Wooten - Steroids Flashcards
Chronic use of glucocorticoids will have what effect on the HPA axis?
Increased levels of glucocorticoids in the system will provide negative feedback to the pituitary and hypothalamus, resulting in decreased ACTH release and eventual atrophy of the adrenal cortex
What happens to leukocyte counts in a patient on glucocorticoids?
Lymphocyte, monocyte, eosinophil, and basophil levels will decrease, but neutrophil levels will INCREASE (these neutrophils cannot enter tissues though).
This elevated WBC does NOT indicate infection, and patient has increased susceptibility to infection in this state.
What are some (8) metabolic effects of glucocorticoid treatment?
- Increased insulin resistance and hyperglycemia
- Increased hepatic gluconeogenesis (exacerbating hyperglycemia)
- Proteolysis in skeletal muscle
- Lipolysis in adipose tissue (increased FA and cholesterol levels)
- Decreased Ca++ absorption
- Increased Ca++ wasting
- Increased K+
- Increased Na+/fluid retention
What are some (9) possible disease states that can be caused by steroid treatment?
Osteoporosis Hypercholesterolemia Hyperkalemia Hypocalcemia Hypernatremia Insulin resistance/iatrogenic diabetes Hyperglycemia Hypertension Reactivation of latent infections
What are some CNS AEs that can occur with steroid administration?
Hypomania Insomnia Mood disorders Depression Hallucinations Psychosis
What are some dermatologic AEs that can occur with steroid administration?
- Occur due to decreased fibroblast activity/collagen deposition
- Purple striae
- Easy bruising
- Thin skin
What supplementation should be considered in a patient on chronic glucocorticoids?
Ca++ and vitamin D
What is the name for primary adrenal insufficiency?
Addison’s disease
What hormones are affected in Addision’s disease?
All adrenal hormones: cortisol, aldosterone, DHEA
What are some characteristic findings in Cushing’s syndrome, and what is the cause?
Too much cortisol in the body causes Cushing’s syndrome (Cushing’s disease, specifically, is caused by a problem in the pituitary gland)
- Moon facies
- Purple striae
- Thin skin/easy bruising
- Proximal weakness/wasting of extremities
- Central adiposity
- Buffalo hump
- Osteoporosis/osteopenia
- Immunosuppression
- Insulin resistance/hyperglycemia
What are some things that can occur with sudden withdrawal from chronic glucocorticoid treatment?
Hyperkalemia
Hyponatremia –> hypotension
Hypoglycemia
Condition being treated by steroids may flare back up
Chronic glucocorticoid use for longer than _____ requires a taper before discontinuing use.
2 weeks
What are the short-acting glucocorticoid drugs?
Hydrocortisone, cortisone
What are the intermediate-acting glucocorticoid drugs?
Prednisone
Prednisolone
Methylprednisolone
What are the long-acting glucocorticoid drugs?
Dexamethasone
What are the mineralcorticoid drugs?
Fludrocortisone
Desocycorticosterone
Your patient has Addison’s disease and i receiving predisone. However, they are still hypotensive. What drug might be added to increase BP?
Fludrocortisone or desoxycorticosterone: these are both potent Na+ retaining mineralcorticoids.
Compare the relative anti-inflammatory, dosing, and Na+ potency between the short-acting glucocorticoid drugs and cortisol.
Cortisol:
Anti-inflammatory potency = 1
Dose = (na)
Na+ retaining potency = 1
Hydrocortisone:
Anti-inflammatory potency = 1
Dose = 20
Na+ retaining potency = 1
Cortisone:
Anti-inflammatory potency = 0.8
Dose = 25
Na+ retaining potency = 0.8
Compare the relative anti-inflammatory, dosing, and Na+ potency between the intermediate-acting glucocorticoid drugs and cortisol.
Cortisol:
Anti-inflammatory potency = 1
Dose = (na)
Na+ retaining potency = 1
Prednisone:
Anti-inflammatory potency = 4
Dose = 4
Na+ retaining potency = 0.8
Prednisolone: (same as above)
Anti-inflammatory potency = 4
Dose = 4
Na+ retaining potency = 0.8
Methylprednisolone:
Anti-inflammatory potency = 5
Dose = 4
Na+ retaining potency = 0.5
Compare the relative anti-inflammatory, dosing, and Na+ potency between the long-acting glucocorticoid drug and cortisol.
Cortisol:
Anti-inflammatory potency = 1
Dose = (na)
Na+ retaining potency = 1
Dexamethasone:
Anti-inflammatory potency = 25
Dose = 0.75
Na+ retaining potency = 0
How strong an effect does dexamethasone have on Na+ retention?
None
How strong an effect does methylprednisolone have on Na+ retention?
Half that of cortisol
How strong an effect does flurdocortisone have on Na+ retention?
125 times that of cortisol
How strong an effect does desocycorticosterone have on Na+ retention?
100 times that of cortisol
Compare the relative anti-inflammatory, dosing, and Na+ potency between the mineralcorticoid drugs and cortisol.
Cortisol:
Anti-inflammatory potency = 1
Dose = (na)
Na+ retaining potency = 1
Fludrocortisone:
Anti-inflammatory potency = 10
Dose = (na)
Na+ retaining potency = 125
Desoxycorticosterone:
Anti-inflammatory potency = 0
Dose = (na)
Na+ retaining potency = 100
In a patient who has adequate anti-inflammatory response to their current steroid treatment but still experiencing hypotension, which steroid drug should be added?
Desoxycorticosterone: 100x cortisol’s Na+ retaining potency and 0 anti-inflammatory potency
What is the glucocorticoid of choice in pediatric patients?
Prednisolone. It is available in a liquid form.
A patient was started on steroid therapy yesterday and labs are drawn today. What are two important changes to be expected?
Increased BSG Increased WBC (NOT a sign of infection)
Which glucocorticoid drug crosses the BBB?
Dexamethasone
What are three glucocorticoids that would be inappropriate in the treatment of Addison’s disease?
Methylprednisolone (low Na+ retention)
Dexamethasone (No Na+ retention)
Desoxycortisone (No anti-inflammatory potency)
Your patient on chronic glucocorticoids is scheduled for an appendectomy tomorrow. What must be done prior to surgery?
Stress dose of steroids before (and after) surgery to compensate for non-responsiveness of adrenal cortex to stress
What is the MOA of mifepristone?
Antagonizes steroid receptors
What is the MOA of cabergoline?
Dopamine agonist
What is the MOA of mitotaine?
Decreases steroid synthesis and has cytotoxic effects
What are three drugs used in the treatment of Cushing’s disease?
Mifepristone, cabergoline, and mitotane
Which drug, used in the treatment of Cushing’s disease, works in the pituitary gland?
Cabergoline
Which drug, used in the treatment of Cushing’s disease, works at the glucocorticoid receptors?
Mifepristone
Most drugs used in the treatment of Cushing’s disease (other than cabergoline and mifepristone) work where?
The adrenal gland
Ex: Ketoconazole Mitotane Metyrapone Etomidate
