21
Q

What is the principle MOA of mineralocorticoids?

A

Evoke distal renal tubular re-absorption of Na+ in exchange for K+

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22
Q

Which medication is closest to naturally occurring cortisol?

A

hydrocortisone

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23
Q

What are the 5 naturally occurring steroids?

A 
Cortisol 
Cortisone
Corticosterone
Desoxycorticosterone
Aldosterone
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24
Q

Which synthetic corticosteroids are glucocorticoids?

A 
Prednisolone
Prednisone
Methylprednisolone
Betamethasone
Dexamethasone
Triamcinolone
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25
Q

What is the only synthetic mineralocorticoid?

A

fludrocortisone

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26
Q

Cortisol is equal part ____ and ____

A

sodium retaining potency and anti-inflammartory potency

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27
Q

what is the sodium retaining potency and antiinflammartory potency of methylprednisone compared to cortisol?

A

Methylprednisone has 5x anti-inflammatory potency of cortisol but half of Na+ retention potency

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28
Q

What 3 synthetic corticosteroids have NO sodium-retaining potency?

A

Betamethasone, dexamethasone, and triamcinolone

These are best choices if to supplement a patient if they have secondary adrenocorticoid insufficiency

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29
Q

When comparing steroids for equivalency, which potency property is typically used?

A

The anti-inflammatory potency

30
Q

T/F

The basic steroid nucleus is very hydrophilic

A

FALSE

very lipophilic

31
Q

What 4 biological processes do steroids affect?

A

Absorption
Protein binding
Rate of metabolism
Intrinsic effectiveness at receptors

32
Q

What is the only thing oral steroids are truly approved for?

A

Deficiency states (ex. addison’s disease)

everything is secondary

33
Q

Can steroids cross any barrier?

A

Yes (BBB, placenta, skin, etc)

34
Q

What form of steroid can be given IV?

A

succinate

35
Q

What form of steroid can be given IM?

A

acetate

36
Q

The dyslipidemia from corticosteroids is the result of _____

A

altered fat metabolism

37
Q

What is the most common electrolyte complication with steroids?

A

Hypokalemic Metabolic Alkalosis

38
Q

What is the pathophysiology of hypokalemic metabolic alkalosis from steroids?

A

Mineralocorticoid effect of cortisol on distal renal tubules leading to enhanced absorption of Na+ and loss of K+ (alkalotic charge)

39
Q

Corticosteroids inhibit glucose use in peripheral tissues and promote _____

A

hepatic gluconeogenesis

40
Q

2 ways to manage the hyperglycemia associated with steroids

A
  • diet

- insulin (type II DM may need oral hypoglycemics and insulin when on corticocosteroids)

41
Q

How do steroids affect fat distribution?

A
  • Deposition on back (buffalo hump), supraclavicular, and face (moon facies)
  • Loss of fat from the extremities
  • Come from moving amino acids and fat from the periphery
42
Q

What are the catabolic effects of corticosteroids?

A

Peripherally, corticosteroids mobilize amino acids from tissues.

43
Q

The peripheral mobilization of amino acids from corticosteroids results in what 4 things?

A
  • Decreased skeletal muscle mass
  • Osteoporosis
  • Thinning of the skin
  • Negative nitrogen balance
44
Q

CNS dysfunction from steroids results manifest how?

A
  • neurosis
  • psychosis
  • manic depression
  • psychosis
45
Q

Cataracts can develop with long-term corticosteroid use last longer than ___

A

4 years

46
Q

How does long term corticosteroids affect blood changes?

A

Increase hematocrit and number of leukocytes

Results in steroid induced leukemia

47
Q

How does a single dose of cortisol affect blood changes?

A
  • Decreases by 70% circulating lymphocytes
  • Decreases by 90% circulating monocytes
  • Cells are sequestered rather than destroyed
48
Q

How do corticosteroids inhibit normal growth?

A

Arrest of growth can result from the administration of relatively small doses of glucocorticoids to children

Inhibits DNA synthesis and cell division

49
Q

What is the only absolute contraindication for steroids?

A

allergic reaction

50
Q

what are relative contraindications for steroids?

A
  • Active systemic -infection
  • Immunosuppression
  • Acute psychosis
  • Primary glaucoma
  • Hypokalemia
  • CHF (b/c fluid shifts and edema can worsen it)
  • Cushing’s Syndrome
  • Diabetes (DKA)
  • Hypertension
  • Osteoporosis
  • Hyperthyroidism (b/c TH and cortisol are linked
51
Q

What are surgeon’s concerns regarding intro steroids?

A

Masking infection or further complicating surgery intended to treat infection

Altering glucose control in diabetics

Aseptic necrosis of the femoral head

Failure of bone fusion

52
Q

T/F

Any corticosteroid administration may result in suppression of the H-P-A axis, regardless of dose or duration.

A

True

53
Q

With H-P-A axis suppression, release of cortisol in response to stress could be blunted or absent and lead to _____.

A

hypotensive shock

54
Q

what 2 factors increase the likelihood of H-P-A axis supression from steroids?

A

longer duration and larger doses

55
Q

Does aldosterone secretion remain intact with secondary adrenzcrtoicoid insufficiency?

A

yes

56
Q

Prednisone or Dexamethasone (even physiologic doses) given as a single daily dose at ____ is associated more commonly with H-P-A Axis suppression

A

bedtime

57
Q

how much cortisol does the body produce daily?

A

10mg

58
Q

What therapies are unlikely to suppress H-P-A axis?

A
  • Prednisone 5mg/day or less or 10 mg QOD
  • Long term every other day dosing associated with less suppression
  • Glucocorticoids, any dose < 3 weeks does not clinically suppress the H-P-A Axis
59
Q

What therapies are assumed to suppress H-P-A axis?

A

Prednisone 20mg/day (or equivalent) for > 3 weeks within the previous year

Patient with clinical signs of Cushing Syndrome from any steroid dose

No need to test the H-P-A Axis in these patients, just supplement with stress dose steroids

60
Q

What therapies may or may not suppress H-P-A axis?

A

> 5mg/day but < 20mg/day of prednisone (or equivalent) for > 3 weeks the previous year bc it can take up to a full year to recover

61
Q

After cessation of steroid therapy, recovery of the H-P-A function can take ____

A

12 months or longer

62
Q

what returns to normal first, H-P function or adrenal function?

A

H-P function

63
Q

What can be given to test if H-P-A axis is back to normal?

A

Cosyntropin (ACTH) stimulation test, which tests the adrenals. Only do this if time permits.
or
Give stress doses of glucocorticoids prophylactically (assume suppressed

64
Q

Who would definitely need a preoperative stress dose steroids?

A

Patients who have diagnosed secondary adrenal insufficiency as demonstrated by the short acting ACTH test

65
Q

What patients would be considered high risk for H-P-A suppression?

A

Those treated with at least 20mg/day of prednisone for > 3 weeks or who have s/sx of Cushings
- unless data states otherwise, supplementation is recommended.

66
Q

What patients would be considered low risk for H-P-A suppression?

A

Any dose of steroid for < 3 weeks, less than 5mg/day of prednisone (or 10 mg QOD)
- steroids are not required unless s/sx of HPA suppression are observed.

67
Q

What patients would be considered intermediate risk for H-P-A suppression?

A

Any one who does not fall into #definite, high risk, or low risk
- consider HPA testing, exercise clinical judgement based on hemodynamic stability and surgical risk.

68
Q

How does burns or sepsis affect corticosteroid supplementation?

A

They can exaggerate the need for exogenous corticosteroid supplementation (due to leaking proteins from liver, kidney dysfunction)

100mg cortisol I.V. every 12 hours

69
Q

What are the signs and symptoms of acute adrenal crisis?

A

basically the opposite effects of steroids

  • Hypotension unresponsive to vasopressors
  • Hyperdynamic circulation
  • Hypoglycemia
  • Hyperkalemia
  • Hyponatremia
  • Hypovolemia
  • Metabolic acidosis
  • Decreased level of consciousness
70
Q

What steroid has the shortest DOA? What steroids have the longest DOA?

A
  • Cortisol (8-12 hrs)

- Betamethasone, Dexamethasone (36-54 hrs)

71
Q

What steroids have 25x the anti-inflammatory potency and zero sodium-retaining potency?

A

Betamethasone and dexamethasone

72
Q

Which steroid has the highest sodium-retaining potency?

A

Fludrocortisone (the only synthetic mineralocorticoid)

Pharm 2 (19 decks)

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