Steroids

Question 1

What is Cushings vs Addisons?

Answer 1

Cushings: too much steroids
Addisons: not enough steroids

Question 2

Who first described steroid disease?

Answer 2

Dr. Thomas Addison 1855

Question 3

What were the initial methods of treating adrenal disease?

Answer 3

• extracting small concentrations of cortical steroids from extracts
• synthesis of cortisone, availability of ACTH

Question 4

What is ACTH used for now?

Answer 4

diagnostic agent, NOT therapeutic

Question 5

What happened in 1950?

Answer 5

synthesis of hydrocortisone

Question 6

What does the cortex produce?

Answer 6

• Mineralcorticoids
• Glucocorticoids
• Androgens

Question 7

What does the medulla produce?

Answer 7

Epi, NE

Question 8

What is the principal hormone of the adrenals?

Answer 8

Hydrocortisone

Question 9

HC secretion is regulated by what 2 things?

Answer 9

• ACTH (from pituitary)

- Corticotropin releasing factor (from hypothalamus)

Question 10

What do glucocorticoids act on?

Answer 10

Membrane bound receptors and cystolic receptors (intracellular and extracellular)

Question 11

Glucocorticoid interactions with nucleus cause what?

Answer 11

Genomic effects, turn genes off and on (potent effects)

Question 12

What is the primary pharmacologic effect of glucocorticoids?

Answer 12

Suppression of DN Amediated synthesis of pro-inflammatory chemicals (LT, PG, cytokines)

Question 13

What are the 7 adverse effects of glucocorticoids?

Answer 13

• Gluconeogenesis (steroid induced DM)
• Osteoporosis, increased Ca excretion
• Delayed growth in kids
• Suppresed allergic responses and Ab production
• Reduced healing
• Fat deposition (shoulders, face, abdomen)

Question 14

Result of chronic use of steroids?

Answer 14

20mg of Prednisone for at least 14 days can suppress HPA system

Question 15

Steroids must be _______

Answer 15

TAPERED! to reactivate HPA system and avoid acute adrenocortical insufficiency

Question 16

Suppressed patients require what special thing?

Answer 16

increased stress dose steroids during stressful event

Question 17

What is the average therapeutic daily dose of HC?

Answer 17

10 mg / day

Question 18

What is unique about topical and inhaled steroids?

Answer 18

do not typically achieve serum concentrations that may cause HPA suppression

Question 19

What is so potent it causes even inhaled steroid to accumulate?

Answer 19

Rotonovir

Question 20

Dexamethasone is used for what?

Answer 20

diagnostic test

It is highly lipophilic, acts on hypothalamus to suppress CRH secretion without altering serum corticosteroid levels

Question 21

An intact HPA axis will show what with D test?

Answer 21

normal suppression of cortical production (should see a decrease in serum cortisol levels)

Question 22

What is the naturally occurring hormone?

Answer 22

hydrocortisone

Short acting

Highly bound to cortisol binding globulin (CBG)

available PO and IV and OTC

Question 23

CBG levels are highest when?

Answer 23

at night, lowest in the morning

Question 24

What is the primary PO agent used in US?

Answer 24

Prednisone

Lipid soluble, well absorbed from gut, give in the morning

Question 25

What is the IV formulation of prednisone?

Answer 25

methylprednisolone (but no faster than PO, like warfarin)

Question 26

What are the a/e of prednisone?

Answer 26

- Fat redistruction - Osteopenia - Reduced gastric mucus production - Depression / psychosis - Hyperglycemia - Weight gain - Hypokalemia

Question 27

What causes weight gain with prednisone?

Answer 27

sodium retention and increased appetite

Question 28

What are the rare a/e of prednisone?

Answer 28

- Cataracts - Avascular necrosis - Menstrual disorders - Peptic ulcerations -- Tendon rupture Thromboembolism

Question 29

What are side effects from the immune suppression of prednisone?

Answer 29

- Low grade temp - Sore throat - Mouth ulcerations - Oral candidasis

Question 30

What is demargination?

Answer 30

when needed, WBC unstick from the vessel wall

Question 31

Steroids cause what?

Answer 31

Demargination, muck with the WBC count

Question 32

Increase in WBC and left shift (increase in bands) indicates what?

Answer 32

Infection

Question 33

Increase in WBC and no shift indicates what?

Answer 33

Steroids

Question 34

CAUTION with what and prednisone?

Answer 34

live vaccines- if 20mg/day for 14 days or more do not give live vaccine

Question 35

What is the oral methylprednisolone?

Answer 35

Medrol Dos-Pak 21 4mg tablets that last for 6 days 6 5 4 3 2 1 no risk of HPA suppression

Question 36

How many joint injections can you get per year?

Answer 36

3

Question 37

What is DOC for Addisons?

Answer 37

Fludrocortisone

Question 38

What is DOC for neurologic uses?

Answer 38

Dexamethasone it is very lipophilic also for thyroid storm

Question 39

What is special about newer agents?

Answer 39

Less likely to be absorbed (hydrophilic)

Question 40

How do you treat a pregnant patient?

Answer 40

lowest possible doses | avoid fluorinated agents (T F D B)

Question 41

What are the live vaccines?

Answer 41

- MMR - Varicella - Zoster - Injectable influenza - Internasal influenza