Steroids Flashcards
Where are mineralocorticoids produce in the adrenal cortex?
Zona glomerulus (outer layer)
Where are glucocorticoids produce in the adrenal cortex?
Zona fascicule (middle layer)
Where are weak androgens produced in the adrenal cortex?
Zona reticularis (inner layer)
What is cortisol?
Hormone produced in the adrenal cortex
When is cortisol released?
stimulation of the H-P-A axis due to stresss
also upon waking up
What does cortisol do?
It initiates a series of metabolic effects directed at relieving the damaging nature of the stress response
What are the effects of cortisol throughout the body?
Carbohydrate, Protein, Fat metabolism
Fluid and electrolyte balance
CV, CNS, Immune, Endocrine, Renal stability
Inhibition of inflammatory, allergic response
What does cortisol do at the cellular level?
Partakes in RNA transcription which affects protein metabolism
this is why steroids take several hours to work
What are the effects of aldosterone?
- Increase K excretion
- Increase Na retention
- Increase water retention, increase blood volume
When causes aldosterone to be secreted?
- Increased K+
- Decreased Na+
- Decreased BP/Fluid volume
T/F
Secretory rates of CRH, ACTH, and cortisol are high in the morning and low in the late eveing
True
Should higher does of the steroids be taken in the AM or PM?
AM, to correlate with circadian rhythm (unless you work night shift)
Primary adrenocortical insufficiency is also known as ____
Addison’s disease
Adrenals do not secrete cortisol or aldosterone
Do you need give mineralocortocids or glucocorticoids for addison’s disease?
Both
What is secondary adrenocortical insufficiency related to?
Due to chronic steroid use and suppression (negative feedback loop) of the H-P-A axis…like COPD
Why is aldosterone secretion maintained with secondary adrenocortical insufficiency?
b/c it does not affect mineralocorticoids
Do you need give mineralocortocids or glucocorticoids for secondary adrenocortical insufficiency?
Glucocortocoid only
What are the physiological effects of steroids?
- Increased cardiac output
- Increased respiratory rate
- Increased gluconeogenesis
- Decreased inflammation
- Decreased immune response
- Inhibition of digestion
- Enhanced analgesia
- Redistribution of CNS blood flow
Steroids are classified according to their ____
potencies
What is the effect of glucocorticoids?
anti-inflammatory response
What is the principle MOA of mineralocorticoids?
Evoke distal renal tubular re-absorption of Na+ in exchange for K+
Which medication is closest to naturally occurring cortisol?
hydrocortisone
What are the 5 naturally occurring steroids?
Cortisol Cortisone Corticosterone Desoxycorticosterone Aldosterone
Which synthetic corticosteroids are glucocorticoids?
Prednisolone Prednisone Methylprednisolone Betamethasone Dexamethasone Triamcinolone
What is the only synthetic mineralocorticoid?
fludrocortisone
Cortisol is equal part ____ and ____
sodium retaining potency and anti-inflammartory potency
what is the sodium retaining potency and antiinflammartory potency of methylprednisone compared to cortisol?
Methylprednisone has 5x anti-inflammatory potency of cortisol but half of Na+ retention potency
What 3 synthetic corticosteroids have NO sodium-retaining potency?
Betamethasone, dexamethasone, and triamcinolone
These are best choices if to supplement a patient if they have secondary adrenocorticoid insufficiency
When comparing steroids for equivalency, which potency property is typically used?
The anti-inflammatory potency
T/F
The basic steroid nucleus is very hydrophilic
FALSE
very lipophilic
What 4 biological processes do steroids affect?
Absorption
Protein binding
Rate of metabolism
Intrinsic effectiveness at receptors
What is the only thing oral steroids are truly approved for?
Deficiency states (ex. addison’s disease)
everything is secondary
Can steroids cross any barrier?
Yes (BBB, placenta, skin, etc)
What form of steroid can be given IV?
succinate
What form of steroid can be given IM?
acetate
The dyslipidemia from corticosteroids is the result of _____
altered fat metabolism
What is the most common electrolyte complication with steroids?
Hypokalemic Metabolic Alkalosis
What is the pathophysiology of hypokalemic metabolic alkalosis from steroids?
Mineralocorticoid effect of cortisol on distal renal tubules leading to enhanced absorption of Na+ and loss of K+ (alkalotic charge)
Corticosteroids inhibit glucose use in peripheral tissues and promote _____
hepatic gluconeogenesis
2 ways to manage the hyperglycemia associated with steroids
- diet
- insulin (type II DM may need oral hypoglycemics and insulin when on corticocosteroids)
How do steroids affect fat distribution?
- 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
What are the catabolic effects of corticosteroids?
Peripherally, corticosteroids mobilize amino acids from tissues.
The peripheral mobilization of amino acids from corticosteroids results in what 4 things?
- Decreased skeletal muscle mass
- Osteoporosis
- Thinning of the skin
- Negative nitrogen balance
CNS dysfunction from steroids results manifest how?
- neurosis
- psychosis
- manic depression
- psychosis
Cataracts can develop with long-term corticosteroid use last longer than ___
4 years
How does long term corticosteroids affect blood changes?
Increase hematocrit and number of leukocytes
Results in steroid induced leukemia
How does a single dose of cortisol affect blood changes?
- Decreases by 70% circulating lymphocytes
- Decreases by 90% circulating monocytes
- Cells are sequestered rather than destroyed
How do corticosteroids inhibit normal growth?
Arrest of growth can result from the administration of relatively small doses of glucocorticoids to children
Inhibits DNA synthesis and cell division
What is the only absolute contraindication for steroids?
allergic reaction
what are relative contraindications for steroids?
- 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
What are surgeon’s concerns regarding intro steroids?
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
T/F
Any corticosteroid administration may result in suppression of the H-P-A axis, regardless of dose or duration.
True
With H-P-A axis suppression, release of cortisol in response to stress could be blunted or absent and lead to _____.
hypotensive shock
what 2 factors increase the likelihood of H-P-A axis supression from steroids?
longer duration and larger doses
Does aldosterone secretion remain intact with secondary adrenzcrtoicoid insufficiency?
yes
Prednisone or Dexamethasone (even physiologic doses) given as a single daily dose at ____ is associated more commonly with H-P-A Axis suppression
bedtime
how much cortisol does the body produce daily?
10mg
What therapies are unlikely to suppress H-P-A axis?
- 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
What therapies are assumed to suppress H-P-A axis?
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
What therapies may or may not suppress H-P-A axis?
> 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
After cessation of steroid therapy, recovery of the H-P-A function can take ____
12 months or longer
what returns to normal first, H-P function or adrenal function?
H-P function
What can be given to test if H-P-A axis is back to normal?
Cosyntropin (ACTH) stimulation test, which tests the adrenals. Only do this if time permits.
or
Give stress doses of glucocorticoids prophylactically (assume suppressed
Who would definitely need a preoperative stress dose steroids?
Patients who have diagnosed secondary adrenal insufficiency as demonstrated by the short acting ACTH test
What patients would be considered high risk for H-P-A suppression?
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.
What patients would be considered low risk for H-P-A suppression?
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.
What patients would be considered intermediate risk for H-P-A suppression?
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.
How does burns or sepsis affect corticosteroid supplementation?
They can exaggerate the need for exogenous corticosteroid supplementation (due to leaking proteins from liver, kidney dysfunction)
100mg cortisol I.V. every 12 hours
What are the signs and symptoms of acute adrenal crisis?
basically the opposite effects of steroids
- Hypotension unresponsive to vasopressors
- Hyperdynamic circulation
- Hypoglycemia
- Hyperkalemia
- Hyponatremia
- Hypovolemia
- Metabolic acidosis
- Decreased level of consciousness
What steroid has the shortest DOA? What steroids have the longest DOA?
- Cortisol (8-12 hrs)
- Betamethasone, Dexamethasone (36-54 hrs)
What steroids have 25x the anti-inflammatory potency and zero sodium-retaining potency?
Betamethasone and dexamethasone
Which steroid has the highest sodium-retaining potency?
Fludrocortisone (the only synthetic mineralocorticoid)
