Steroids Flashcards
Which disease causes destruction of adrenal tissue?
Addison’s disease
Which disease causes excess adrenal action?
- Cushing’s disease
Where is the adrenal gland found in the body?
- Found on your kidney but nothing to do with your kidney
Which hormone is released from the Zona Glomerulosa region of the adrenal gland?
Aldosterone
Which hormone is released from the Zona Fasicularis region of the adrenal gland?
Cortisol (hypothalamus/pituitary)
Which hormone is released from the Zona Reticularis region of the adrenal gland?
Adrenal Androgens
Adrenal hormones are largely the same compound but will have small changes on them. Which hormone do they all broadly tend to come from?
- Cholesterol
What does aldosterone regulate? (2 points)
- Salt and water regulation
- Enhances Na+ reabsorption and K+ loss
- Renin-angiotensin system
What does aldosterone have an indirect effect on?
- Blood pressure
Which 2 types of drugs inhibits the action of aldosterone?
- ACE inhibitors
- AT2 blockers
What does ACE inhibitor stand for?
Angiotensin converting enzyme inhibitors
What are 3 side effects of ACE inhibitors?
- Cough
- Angio-oedema
- Oral lichenoid drug reactions
What do AT2 blockers do?
- Block angiotensin receptor
What is angio-oedema?
- Severe swelling underneath the skin surface
If someone is on ACE inhibitors which causes lichenoid reactions. What should you ask their GP to swap them to?
AT2 blocker
What is Enalapril and what is it used to treat?
- Used alone or in combination with other medications to treat high BP
- It is in a class of medications called ACE inhibitors
- IT works by decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly and the heart can pump more efficiently
What type of drug is Losartan and what does it do?
- AT2 blocker
- it keeps blood vessels from narrowing, which lowers BP and improves blood flow
What is Cortisol?
A glucocorticoid
Does Cortisol have ‘physiological’ steroid effects?
- Yes
Does cortisol have a circadian release?
- Yes, with a nocturnal peak (more is released during the night)
Cortisol has physiological steroid effects, meaning these are things that will happen because of cortisol in the blood at a NORMAL level. Give 4 examples of these?
- Antagonist to insulin (gluconeogenesis, fat & protein breakdown)
- Lowers the immune reactivity
- Raises BP
- Inhibits bone synthesis
None of these will cause any disease at the normal level
What are the normal levels of hydrocortisone in the body a day?
14/15g a day
What are examples of 5 therapeutic hormones and their potency in relation to cortisol?
- Hydrocortisone (1 - equivalent to cortisol)
- Prednisolone (4)
- Triamcinolone (5)
- Dexamethasone (25)
- Betamethasone (30)
What are the 2 kinds of effects therapeutic steroids can have?
- Enhanced Glucocorticoid effect
- Enhanced Mineralocorticoid effect
What are 2 effects of therapeutic steroids that have an enhanced mineralocorticoid effect?
- Salt and water retention
- Hypertension
What are possible adverse effects of therapeutic steroids? (11 points)
- Hypertension
- Type 2 diabetes
- Osteoporosis
- Increased infection risk
- Peptic ulceration
- Thinning of the skin
- Easy bruising
- Cataracts & Glaucoma
- Hyperlipidaemia (atherosclerosis)
- Increased cancer risk
- Psychiatric disturbance
What disease does hyperfunction of the adrenal gland, leading to increased glucocorticoids cause?
Cushing’s syndrome
What is the primary cause of Cushing’s syndrome?
An adrenal Tumour
What is the secondary cause of Cushing’s syndrome?
Pituitary tumour
What disease does hyperfunction of the adrenal gland, leading to increased aldosterone levels cause?
- Conn’s Syndrome
What is the cause of Conn’s syndrome?
- Increased aldosterone levels as a result of an adrenal tumour
What is the primary cause of hypofunction of the adrenal gland?
- Addison’s disease
What is the secondary cause of hypofunction of the adrenal gland?
- Pituitary failure
What is the female to male ratio for Cushing’s syndrome?
F 4:1 M
What % of spontaneous Cushing’s patient have a pituitary tumour?
70%
What are the 3 possible causes of Cushing’s syndrome?
- Pituitary tumour
- Adrenal adenoma or hyperplasia
- Ectopic ACTH production (some lung tumours)
What are the 2 possible causes of Conn’s Syndrome?
- Adrenal tumour
- Adrenal hyperplasia
What are common signs of Cushing’s syndrome? (5 points)
- Centripetal obesity (moon face, buffalo hump)
- Hypertension
- Thick skin and purpura
- Muscle weakness
- Osteoporotic changes & fractures
What are common symptoms of Cushing’s syndrome? (7 points)
- ‘diabetes mellitus’ features
- Poor resistance to infections
- Osteoporotic changes (back pain & bone fractures)
- Psychiatric disorders (depression, emotional lability, psychosis)
- Hirsuitism
- Skin and mucosal pigmentation
- Amenorrhoea, impotence & infertility
What is Hirsuitism?
Abnormal growth of hair on a womens’ face or body
Why, when you get increased levels of ACTH, do you also start to develop skin pigmentation?
- If you have ACTH, you also have alpha MSH
- Alpha MSH = melanocyte stimulating hormone
- If have high levels of ACTH will start to develop pigmentation because of higher levels of alpha-MSH
- Important as will show in the mouth maybe more than the skin
Adrenal hypofunction can be caused by gland failure. What can cause the gland to fail? (3 points)
- Autoimmune gland destruction
- Infection
- Infarction
Adrenal hypofunction can be caused by pituitary failure. What can cause the pituitary to fail? (2 points)
- Compression from other adenoma
- Sheehan’s syndrome
What is Sheehan’s syndrome?
- Postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive haemorrhage during or after delivery
What is the biggest <i>worldwide</i> cause of Addison’s disease?
TB
What is the name of an organ-specific autoimmune disease that causes Addison’s disease?
- Atoimmune Adrenalitis
- Thyroid, Diabetes mellitus, Pernicious anaemia
Is Addison’s disease fast or slow onset?
- Usually slow onset - months
What are common signs for Addison’s disease? (4 points)
- Postural hypotension (salt and water depletion as absence of aldosterone and aldosterone effects of glucocorticoids)- Weight loss and lethargy
- Hyperpigmentation (scars, mouth, skin creases)
- Vitiligo
What are common symptoms of Addison’s disease? (3 points)
- Weakness
- Anorexia
- Loss of body hair (females)
How could you test for Cushing’s disease? (3 points)
- High 24hr urinary cortisol excretion
- Abnormal dexamethasone sppression tests (feedback suppression of cortisol via ACTH)
- CRH tests (Cushing’s disease show rise in ACTH with CRH)
How could you test for Addison’s disease? (2 points)
- High ACTH level
- Negative synACTHen tests (no plasma cortisol rise in response to ACTH injection)
If you have adrenal hyperfunction due to pituitary adenoma or ectopic ACTH production. What will the levels of ACTH and cortisol be?
- High ACTH
- High Cortisol
If you have adrenal hyperfunction due to a gland adenoma. What will the levels of ACTH and cortisol be?
- Low ACTH
- High Cortisol
If you have adrenal hypofunction due to pituitary failure. What will the levels of ACTH and cortisol be and what will the outcome of the STNACTHEN test be?
- Low ACTH
- Low cortisol
- STNACTHEN = positive
If you have adrenal hypofunction due to gland destruction. What will the levels of ACTH and cortisol be and what will the outcome of the STNACTHEN test be?
- High ACTH
- Low Cortisol
- SYNACTHEN = Negative
To determine the treatment of an adrenal hyperfunction disease, first you need to detect the cause (adenoma). What are the 3 possible causes ?
- Pituitary
- Adrenal
- Ectopic (lung)
To treat adrenal hyperfunction you can carry out surgery. What would this be on? (2 points)
- Pituitary
- Adrenal - partial/complete adrenalectomy
If someone has untreated Addison’s disease this can be a crisis. What can it cause? (3 points)
- Hypotension
- Vomiting
- Eventual coma
Untreated Addison’s disease can lead to hypovolaemic shock ( due to the absence of mineralocorticoid and mineralocorticoid effects of glucocorticoids) . What is this?
Loss of more than a fifth of blood plasma/body fluids leading to reduced tissue perfusion
Untreated Addison’s disease can lead to Hyponatraemia (due to the absence of mineralocorticoid and mineralocorticoid effects of glucocorticoids) . What is this?
Condition where sodium levels in the blood are abnormally low
Addison’s disease can be managed by hormone replacement. What hormones would be given? (2 points)
- Cortisol
- Fludrocortisone
A patient with Addison’s disease should be on hormone replacement. This includes giving them Cortisol, but the dose of Cortisol varies with the environment. Give 2 examples of this?
- Increased by physical/psychological stress
- Increased by infection
How would you manage a patient with Addison’s disease who had be vomiting for a few hours?
- Require IV steroids and hospital administration
How would you manage a patient with Addison’s disease who had a significant infection? (2 points)
- Double oral cortisol dose during illness
- not for mild cold or stressful day at work
How would you manage a patient with Addison’s disease who needed perioperative management? (3 points)
- For GA need 100mg hydrocortisone on induction (BNF)
- Repeat every 8hrs
- Half every 24hrs until day 5 then normal dose again
Why is steroid prophylaxis important for a patient with Addison’s disease in the dental setting?
- If you have a patient who is coming in for a fair bit of treatment - need to make sure they have taken extra steroids
For a patient with Addison’s disease they may need to increase the steroid dose when increased physiological requirements are anticipated. What are 3 examples of these?
- Infection
- Surgery
- Physiological stress (not psychological stress)
For a patient with Addison’s disease who is pregnant, do you need to increase the hydrocortisone dose?
- NO routine increase in hydrocortisone dose
For a patient with Addison’s disease who is pregnant, do you need to increase the hydrocortisone dose when they are in labour? (2 points)
- DOUBLE oral dose for 24hrs
- Increase dose for a ‘few days’
Does a patient with Addison’s need extra steroids when getting routine restorative treatment?
No cover needed
Does a patient with Addison’s need extra steroids when getting a simple dental extraction?
No cover usually needed
Does a patient with Addison’s need extra steroids when getting minor oral surgery?
Give steroid prophylaxis
Does a patient with Addison’s need extra steroids when they have spreading dental or facial infection?
Give steroid prophylaxis
Why can vomiting be a problem when treating a patient with Addison’s disease?
- Problem as the patient can’t keep the pills down
Why might someone be on therapeutic steroid treatments? (2 points)
2 examples:
- Organ transplants
- Rheumatoid arthritis
Steroids given for Addison’s disease are given as physiological replacement. What does this mean?
- They are given at a dose that is the same as the level the body should be producing
Do people with Addison’s have a tendency to hypotension or hypertension?
HYPOTENSION
Do people on therapeutic steroid treatment have a tendency to hypotension or hypertension?
HYPERTENSION
Are all steroids provided for people with Addison’s disease exogenous or endogenous?
EXOGENOUS
Are all steroids provided for people on therapeutic steroid treatment exogenous or endogenous?
Exogenous
For people on therapeutic steroid treatment, the dose given is supraphysiological. What does this mean?
- They are given at way higher a dose than the body would produce on its own in a healthy state
How many times more potent is Prednisolone than hydrocortisone?
- 4 times
What will happen if a patient is on therapeutic steroid treatment for a long time (over 3 months)? (4 points)
- Bodies process of negative feedback will stop working
- If stop making cortisol for long enough the body will forget how to do it
- The adrenal cortex will atrophy if it is not being asked to make cortisol
- Patient will be fine as long as they are kept on the steroid treatment
How long will it take for the adrenal cortex to begin producing Cortisol again after therapeutic steroid treatment has been stopped and what is the problem with this? (2 points)
- Will take months for the adrenal cortex to start working as it should again
- This will cause patient to get sudden onset Addison’s disease
If a patient has untreated Addison’s disease they will have a tendency to get hypotensive. What does this cause?
- Means they are not reabsorbing salt and water so will become hypovolaemic and hyponatraemic
- So they will collapse as they do not have enough circulating volume and will not have enough sodium so will fit
What is hypovolaemic?
Volume of blood plasma is too low
What is hyponatraemia?
Condition where sodium levels in the blood are abnormally low
People on therapeutic steroid therapy tend to have hypertension. What is this caused by?
- Caused by reabsorption of salt and water in the body (more than the body would expect)
What is the general cut off point for where someone on therapeutic steroids would need to be given extra steroids if they are having surgery etc.?
- Somewhere between 10-20mg of prednisolone is going to, be cut off between where they need to be given extra steroids and when they don’t need it - this is a grey area
If someone is taking steroid tablets for a disease and you are about to give them LA they may need to be advised to take more steroids. How would you know this?
- You would ask a GP/specialist for advice
If you are unsure about treating a patient on steroid treatment, who would you speak to?
- The patients GP
Is routine dental care a risk for patients on oral therapeutic steroids?
- No evidence that this is the case
- Only may be an issue in certain circumstances
If you give a patient extra steroids for a treatment but you are not sure they actually need them, is this an issue?
It is unlikely to do them any harm - fall back option
Is there any evidence of harm from small short duration increase in dose of therapeutic steroids?
- No
If someone is on Above 15mg of Prednisolone (steroids), when giving treatment do they require extra steroids?
No indication for increased dose/cover
After how long on therapeutic steroids would you suspect adrenal suppression to be happening?
After about 3 months
If someone is on between 1-15mg of prednisolone (steroids), when giving treatment do they require extra steroids?
- Yes, would cover with double dose steroids
- ‘perioperative’ period - give on surgery day + 2 days after
Which patients are at highest risk in relation to therapeutic steroid therapy and what is the treatment for this?
- People who have stopped PROLONGED systemic steroids in the last 3 months
- Cover with 100mg IM dose if cover is required
What is it important to always ask a patient in relation to steroids?
ALWAYS ask about STEROID use in the previous 6 months
How long does it take for an ‘Addisonian’ crisis to occur?
- Over a period of time (probably a few days)
How would you manage Addisonian crisis? (2 points)
Treat the problem:
- Hypovolaemia, hyponatraemia, hyperkalaemia
- Fluid resuscitation
What is hyperkalaemia?
Higher than normal level of potassium in the blood
One way of managing Addisonian crisis is by fluid resuscitation. How can this be done? (4 points)
SALINE infusions
- Volume expanded with colloid if shock present
Corticosteroids IV
- 100mg hydrocortisone every 6hrs
Correct Hypoglycaemia
- Present in CRISIS only
Treat precipitating event
- Infections
What conditions can people on big doses of steroids be susceptible to? (2 points)
- Diabetes
- CV disease (as increased atherosclerosis)
Are people with Cushing’s disease more susceptible to candidiasis?
- Yes
Can Addison’s/Cushing’s disease cause oral pigmentation?
- Yes but there are many other things that can cause it too that are more common
What are common causes of oral pigmentation? (8 points)
- Racial
- SMOKING
- Melanotic Macule (freckle)
- Drugs (OCP, minocycline, antimalarials, AZT)
- Pigmented naevus
- Pregnancy
- Chronic trauma
- Melanoma (sometimes these don’t produce pigmentation)
