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Flashcards in Exam III Steroids Deck (53):
1

What is a natural cortisol (glucocorticoid) ?

1) regulates carbohydrate, fat and protein metabolism
2) Maintains vascular reactivity
-response to vasoactive amines
3) Anti-inflammatory effects
4) Maintenance of homeostasis during periods of stress
-maintains stability during emotional/physical stress

2

What increases the level of endogenous cortisol?

1) Surgery = most potent activator
2) Pain = important to use good pain control
3) Other= illness, trauma, burns, fever, hypoglycemia, emotional upset (periods of stress)

3

What are disorders of Adrenal Glands?

1) Excessive production of cortisol:
-Cushing disease (primary disorder)

2) Insufficient production of cortisol
-Addison disease (primary disorder)
-Secondary disorder = HPA axis is suppressed due to taking glucocortocids meds

4

What is a medication induced adrenal insufficiency?

Secondary disorder
-taking glucocorticoids meds
(exogenous steroids) suppresses the boys own production of endogenous steroids.

5

What is secondary adrenal insufficiency?

1) More common than Addison's disease
2) ASSOCIATED WITH CHRONIC STEROID USE
3) CONDITION DOES NOT PRODUCE SYMPTOMS UNLESS PATIENT IS SIGNIFICANTLY STRESSED (not enough circulating cortisol)

6

What is an Adrenal crisis?

1) Medical emergency
2) RARE with secondary adrenal insufficiency
3) EMERGENCY situation
4) LIFE-THREATENING
5) triggered by stress, illness, infection, surgery
6) SEVERE EXACERBATION of PATIENTS SYMPTOMS

7

What are the signs and symptoms of Adrenal Crisis?

1) Sunken eyes
2) PROFUSE SWEATING
3) HYPOTENSION
4) WEAK PULSE
5) DYSPNEA
6) CYANOSIS
7) nausea/vomiting
8) headache
9) dehydration
10) fever
11) myalgias
12) arthralgias
13) hyponatremia
14) eosinophilia

8

Without intervention of adrenal crisis, patient will continue to decline how?

1) hypothermia
2) SEVERE HYPOTENSION
3) hypoglycemia
4) circulatory collapse (SHOCK)
5) death
6) EMS for TRANSPORT AND SIGNIFICANT MEDICAL INTERVENTION REQUIRED

9

What is the TX for ADRENAL CRISIS?

1) Elevate feet above head
2) IV glucocorticoids
3) Fluid and electrolyte replacement therapy
4) Over 24 hr period, slow IV infusion of glucocorticoids every 6 to 8 hours
5) Correction of hypoglycemia
6) Administration of vasopressors (epinephrine)
7) monitor BP
8) resolution of event that triggered crisis

10

Synthetic Glucocorticoid medications are indicated for what?

1) Autoimmune diseases
2) Immunosuppressive therapy in organ transpant patients
3) Respiratory disease management

11

What are examples of Autoimmune disease?

1) Type I Diabetes
2) MS
3) Scleroderma
4) Lupus
5) Rheumatoid arthritis
6) Grave's disease/thyroid disease
7) Sjogren's syndrome
8) Pernicious anemia
9) Fibromyalgia?
10) Chronic fatigue syndrome?

12

Which systemic diseases require steroid use?

1) Replacement therapy (adrenal insufficiency, pituitary insufficiency, adrenal hyperplasia)
2) Arthritis (rheumatoid, osteoarthritis)
3) Rheumatic Carditis
4) Renal diseases
5) Collagen Disease (lupus erythematosus)
6) Allergic disease (anti-inflammatory effect)

13

What is the mechanism of action of steroids?

1) Steroids binds to specific receptors

2) Steroid-receptor complex translocates into the nucleus and alters gene expression
-turns genes off/on
-regulation of many cellular processes

3) Other effects of glucocorticoids are mediated by catecholamines
-producing vasodilation/bronchodilation

4) *Anti-inflammatory effects

5) Effect on #, distribution and function of PERIPHERAL LEUKOCYTES
-increased [ ] in NEUTS and decrease in T and B cells, monocytes, eosinophils and basophils

6) INHIBITION OF PHOSPHOLIPASE A
-decrease production of prostaglandins and leukotrienes from arachidonic acid

7) inhibit IL-2 migration inhibition factor and macrophage inhibition factor (causes therapeutic and adverse effects)

14

What are the contradictions for steroids?

-Effects for which steroids are used:
1) Anti-inflammatory action
2) suppression of allergic runs
3) suppresses the immune response (desired and undesired effect)
4) Adverse reactions are proportional to dose, frequency, time of administration and duration of TX
5) *TREATMENT is PALLIATIVE RATHER than CURATIVE

15

How is steroid preparations determined?

1)Each steroid is rated as to potency as COMPARED TO a HYDROCORTISONE EQUIVALENT DOSE
2) More potent the drug, the lower the dose and higher the risk for adrenal suppression.
3) TOPICAL APPLICATIONS LEAST LIKELY to cause adrenal suppression (except those w/ high potency)
4) SYSTEMIC STEROIDS MORE LIKELY to CAUSE adrenal suppression

16

Corticosteroid products are characterized by what?

-DURATION OF ACTION (short, intermediate, and long)

-relative anti-inflammatory activity and equivalent oral dose, w/ hydrocortisone (value of 1)

-Other agents are then given values in relation to those of hydrocortisone

17

What are the short acting selected corticosteroids (oral)?

a) What is the anti-inflammatory values in relation to hydrocortisone?
b) equivalent oral dose (mg)

1) Hydrocortisone (Cortisol)
Value: 1 Dose: 20 mg

2) prednisone (Deltasone)
Value: 4 Dose: 5 mg

3) methylprednisolone (Medrol)
Value: 5 Dose: 4 mg

18

Prednisone = anti-inflammatory of _______. It has ______ times the anti-inflammatory action of hydrocortisone.
_________ as much prednisone is required to produce the same effect produced by ______

-4
-4 X
-One fourth 1/4
-hydrocortisone

19

EQUIVALENT DOSES ARE BASED ON ______ HYDROCORTISONE = __________ NORMALLY SECRETED DAILY BY AN ADULT WITHOUT STRESS.

______mg mg dexamethasone and _____ mg prednisone = ____ mg of hydrocortisone

-20 MG
-AMOUNT

-0.75
-5
-20

20

What are the Intermediate acting selected corticosteroids (oral)?

a) What is the anti-inflammatory values in relation to hydrocortisone?
b) equivalent oral dose (mg)

1) triamcinolone
Value: 4 Dose: 4 mg

2) prednisolone
Value: 4 Dose 5 mg

21

What are the Long acting selected corticosteroids (oral)?

a) What is the anti-inflammatory values in relation to hydrocortisone?
b) equivalent oral dose (mg)

1) dexamethasone
Value: 30 Dose: 0.75 mg

2) betamethasone
Value: 25 Dose: 0.6-0.75 mg

22

What are the dosing considerations with steroids?

1) Taken in the A.M

2) Alternate day therapy
-lengthening interval between dosing allows for same effects with fewer side effects

3) ALTERNATE DAY THERAPY IS USED FOR PATIENTS WHO MUST TAKE STEROIDS FOR LONGER THAN 1 MONTH

4) Adrenal gland functions normally on "off" day
-HPA axis not suppressed; less risk for adrenal suppression

5) DAILY THERAPY POSES GREATER RISK FOR ADRENAL SUPPRESSION

6) "wean off" steroid in descending doses (tapered)

7) Normal adrenal output of cortisol = 20-30 mg hydrocortisone equivalent

8) ANY MED. DOSAGE that EXCEEDS THIS AMOUNT MAY CAUSE SUPPRESSION

9) During stress, adrenals secrete up to 300 mg of hydrocortisone eq.

23

What are the adverse events associated with chronic steroid use?

1) Insomnia
2) Peptic ulceration (AVOID ASPIRIN and NSAIDS)
3) osteoporosis
4) hyperglycemia
5) cataract formation
6) glaucoma
7) redistribution of fat pads
8) growth suppression
9) delayed wound healing

24

What are the oral side effects of steroids?

1) CANDIDIASIS = MOST COMMON
-pt's using inhalers
-use topical antiphonal therapy

2) POOR WOUND HEALING = long term use

3) MASKING OF ORAL INFECTIONS = anti-inflammatory

4) XEROSTOMIA = inhaled and systemic steroids
-power assisted devices
-fluorides
-chemotherapeutics

25

What are the contradiction to steroids?

1) Systemic fungal infections

2) Viral infections
-oral herpetic lesions

3) Latent or active tuberculosis

4) Allergy to any component of medications

26

What is the steroid sue in dentistry?

1) FOR REDUCTION OF PAIN/SWELLING
2) TX OF INFLAMTORY PATHOLOGIES OR ORAL MUCOSA

27

How do steroids reduce inflammation?

1) Suppress migration of PMNs
2) Reverse increased capillary permeability

28

What are the indications of steeds use in dentistry?

1) Reduce swelling and pain AFTER MAJOR ORAL SURGERY

2) TX of INFLAMMATORY CONDITIONS
-lichen planus
-aphthous ulcers
-benign mucous membranes pemphigoid
-pemphigus
-postherpetic neuralgia
-TMD

29

Describe the routes of delivery for steroids?

- TOPICAL- MOST COMMON ROUTE
-When used for less than 1 month, no serous adverse effects
-HIGH POTENCY TOPICALS = **use for 2 WKS ONLY

-longer use of high potency topicals requires physician consolation (RISK FOR ADRENAL SUPPRESSION)

30

Describe the ointments/gels (topical application) route of delivery for steroids

-Used intramurally
-applied directly to lesion
-teach patients to apply w/ cotton-tip
-apply after brushing, eating/drinking and at bedtime
-do not take anything by month for at 30 minutes following application

31

Topical ointments:
Can be placed in _________ to prolong contact with lesion.
__________ adhere best
Ointments are usually mixed with _________ to prolong contact -->_________________
Lesions should respond in _____ days

_____________= 0.5% gel used for Mild lichen plans, recurrent _____________

________________ = 0.5% gel used for oral inflammation; apply w/ Q-tip

_______________ = 0.1% Apply w/ Q-tip

-mouthguard
-Gels
-tissue adhesive
**triamcinolone (Kenalog in Orabase)
7-14
-Flucinonide (Lidex)
-Aphthous stomatitis

**clobetasol proprionate (Temovate)

**betamethasone valerate (Valisone)

32

Topical Rinse:

dexamethasone (Decadron) ____________ or prednisolone ________
Rinse for ______ seconds
____________
Use _____ to _____ times per day

-elixir
-syrup
-expectorate
-2-4

33

Give examples of low potency of steroids preparations

1) hydrocortisone cream 1 % (OTC)
2) hydrocortisone cream 2.5 %

34

Give examples of moderate potency of steroids preparations

1) triamcinolone acetonide (0.025%, 0.1%)

35

Give examples of high potency of steroids preparations

1) triamcinolone acetonide (0.5%)
2) fluocinonide (Lidex) 0.05% (gel, ointment or solution)
3) clobetasol (Temovate) 0.05% cream or solution

36

Injected steroids

1) Intralesional
-used intermeittently
-no systemic complications

2) Intra-articular
-used at 3 week intervals to treat bone pathology

37

Why are oral steroids used?

1) Before or during and after oral surgery
2) Reduce swelling and pain postoperatively
3) Treatment of oral lesions

38

What are oral steroid preparations?

1) methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)
2) prednisone (Prednisone Intensol, Sterapred)

39

What are the special population considerations?

1) **Avoid pregnant/lactating women
-Category C

2)**Use with EXTREME CAUTION in ped. patients
-More susceptible to suppression w/ topicals
-5 mg can limit growth

3) GERIATRIC PATIENTS more susceptible o HYPERTENSION and osteoporosis side effects
-check liver function
-lower dose to limit liver/kidney damage

40

What are the special populations at risk for adverse effects of steroids?

1) Hypertension or CV disease
2) Peptic ulcer, gastritis, esophagitis
3) Osteoporosis
4) DM
5) TB or other infections
6) Psychological difficulties
7) Glaucoma
8) Pregnancy
9) Young patients
10) elderly patients

41

What is the need for steroid supplementation ?

-Other than surgical procedures, FEW DENTAL PROCEDURES WARRANT USE.

-Routine dental procedure do not stimulate cortisol production at levels comparable this product tithe of surgery

-CORTISOL increases are not typically seen before or during the procedure: INCREASE IN POSTOPERATIVE PEROID 1 to 5 HRS AFTER PROCEDURE HAS BEGUN.

-MOST LIKELY A RESPONSE TO PAIN
-Correlates w/ loss of local anesthesia
-Improves with use of analgesics and anti anxiety meds

42

What increases risk for adrenal cease preoperatively? (4 main)

1) Severity of surgery
2) Drugs administered
3) Overall health of patient
4) Extent of pain control

Additional:
-Amount of blood loss (hypotension)
-Fasting state (hypoglycemia)

43

What are the clinical considerations of steroids?

1) Surgeries that last longer than 1 hour are more stressful than shorter surgeries

2) Blood and fluid loss exacerbate hypotension
-use method to recycle blood loss

3) Monitor BP
-SYSTOLIC BP

44

Patients with past history of steroid use ?

1) Medical history interview
2) Determine if steroids used within past 2 wks
3) reason for stopping? (previous indication)
4) Type, dose and duration of therapy
5) look for signs/symptoms of adrenal insufficiency
6) Identify dental treatment needs
7) Routine dental care
-NO SUPPLEMENTATION NECESSARY
8) Major invasive oral surgical procedure
-Physician consultation
-Lab testing

45

What is the laboratory testing for steroids?

1) Basal plasma ACTH and cortisol levels
-ACTH stimulation test

2) Urine tests

3) Stimulation tests
-Adrenal fxn is normal and pt needs routine care no supplementation
-If adrenal insufficient implement steroid supplementation

46

What can be done with patients currently taking steroids?

1) medical history
2) dose and duration of systemic steroid use
3) Identify signs/symptoms of possible insufficiency

47

What should a patient taking steroids do for diagnostic and minimally invasive procedures ?

1) Patient takes usual daily dose
2) Schedule patient first thing in morning
3) Stress reduction protocol
-pain and anxiety control
4) Monitor blood pressure

48

What should a patient do for major invasive procedures? (oral surgery)

1) Physician consultation
2) Laboratory testing
3) Steroid supplementation as needed

49

Should patients during routine dental procedure excluding extractions do steroid supplementation?

-Patients currently taking steroids
-none
-use good pain and anxiety control

50

Should patients with history of regular steroid use do steroid supplementation?

none

51

Should patients currently using tropical or inhaled steroids use steroid supplementation?

none

52

What is the stress reduction protocol for steroids?

1) Schedule surgeries in the A.M

2) Anxiety control
-nitrous oxide
-benzodiazepines (Valium)
-these drugs do not alter normal plasma cortisol levels

3) Monitor BP

*General anesthetics and extubation following surgery increase the boys steered demand

53

Extractions or other surgery, extensive processes, anxiety

-local anesthetics for pain control

-anxiety control

-target does of 25 mg hydrocortisone per day for minor oral and periodontal surgery

-target those of 50-100 mg hydrocortisone per day for maker oral surgery involving general anesthesia