Steroids

Question 1

Differentiate, broadly, Addison’s Disease from Cushing’s Disease

Answer 1

Addison’s: Underproduction of cortisol s/p adrenal insufficiency
Cushing’s: Overproduction of cortisol

Question 2

How is synthetic ACTH used in current practice?

Answer 2

As a diagnostic agent only

Question 3

What are the primary ways in which steroids differ from one another

Answer 3

Steroids differ in their potency and their lipophilicity

Question 4

T/F: A steroid used in a joint injection should be highly lipophilic.

Answer 4

False: A hydrophilic steroid should be used so the steroid stays in the joint

Question 5

What is the principle hormone secreted by the adrenal gland and how is it regulated?

Answer 5

Hydrocortisone: regulated by CRF from the hypothalamus and ACTH from the pituitary

Question 6

How does the mechanism of glucocorticoids differ from most other medications we administer?

Answer 6

They both bind to membrane receptors and enter the cell nucleus to influence the activation and deactivation of genes on DNA which subsequently influences production of various proteins

Question 7

What is the primary pharmacologic effect of administering steroid medications?

Answer 7

Suppression of DNA mediated synthesis of pro-inflammatory chemicals (LTs, PGs, cytokines, interleukins)

Question 8

What is the general mechanism through which steroids cause adverse effects?

Answer 8

Through DNA activation of certain genes different from those that suppress inflammatory chemicals

Question 9

Describe 7 AEs of steroids administration.

Answer 9

Hyperglycemia from gluconeogenesis and decreased use of glucose in the periphery
Catabolism and reduced anabolism
Osteoporosis with increased calcium excretion
Delayed growth in children
Fat deposition in the shoulders, face, and abdomen
Reduced healing
Suppress allergic responses and Ab production

Question 10

T/F: IV administration of steroids has essentially the same onset of action as PO administration of the same drug.

Answer 10

True: Since steroids must enter the cell to have an effect, IV administration of the drug is not markedly faster than PO

Question 11

In what patient populations do we need to be particularly cautious in using steroids?

Answer 11

Post-menopausal women s/p osteoporosis risk

Children s/p delayed growth

Question 12

How are steroids dosed, generally?

Answer 12

Multiple dosing strategies - QD, QOD, short courses, etc.

Question 13

Describe the term pulse therapy in relation to steroid administration.

Answer 13

High dose administration in very short courses (1 - 5 days)

Question 14

If a person is instructed to take a steroid QD, what would be the best time for them to take their steroid?

Answer 14

In the morning because steroids are part of our wake-up cycle

Question 15

What dose of steroids is required to suppress the HPA axis and decrease endogenous steroid production?

Answer 15

At least 20mg of prednisone or equivalent for at least 14 days

Question 16

If a patient is on enough steroids to suppress their HPA axis, what will result from rapid withdrawal of the drug?

Answer 16

Acute adrenocortical insufficiency

Question 17

In patients on enough steroids to suppress their HPA axis, when might a clinician need to increase their dose?

Answer 17

During the course of stressful events (surgery for ex) - aka stress dose steroids

Question 18

What is the typical dose for stress dose steroids and what would the dose be for a minor procedure?

Answer 18

Typical: 50-100mg hydrocortisone IV

Minor procedure: 20mg hydrocortisone PO

Question 19

What is the minimum dose of topical or inhaled steroids needed to cause HPA axis suppression?

Answer 19

Topical and inhaled steroids do not usually cause HPA suppression regardless of dose

Question 20

Why should a person taking steroids wear a medical alert bracelet?

Answer 20

Tells providers to continue their steroid therapy if they are in an accident or other emergency

Question 21

Describe the dexamethasone suppression test.

Answer 21

Dex acts on the hypothalamus directly to suppress CRF. If adrenal production of hydrocortisone is subsequently reduced, it indicates an intact HPA axis. Used to diagnose Cushing’s disease.

Question 22

Describe the pharmacokinetics of hydrocortisone and state how it is available.

Answer 22

Naturally occuring hormone with an onset of action of about 1 hour
Highly bound to cortisol binding globulin - lowest in the morning
PO, IV, OTC topical formulations

Question 23

Describe the pharmacokinetics of prednisone and state how it is available.

Answer 23

Half life of 1-3 hours with biological effects in 2-8 hours
Lipophilic - high absorption in the gut
Primary PO agent used in the US - available IV as methylprednisolone

Question 24

List 8 common AEs associated with prednisone administration.

Answer 24

Osteopenia
Reduced gastric mucus production
Fat redistribution
Hyperglycemia
Depression and psychosis at high doses
Weight gain s/p Na retention and increased appetite
Hypokalemia
Immune suppression

Question 25

List some rare AEs associated with prednisone administration.

Answer 25

Avascular necrosis, tendon rupture, peptic ulcers, cataracts, menstrual disorders, thromboembolism

Question 26

What affect does steroid administration have on white blood cells?

Answer 26

Increase serum WBC count (aka demargination) because the WBCs become less sticky and not as many stick to the walls of the blood vessels

Question 27

What differentiates leukocytosis due to demargination from leukocytosis due to an infection?

Answer 27

Infection shows a left shift –> increase in immature WBCs called bands

Question 28

T/F: Patients on steroid therapy should not be given a vaccine.

Answer 28

False: use caution in live vaccines

There may be a blunted response to all vaccines but steroids are not a contraindication

Question 29

Describe a Medrol Dose Pack.

Answer 29

Twenty-one 4mg tabs - 6 tabs on the first day and take 1 less each subsequent day until the pack is finished (6 days).

Question 30

Define fluorinated steroids.

Answer 30

Steroids with something added to them to make them more potent.

Question 31

List the fluorinated steroids discussed in class.

Answer 31

Triamcinolone - joint injections and topical agents
Fludrocortisone - PO for Addison’s
Dexamethasone - most lipophilic steroid
Betamethasone - similar to dexamethasone

Question 32

List the inhaled steroid products discussed in class.

Answer 32

Beclomethasone, budesonide, fluticasone, mometasone, ciclesonide

Question 33

How are steroids used in pregnancy?

Answer 33

Use lowest possible dose and avoid fluorinated agents.

Question 34

What is the goal of treatment in Cushing’s disease?

Answer 34

Decrease the production of steroids

Question 35

List 5 medications used in Cushing’s disease.

Answer 35

Aminoglutethimide, Metyrapone, Ketoconazole, Finasteride, Dutasteride

Question 36

Describe the mechanism of action of finasteride and dutasteride.

Answer 36

5-alpha-reductase inhibitors –> they keep testosterone from getting converted to its more active metabolite.

Question 37

Describe the clinical uses (other than Cushing’s Disease) of finasteride and dutasteride.

Answer 37

Finasteride: male pattern baldness at low doses and BPH at high doses
Dutasteride: only for BPH –> twice as potent as finasteride