steroids in practice

Question 1

what are the two main types of steroids?

Answer 1

1- steroids to suppress anti inflammatory process

2-steroid replacement where the body doesnt make enough

Question 2

what are some examples of steroids to suppress an anti-inflam process?

Answer 2

oral prendisolone to suppress chest infection

topical hydrocortisone for ezcema flare up

Question 3

give an example of when steroid repacement may be necessary

Answer 3

oral hydrocortisone and fludrcortisone in addison’s disease

Question 4

what are the two main properties of corticosteroids?

Answer 4

glucocorticoid- regulate carb, protein and fat metabolism. also an anti-inflamatory and immunosuppressant
mineralocortoid- regulate fluid and electrolyte levels

Question 5

what does the choice of corticosteroid depend on?

Answer 5

depends on indication
e.g. fludorcortisone acetate has a high mineralocorticoid activity while little inflammatory action therefore you wouldn’t use this for a chest infection

Question 6

what do we refer back to for the dose equivilant of certain steroids?

Answer 6

in the bnf = 5mg of prednisolone

Question 7

when would you use physiological replacement in deficient states?

Answer 7

addison’s disease- destruction of adrenal cortex
hypopituraism -pituitary tumour- release of ACTH
congenital renal hyperplasia

Question 8

what does the adrenal cortex normally secrete?

Answer 8

cortisol- glucorticoid activity and weak mineralocortcoid activity
aldosterone- mineralocortcoid

Question 9

what is the function of cortisol?

Answer 9

primary hormone of importance in acute adrenal crisis

Question 10

what is used to replace cortisol?

Answer 10

oral hydrocortisone tablets- iv or im in crisis

Question 11

what does aldosterone do?

Answer 11

acts to promote reabsorption and promote potassium excretion

promotes sodium retention

Question 12

what does a deficiency in aldosterone cause?

Answer 12

sodium loss, hypotension and volume depletion

Question 13

what is used to replace aldosterone?

Answer 13

fludrocortisone 50-300 micrograms daily in the morning

Question 14

what does biochemical monitoring allow for?

Answer 14

detection of minor degrees of under or over replacement

Question 15

what are the symptoms that people with adrenal insufficiency may experience?

Answer 15

Appetite loss
Discolouration of the skin
Dehydration
Increased thirst and polyuria
Salt cravings
Olignomemorrhea
No energy/ faituge
Sore/ weakness in muscle joints

Question 16

when do you notice people with adrenal insufficency?

Answer 16

they will remain well usually until times of cricis such as adrenal insufficency

Question 17

what is an adrenal crisis?

Answer 17

it is a medical emergency
the adrenal glands cant cope with the extra corticosteroids needed and life threatening symptoms may develop
acute deteoriation in health status with marked hypotension (systolic <100 or at least 20 cognitive drop)

Question 18

what are the signs and symptoms of an adrenal crisis?

Answer 18

can appear quick:
vomiting and diarrhoea
abdominal pain
drowsiness/ fatigue
diziness
confusion
limb and back pain

Question 19

what advice should be given to patients who are on steroid replacement?

Answer 19

• should be regularly reviewed
• this is a life long therapy
• free prescriptions available- have enough
• carry extra medication when travelling
• steoid card/ emergency bracelet
• ensure health professionals are aware

Question 20

who should steroid cards be given to?

Answer 20

people on long term prendnsolone 5mg or more

Question 21

what happens if a person with steroid replacment is ill or has undergone strenous exercise?

Answer 21

corticoids are increased due to the risk of adrenal crisis
-may have an individual plan
generally just doubled

Question 22

what happens if a person with steroid replacement therapy is vomiting?

Answer 22

may use emergency hydrocotisone injection and seek immediate medical attention

Question 23

what hydrocortisone should be given in an emergency?

Answer 23

hydrocortisone sodium not acetate as it has delayed onset of action

Question 24

what is the most common treatment for suppression of inflammatory diseases?

Answer 24

oral prednisolone 30mg daily

Question 25

when do steroids need to be tapered down?

Answer 25

usually if its a long course treatment- more than 3 weeks

Question 26

is short and long term use of glucocorticoids harmful?

Answer 26

short-not harmful | long term- more harmful

Question 27

how should patients be advised on how to take steroids?

Answer 27

in the morning after food to avoid GI disturbances and insominia

Question 28

what mood chages are associated with steroids?

Answer 28

confusion, irritability, sucidial thoughts usually associated with higher doses- early treatment or when being withdrawn seek medical advice if any changes occur

Question 29

what problems may people with long term steroid use have?

Answer 29

susceptibility to infection | suppression of normal adrenal function

Question 30

who should people with long term steroid use avoid ?

Answer 30

chicken pox or measles

Question 31

how can adrenal crisis occur?

Answer 31

chronic deficieny conditions lt steroids\ dose decrease infection, trauma, surgery

Question 32

what are the potential side effects of short term steroids?

Answer 32

insomina mood disturbances gi disturbances

Question 33

what are the potential side effects of long term steroids?

Answer 33

``` same as a short course plus; increased susptibility to infectin osteoporosis adrenal suppression diabtes occular effects skin changes gi bruising hypokalemia skin changes skin bruising ```

Question 34

who are the people to be cautious about with steroid use?

Answer 34

``` children and adoslecents elderly recent cv event peptic ulcer diabtes pregnancyeplipsy renal failure glaucoma ```

Question 35

what are te c/i in steroid treatment?

Answer 35

systemic infections | avoid live viruses

Question 36

how do you minimise the s/e of steorid?

Answer 36

``` morning dose eaten before hand alt day dosing shortest course of treatment topical application? ```

Question 37

how does steroids affect diabetes?

Answer 37

steroids can worsen diabetes it can worsen blood glucose control increased monitoring necessary

Question 38

how does steroids affect surgery?

Answer 38

increased stress- most likely increase dose of steroids or iv steroids if necessary

Question 39

how does glucocorticoid induced osteporosis occur?

Answer 39

rate of bone density loss is highest at the start of treatment continued reduction with long term use need to take into acccount patients fracture risk

Question 40

if a person is of high fracure risk what therapy should they be put on?

Answer 40

biophosphate +- calcuim / vit d

Question 41

what is said about the use of steroids in pregnancy and breast feeding

Answer 41

variable ability of corticosteroids to cross placenta no signifigant evidence that corticosteroids cause congenital abnormalities increased risk of intra-urine growth restriction with prolonged or repeated admin adrenal suppression in neonate resolves after birth

Question 42

what drug interactions would you avoid if possible with corticosteroids?

Answer 42

NSAIDS enzyme inducers cholestyramine

Question 43

when do you have to taper the withdrawl of oral corticosteroids?

Answer 43

when there is a likely degree of adrenal suppression: >3 weeks any dose >40mg prednisolone or equivilant for more than 1 week multiple recent repeated courses short course within a year of stopping a long course been given repeated doses in the evening

Question 44

how do you taper oral steroids?

Answer 44

Indication, duration & intensity of treatment | impact on how and when tapering required

Question 45

what does slow tapering of oral corticosteroids involve

Answer 45

-decreasing the steroid dosage by the equivilant of 2.5-5mg of prendisone every 3-7 days until the physiological dosage is reached then a more gradual reduction of prednisolone 0.5-1mg every 2-4 weeks should be considered

Question 46

what are the symptoms of adrenal insufficiency?

Answer 46

``` Fatigue • Weight loss • Abdominal pain • Nausea • Vomiting • Headaches • Joint pains • Dizziness • Fever • Hypotension • Confusion • Loss of consciousness ```

Question 47

how does an intra-articular steroid injection work?

Answer 47

Insoluble/long-acting steroid remains in the joint, contact with inflamed synovial surface, taken up by synovial cells and absorbed into blood stream -side effecrs less

Question 48

when should topical corticosteroids be given?

Answer 48

inflammatory condition of the skin other than infection. | • E.g. eczema, contact dermatitis, insect sting, eczema of scabies

Question 49

when should topical corticosteroids not be given?

Answer 49

infection (bacteria/viral/fungal) unless | concomitant treatment e.g. antibiotic/antifungal, rosacea

Question 50

when and where should potent topical steroids be avoided?

Answer 50

``` Potent topical steroid should generally be avoided on the face and skin flexures except under special circumstances by specialist supervision ```

Question 51

how would you council someone on the ammount of cream to apply?

Answer 51

• Finger tip application | – Enough for twice size of adult palm+fingers

Question 52

what other counselling points would you give to someone with a topical steroid?

Answer 52

• No more frequently than twice daily (once daily normally sufficient) apply thinly to the affected area only • Use the least potent formulation which is fully effective • Avoid prolonged use on the face and keep away from eyes • Caution in children and during pregnancy

Question 53

what are the side effects of topical steroids?

Answer 53

``` • Spread/worsening of untreated infection (do not use on infected skin unless specific treatment for infection given alongside) • Thinning of skin with long-term use • Contact dermatitis • Perioral dermatitis • Acne, worsening of acne rosacea • Depigmentation • Hypertrichosi ```

Question 54

what are the risk of systemic side effects of ICS at high doses?

Answer 54

``` • Spread/worsening of untreated infection (do not use on infected skin unless specific treatment for infection given alongside) • Thinning of skin with long-term use • Contact dermatitis • Perioral dermatitis • Acne, worsening of acne rosacea • Depigmentation • Hypertrichosi ```

Question 55

before increasing the dose of inhaled steroids what should you check?

Answer 55

• Patient adherence • Inhaler technique ?consider spacer • Encourage smoking cessation

Question 56

when would rectal steroids be used?

Answer 56

Enemas or suppositories e.g. prednisolone in inflammatory bowel disease (IBD) affecting lower parts of the colon and rectum – Local action