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Steroids In Practice (Louise) Flashcards

1
Q

2 ways steroids are used

A
  1. To suppress inflammatory process

2. Steroid replacement when the body doesn’t make enough

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2
Q

What do glucocorticoid steroids do?

A

Regulate carbohydrate, protein and fat metabolism

Anti-inflammatory and immunosuppressant properties

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3
Q

What do mineralocorticoid steroids do?

A

Regulate fluid and electrolyte levels

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4
Q

When is steroid replacement used?

A

Addison’s disease
Hypopituitarism
Congenital adrenal hyperplasia

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5
Q

What does the adrenal cortex secrete?

A

Cortisol

Aldosterone

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6
Q

Do cortisol/aldosterone have mineralocorticoid/glucocorticoid activity?

A

Cortisol - glucocorticoid and weak mineralocorticoid

Aldosterone - mineralocorticoid

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7
Q

What is cortisol responsible for?

A

Primary hormone in acute adrenal crisis

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8
Q

What does aldosterone do?

A

Promotes reabsorption of Na

Increases K excretion

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9
Q

What does a deficiency in aldosterone lead to?

A

Na loss

Volume depletion

Hypotension

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10
Q

What is given to replace cortisol?

A

Hydrocortisone

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11
Q

What is given to replace aldosterone?

A

Fludrocortisone

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12
Q

What should prescribing mimic for hydrocortisone?

A

Natural cycle of cortisol release

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13
Q

Dose of hydrocortisone

A

15 - 40mg daily in divided doses (2-3 doses)

Larger dose taken in the morning

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14
Q

How is hydrocortisone given in suspected adrenal crisis?

A

Given IM or IV

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15
Q

What is given to treat hypopituitarism and why?

A 
Just hydrocortisone
(No mc because aldosterone also regulated by renin angiotensin system)
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16
Q

What is given to treat Addison’s disease?

A

Hydrocortisone and fludrocortisone

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17
Q

What effect does fludrocortisone have?

A

Potent mineralocorticoid effect

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18
Q

When is fludrocortisone used?

A

When adrenal cortex is destroyed

eg. Addison’s

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19
Q

Dose of fludrocortisone

A

50 - 300mg daily in the morning

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20
Q

Unlicensed use for fludrocortisone

A

Hypotension (because of its fluid retaining properties)

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21
Q

Symptoms of adrenal insufficiency

A 
ADDISONS
Appetite loss, weight loss, abdominal pain
Discolouration of skin
Dehydration
Increased thirst, polyuria
Salt cravings
Oligomenorrhoea
No energy/fatigue/low mood
Sore/weakness in muscles/joints
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22
Q

What to do when adrenal insufficiency is suspected?

A

further investigations eg. ACTH stimulation test

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23
Q

Definition of adrenal crisis

A

Acute deterioration in health status with hypotension with marked improvement within 1-2 hrs of parenteral glucocorticoids

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24
Q

systolic BP for adrenal crisis

A

< 100 mmHg

Or at least 20 mmHg drop

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25
Symptoms of adrenal crisis
GI - severe vomiting/diarrhoea/dehydration Abdominal pain Severe muscle weakness/cramps Drowsiness/fatigue Pyrexia Dizziness/low BP confusion Limb and back pain Delirium/loss of consciousness
26
What can adrenal crisis lead to?
Hypovolaemic shock Altered consciousness Biochemical abnormalities seizures Stroke/cardiac arrest
27
What is adrenal crisis treated with?
IV fluids | IV steroids
28
What treatment is given for an emergency adrenal crisis IM?
Hydrocortisone sodium phosphate 100mg Or Hydrocortisone sodium succinate 100mg
29
When is steroid dose increased and why?
If patient is ill/injured, doing strenuous exercise or surgery To reduce the risk of adrenal crisis
30
Why can’t you abruptly stop a glucocorticoid > 3 weeks?
Can precipitate adrenal insufficiency
31
Infection susceptibility and long term courses of glucocorticoids
Avoid contact with people with chickenpox/measles unless immune Serious infections can go unrecognised
32
What happens when taking cholestyramine with steroids?
Cholestyramine inhibits GI absorption of oral steroid Doses should be separated
33
When can you not abruptly withdraw a glucocorticoid steroid?
If give for > 3 weeks
34
What steroid is most commonly given for inflammatory disease and it’s dose?
Prednisolone 30mg daily in the morning | 6 x 5mg tabs
35
What is not given for an adrenal crisis and why?
NOT hydrocortisone acetate It has a delayed onset
36
Why are glucocorticoids taken in the morning and after breakfast?
Reduced the risk of insomnia and GI adverse effects
37
When does adrenal crisis occur?
When there’s not enough steroid in the body
38
When can adrenal crisis occur?
Chronic deficiency conditions Stopping LT steroids or rapid dose decrease Infection, trauma, surgery
39
ST side effects
Insomnia Mood disturbances GI disturbances
40
LT side effects
Same as ST & Increased susceptibility to infection Osteoporosis Adrenal suppression Cushingoid state Diabetes Ocular effects (cataracts, glaucoma) Skin changes (thinning, easy bruising) GI ulceration Growth retardation Hypokalaemia Fluid retention
41
New risk of what rare disorder when taking steroids?
Retinal disorder - chorioretinopathy Rare Local to systemic steroids Report blurred vision or visual disturbances
42
Contraindications for steroids
Systemic infection (give with antibiotic) Avoid live virus vaccines
43
How to mimimize side effects of steroids?
Morning dose Minimum duration of course Local application where possible Alternate day dosing Supportive therapies - PPI (GI irritiation) bisphosphonates (osteoporosis prevention)
44
Monitoring for side effects on LT steroids
Body weight Growth charts BP Signs of oedema Lipid levels Glucose levels Ocular pressure Cardiac insufficiency Bone mineral density
45
What can happen if taking steroids with diabetes?
Steroids can worsen glucose control - steroid induced hyperglycaemia - steroid induced diabetes
46
Risk factors for hyperglycaemia with steroids
- existing diabetes - risk factors for diabetes (family Hx, obesity, pre diabetes) - previous hyperglycaemia with steroids
47
When do glucose levels rise when taking steroids with diabetes?
After 4-8 hrs
48
When do glucose levels improve after taking steroid with diabetes?
24 hrs after discontinuing them
49
What does surgery do to steroid requirement?
Increased steroid requirement (physiological stress)
50
When is bone density the highest when taking gc?
At the start of treatment
51
What bone protection is given for risk of osteoporosis when taking gc?
Bisphosphonate | with/withoug Ca and Vit D
52
What steroids cross the placenta?
Betamethasone and dexamethasoe
53
How much prednisolone is inactivated across the placenta?
88%
54
What can happen with long term use of steroids in pregnancy?
Risk of intra-uterine growth restriction
55
When should steroids be tapered down?
- > 3 weeks on any dose - > 40mg prednisolone for > 1 week - multiple recent repeated courses - short course within a year of stopping a long course - been given repeated doses in the evening
56
How to taper steroid slowly?
Decrease steroid dose to equivalent of 2.5 - 5mg prednisolone every 3 - 7 days until physiologic dosage (7.5mg) reached Then gradual reduction of 0.5 - 1mg every 2 - 4 weeks considered
57
How does intra articular steroid injection work?
Insoluble/long acting steroid remains in the joint It’s in contact with the inflamed synovial surface Taken up by synovial cells and absorbed into bloodstream
58
patient advice for steroid replacement
education about regular reviews renew perscriptions on time carry extra meds when travelling steroid card/bracelet carried/worn ensure hc professionals are aware (surgery, dentist)
59
Local side effects of intra articular steroid injection
Post injection flare of pain Skin depigmentation Bleeding Infection
60
What is prolonged steroid injection associated with?
Osteonecrosis
61
advice about increased susceptibility to infection
avoid contact with people with chickenpox/mealels unless already immune
62
What drugs should be avoided with steroids?
NSAIDs (ulcerogenic agents)
63
steroids and cholestyramine
inhibits GI absorption of steroid | doses should be separated
64
What enzyme inducers reduce serum concentrations of oral corticosteroids?
babrbiturates phenytoin carbamazepine rifampicin
65
What are topical corticosteroids used for?
inflammatory conditions of the skin | eczema, contact dermatitis, insect sting, eczema of scabies
66
most potent steroid
clobetasol
67
mild steroid
hydrocortisone 1% and 2.5% all formulations
68
Where should potent steroids not be used?
on the face and skin flexures
69
How much topical stroid should be used and how much does that cover?
finger tip application | enough for twice the size of an adult palm and fingers
70
How often should topical steroids be applied?
not more than twice a day | normally once
71
What can happen with prolonged use of topical steroid in a large area?
suppression of pituitary adrenal axis | Cushing's syndrome
72
Do oral or topical steroids have more side effects?
oral
73
side effects with topical steroids
``` spread/worsening of untreated infection (don't use without antibiotics) thinning of skin (LT) contact dermatitis perioral dermatitis acne, worsening of acne rosacea depigmentation hypertrichosis ```
74
systemic side effects of ICS at high doses
adrenal suppression reduced bone mineral density growth retardation lower respiratory tract infections
75
What are rectal steroids used for and their formulation?
enemas or suppositories | IBD affecting lower colon and rectum
76
steorids used in rectal application
prednisolone | budesonide

PHA223 (43 decks)

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