Therapeutics of Corticosteroids

Question 1

The two main effects of corticosteroids are?

Answer 1

immunosuppression and anti-inflammation

Question 2

The incidence of side effects with long-term glucocorticoid therapy is ____ and ____ related.

Answer 2

time, dose

Question 3

What is the primary concern with abrupt cessation of long-term glucocorticoid therapy?

Answer 3

adrenal insufficiency - an Addisonian crisis

Question 4

What is the general practice guideline for corticosteroid use?

Answer 4

prescribe the lowest amount possible for the shortest amount of time

Question 5

How does GC use for pain/distressing symptoms differ from their use in life-threatening conditions, like an organ transplant?

Answer 5

for pain, start with a low dose and titrate to the lowest therapeutic dose. For life-threatening conditions, start with a high dose (pred 1-3 mg/kg) and double or triple if effect not seen.

Question 6

State the replacement doses of hydrocortisone, prednisone, methylprednisolone, and dexamethasone for PO treatment.

Answer 6

hydro = 20 mg QD
pred = 5-7.5 mg QD
methylpred = 4 mg QD
dexa = 0.75 mg QD

Question 7

Give the general pharmaceutical doses in terms of prednisone (maintenance, moderate, high, massive).

Answer 7

maintenance: 5-15 mg QD
moderate: 0.5 mg/kg/day
high: 1-3 mg/kg/day
massive: 15-30 mg/kg/day

Question 8

What time of day should you tell patients to take their first dose of corticosteroid, and why?

Answer 8

In general, before 9 AM and with food to avoid an upset stomach. This timing more naturally mimics they body’s circadian rhythm in regards to cortisol production. Also, the pituitary is less sensitive to steroid at this time of day.

Question 9

What is an advantage of intra-articular administration of CS?

Answer 9

slows absorption and prolongs action, sometimes up to months

Question 10

What factors should be considered in selection of a CS for treating an inflammatory condition?

Answer 10

Select one with minimal MC activity. Should be intermediate acting to improve adherence, but not long acting because their half-lives are too long.

Question 11

What things, other than dose conversion, must be considered when switching between different CSs?

Answer 11

duration of HPA axis suppression, MC activity

Question 12

What long-term complications should be monitored for in GC use?

Answer 12

(1) bone loss (DEXA scan)
(2) cataracts or glaucoma
(3) GI ulcers
(4) BP/fluid retention
(5) myopathy
(6) Cushing’s sx
(7) psychiatric events
(8) infections

Question 13

What are some potential culprits of drug-induced hypercortisolism?

Answer 13

(1) excess CS
(2) herbal products containing steroids
(3) megestrol acetate, medroxyprogesterone

Question 14

Name some clinical presentation of Cushing’s Syndrome.

Answer 14

(1) truncal obesity with thinner extremities
(2) abdominal striae from tissue destruction
(3) DM
(4) psychiatric events
(5) fat redistribution
(6) steroid myopathy
(7) delayed wound healing
(8) menstrual irregularity, infertility
(9) recurrent and atypical infections from immunosuppression

Question 15

What are some indications for GC withdrawal/cessation?

Answer 15

(1) therapeutic effect has been achieved
(2) not benefit observed
(3) incidence of side effects to high/severe

Question 16

What kinds of patients require tapering off of GC therapy?

Answer 16

(1) those who have been on prednisone 7.5 mg (equivalent) for longer than 3 weeks
(2) those with Cushing’s symptoms
(3) those who have been on evening doses at or greater than 5 mg prednisone or equivalent

Question 17

How should steroid doses be tapered?

Answer 17

There are several different ways, but a good general goal is about a 10% reduction in dose every 1-4 weeks. Consider convenience, available dose formulations, and the individual patient response.

Question 18

What are some counseling points for patients on long-term corticosteroids?

Answer 18

(1) take with food to prevent an upset stomach
(2) never stop taking or change the way you take them without medical advice
(3) wear identification so that providers know you are on corticosteroids
(4) be aware of side effects of visual disturbances, bruising, delayed wound healing

Question 19

What should a patient do if they miss a dose of corticosteroid (a) if they are taking every other day (b) if they are taking every day?

Answer 19

(a) take the dose as soon as they remember. If it is later in the day, wait until the next morning, then take a dose and resume EOD dosing.
(b) take the dose as soon as they remember. If it is later in the day, wait until the morning and resume daily dosing.

Question 20

What are the symptoms of chronic adrenal insufficiency?

Answer 20

(1) fatigue
(2) anorexia/weight loss
(3) amenorrhea
(4) hypoglycemia
(5) salt craving

Question 21

What are the symptoms of acute adrenal insufficiency?

Answer 21

(1) fatigue

(2) abd px

Question 22

The two traditional replacement strategies for adults with adrenal insufficiency are?

Answer 22

15-25 mg hydrocortison/day

3-5 mg prednisone QD or BID

Question 23

If dosing BID, how should the doses be divided throughout the day?

Answer 23

2/3 of daily dose in morning, remaining 1/3 in early afternoon (~2 hrs after lunch)

Question 24

Which form of adrenal insufficiency necessitates mineralocorticoid replacement as a part of therapy?

Answer 24

primary (in other forms adrenal gland is not damaged, so aldosterone levels are unaffected)

Question 25

When treating a patient with primary adrenal insufficiency, what should be done to their corticosteroid dose during times of high stress (surgery, mild/severe illness)?

Answer 25

increase the dose, sometimes doubling or tripling

Question 26

Describe the general course of treatment of an acute adrenal crisis.

Answer 26

IV hydrocortisone bolus and drip that is gradually tapered down as patient stabilizes, using MC therapy as required. Increase dose if complications occur. Supportive measures include fluid replacement and electrolyte balancing, sugar replacement. Find the underlying cause and treat it as well (infection?).

Question 27

Medication that strongly inhibit or induce CYP___ require monitoring and adjustment of corticosteroid therapy.

Answer 27

3A4

Question 28

signs of over-replacement with glucocorticoids

Answer 28

weight gain, truncal obesity, stretch marks, high BG, osteoporosis, impaired glucose tolerance, high BP

Question 29

signs of under-replacement with glucocorticoids

Answer 29

myalgia, fatigue, nausea, weight loss, lack of energy