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PHA223 > Steroids In Practice (Louise) > Flashcards

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
Q

Symptoms of adrenal crisis

A

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

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26
Q

What can adrenal crisis lead to?

A

Hypovolaemic shock

Altered consciousness

Biochemical abnormalities

seizures

Stroke/cardiac arrest

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27
Q

What is adrenal crisis treated with?

A

IV fluids

IV steroids

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28
Q

What treatment is given for an emergency adrenal crisis IM?

A

Hydrocortisone sodium phosphate 100mg

Or

Hydrocortisone sodium succinate 100mg

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29
Q

When is steroid dose increased and why?

A

If patient is ill/injured, doing strenuous exercise or surgery

To reduce the risk of adrenal crisis

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30
Q

Why can’t you abruptly stop a glucocorticoid > 3 weeks?

A

Can precipitate adrenal insufficiency

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31
Q

Infection susceptibility and long term courses of glucocorticoids

A

Avoid contact with people with chickenpox/measles unless immune

Serious infections can go unrecognised

32
Q

What happens when taking cholestyramine with steroids?

A

Cholestyramine inhibits GI absorption of oral steroid

Doses should be separated

33
Q

When can you not abruptly withdraw a glucocorticoid steroid?

A

If give for > 3 weeks

34
Q

What steroid is most commonly given for inflammatory disease and it’s dose?

A

Prednisolone 30mg daily in the morning

6 x 5mg tabs

35
Q

What is not given for an adrenal crisis and why?

A

NOT hydrocortisone acetate

It has a delayed onset

36
Q

Why are glucocorticoids taken in the morning and after breakfast?

A

Reduced the risk of insomnia and GI adverse effects

37
Q

When does adrenal crisis occur?

A

When there’s not enough steroid in the body

38
Q

When can adrenal crisis occur?

A

Chronic deficiency conditions

Stopping LT steroids or rapid dose decrease

Infection, trauma, surgery

39
Q

ST side effects

A

Insomnia

Mood disturbances

GI disturbances

40
Q

LT side effects

A

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
Q

New risk of what rare disorder when taking steroids?

A

Retinal disorder - chorioretinopathy

Rare

Local to systemic steroids

Report blurred vision or visual disturbances

42
Q

Contraindications for steroids

A

Systemic infection (give with antibiotic)

Avoid live virus vaccines

43
Q

How to mimimize side effects of steroids?

A

Morning dose

Minimum duration of course

Local application where possible

Alternate day dosing

Supportive therapies - PPI (GI irritiation) bisphosphonates (osteoporosis prevention)

44
Q

Monitoring for side effects on LT steroids

A

Body weight

Growth charts

BP

Signs of oedema

Lipid levels

Glucose levels

Ocular pressure

Cardiac insufficiency

Bone mineral density

45
Q

What can happen if taking steroids with diabetes?

A

Steroids can worsen glucose control

  • steroid induced hyperglycaemia
  • steroid induced diabetes
46
Q

Risk factors for hyperglycaemia with steroids

A
  • existing diabetes
  • risk factors for diabetes (family Hx, obesity, pre diabetes)
  • previous hyperglycaemia with steroids
47
Q

When do glucose levels rise when taking steroids with diabetes?

A

After 4-8 hrs

48
Q

When do glucose levels improve after taking steroid with diabetes?

A

24 hrs after discontinuing them

49
Q

What does surgery do to steroid requirement?

A

Increased steroid requirement (physiological stress)

50
Q

When is bone density the highest when taking gc?

A

At the start of treatment

51
Q

What bone protection is given for risk of osteoporosis when taking gc?

A

Bisphosphonate

with/withoug Ca and Vit D

52
Q

What steroids cross the placenta?

A

Betamethasone and dexamethasoe

53
Q

How much prednisolone is inactivated across the placenta?

A

88%

54
Q

What can happen with long term use of steroids in pregnancy?

A

Risk of intra-uterine growth restriction

55
Q

When should steroids be tapered down?

A
  • > 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
Q

How to taper steroid slowly?

A

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
Q

How does intra articular steroid injection work?

A

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
Q

patient advice for steroid replacement

A

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
Q

Local side effects of intra articular steroid injection

A

Post injection flare of pain
Skin depigmentation
Bleeding
Infection

60
Q

What is prolonged steroid injection associated with?

A

Osteonecrosis

61
Q

advice about increased susceptibility to infection

A

avoid contact with people with chickenpox/mealels unless already immune

62
Q

What drugs should be avoided with steroids?

A

NSAIDs (ulcerogenic agents)

63
Q

steroids and cholestyramine

A

inhibits GI absorption of steroid

doses should be separated

64
Q

What enzyme inducers reduce serum concentrations of oral corticosteroids?

A

babrbiturates
phenytoin
carbamazepine
rifampicin

65
Q

What are topical corticosteroids used for?

A

inflammatory conditions of the skin

eczema, contact dermatitis, insect sting, eczema of scabies

66
Q

most potent steroid

A

clobetasol

67
Q

mild steroid

A

hydrocortisone 1% and 2.5% all formulations

68
Q

Where should potent steroids not be used?

A

on the face and skin flexures

69
Q

How much topical stroid should be used and how much does that cover?

A

finger tip application

enough for twice the size of an adult palm and fingers

70
Q

How often should topical steroids be applied?

A

not more than twice a day

normally once

71
Q

What can happen with prolonged use of topical steroid in a large area?

A

suppression of pituitary adrenal axis

Cushing’s syndrome

72
Q

Do oral or topical steroids have more side effects?

A

oral

73
Q

side effects with topical steroids

A 
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
Q

systemic side effects of ICS at high doses

A

adrenal suppression
reduced bone mineral density
growth retardation
lower respiratory tract infections

75
Q

What are rectal steroids used for and their formulation?

A

enemas or suppositories

IBD affecting lower colon and rectum

76
Q

steorids used in rectal application

A

prednisolone

budesonide

PHA223 (43 decks)

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