corticosteroids Flashcards
use of CCs in psoriasis
should be avoided or only used under specialist supervision
which drug can be used to treat postural hypotension in autonomic neuropathy and why
mineralocorticoid activity of fludrocortisone
name 2 CCs that are appropriate for conditions where water retention would be a disadvantage
betamethasone
dexamethasone
5 side effects of mineralocorticoids
- hypertension
- sodium retention
- water retention
- potassium loss
- calcium loss
mineralocorticoid side effects are most marked with this drug
fludrocortisone
mineralocorticoid side effects are most marked with fludrocortisone, but are significant with the following 3 drugs
HC, corticotropin, tetracosactide
there are negligible mineralocorticoid actions with the high potency GCs betamethasone and dexamethasone, but they do occur slightly with the following three drugs
methylprednisolone, prednisolone, and triamcinolone.
5 SE of glucocorticoids
- diabetes
- osteoporosis (danger esp in elderly as can result in osteoporotic fractures e.g. hip or vertebrae)
- high doses associated with avascular necrosis of femoral head
- muscle wasting
- CC therapy weakly linked with peptic ulcers and perforation
- psychiatric reactions
main way to manage side effects of CCs
- use lowest effective dose for minimum period possible
suppressive action of a CC on cortisol secretion is least when it is….
given as a single dose in the morning
side effects of CCs - MHRA advice on rare risk of central serous chorioretinopathy with local and systemic administration
- retinal disorder linked to systemic use of CCs, and local aswell
- pt to report any blurred vision and other visual disturbances with CC treatment
- consider referral to ophthalmologist for elevation of possible causes if a pt presents with vision problems
glucocorticoid suppression action on hypothalamic-pituitary-adrenal axis is greatest and most prolonged when they are given…
at night
in most individuals a single dose of …… at night is sufficient to inhibit corticotropin secretion for 24h
dexamethasone
overnight dexamethasone suppression test for diagnosing Cushing’s syndrome
- finds out if there is excess amount of cortisol in body
- after measuring baseline cortisol, dexamethasone is given with the intention of suppressing cortisol
- if it does not suppress after taking dexamethasone at night, it means there is too much cortisol production aka Cushing’s syndrome
why is dexamethasone given to pt to diagnose cushings syndrome
In most individuals a single dose of dexamethasone at night, is sufficient to inhibit corticotropin secretion for 24 hours
therefore if cortisol has not reduced, it means they have the syndrome
should a CC be used for management of head injury or stroke
no - unlikely to be of benefit and may even be harmful
how does adrenal insufficiency occur
as a result of inadequate production of steroid hormones in adrenal cortex
what are the two main groups of steroid hormones produced by the adrenal cortex and what primary regulates their production?
- GCs (e.g. cortisol) - production largely regulation by HPA
- MCs (e.g. aldosterone) - production largely regulated by renin-angiotensin system
symptoms of adrenal insufficiency can be mild, non-specific, and may include
fatigue, gastrointestinal upset, anorexia, weight loss, musculoskeletal symptoms, salt cravings, and dizziness or syncope due to hypotension.
classifications of adrenal insufficiency
- primary
- secondary
- tertiary
primary adrenal insufficiency results from disorders that affect the …….. e.g. ……..
adrenal cortex e.g. Addison’ disease, congenital adrenal hyperplasia
secondary adrenal insufficiency results from disorders of the …. e.g. ……
anterior pituitary gland e.g. pituitary tumour or subarachnoid haemorrhage
tertiary adrenal insufficiency results from disorders of the ….. e.g. …..
hypothalamus e.g. HPA axis suppression
Some drugs can also cause adrenal insufficiency. for example the systemic use of ….. is most common cause due to suppression of the HPA axis
GC
what is the most common cause of adrenal insufficiency and how?
systemic use of GC due to suppression of HPA axis
if GC are stopped or decreased too quickly after prolonged, …..
endogenous glucocorticoid production may not be sufficient to meet the body’s needs. this could result in adrenal crisis (acute adrenal insufficiency)
life threatening symptoms of adrenal crisis
- severe dehydration
- hypotension
- hypovalaemic shock
- altered consciousness
- seizures
- stroke
- cardiac arrest
- if untreated can lead to death or permanent disability
adrenal crisis can occur in pt particular during times of increased need e.g. …… as pt are unable to mount a stress response buy increasing endogenous GC production
surgery
infection
trauma
treatment of adrenal insufficiency
physiological glucocorticoid replacement with mainly hydrocortisone (most similar to cortisol), prednisolone, or rarely dexamethasone.
pt with primary adrenal insufficiency usually also require mineralocorticoid replacement with …. due to aldosterone deficiency
fludrocortisone
Some patients, usually those with secondary or tertiary adrenal insufficiency, including treatment with exogenous steroids or other drugs (such as some antifungals and antiretroviral medication), may have a suboptimal cortisol response but…..
do not require maintenance GC treatment
advice pt with adrenal insufficiency/ at risk of it on stress GC doses
- advice all pt with adrenal insufficiency & pt at risk of adrenal insufficiency on the impotent of stress GC doses (increases doses0 to prevent adrenal crisis during times of stress
e.g. surgical or invasive procedures
this maintains cortisol levels as close to physiological conc as possible
pt with adrenal insufficiency who not usually require maintenance GC should still be avoid of the likely need for GC replacement during times of stress
sick day rules for pt with adrenal insufficiency and intercurrent illness
- unwell with moderate intercurrent illness (e.g. fever and infection requiring abx), generally double the daily GC dose
- if on long acting HC prep, switch to short acting, more rapidly absorbed preps during intercurrent illness
- for severe intercurrent illness (e.g. persistent vomiting from GI viral illness), give IM or IV HC
pt with adrenal insufficiency and have vomiting or diarrhoea
- higher risk of GC deficiency
- for pt with established adrenal insufficiency, provide HC emergency injection kit and train in administration of IM HC and advise to go to hospitality vomiting or diarrhoea
management of adrenal crisis
- medical emergency
- treat immediately, esp pregnant women
- initiate investigations once pt clinically stable
- no adverse consequences of initiating a life saving bolus dose of HC treatment
- treatment involves prompt GC replacement with HC and rehydration using crystalloid fluid (e.g. sodium chloride 0.9%)
- for pt on fludrocortisone, high dose HC has sufficient mineralocorticoids effect to cover this
prompt treatment of adrenal crisis involves
prompt glucocorticoid replacement with hydrocortisone, and rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%). For patients usually on fludrocortisone, high-dose hydrocortisone has sufficient mineralocorticoid effect to cover this.
Particular care is required in patients with diabetes insipidus and adrenal insufficiency related to hypothalamic-pituitary disease who are treated with desmopressin because..
they are at risk of uncontrolled diabetes insipidus if doses of desmopressin are omitted, or hyponatraemia if excess fluid is given.