Steroids In Practice (Louise) Flashcards
2 ways steroids are used
- To suppress inflammatory process
2. Steroid replacement when the body doesn’t make enough
What do glucocorticoid steroids do?
Regulate carbohydrate, protein and fat metabolism
Anti-inflammatory and immunosuppressant properties
What do mineralocorticoid steroids do?
Regulate fluid and electrolyte levels
When is steroid replacement used?
Addison’s disease
Hypopituitarism
Congenital adrenal hyperplasia
What does the adrenal cortex secrete?
Cortisol
Aldosterone
Do cortisol/aldosterone have mineralocorticoid/glucocorticoid activity?
Cortisol - glucocorticoid and weak mineralocorticoid
Aldosterone - mineralocorticoid
What is cortisol responsible for?
Primary hormone in acute adrenal crisis
What does aldosterone do?
Promotes reabsorption of Na
Increases K excretion
What does a deficiency in aldosterone lead to?
Na loss
Volume depletion
Hypotension
What is given to replace cortisol?
Hydrocortisone
What is given to replace aldosterone?
Fludrocortisone
What should prescribing mimic for hydrocortisone?
Natural cycle of cortisol release
Dose of hydrocortisone
15 - 40mg daily in divided doses (2-3 doses)
Larger dose taken in the morning
How is hydrocortisone given in suspected adrenal crisis?
Given IM or IV
What is given to treat hypopituitarism and why?
Just hydrocortisone (No mc because aldosterone also regulated by renin angiotensin system)
What is given to treat Addison’s disease?
Hydrocortisone and fludrocortisone
What effect does fludrocortisone have?
Potent mineralocorticoid effect
When is fludrocortisone used?
When adrenal cortex is destroyed
eg. Addison’s
Dose of fludrocortisone
50 - 300mg daily in the morning
Unlicensed use for fludrocortisone
Hypotension (because of its fluid retaining properties)
Symptoms of adrenal insufficiency
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
What to do when adrenal insufficiency is suspected?
further investigations eg. ACTH stimulation test
Definition of adrenal crisis
Acute deterioration in health status with hypotension with marked improvement within 1-2 hrs of parenteral glucocorticoids
systolic BP for adrenal crisis
< 100 mmHg
Or at least 20 mmHg drop
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
What can adrenal crisis lead to?
Hypovolaemic shock
Altered consciousness
Biochemical abnormalities
seizures
Stroke/cardiac arrest
What is adrenal crisis treated with?
IV fluids
IV steroids
What treatment is given for an emergency adrenal crisis IM?
Hydrocortisone sodium phosphate 100mg
Or
Hydrocortisone sodium succinate 100mg
When is steroid dose increased and why?
If patient is ill/injured, doing strenuous exercise or surgery
To reduce the risk of adrenal crisis
Why can’t you abruptly stop a glucocorticoid > 3 weeks?
Can precipitate adrenal insufficiency
Infection susceptibility and long term courses of glucocorticoids
Avoid contact with people with chickenpox/measles unless immune
Serious infections can go unrecognised
What happens when taking cholestyramine with steroids?
Cholestyramine inhibits GI absorption of oral steroid
Doses should be separated
When can you not abruptly withdraw a glucocorticoid steroid?
If give for > 3 weeks
What steroid is most commonly given for inflammatory disease and it’s dose?
Prednisolone 30mg daily in the morning
6 x 5mg tabs
What is not given for an adrenal crisis and why?
NOT hydrocortisone acetate
It has a delayed onset
Why are glucocorticoids taken in the morning and after breakfast?
Reduced the risk of insomnia and GI adverse effects
When does adrenal crisis occur?
When there’s not enough steroid in the body
When can adrenal crisis occur?
Chronic deficiency conditions
Stopping LT steroids or rapid dose decrease
Infection, trauma, surgery
ST side effects
Insomnia
Mood disturbances
GI disturbances
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
New risk of what rare disorder when taking steroids?
Retinal disorder - chorioretinopathy
Rare
Local to systemic steroids
Report blurred vision or visual disturbances
Contraindications for steroids
Systemic infection (give with antibiotic)
Avoid live virus vaccines
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)
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
What can happen if taking steroids with diabetes?
Steroids can worsen glucose control
- steroid induced hyperglycaemia
- steroid induced diabetes
Risk factors for hyperglycaemia with steroids
- existing diabetes
- risk factors for diabetes (family Hx, obesity, pre diabetes)
- previous hyperglycaemia with steroids
When do glucose levels rise when taking steroids with diabetes?
After 4-8 hrs
When do glucose levels improve after taking steroid with diabetes?
24 hrs after discontinuing them
What does surgery do to steroid requirement?
Increased steroid requirement (physiological stress)
When is bone density the highest when taking gc?
At the start of treatment
What bone protection is given for risk of osteoporosis when taking gc?
Bisphosphonate
with/withoug Ca and Vit D
What steroids cross the placenta?
Betamethasone and dexamethasoe
How much prednisolone is inactivated across the placenta?
88%
What can happen with long term use of steroids in pregnancy?
Risk of intra-uterine growth restriction
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
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
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
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)
Local side effects of intra articular steroid injection
Post injection flare of pain
Skin depigmentation
Bleeding
Infection
What is prolonged steroid injection associated with?
Osteonecrosis
advice about increased susceptibility to infection
avoid contact with people with chickenpox/mealels unless already immune
What drugs should be avoided with steroids?
NSAIDs (ulcerogenic agents)
steroids and cholestyramine
inhibits GI absorption of steroid
doses should be separated
What enzyme inducers reduce serum concentrations of oral corticosteroids?
babrbiturates
phenytoin
carbamazepine
rifampicin
What are topical corticosteroids used for?
inflammatory conditions of the skin
eczema, contact dermatitis, insect sting, eczema of scabies
most potent steroid
clobetasol
mild steroid
hydrocortisone 1% and 2.5% all formulations
Where should potent steroids not be used?
on the face and skin flexures
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
How often should topical steroids be applied?
not more than twice a day
normally once
What can happen with prolonged use of topical steroid in a large area?
suppression of pituitary adrenal axis
Cushing’s syndrome
Do oral or topical steroids have more side effects?
oral
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
systemic side effects of ICS at high doses
adrenal suppression
reduced bone mineral density
growth retardation
lower respiratory tract infections
What are rectal steroids used for and their formulation?
enemas or suppositories
IBD affecting lower colon and rectum
steorids used in rectal application
prednisolone
budesonide
