LECTURE 33 & 34: therapeutics of corticosteroids Flashcards by Margaret Whitmer

What happens if a patient abruptly stops taking a high dose of corticosteroids?

adrenal insufficiency – contraindication !!

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What is the physiologic dose of hydrocortisone?

20mg daily

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What is the physiologic dose of prednisone?

5 - 7.5 mg daily

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What is the physiologic dose of dexamethasone?

0.75mg daily

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What is the physiologic dose of methylprednisolone?

4mg daily

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What is the pharmacologic dose?

Any doses greater than physiologic dose

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What is the maintenance/low dose of prednisone?

~ 5 - 15 mg daily

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What is the moderate dose of prednisone?

~0.5 mg/kg daily

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What is the high dose of prednisone?

~ 1 - 3 mg/kg daily

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What is the massive dose of prednisone?

~15 - 30 mg/kg daily

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What is the principle for prescribing corticosteroids?

prescribe the lowest dose to achieve the desired effects → for the shortest duration possible

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Describe the process of prescribing corticosteroids for pain/distressing symptoms

Start with lower dose
May gradually reduce dose until worsening symptoms → lowest acceptable dose
Substitute with other medications (e.g. NSAIDs)

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Describe the process of prescribing corticosteroids for treatment of life-threatening conditions

Initial dose must be high
No benefits observed quickly → double/triple dose
Reserve high dose, long therapy for life threatening diseases

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What should patients on HIGH DOSE glucocorticoid NEVER receive?

live vaccine(s)

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List the equivalent doses to hydrocortisone

Hydrocortisone 20mg
Cortisone 25mg
Prednisone 5mg
Methylprednisolone 4mg
Dexamethasone 0.75mg

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What are the 2 types of cushing’s syndrome?

endogenous and exogenous hypercortolism

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What is endogenous cushing’s syndrome caused by?

Supraphysiologic cortisol concentration

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What is the cause of exogenous hypercortisolism

Pharmacological doses of glucocorticoids
- drug induced
- nonprescription & herbal products
- etc

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What is the most common mode of delivery of glucocorticoids that has been implicated in drug-induced cushing’s syndrome?

oral delivery

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Describe the clinical presentation of cushing’s syndrome (hypercortisolism)

Redistribution of body fat (central obesity)
Moon facies
Thick neck
Buffalo hump & supraclavicular fat accumulation
Muscle wasting & weakness (steroid myopathy)
Easy bruising

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List factors that likely indicate that a patient requires a steroid taper.

Receive glucocorticoid dose equivalent to prednisone >/= 7.5 mg/day for long-term (> 3 weeks)
Receive evening dose of prednisone >/= 5mg for more than a few weeks
Patients with Cushingoid appearance
Cautious in frail or dangerously ill patients
Evaluate HPA function - not necessary
Ultimate end point: monitor pts signs & symptoms

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List key therapy monitoring paraments for patients with adrenal insufficiency

Subjective well-being of the pt is an important clinical parameter in primary and secondary disease
Resolution of hypotension, dizziness, dehydration, hyponatremia, hyperkalemia
Monitor for adverse reactions of steroid
Maintenance of normal weight
Blood Pressure
Electrolytes with regression of clinical features
Adjust doses accordingly as needed

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List some signs that a patient with adrenal insufficiency is experiencing under-replacement

Study These Flashcards

weight loss
fatigue
nausea
myalgia (lack of energy)

List some signs that a patient with adrenal insufficiency is experiencing over-replacement (cushing syndrome)

Study These Flashcards

weight gain
central obesity
stretch marks
osteopenia/osteoporosis
impaired glucose tolerance
high blood pressure

List some key counseling points for patients with adrenal insufficiency

Take with meals (or milk) Do NOT stop therapy w/o seeking healthcare provider’s advice Increase the dose of glucocorticoid during excessive physiologic stress Double maintenance dose in the presence of fever, invasive dental procedure or diagnostic procedures, or surgery How to administer parenteral glucocorticoid if unable to immediately access medical care during an emergency Need to wear or carry medical identifiers (eg. card, necklace, bracelet) Causes of adrenal insufficiency, including drug-induced etiologies How to recognized the clinical manifestations How to prevent an acute adrenal crisis

Describe the tapering process for glucocorticoids

- Gradually taper the dose to prednisone ~20mg (or equivalent) daily, given in AM - There is not much clinical evidence to support any particular tapering regimen, so, generally, aim for a relatively stable taper - 10-20% of total daily dose (5-10% every 1-4 weeks) - Accommodate convenience - Consider individual patient response - Then, change steroid to every other day administration - Stop steroid when equivalent physiologic dose is reached

List the types of drugs that, when taken concurrently, could impact the metabolism of steroids

Drugs that strongly inhibit/induce P-glycoprotein transporters & CYP450 3A4

List examples of CYP450 3A4 inducers

phenytoin, rifampin, barbiturates, carbamazepine

List examples of CYP450 3A4 inhibitors

protease inhibitors, antifungals

How should the steroid dose be adjusted if the patient is taking CYP450 3A4 inducers?

heavily increase dose of glucocorticoids in presence of inducers

How should the steroid dose be adjusted if the patient is taking CYP450 3A4 inhibitors?

heavily decrease dose of glucocorticoids in presence of inhibitors

List possible complications that patients taking exogenous glucocorticoids may experience

Infections Myopathy Osteonecrosis Osteoporosis Psychiatric symptoms Fluid & Salt retention Metabolic changes Gastric ulcer Cataract Cardiovascular risks

What should be monitored to prevent an infection complication for patients taking exogenous glucocorticoids?

signs & symptoms of all infections

What should be monitored to prevent a myopathy complication for patients taking exogenous glucocorticoids?

muscle weakness

What should be monitored to prevent an osteonecrosis complication for patients taking exogenous glucocorticoids?

hip, shoulder, knee pain

What should be monitored to prevent an osteoporosis complication for patients taking exogenous glucocorticoids?

bone loss (DEXA scan), height, fractures, pain

What should be monitored to prevent a psychiatric complication for patients taking exogenous glucocorticoids?

nervousness, anxiety, euphoria, insomnia, mood swings, depression, personality changes, poor concentration, poor memory, overt psychosis, hallucinations

What should be monitored to prevent a fluid & salt retention complication for patients taking exogenous glucocorticoids?

blood pressure, edema, electrolytes

What should be monitored to prevent a metabolic changes complication for patients taking exogenous glucocorticoids?

fasting blood sugar, weight, cholesterol, excessive thirst, frequent urination, fatigue, weight loss/gain

What should be monitored to prevent a gastric ulcer complication for patients taking exogenous glucocorticoids?

burning pain, bloating, heartburn, nausea, vomiting, dark/black stools, vomiting blood, weight loss

What should be monitored to prevent a cataract complication for patients taking exogenous glucocorticoids?

screen before treatment, 3 months after treatment, and yearly

What should be monitored to prevent a cardiovascular complication for patients taking exogenous glucocorticoids?

blood pressure, heart rate, edema, cholesterol

How should an infection complication be managed for a patient taking exogenous glucocorticoids?

- treat infection aggressively - rinse mouth with inhaled steroid

How should a myopathy complication be managed for a patient taking exogenous glucocorticoids?

physical activity

How should an osteonecrosis complication be managed for a patient taking exogenous glucocorticoids?

- discontinue/decrease therapy - joint replacement therapy

How should an osteoporosis complication be managed for a patient taking exogenous glucocorticoids?

- supplement with Calcium + Vitamin D - weight bearing exercises - avoid smoking - treat with bisphosphate or others

How should a psychiatric complication be managed for a patient taking exogenous glucocorticoids?

decrease dose or discontinue agent, if possible

How should a fluid & salt retention complication be managed for a patient taking exogenous glucocorticoids?

- treat edema & HTN - reduce salt intake - supplement with K (if needed)

How should a metabolic changes complication be managed for a patient taking exogenous glucocorticoids?

- diet - hypoglycemia agents - insulin (short-term)

How should a gastric ulcer complication be managed for a patient taking exogenous glucocorticoids?

- prophylaxis with proton pump inhibitor or H2 receptor antagonist - avoid large doses of antacids

How should a cataract complication be managed for a patient taking exogenous glucocorticoids?

surgery

How should a cardiovascular complication be managed for a patient taking exogenous glucocorticoids?

treat as indicated

Describe the onset of chronic adrenal insufficiency

gradual

Describe the symptoms of chronic adrenal insufficiency

weakness & fatigue anorexia, nausea, and diarrhea hypoglycemia amenorrhea salt craving (22%)

Describe the signs of chronic adrenal insufficiency

- weight loss - orthostatic htn (<110/70 mmHg) - dehydration (hypo-Na, Hyper K+) - personality changes (irritability & restlessness) - loss of auxiliary & pubic hair for women - blood count abnormalities - hyperpigmentation of skin & mucous membranes

LECTURE 33 & 34: therapeutics of corticosteroids Flashcards

(55 cards)