steroids in practice Flashcards
what are the two main types of steroids?
1- steroids to suppress anti inflammatory process
2-steroid replacement where the body doesnt make enough
what are some examples of steroids to suppress an anti-inflam process?
oral prendisolone to suppress chest infection
topical hydrocortisone for ezcema flare up
give an example of when steroid repacement may be necessary
oral hydrocortisone and fludrcortisone in addison’s disease
what are the two main properties of corticosteroids?
glucocorticoid- regulate carb, protein and fat metabolism. also an anti-inflamatory and immunosuppressant
mineralocortoid- regulate fluid and electrolyte levels
what does the choice of corticosteroid depend on?
depends on indication
e.g. fludorcortisone acetate has a high mineralocorticoid activity while little inflammatory action therefore you wouldn’t use this for a chest infection
what do we refer back to for the dose equivilant of certain steroids?
in the bnf = 5mg of prednisolone
when would you use physiological replacement in deficient states?
addison’s disease- destruction of adrenal cortex
hypopituraism -pituitary tumour- release of ACTH
congenital renal hyperplasia
what does the adrenal cortex normally secrete?
cortisol- glucorticoid activity and weak mineralocortcoid activity
aldosterone- mineralocortcoid
what is the function of cortisol?
primary hormone of importance in acute adrenal crisis
what is used to replace cortisol?
oral hydrocortisone tablets- iv or im in crisis
what does aldosterone do?
acts to promote reabsorption and promote potassium excretion
promotes sodium retention
what does a deficiency in aldosterone cause?
sodium loss, hypotension and volume depletion
what is used to replace aldosterone?
fludrocortisone 50-300 micrograms daily in the morning
what does biochemical monitoring allow for?
detection of minor degrees of under or over replacement
what are the symptoms that people with adrenal insufficiency may experience?
Appetite loss Discolouration of the skin Dehydration Increased thirst and polyuria Salt cravings Olignomemorrhea No energy/ faituge Sore/ weakness in muscle joints
when do you notice people with adrenal insufficency?
they will remain well usually until times of cricis such as adrenal insufficency
what is an adrenal crisis?
it is a medical emergency
the adrenal glands cant cope with the extra corticosteroids needed and life threatening symptoms may develop
acute deteoriation in health status with marked hypotension (systolic <100 or at least 20 cognitive drop)
what are the signs and symptoms of an adrenal crisis?
can appear quick: vomiting and diarrhoea abdominal pain drowsiness/ fatigue diziness confusion limb and back pain
what advice should be given to patients who are on steroid replacement?
- should be regularly reviewed
- this is a life long therapy
- free prescriptions available- have enough
- carry extra medication when travelling
- steoid card/ emergency bracelet
- ensure health professionals are aware
who should steroid cards be given to?
people on long term prendnsolone 5mg or more
what happens if a person with steroid replacment is ill or has undergone strenous exercise?
corticoids are increased due to the risk of adrenal crisis
-may have an individual plan
generally just doubled
what happens if a person with steroid replacement therapy is vomiting?
may use emergency hydrocotisone injection and seek immediate medical attention
what hydrocortisone should be given in an emergency?
hydrocortisone sodium not acetate as it has delayed onset of action
what is the most common treatment for suppression of inflammatory diseases?
oral prednisolone 30mg daily
when do steroids need to be tapered down?
usually if its a long course treatment- more than 3 weeks
is short and long term use of glucocorticoids harmful?
short-not harmful
long term- more harmful
how should patients be advised on how to take steroids?
in the morning after food to avoid GI disturbances and insominia
what mood chages are associated with steroids?
confusion, irritability, sucidial thoughts
usually associated with higher doses- early treatment or when being withdrawn
seek medical advice if any changes occur
what problems may people with long term steroid use have?
susceptibility to infection
suppression of normal adrenal function
who should people with long term steroid use avoid ?
chicken pox or measles
how can adrenal crisis occur?
chronic deficieny conditions
lt steroids\ dose decrease
infection, trauma, surgery
what are the potential side effects of short term steroids?
insomina
mood disturbances
gi disturbances
what are the potential side effects of long term steroids?
same as a short course plus; increased susptibility to infectin osteoporosis adrenal suppression diabtes occular effects skin changes gi bruising hypokalemia skin changes skin bruising
who are the people to be cautious about with steroid use?
children and adoslecents elderly recent cv event peptic ulcer diabtes pregnancyeplipsy renal failure glaucoma
what are te c/i in steroid treatment?
systemic infections
avoid live viruses
how do you minimise the s/e of steorid?
morning dose eaten before hand alt day dosing shortest course of treatment topical application?
how does steroids affect diabetes?
steroids can worsen diabetes
it can worsen blood glucose control
increased monitoring necessary
how does steroids affect surgery?
increased stress- most likely increase dose of steroids or iv steroids if necessary
how does glucocorticoid induced osteporosis occur?
rate of bone density loss is highest at the start of treatment
continued reduction with long term use
need to take into acccount patients fracture risk
if a person is of high fracure risk what therapy should they be put on?
biophosphate +- calcuim / vit d
what is said about the use of steroids in pregnancy and breast feeding
variable ability of corticosteroids to cross placenta
no signifigant evidence that corticosteroids cause congenital abnormalities
increased risk of intra-urine growth restriction with prolonged or repeated admin
adrenal suppression in neonate resolves after birth
what drug interactions would you avoid if possible with corticosteroids?
NSAIDS
enzyme inducers
cholestyramine
when do you have to taper the withdrawl of oral corticosteroids?
when there is a likely degree of adrenal suppression:
>3 weeks any dose
>40mg prednisolone or equivilant for more than 1 week
multiple recent repeated courses
short course within a year of stopping a long course
been given repeated doses in the evening
how do you taper oral steroids?
Indication, duration & intensity of treatment
impact on how and when tapering required
what does slow tapering of oral corticosteroids involve
-decreasing the steroid dosage by the equivilant of 2.5-5mg of prendisone every 3-7 days until the physiological dosage is reached
then a more gradual reduction of prednisolone 0.5-1mg every 2-4 weeks should be considered
what are the symptoms of adrenal insufficiency?
Fatigue • Weight loss • Abdominal pain • Nausea • Vomiting • Headaches • Joint pains • Dizziness • Fever • Hypotension • Confusion • Loss of consciousness
how does an intra-articular steroid injection work?
Insoluble/long-acting steroid remains in the joint, contact with inflamed synovial surface, taken up by synovial cells and absorbed
into blood stream
-side effecrs less
when should topical corticosteroids be given?
inflammatory condition of the skin other than infection.
• E.g. eczema, contact dermatitis, insect sting, eczema of scabies
when should topical corticosteroids not be given?
infection (bacteria/viral/fungal) unless
concomitant treatment e.g. antibiotic/antifungal, rosacea
when and where should potent topical steroids be avoided?
Potent topical steroid should generally be avoided on the face and skin flexures except under special circumstances by specialist supervision
how would you council someone on the ammount of cream to apply?
• Finger tip application
– Enough for twice size of adult palm+fingers
what other counselling points would you give to someone with a topical steroid?
• No more frequently than twice daily (once daily normally sufficient) apply
thinly to the affected area only
• Use the least potent formulation which is fully effective
• Avoid prolonged use on the face and keep away from eyes
• Caution in children and during pregnancy
what are the side effects of topical steroids?
• Spread/worsening of untreated infection (do not use on infected skin unless specific treatment for infection given alongside) • Thinning of skin with long-term use • Contact dermatitis • Perioral dermatitis • Acne, worsening of acne rosacea • Depigmentation • Hypertrichosi
what are the risk of systemic side effects of ICS at high doses?
• Spread/worsening of untreated infection (do not use on infected skin unless specific treatment for infection given alongside) • Thinning of skin with long-term use • Contact dermatitis • Perioral dermatitis • Acne, worsening of acne rosacea • Depigmentation • Hypertrichosi
before increasing the dose of inhaled steroids what should you check?
• Patient adherence
• Inhaler technique
?consider spacer
• Encourage smoking cessation
when would rectal steroids be used?
Enemas or suppositories e.g. prednisolone in
inflammatory bowel disease (IBD) affecting
lower parts of the colon and rectum
– Local action
