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BDS2 BAMS > steroids > Flashcards

steroids Flashcards

1
Q

3 main adrenal issues

A

Destruction of adrenal tissue
- Addison’s Disease

Excess adrenal action
- Cushings Disease

Therapeutic corticosteroids

  • Suppression of adrenal action
  • Steroid adverse effects
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2
Q

where is the adrenal gland

A

on kidney (cap)

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3
Q

2 parts of adrenal gland

A

medulla

cortex

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4
Q

what is the role of the medulla in the adrenal gland

A

secretes adrenaline

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5
Q

what is the role of the cortex in the adrenal gland

A

secretes other hormones

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6
Q

3 zones in the adrenal cortex

A

zona glomerulosa

zona fasicularis

zona reticularis

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7
Q

zona glomerulosa secretes

A

aldosterone

Renin/Angiotensin – angiotensin II triggers aldosterone release, salt and water reabsorption

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8
Q

what does ATII trigger

A

aldosterone release, salt and water reabsorption

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9
Q

what does the zona fasicularis secrete

A

cortisol

controlled by hypothalamus/pituitary

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10
Q

what does the zona reticularis secrete

A

adrenal androgens

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11
Q

what does pituitary release is lack cortisol

A

ACTH

triggered by CRH from hypothalamus

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12
Q

what are the variations in adrenal hormones

A

largely the same compound with small conformation changes

Synthetically close but variations fit into receptors
- Tend to all come from cholesterol
- Slightly different derivatives from same precursors
Some people lack certain metabolic enzymes

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13
Q

3 main groups of adrenal hormones

A

Mineralocorticoids
Glucocorticoids
Sex hormones

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14
Q

what tends to be the main starting factor for adrenal hormones

A

cholesterol

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15
Q

aldosterone effect

A

salt and water regulation

Enhances Na+ reabsorption and K+ loss
- End product of Renin-angiotensin system

Indirect effect on blood pressure

  • Causes raise in BP
  • Retention of salt and water
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16
Q

aldosterone effect on Na+

A

causes reabsorption

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17
Q

aldosterone effect on k+

A

causes loss

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18
Q

aldosterone effect on blood pressure

A

Indirect effect on blood pressure

  • Causes raise in BP
  • Retention of salt and water
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19
Q

what released aldosterone

A

adrenal gland

- zona glomerulosa in cortex

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20
Q

what 2 drugs inhibit aldosterone action

A

ACE inhibitors

AT2 Blockers

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21
Q

ACE inhibitors action on Aldosterone

A

inhibit aldosterone (Angiotensin Converting enzyme inhibitors)

Side effects related to the fact that they inhibit enzymes, some people more effected
Side effects –

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22
Q

side effects of ACE inhibitors for aldosterone inhibition

A

Cough
- Bradykinin

angio-oedema
- sudden onset of tissue fluid
- complement system fires when there is no damage/infection
triggers cascade
- get inflammation for hour or so before recession

Oral lichenoid drug reactions (tissue reaction and infection)

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23
Q

AT2 blockers action on aldosterone

A

Block angiotensin receptor

Stops the AT2 made from working
- Reduces amount of AT2 available to work

Very specific – effective against high BP
- But other health benefits from ACE inhibitors do not get from AT2 blockers

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24
Q

when would drugs acting on aldosterone be commonly used

A

first line in BP treatmetn in young

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25
Q

describe how aldosterone increase blood pressure

A

increases salt and water reabsorption, increasing circulating volume

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26
Q

what type of adrenal hormone is cortisol

A

natural glucocorticoid

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27
Q

where does cortisol work

A

Works in the nucleus

Doesn’t work through receptor on cell surface

Receptor takes cortisol into cell and leads to protein transcription reaction

  • Change in expression of cell’s nucleic acid
  • Can lead to another reaction by different protein
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28
Q

what is the level of effect cortisol has

A

physiological steroid effect

relative to physiological levels, small effect as natural low level but when add steroid more severe

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29
Q

4 physiological effects of cortisol

A

Antagonist to insulin
- Gluocneogenesis, fat & protein breakdown
Make it harder for insulin to work
- Move glucose into cells, prevent ketoacidosis
- Move glucose into storage

Lowers the immune reactivity
- Duller response

Raises blood pressure

Inhibits bone synthesis

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30
Q

release of cortisol

A

circadian

nocturnal peak (like growth hormone)

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31
Q

what is the effect of cortisol on insuline

A

antagonist

need to generate energy frm breakdown of other products (fat and protein)

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32
Q

what controls cortisol

A

Inhibit pituitary ACTH

Hypothalamic cortico-releasing hormone

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33
Q

what is a key difference in therapeutic steroids

A

different levels of potency

slight chemical differences can lead to more extreme responses

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34
Q

what can be the effect of taking steroid tablets for a long period

A

swamp natural hormone effect so hypothalamus/pituitary stop making ACTH (no more additonal steroid in blood)

May not be effective quickly if taking tablets for several months

  • Can’t immediately kick back into action
  • Starts to atrophy
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35
Q

what does adreanl suppression do

A

stop the release system of cortisol (ACTH production)

levels drop quickly

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36
Q

what are the 2 roles of therapeutic steroids

A

Enhanced Glucocorticoid effect

Enhanced Mineralcorticoid effect
- More than expected effect
- Salt and water retention
hypertension

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37
Q

therapeutic steroid action of prednisolone

A

More effect than cortisol
- At all cortisol effects

But also mimics aldosterone

  • Not same shape but similar enough to trigger aldosterone in kidney actions
  • Saves top much salt and water leads to hypertension
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38
Q

11 possible adverse effects of therapeutic steroids

A

Hypertension

Type 2 diabetes

  • Antagonist effect on insulin
  • Raise secretion – need more insulin to keep normal
  • Faster using it up the shorter time have left to use it
  • More insulin needed to keep blood level constant
  • Quicker progress to diabetes

Osteoporosis
- Inhibit bone synthesis

Increased infection risk

Peptic ulceration
- Changed mucosa production

Thinning of the skin

Easy bruising

Cataracts & Glaucoma

Hyperlipidaemia (atherosclerosis)

Increased cancer risk

Psychiatric disturbance

39
Q

how can taking steroids for a disease cause adverse effects

A

given too much of a substance which naturally controls body system

40
Q

what are 2 factors to take into consideration when giving steroid tablets

A

amount of steroid is important

  • Steroid skin cream might tip into this
  • Most adults with inhaled steroids (asthma)and skin cream not issue
  • Children on high steroid cream

length of prescription
- few weeks some changed but return to normal

41
Q

glucocorticoid hyperfunction of adrenal gland

A

cushings syndrome

adrenal tumour - primary
pituitary tumour - secondary (site of making ACTH)

42
Q

cushings syndrome caused by

A

adrenal hyperfunction of glucocorticoid

43
Q

aldosrerone hyperfunction of adrenal gland

A

Conn’s syndrome

adrenal tumour

  • high level of cortisol in blood
  • lots of aldosterone leads to hypertension by salt and water retention
44
Q

primary hypofunction of adrenal gland

A

addison’s disease

- gland itself damaged or destroyed

45
Q

secondary hypofuntion of adrenal gland

A

pituitary failure

- tumour squashed cells that make ACTH

46
Q

2 casues of Conn’s syndrome

A

excess aldosterone/ adrenal hyperfunction

adrenal tumour 
adrenal hyperplasia (rare)
47
Q

causes of cushing’s syndrome (4)

A

excess glucocorticoid

CUSHINGS DISEASE

  • pituitary tumour
  • then leads to high level of ACTH
  • 70% spontaneous Cushing’s patients

Adrenal adenoma or hyperplasia

  • Syndrome is tumour in pituitary/ adrenal or taken tablets in larger physiological need
  • Symptoms and signs of excess glucocorticoid

Ectopic ACTH production
- Some Lung tumours – excess cortisol made due to ACTH in excess

excess steroid tablets for disease treatment

48
Q

5 cushing’s syndrome signs

A

centripetal obesity

  • moon face
  • buffalo hump
  • Fat collection at back of neck

hypertension

thin skin & purpura

muscle weakness

Osteoporotic changes & fractures

49
Q

8 cushing’s syndrome symptoms

A

diabetes mellitus’ features
- thirst, peeing, tiredness

poor resistance to infections
- less ability to fight of fungal and candida

osteoporotic changes
- back pain & bone fractures

psychiatric disorders

  • depression
  • emotional lability
  • psychosis

hirsuitism

skin and mucosal pigmentation

amenorrhoea, impotence & infertility
- all related to adrenal androgens and these are similar to corticosteroids

Abdominal striae

  • thinning of skin
  • stretch marks – purple marks where torn and bleeding into surface
50
Q

MSH

A

melanocyte stimulating hormone

alpha MSH in ACTH seqeunce

51
Q

what effect can be seen in melanocytes of excess ACTH

A

ACTH in excess will have noticeable effect on melanocytes

  • Develop pigmentation of skin and mucosa
  • Can show in the mouth more than skin as a response to high ACTH levels
52
Q

2 causes of adrenal hypofunction

A

gland failure

pituitary failure

53
Q

3 possible causes for adrenal gland failure in hypofunction

A

autoimmune gland destruction In Western World
- adrenal failure from adrenal antibodies

infection

  • more globally
  • especially Tuberculosis

infarction

54
Q

2 possible causes of pituitary failure in adrenal hypofunction

A

compression from other adenoma

Sheehan’s syndrome

  • Sudden drop in BP causes sudden drop in adrenal secretions
  • E.g. bleeding at birth
  • Recover drop in BP but pituitary gland no longer functioning
55
Q

what is the biggest worldwide cause of Addison’s disease

A

TB

56
Q

addison’s disease

A

primary hypofunction of adrenal gland

57
Q

describe the onset for addison’s disease usually

A

slow

months

58
Q

what are potential causes of addison’s disease

A

Previously TB a major cause in UK
- TB still the biggest worldwide cause

Autoimmune adrenalitis - (90%)

  • Organ-specific Autoimmune disease
  • thyroid, diabetes mellitus, Pernicious anaemia
59
Q

outcome of addison’s disease

A

death

not enough adrenal hormones
need to have hormone replacement to keep them alive

60
Q

4 signs of addison’s disease

A

postural hypotension

  • salt and water depletion
  • absence of ALDOSTERONE and aldosterone effects of GLUCOCORTICOIDS
  • standing up and feel faint
  • not enough capacity in blood stream to pump to head

weight loss & lethargy

  • not retaining fluid
  • loss fluid = loss weight
  • losing fat too (energy)

hyperpigmentation (not in secondary hypofunction)
- - scars, mouth, skin creases
pigmentation effect of increased ACTH secretion by pituitary
—–in attempt to try and trigger cortisol but not functioning
causes excess MSH
—–often in areas of skin trauma as melanocytes overreact

vitiligo associated

61
Q

3 symptoms of addison’s disease

A

weakness
anorexia
loss of body hair (females)

62
Q

3 investigations for cushing’s syndrome

A

high 24hr urinary cortisol excretion

abnormal dexamethasone suppression tests
- feedback suppression of cortisol via ACTH

CRH test
- cushings disease show rise in ACTH with CRH

63
Q

2 investigations for Addison’s disease

A

high ACTH level

negative synACTHen tests
- No plasma cortisol rise in response to ACTH injection

64
Q

what hormone is high in cushing’s disease

A

cortisol

65
Q

hyperfunction of adrenal due to pituitary adenoma or ectopic ACTH production causes

A

high ACTH

high cortisol

66
Q

hyperfunction of adrenal due to gland adenoma causes

A

low ACTH

high cortisol

67
Q

hypofunction of adrenal due to pituitary failure causes

A

low ACTH
low cortisol

and will have positive synACTHen test

(gland is OK but pituitary failure, inject synACTHen and should rise)

68
Q

hypofunction of adrenal due to gland destruction causes

A

high ACTH
low cortisol

and will have negative synACTHen test

(nothing to response to ACTH)

69
Q

how to treat adrenal hyperdunction

A

detect cause

  • pituitary
  • adrenal
  • ectopic (lung)

surgery

  • pituitary (transsphenoidal surgery)
  • adrenal - partial/complete adrenalectomy
70
Q

what is a severe outcome of addison’s disease

A

crisis

  • hypotension
  • vomiting
  • eventual coma/collapse

Absence of MINERALOCORTICOID and mineralocorticoid effects of GLUCOCORTICOIDS

  • CRISIS takes time to develop
  • hypopvolaemic shock
  • Hyponatraemia low sodium
71
Q

what are the symptoms of addison’s crisis

A

low BP
collapse
low Na

treat with salty water
replace cortisol and aldosterone to maintain health

72
Q

2 drugs used to manage addison’s disease

A

cortisol

fludrocortisone - mimics aldosterone

73
Q

how does addison disease treatment need to vary with environment

A

cortisol dose varies

  • increased by physical/psychological stress
  • increased by infection
74
Q

treatment for persistent vomiting

A

IV steroids and hospital admission

75
Q

treatment of significant infection in Addison’s disease

A

Double oral cortisol dose during illness

Acute infections e.g. ‘herpes’
not for ‘mild cold’ ‘stressful day at work’

physiological stresses cause increase work on body
- not defined – need to be aware of potential problems and enquire

76
Q

preoperative cortisol management of Addison’s disease

A

for GA need 100mg hydrocortisone on induction (BNF)

  • repeat every 8hrs
  • halve every 24hrs until day 5 - then normal dose
77
Q

what is steroid prophylaxis

A

increase the steroid dose when increased physiological requirement anticipated:

  • infection
  • Surgery
  • Physiological stress

e.g. mandible surgery, 3 molars extracted
Not psychological stress

78
Q

influence of addison’s disease in pregnancy

A

NO routine increase in hydrocortisone dose
- seek advice

LABOUR
- DOUBLE oral dose for 24hrs
increase dose for a ‘few days’

Is having a tooth out worse than childbirth?

  • Decide each case on merit for steroid cover!
  • Art rather than a science!
79
Q

steroid cover in Addison’s Disease for routine restorative treatment

A

no cover needed

80
Q

steroid cover in Addison’s Disease for simple dental extractions

A

no cover usually needed

81
Q

steroid cover in Addison’s Disease for minor oral surgery

A

give steroid prophylaxis

82
Q

steroid cover in Addison’s Disease for spreading dental or facial infection

A

give steroid prophylaxis

83
Q

do patients on therapeutic steroids have a tendency for hyper or hypotension

A

hypertension

84
Q

do pt with addison’s disease have a tendency for hyper or hypotension

A

hypotension

85
Q

type of steroid replacement in addison’s disease pt

A

physiological replacement

20-30mg hydrocortisone

86
Q

type of steroid replacement in therapeutic steroid pt

A

supra-physiological

10mg Prednisolone = 40mg hydrocortisone

87
Q

is there need for increase dose/cover for above 15mg Prednisolone at treatment

A

no case for increase dose/cover

88
Q

is there need for increase dose/cover for 1-15mg Prednisolone at treatment

A

cover with double oral dose if required

perioperative’ period -
surgery day + 2days
- NO evidence base!

Low risk - have exogenous + endogenous steroids

89
Q

is there need for increase dose/cover for pt who have stopped prolonged systemic steroids in last 3 months

A

cover with 100mg IM dose if required

highest risk?

90
Q

preoperative period

A

surgery day and 2 days

91
Q

how to manage addisonian crisis

A

Treat the problem
- hypovolaemia, hyponatraemia, hyperkalaemia

FLUID RESUSCITATION

  • SALINE infusions
  • —–Volume expansion with colloid if shock present
  • corticosteroids IV
  • ——100mg hydrocortisone every 6hrs
  • correct hypoglycaemia
  • ——present in CRISIS only
  • treat precipitating event
  • ——infection
92
Q

dental aspects with steroids

A

steroid precautions

liase with physician for infections/illness

?diabetes or CV disease

Candidiasis in Cushings

Oral pigmentation in Addison’s/Cushings

93
Q

9 causes of oral pigmentation

A

Racial

SMOKING

Melanotic Macule

Drugs

  • Oral Contraceptive pill
  • Minocycline
  • Antimalarials
  • AZT

Pigmented Naevus

Pregnancy

Chronic

Trauma

Melanoma

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