Chapter 184 - Glucocorticoids Flashcards
1
Q
Complications are increased with (4)
A
- Fluorinated compounds
- Higher doses
- Longer duration of therapy
- More frequent administration
2
Q
Essential component of therapy
A
Careful monitoring of systemic and cutaneous side effects
3
Q
Major naturally occurring glucocorticoid
A
Hydrocortisone / cortisol
4
Q
Daily cortisol production is ___ with a diurnal peak around ___ with plasma half life of ____
A
5-7 mg/m2
8am
90minutes
5
Q
Glucocorticoids suppress monocyte and lymphocyte function (Th1 and Th2) more than polymorphonuclear lymphocyte function.
True or False
A
True, hence granulomatous diseases such as Tb are prone to exacerbation and relapse
6
Q
B lymphocytes and plasma cells are not resistant to suppressive effects of glucocorticoids.
True or False
A
False, relatively resistant
7
Q
The use of glucocorticoids is controversial in the treatment of: (4)
A
EN
LP
CTCL
DLE
8
Q
Most common indications of systemic steroids: (9)
A
Serious blistering diseases CT diseases Vasculitis Neutrophilic dermatoses Sarcoidosis Type I reactive leprosy Hemangioma of infancy Panniculitis Urticaria/Angioedema
9
Q
For IL admin in conditions like keloids and aa, the ff drugs are used
A
Triamcinolone acetate (Aristospan) + Triamcinolone acetonide (Kenalog)
10
Q
It is best to limit monthly dose of triamcinolone acetonide (Kenalog) to ___ to ensure that HPA axis will not be suppressed
A
20 mg
11
Q
Disadvantages of IM admin: (2)
A
Erratic absorption
Lack of daily control of dose
12
Q
ADE of IM inj: (2)
A
Lipoatrophy
Sterile abscesses
13
Q
Short acting have more side effects than long-acting formulations
True or False
A
False
14
Q
IM administration produce lasting effects up to ___
A
3 weeks
15
Q
IV glucocorticoids are used in 2 situations:
A
- Acutely ill/undergoing surgery
2. Resistant PG, pemphigus, BP, severe SLE or DM
16
Q
____ is used for its high potency and low sodium retaining activity
A
Methylprednisolone 500mg-1g OD
17
Q
Serious side effects associated with IV administration (4)
A
Anaphylaxis
Seizures
Arrythmias
Sudden death
18
Q
Most commonly prescribed oral glucocorticoid
A
Prednisone
19
Q
For intermediate acting glucocorticoids, the ff have zero mineralocorticoid activity
A
Triamcinolone
Methylprednisolone
20
Q
For long acting glucocorticoids, the ff have zero mineralocorticoid activity
A
Dexamethasone
Betamethasone
21
Q
Examples of short acting glucocorticoids
A
Cortisol
Cortisone
22
Q
Biologic half life of short-acting glucocorticoids
A
8-12h
23
Q
Biologic half life of intermediate-acting glucocorticoids
A
18-36 hours
24
Q
Biologic half life of long acting glucocorticoids
A
36-54h
25
Examples of mineralocorticoid
Fludrocortisone
| Desoxycorticosterone acetate
26
Diet should be high in ___ (3)___and low in ___(3)___
Protein, potassium, calcium
| Calories, fat, sodium
27
All patients taking glucocorticoids ___ or higher for ___ should be screened for Tb
15mg or higher
| 1 month
28
As glucocorticoids may downregulate delayed type hypersensitivity reactions, a PPD is considered positive if with ___ or more of induration
5mm
29
Immunization with live vaccines can be done if:
1. Duration of glucocorticoid us is less than ____ weeks at any dose
2. If dose of glucocorticoid is less than ____mg/day of any duration
3. Less than ____ mg/kg in patients who weigh less than ___
4. Long term alternate day treatment with____ acting preparation is used
1. 2 weeks
2. 20 mg/ day
3. 2mg/kg, 10kg
4. Short
30
Immunization with live vaccines should nit ve done for at least ___ after receiving high doses of glucocorticoids ____mg/day for more than ____
1 month
>20mg/day
2 weeks
31
Testing the HPA axis should be done with an 8am cortisol after tapering to dose less than or equal to physiologic cortisol level
Eg. ___/ day prednisone
_____/day hydrocortisone
<5mg
| 15 to 20 mg
32
With HPA axis testing, if
1. ___ ug/dl or less, continue glucocorticoids therapy and rechecking of serum cortisol every ____ months until levels are higher than ___ug/dl is required
2. ___ ug/dl or higher, but ___ ug/dl or less, perform further testing such as
1. 5 ug/dl, 3 to 6 months, 10ug/dl
| 2. 5ug/dl, 20ug/dl, corticotropin releasing hormone stimulation test
33
Most complications are associated with higher doses, longer duration except for(3)
1. Osteoporosis &; cataracts, alternate day dosing
| 2. Avascular necrosis, short courses
34
Even low doses if prednisone (___ mg/day) adversely affect bone and increase vertebral and hip fractures
2.5 mg/day
35
Osteoporosis occurs in ___% of individuals treated with long term systemic glucocorticoids
40%
36
Bone loss occurs more rapidly in the first few months of life
True or False
True
37
Any patient anticipated to be on glucocorticoid therapy for ___ months or longer should receive
3 mos
1. Vit D 800 IU
2. Ca 1200 mg/ day
38
The ff should be evaluated with DEXA for initiation of bisphosphonates
1. Patients anticipated to be on prednisone 5mg or more for 3 months
2. All ptients at high risk for osteoporosis
39
Rare side effects of bisphosphonates
Osteonecrosis of jaw
| Atypical femoral fractures
40
Bisphosphonates are contraindicated in 1.patients with creatinine clearance below ____ml/min
2. Who cannot sit upright for ___ after swallowing pill
3. Patients with esophageal disorders
30
| 30 mins
41
Long term use of glucocorticoids and/ or high risk patients may be evaluated for initiation of
Teriparatide
42
Radiographs can be normal in avascular necrosis.
| True or Flase
True
43
Greatest risk for CV disease in patients with
Iatrogenic Cushing syndrome
44
Symptoms of adrenal insufficiency despite normal cortisol response to ACTH
Steroid withdrawal syndrome
45
For psychiatric side effects, women may be more likely to develop ___ whereas men may be more likely to develop ___
Depression
| Mania
46
The risk of depression, mania, delirium, confusion, and disorientation increases with age.
True or False
True
47
The risk of suicidal behavior and panic disorder increases with age
True or False
False
48
The incidence of neuropsychiatric events is higher in the ____ months of therapy
First 3 months
49
Prednisone doses greater than ____mg/ day place patients at increased risk for steroid psychosis
80 mg/day
50
Glucocorticoids are teratogenic.
| True or False
False
51
To decrease amount of drug transferred during breastfeeding: (2)
1. Use prednisolone instead of prednisone
| 2. Avoid breastfeeding for 4 hours after a dose
52
Glucocorticoid- induced osteoporosis is irreversible
| True or False
False, reverse after DC of Tx
53
Growth suppression can be reversed with treatment of ____
Growth hormone
54
Effects of topical glucocorticoids: (3)
Antiinflammatory
Immunosuppressive
Antiproliferative
Vasoconstrictive
55
Used to predict clinical activity of topical glucocorticoids
Vasoconstriction assays
56
Examples of Class I - superpotent
Clobetasol propionate 0.05%
Halobetasol propionate 0.05%
Fluocinonide 0.1% optimized vehicle
Flurandrenolide 4ug/cm2
57
Examples of Class II - Potent
Desoximethasone 0.25%
| Halcinonide 0.1%
58
Examples of Class III - Potent, Upper Midstrength
Fluticasone propionate 0.005%
| Triamcinolone acetonide 0.5%
59
Examples of Class IV- Midstrength
```
Betamethasone valerate 0.12%
Clocortolone pivalate 0.1%
Desoximethasone 0.05%
Fluocinolone acetonide 0.025%
Hydrocortisone probutate 0.1%
```
60
Examples of Class V - lower Midstrength
Hydrocortisone butyrate 0.1%
61
Examples of Class 6- Mild strength
Aclometasone dipropionate 0.05%
| Desonide 0.05%
62
Class 7- Least potent
```
Dexamthasone
Flumethasone
Hydrocortisone
Methylprednisolone
Prednisolone
```
63
Radiographs can be normal in avascular necrosis.
| True or Flase
True
64
For psychiatric side effects, women may be more likely to develop ___ whereas men may be more likely to develop ___
Depression
| Mania
65
The risk of depression, mania, delirium, confusion, and disorientation increases with age.
True or False
True
66
The risk of suicidal behavior and panic disorder increases with age
True or False
False
67
The incidence of neuropsychiatric events is higher in the ____ months of therapy
First 3 months
68
Prednisone doses greater than ____mg/ day place patients at increased risk for steroid psychosis
80 mg/day
69
Glucocorticoids are teratogenic.
| True or False
False
70
To decrease amount of drug transferred during breastfeeding: (2)
1. Use prednisolone instead of prednisone
| 2. Avoid breastfeeding for 4 hours after a dose
71
Glucocorticoid- induced osteoporosis is irreversible
| True or False
False, reverse after DC of Tx
72
Growth suppression can be reversed with treatment of ____
Growth hormone
73
Highly responsive to glucocorticoids
Atopic dermatitis (children)
Intertrigo
Psoriasis (intertrignous)
Seborrheic dermatitis
74
Moderately responsive to topical application of corticosteroids (7)
```
Atopic dermatitis (adults)
Lichen simplex chronicus
Nummular eczema
Papular urticaria
Parapsoriasis
Primary irritant dermatitis
Psoriasis
```
75
A risk for LBW is associated with ___topical corticosteroids
High potency
76
It is recommended to limit short term exposure to high potency corticosteroids while breastfeeding
True or False
False, long term
77
Tachyphylaxis has been demonstrated by: (3)
Diminished vasoconstriction
Rebound of DNA synthesis
Recovery of histamine wheals
78
___ should be avoided in infants and young children other than for short term application to decrease risk of systemic absorption
High potency preparations
| Halogenated medium potency preparations
79
Prominent and potential cutaneous ADE of glucocorticoids that involve epidermis and dermis
Skin atrophy
80
Major glycosaminoglycan in the skin that is rapidly decreased after short term glucocorticoid treatment
Hyaluronan
81
Reddish purplish granulomatous lesions in diaper area which is a well known complication of diaper dermatitis during treatment with corticosteroids
Granuloma gluteale infantum
82
Classification of corticosteroids by cross reactivity
1. Triamcinolone acetonide
2. Clobetasol - 17- propionate
3. Hydrocortisone -17- butyrate
4. Budesonide
5. Tixocortol -21-pivalate
1. B
2. D1
3. D2
4. B
5. A
83
Classification of corticosteroids by cross reactivity
1. Methylprednisolone aceponate
2. Betamethasone
3. Triamcinolone acetonide
4. Betamethasone dipropionate
5. Hydrocortisone
1. D2
2. C
3. B
4. D1
5. A
84
Esophageal disorders wherein bisphosphonates are contraindicated (4)
Achalasia
Strictures
Reflux
Varices
85
If multiple joints are involved in avascular necrosis, a ___ may be needed
Bone scan
86
Glucocorticoid use is associated with increased risk for CV diseases like: (2)
Ischemic heart disease
| Heart failure
87
Increased CV risk may persist for years despite normalization of serum cortisol level.
True or False
True
88
Symptoms of adrenal insufficiency: (3)
Orthostatic hypotension
Hypoglycemia
Weakness
89
Symptoms of steroid withdrawal syndrome (5)
```
Desquamation of skin
Headache
Malaise
Myalgia
Arthralgia
```
90
Side effects of glucocorticoids in the pediatric population (2)
Growth suppression
| Early osteoporosis
91
Mechanism of antiproliferative effects of steroids (3)
Inhibition of DNA synthesis and mitoses
Reduce keratinocyte size and proliferation
Inhibits fibroblast activity and collagen formation
92
Clinical response to a formulation is directly proprotional to ___ of corticosteroid achieved at target site.
Concentration
93
Most topical steroids are USFDA Category __
C
94
___ steroid under occlusion is usually required for hyperkeratotic or lichenified dermatoses
Very potent steroid
95
Potential allergens in topical corticosteroids vehicles (7)
```
Formaldehyde-releasing preservatives
Fragrance
Lanolin
Methylchloroisothiazolinone
Parabens
Propylene glycol
Sorbitan sequioleate
```
96
In patients on concomitant NSAIDS therapy, initiate prophylaxis with a __
PPI
97
Consideration may be given to high dose glucocorticoids (___) for patients undergoing major surgical procedures or patients with primary adrenal failure, congenital adrenal hyperplasia, or hypopituitarism
50 mg hydrocortisone every 8 hours until tolerating oral intake
98
Attention must be paid to patients on high doses of glucocorticoids with underlying lung disease, low lymphocyte counts, underlying conditions further contributing to immunosuppression, and/ or patients on concomitant cytotoxic therapies, as these patients are at increased risk for development of
Pneumocystis pneumonia
