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BDS2 BAMS > Steroids > Flashcards

Steroids Flashcards

1
Q

Which disease causes destruction of adrenal tissue?

A

Addison’s disease

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2
Q

Which disease causes excess adrenal action?

A
  • Cushing’s disease
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3
Q

Where is the adrenal gland found in the body?

A
  • Found on your kidney but nothing to do with your kidney
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4
Q

Which hormone is released from the Zona Glomerulosa region of the adrenal gland?

A

Aldosterone

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5
Q

Which hormone is released from the Zona Fasicularis region of the adrenal gland?

A

Cortisol (hypothalamus/pituitary)

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6
Q

Which hormone is released from the Zona Reticularis region of the adrenal gland?

A

Adrenal Androgens

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7
Q

Adrenal hormones are largely the same compound but will have small changes on them. Which hormone do they all broadly tend to come from?

A
  • Cholesterol
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8
Q

What does aldosterone regulate? (2 points)

A
  • Salt and water regulation
  • Enhances Na+ reabsorption and K+ loss
  • Renin-angiotensin system
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9
Q

What does aldosterone have an indirect effect on?

A
  • Blood pressure
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10
Q

Which 2 types of drugs inhibits the action of aldosterone?

A
  • ACE inhibitors

- AT2 blockers

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11
Q

What does ACE inhibitor stand for?

A

Angiotensin converting enzyme inhibitors

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12
Q

What are 3 side effects of ACE inhibitors?

A
  • Cough
  • Angio-oedema
  • Oral lichenoid drug reactions
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13
Q

What do AT2 blockers do?

A
  • Block angiotensin receptor
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14
Q

What is angio-oedema?

A
  • Severe swelling underneath the skin surface
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15
Q

If someone is on ACE inhibitors which causes lichenoid reactions. What should you ask their GP to swap them to?

A

AT2 blocker

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16
Q

What is Enalapril and what is it used to treat?

A
  • 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
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17
Q

What type of drug is Losartan and what does it do?

A
  • AT2 blocker

- it keeps blood vessels from narrowing, which lowers BP and improves blood flow

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18
Q

What is Cortisol?

A

A glucocorticoid

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19
Q

Does Cortisol have ‘physiological’ steroid effects?

A
  • Yes
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20
Q

Does cortisol have a circadian release?

A
  • Yes, with a nocturnal peak (more is released during the night)
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21
Q

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?

A
  • 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

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22
Q

What are the normal levels of hydrocortisone in the body a day?

A

14/15g a day

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23
Q

What are examples of 5 therapeutic hormones and their potency in relation to cortisol?

A
  • Hydrocortisone (1 - equivalent to cortisol)
  • Prednisolone (4)
  • Triamcinolone (5)
  • Dexamethasone (25)
  • Betamethasone (30)
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24
Q

What are the 2 kinds of effects therapeutic steroids can have?

A
  • Enhanced Glucocorticoid effect

- Enhanced Mineralocorticoid effect

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25
Q

What are 2 effects of therapeutic steroids that have an enhanced mineralocorticoid effect?

A
  • Salt and water retention

- Hypertension

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26
Q

What are possible adverse effects of therapeutic steroids? (11 points)

A
  • 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
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27
Q

What disease does hyperfunction of the adrenal gland, leading to increased glucocorticoids cause?

A

Cushing’s syndrome

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28
Q

What is the primary cause of Cushing’s syndrome?

A

An adrenal Tumour

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29
Q

What is the secondary cause of Cushing’s syndrome?

A

Pituitary tumour

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30
Q

What disease does hyperfunction of the adrenal gland, leading to increased aldosterone levels cause?

A
  • Conn’s Syndrome
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31
Q

What is the cause of Conn’s syndrome?

A
  • Increased aldosterone levels as a result of an adrenal tumour
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32
Q

What is the primary cause of hypofunction of the adrenal gland?

A
  • Addison’s disease
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33
Q

What is the secondary cause of hypofunction of the adrenal gland?

A
  • Pituitary failure
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34
Q

What is the female to male ratio for Cushing’s syndrome?

A

F 4:1 M

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35
Q

What % of spontaneous Cushing’s patient have a pituitary tumour?

A

70%

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36
Q

What are the 3 possible causes of Cushing’s syndrome?

A
  • Pituitary tumour
  • Adrenal adenoma or hyperplasia
  • Ectopic ACTH production (some lung tumours)
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37
Q

What are the 2 possible causes of Conn’s Syndrome?

A
  • Adrenal tumour

- Adrenal hyperplasia

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38
Q

What are common signs of Cushing’s syndrome? (5 points)

A
  • Centripetal obesity (moon face, buffalo hump)
  • Hypertension
  • Thick skin and purpura
  • Muscle weakness
  • Osteoporotic changes & fractures
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39
Q

What are common symptoms of Cushing’s syndrome? (7 points)

A
  • ‘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
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40
Q

What is Hirsuitism?

A

Abnormal growth of hair on a womens’ face or body

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41
Q

Why, when you get increased levels of ACTH, do you also start to develop skin pigmentation?

A
  • 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
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42
Q

Adrenal hypofunction can be caused by gland failure. What can cause the gland to fail? (3 points)

A
  • Autoimmune gland destruction
  • Infection
  • Infarction
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43
Q

Adrenal hypofunction can be caused by pituitary failure. What can cause the pituitary to fail? (2 points)

A
  • Compression from other adenoma

- Sheehan’s syndrome

44
Q

What is Sheehan’s syndrome?

A
  • 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
45
Q

What is the biggest <i>worldwide</i> cause of Addison’s disease?

A

TB

46
Q

What is the name of an organ-specific autoimmune disease that causes Addison’s disease?

A
  • Atoimmune Adrenalitis

- Thyroid, Diabetes mellitus, Pernicious anaemia

47
Q

Is Addison’s disease fast or slow onset?

A
  • Usually slow onset - months
48
Q

What are common signs for Addison’s disease? (4 points)

A
  • 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
49
Q

What are common symptoms of Addison’s disease? (3 points)

A
  • Weakness
  • Anorexia
  • Loss of body hair (females)
50
Q

How could you test for Cushing’s disease? (3 points)

A
  • 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)
51
Q

How could you test for Addison’s disease? (2 points)

A
  • High ACTH level

- Negative synACTHen tests (no plasma cortisol rise in response to ACTH injection)

52
Q

If you have adrenal hyperfunction due to pituitary adenoma or ectopic ACTH production. What will the levels of ACTH and cortisol be?

A
  • High ACTH

- High Cortisol

53
Q

If you have adrenal hyperfunction due to a gland adenoma. What will the levels of ACTH and cortisol be?

A
  • Low ACTH

- High Cortisol

54
Q

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?

A
  • Low ACTH
  • Low cortisol
  • STNACTHEN = positive
55
Q

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?

A
  • High ACTH
  • Low Cortisol
  • SYNACTHEN = Negative
56
Q

To determine the treatment of an adrenal hyperfunction disease, first you need to detect the cause (adenoma). What are the 3 possible causes ?

A
  • Pituitary
  • Adrenal
  • Ectopic (lung)
57
Q

To treat adrenal hyperfunction you can carry out surgery. What would this be on? (2 points)

A
  • Pituitary

- Adrenal - partial/complete adrenalectomy

58
Q

If someone has untreated Addison’s disease this can be a crisis. What can it cause? (3 points)

A
  • Hypotension
  • Vomiting
  • Eventual coma
59
Q

Untreated Addison’s disease can lead to hypovolaemic shock ( due to the absence of mineralocorticoid and mineralocorticoid effects of glucocorticoids) . What is this?

A

Loss of more than a fifth of blood plasma/body fluids leading to reduced tissue perfusion

60
Q

Untreated Addison’s disease can lead to Hyponatraemia (due to the absence of mineralocorticoid and mineralocorticoid effects of glucocorticoids) . What is this?

A

Condition where sodium levels in the blood are abnormally low

61
Q

Addison’s disease can be managed by hormone replacement. What hormones would be given? (2 points)

A
  • Cortisol

- Fludrocortisone

62
Q

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?

A
  • Increased by physical/psychological stress

- Increased by infection

63
Q

How would you manage a patient with Addison’s disease who had be vomiting for a few hours?

A
  • Require IV steroids and hospital administration
64
Q

How would you manage a patient with Addison’s disease who had a significant infection? (2 points)

A
  • Double oral cortisol dose during illness

- not for mild cold or stressful day at work

65
Q

How would you manage a patient with Addison’s disease who needed perioperative management? (3 points)

A
  • For GA need 100mg hydrocortisone on induction (BNF)
  • Repeat every 8hrs
  • Half every 24hrs until day 5 then normal dose again
66
Q

Why is steroid prophylaxis important for a patient with Addison’s disease in the dental setting?

A
  • If you have a patient who is coming in for a fair bit of treatment - need to make sure they have taken extra steroids
67
Q

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?

A
  • Infection
  • Surgery
  • Physiological stress (not psychological stress)
68
Q

For a patient with Addison’s disease who is pregnant, do you need to increase the hydrocortisone dose?

A
  • NO routine increase in hydrocortisone dose
69
Q

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)

A
  • DOUBLE oral dose for 24hrs

- Increase dose for a ‘few days’

70
Q

Does a patient with Addison’s need extra steroids when getting routine restorative treatment?

A

No cover needed

71
Q

Does a patient with Addison’s need extra steroids when getting a simple dental extraction?

A

No cover usually needed

72
Q

Does a patient with Addison’s need extra steroids when getting minor oral surgery?

A

Give steroid prophylaxis

73
Q

Does a patient with Addison’s need extra steroids when they have spreading dental or facial infection?

A

Give steroid prophylaxis

74
Q

Why can vomiting be a problem when treating a patient with Addison’s disease?

A
  • Problem as the patient can’t keep the pills down
75
Q

Why might someone be on therapeutic steroid treatments? (2 points)

A

2 examples:

  • Organ transplants
  • Rheumatoid arthritis
76
Q

Steroids given for Addison’s disease are given as physiological replacement. What does this mean?

A
  • They are given at a dose that is the same as the level the body should be producing
77
Q

Do people with Addison’s have a tendency to hypotension or hypertension?

A

HYPOTENSION

78
Q

Do people on therapeutic steroid treatment have a tendency to hypotension or hypertension?

A

HYPERTENSION

79
Q

Are all steroids provided for people with Addison’s disease exogenous or endogenous?

A

EXOGENOUS

80
Q

Are all steroids provided for people on therapeutic steroid treatment exogenous or endogenous?

A

Exogenous

81
Q

For people on therapeutic steroid treatment, the dose given is supraphysiological. What does this mean?

A
  • They are given at way higher a dose than the body would produce on its own in a healthy state
82
Q

How many times more potent is Prednisolone than hydrocortisone?

A
  • 4 times
83
Q

What will happen if a patient is on therapeutic steroid treatment for a long time (over 3 months)? (4 points)

A
  • 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
84
Q

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)

A
  • 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
85
Q

If a patient has untreated Addison’s disease they will have a tendency to get hypotensive. What does this cause?

A
  • 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
86
Q

What is hypovolaemic?

A

Volume of blood plasma is too low

87
Q

What is hyponatraemia?

A

Condition where sodium levels in the blood are abnormally low

88
Q

People on therapeutic steroid therapy tend to have hypertension. What is this caused by?

A
  • Caused by reabsorption of salt and water in the body (more than the body would expect)
89
Q

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.?

A
  • 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
90
Q

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?

A
  • You would ask a GP/specialist for advice
91
Q

If you are unsure about treating a patient on steroid treatment, who would you speak to?

A
  • The patients GP
92
Q

Is routine dental care a risk for patients on oral therapeutic steroids?

A
  • No evidence that this is the case

- Only may be an issue in certain circumstances

93
Q

If you give a patient extra steroids for a treatment but you are not sure they actually need them, is this an issue?

A

It is unlikely to do them any harm - fall back option

94
Q

Is there any evidence of harm from small short duration increase in dose of therapeutic steroids?

A
  • No
95
Q

If someone is on Above 15mg of Prednisolone (steroids), when giving treatment do they require extra steroids?

A

No indication for increased dose/cover

96
Q

After how long on therapeutic steroids would you suspect adrenal suppression to be happening?

A

After about 3 months

97
Q

If someone is on between 1-15mg of prednisolone (steroids), when giving treatment do they require extra steroids?

A
  • Yes, would cover with double dose steroids

- ‘perioperative’ period - give on surgery day + 2 days after

98
Q

Which patients are at highest risk in relation to therapeutic steroid therapy and what is the treatment for this?

A
  • People who have stopped PROLONGED systemic steroids in the last 3 months
  • Cover with 100mg IM dose if cover is required
99
Q

What is it important to always ask a patient in relation to steroids?

A

ALWAYS ask about STEROID use in the previous 6 months

100
Q

How long does it take for an ‘Addisonian’ crisis to occur?

A
  • Over a period of time (probably a few days)
101
Q

How would you manage Addisonian crisis? (2 points)

A

Treat the problem:

  • Hypovolaemia, hyponatraemia, hyperkalaemia
  • Fluid resuscitation
102
Q

What is hyperkalaemia?

A

Higher than normal level of potassium in the blood

103
Q

One way of managing Addisonian crisis is by fluid resuscitation. How can this be done? (4 points)

A

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
104
Q

What conditions can people on big doses of steroids be susceptible to? (2 points)

A
  • Diabetes

- CV disease (as increased atherosclerosis)

105
Q

Are people with Cushing’s disease more susceptible to candidiasis?

A
  • Yes
106
Q

Can Addison’s/Cushing’s disease cause oral pigmentation?

A
  • Yes but there are many other things that can cause it too that are more common
107
Q

What are common causes of oral pigmentation? (8 points)

A
  • Racial
  • SMOKING
  • Melanotic Macule (freckle)
  • Drugs (OCP, minocycline, antimalarials, AZT)
  • Pigmented naevus
  • Pregnancy
  • Chronic trauma
  • Melanoma (sometimes these don’t produce pigmentation)

BDS2 BAMS (57 decks)

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