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
describe how aldosterone increase blood pressure
increases salt and water reabsorption, increasing circulating volume
26
what type of adrenal hormone is cortisol
natural glucocorticoid
27
where does cortisol work
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
28
what is the level of effect cortisol has
physiological steroid effect relative to physiological levels, small effect as natural low level but when add steroid more severe
29
4 physiological effects of cortisol
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
30
release of cortisol
circadian nocturnal peak (like growth hormone)
31
what is the effect of cortisol on insuline
antagonist need to generate energy frm breakdown of other products (fat and protein)
32
what controls cortisol
Inhibit pituitary ACTH Hypothalamic cortico-releasing hormone
33
what is a key difference in therapeutic steroids
different levels of potency slight chemical differences can lead to more extreme responses
34
what can be the effect of taking steroid tablets for a long period
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
35
what does adreanl suppression do
stop the release system of cortisol (ACTH production) levels drop quickly
36
what are the 2 roles of therapeutic steroids
Enhanced Glucocorticoid effect Enhanced Mineralcorticoid effect - More than expected effect - Salt and water retention hypertension
37
therapeutic steroid action of prednisolone
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
38
11 possible adverse effects of therapeutic steroids
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
how can taking steroids for a disease cause adverse effects
given too much of a substance which naturally controls body system
40
what are 2 factors to take into consideration when giving steroid tablets
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
glucocorticoid hyperfunction of adrenal gland
cushings syndrome adrenal tumour - primary pituitary tumour - secondary (site of making ACTH)
42
cushings syndrome caused by
adrenal hyperfunction of glucocorticoid
43
aldosrerone hyperfunction of adrenal gland
Conn's syndrome adrenal tumour - high level of cortisol in blood - lots of aldosterone leads to hypertension by salt and water retention
44
primary hypofunction of adrenal gland
addison's disease | - gland itself damaged or destroyed
45
secondary hypofuntion of adrenal gland
pituitary failure | - tumour squashed cells that make ACTH
46
2 casues of Conn's syndrome
excess aldosterone/ adrenal hyperfunction ``` adrenal tumour adrenal hyperplasia (rare) ```
47
causes of cushing's syndrome (4)
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
5 cushing's syndrome signs
centripetal obesity - moon face - buffalo hump - Fat collection at back of neck hypertension thin skin & purpura muscle weakness Osteoporotic changes & fractures
49
8 cushing's syndrome symptoms
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
MSH
melanocyte stimulating hormone alpha MSH in ACTH seqeunce
51
what effect can be seen in melanocytes of excess ACTH
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
2 causes of adrenal hypofunction
gland failure pituitary failure
53
3 possible causes for adrenal gland failure in hypofunction
autoimmune gland destruction In Western World - adrenal failure from adrenal antibodies infection - more globally - especially Tuberculosis infarction
54
2 possible causes of pituitary failure in adrenal hypofunction
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
what is the biggest worldwide cause of Addison's disease
TB
56
addison's disease
primary hypofunction of adrenal gland
57
describe the onset for addison's disease usually
slow | months
58
what are potential causes of addison's disease
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
outcome of addison's disease
death not enough adrenal hormones need to have hormone replacement to keep them alive
60
4 signs of addison's disease
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
3 symptoms of addison's disease
weakness anorexia loss of body hair (females)
62
3 investigations for cushing's syndrome
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
2 investigations for Addison's disease
high ACTH level negative synACTHen tests - No plasma cortisol rise in response to ACTH injection
64
what hormone is high in cushing's disease
cortisol
65
hyperfunction of adrenal due to pituitary adenoma or ectopic ACTH production causes
high ACTH | high cortisol
66
hyperfunction of adrenal due to gland adenoma causes
low ACTH | high cortisol
67
hypofunction of adrenal due to pituitary failure causes
low ACTH low cortisol and will have positive synACTHen test (gland is OK but pituitary failure, inject synACTHen and should rise)
68
hypofunction of adrenal due to gland destruction causes
high ACTH low cortisol and will have negative synACTHen test (nothing to response to ACTH)
69
how to treat adrenal hyperdunction
detect cause - pituitary - adrenal - ectopic (lung) surgery - pituitary (transsphenoidal surgery) - adrenal - partial/complete adrenalectomy
70
what is a severe outcome of addison's disease
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
what are the symptoms of addison's crisis
low BP collapse low Na treat with salty water replace cortisol and aldosterone to maintain health
72
2 drugs used to manage addison's disease
cortisol fludrocortisone - mimics aldosterone
73
how does addison disease treatment need to vary with environment
cortisol dose varies - increased by physical/psychological stress - increased by infection
74
treatment for persistent vomiting
IV steroids and hospital admission
75
treatment of significant infection in Addison's disease
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
preoperative cortisol management of Addison's disease
for GA need 100mg hydrocortisone on induction (BNF) - repeat every 8hrs - halve every 24hrs until day 5 - then normal dose
77
what is steroid prophylaxis
increase the steroid dose when increased physiological requirement anticipated: - infection - Surgery - Physiological stress e.g. mandible surgery, 3 molars extracted Not psychological stress
78
influence of addison's disease in pregnancy
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
steroid cover in Addison's Disease for routine restorative treatment
no cover needed
80
steroid cover in Addison's Disease for simple dental extractions
no cover usually needed
81
steroid cover in Addison's Disease for minor oral surgery
give steroid prophylaxis
82
steroid cover in Addison's Disease for spreading dental or facial infection
give steroid prophylaxis
83
do patients on therapeutic steroids have a tendency for hyper or hypotension
hypertension
84
do pt with addison's disease have a tendency for hyper or hypotension
hypotension
85
type of steroid replacement in addison's disease pt
physiological replacement 20-30mg hydrocortisone
86
type of steroid replacement in therapeutic steroid pt
supra-physiological 10mg Prednisolone = 40mg hydrocortisone
87
is there need for increase dose/cover for above 15mg Prednisolone at treatment
no case for increase dose/cover
88
is there need for increase dose/cover for 1-15mg Prednisolone at treatment
cover with double oral dose if required perioperative’ period - surgery day + 2days - NO evidence base! Low risk - have exogenous + endogenous steroids
89
is there need for increase dose/cover for pt who have stopped prolonged systemic steroids in last 3 months
cover with 100mg IM dose if required highest risk?
90
preoperative period
surgery day and 2 days
91
how to manage addisonian crisis
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
dental aspects with steroids
steroid precautions liase with physician for infections/illness ?diabetes or CV disease Candidiasis in Cushings Oral pigmentation in Addison’s/Cushings
93
9 causes of oral pigmentation
Racial SMOKING Melanotic Macule Drugs - Oral Contraceptive pill - Minocycline - Antimalarials - AZT Pigmented Naevus Pregnancy Chronic Trauma Melanoma