Term
Describe how cortisol is released, the effects of cortisol on the body and the regulation of cortisol release. |
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Definition
Hypothalamus disperses releasing factor --> Anterior Pituitary, which disperses ACTH --> Adrenal Cortex, releasing cortisol
Zona Glomerulosa --> Produces mineralcorticoid called Aldosterone
Zona Fasciculata --> Produces Glucocorticoid called Cortisol
Zona Reticularis --> Produces Androgens
Aldosterone affects electrolyte and volume homeostasis
Cortisol affects metabolism of fat, carbs, and protein
Cortisol Effects: Breakdown of skeletal muscle, adipose tissue, bone, suppression of immune system, Gluconeogenesis, anti-inflammatory |
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Term
What are the general hypo and hyper function disease states? |
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Definition
Hyperfunction:
Zona glomerulosa - Aldosteronism
Zona Fasciculata - Cushing's Syndrome
Hypofunction:
Zona Glomerulosa - Hypoaldosteronism
Zona Fasciculata - Addison's Disease |
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Term
Differentiate between glucocorticoids in terms of duration of action, relative glucocorticoid and mineralocorticoid potency. |
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Definition
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Term
Differentiate between the various corticosteroid dosing regimens and routes of administration. |
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Definition
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Term
Convert prednisone to an equivalent dose of another corticosteroid and vice versa. |
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Definition
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Term
List adverse effects of systemic corticosteroid administration. |
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Definition
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Term
Understand dosing of corticosteroids during times of stress. |
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Definition
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Term
Identify ways to reduce the likelihood of HPA axis suppression. |
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Definition
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Term
Describe strategies to discontinue corticosteroid therapy appropriately. |
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Definition
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Term
List monitoring parameters for systemic glucocorticoid therapy. |
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Definition
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Term
Discuss counseling points related to systemic glucocorticoid therapy. |
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Definition
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Term
| What are the three main rheumatologic disorders that corticosteroids can treat, and in what other disease states can oral steroids be used? |
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Definition
- Acute Gouty Arthritis
- Rheumatoid Arthritis
- Osteoarthritis
Other disease:
- Adrenal Gland disorders
- Allergic disorders
- GI disease
- Dermatologic disorders
- Autoimmune disorders
- Respiratory disorders
- Pre-treatment for infusions
- Any other disease that involves an inflammatory component |
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Term
| What are the signs, symptoms, and treatment of aldosteronism? |
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Definition
- Excess aldosteronism, primary or secondary
- Kidneys retain Na+, K+ lost in urine
- Symptoms include HTN, hypokalemia, muscle weakness/fatigue, paralysis, HA, polydipsia, nocturnal polyuria
- Treatment: Surgery, Spironolactone 25-400mg/day, AE include GI upset, impotence, gynecomastia, menstrual irregularities (dose dependent)
Pneumonic: Aldosterone make it like you don't have testosterone
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Term
| What are the signs, symptoms, and treatment of Cushing's Syndrome? |
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Definition
- Supra-physiologic levels of glucocorticoids caused by overproduction of the adrenal gland (ACTH-dependent ~70% of cases), exogenous administration, abnormal adrenocortical tissues
- Central obesity, moon faces, buffalo hump, striae, hypertensive complications, glucose intolerance, hirsutism, amenorrhea, fatigue
- Associated with increased morbidity/mortality if left untreated --> DM, CVD, electrolyte abnormalities
- Treatment based on etiology, remove source of hypercortisolism |
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Term
| What are the signs, symptoms, and treatment of adrenal androgen excess? |
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Definition
- More commonly seen in females
- Most common etiology is congenital enzyme defect
- Features include hirsutism, oligomenorrhea, acne, virilization
- Treatment is suppression of HPA axis (glucocorticoids such as dexamethasone, prednisone, etc.) |
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Term
| What are the signs, symptoms, and treatment of hypoaldosteronism? |
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Definition
- Decreased production of aldosterone
- Low Na+ and high K+ levels (excessive H2O loss --> low BP)
- Treatment is mineralcorticoids (fludrocortisone) |
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Term
| What are the signs, symptoms, and treatment of Addison's Disease? |
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Definition
- Primary adrenal insufficiency involving destruction of all regions of the adrenal cortex
- Features include: hyperpigmentation, weight loss, hyponatremia, hyperkalemia, HoTN, weakness
- Treatment is steroid therapy meant to mimic the normal diurnal adrenal rhythm. |
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Term
| What are the signs, symptoms, and treatment of acute adrenal insufficiency? |
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Definition
- Also referred to as Adrenal Crisis or Addisonian Crisis
- Triggers: Stress, surgery, infection, or trauma, HPA axis suppression ---> abrupt withdrawal of corticosteroids
- Symptoms include myalgia, malaise, vomiting, fever, HoTN, possibly shock
- Treatment: IV Glucocorticoids
** True Endocrine Emergency ** |
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Term
| What are the signs, symptoms, and treatment of HPA Axis Suppression? |
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Definition
- Caused by adrenocortical insuffiency and adrenal gland hypertrophy
- Suppression can result after abrupt discontinuation of corticosteroid therapy at doses equivalent to about 5mg/kg/day of prednisone |
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Term
| What are the indications, mechanisms, dose, and adverse events for mineralcorticoids? |
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Definition
Indication: Replacement therapy for adrenalcortical insuffiency (Addison's), salt-losing syndrome, or off-label orthostatic hypotension
MOA: Facilitates Na+ resorption --> increases BP, same as aldosterone
Dose: 0.1-0.2mg po daily
AE: Fluid imbalance, hypokalemia, edema, increase BP, CHF |
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Term
| What is the mechanism of glucocorticoids, and what do you need to consider before initiating therapy? |
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Definition
MOA: Binds to intracellular receptors and alters protein synthesis, inhibits leukocyte traffic and access to site of inflammation, binds in almost all tissues of the body (wide variety of biologic effects)
- Initiating therapy depends on what you're trating and length of therapy
- Need to consider route, half-life, cost, effects, formulation
- Need to look at dosing regiments, adverse events, and d/c therapy |
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Term
| What are the indications for use of glucocorticoids? |
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Definition
nAdrenal gland deficiencies
nRheumatic disorders
nAllergic disorders
nRespiratory diseases
nDermatologic diseases
nRenal disease
nGI diseases
nCollagen disorders
nHepatic diseases
nMalignancies
nOrgan Transplant
nMultiple sclerosis
nCerebral edema
nSeptic shock
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Term
| What are the routes of administration of glucocorticoids? |
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Definition
nOral
nIntravenously
nIntra-articular
nTopical
nInhaled
nSubcutaneously
nIntra-muscularly
nIntrabursal
nIntradermal
nIntralesional
nRectal
nIntrasynovial
nOcular
nIntranasal
nSoft-tissue injection
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Term
| What are the indications as well as considerations of potency when choosing a topical glucocorticoid? |
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Definition
Indications: Eczema, atopic dermatitis, psoriasis, contact dermatitis, vitiligo, etc.
Choice of potency:
Low - thin skin, acute inflammatory lesions
Medium or High - Chronic, hyperkeratotic, lichenified lesions |
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Term
| Which topical glucocorticoids fall under the very high, high, medium, and low potency categories? |
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Definition
Very High - Clobetasol, Halobeasol, Betamethasone dip. 0.05%
High - Betamethasone Dip/Valerate, Fluocinonide, Triamcinolone Acetonide. 0.2-0.05% (or is it 0.02?)
Medium - Beta/Benz/Dip/Val, Fluocinonide acet., Fluticasone prop., HC, mometasone, triamcinolone. 0.2-0.025%
Low - Aclometasone dip., dexamethasone, fluocinolone, hydrocortisone. 2.5-0.01% |
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Term
| What is the vehicle of choice and duration of therapy for topical glucocorticoids and their adverse effects |
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Definition
Ointment - Thick lichenified lesions, enhances penetration of drug
Cream - Acute and subacute dermatoses, moist skin and intertriginous areas
Solutions, gels, and sprays - Scalp, where non-oil based vehicle is needed
Duration:
Medium-high to very high - <3 weeks due to irreversible skin atrophy
Medium potency with thin skin - <2 weeks
Diaper rash - Mildest potency for 3-7 days
Chronic use - Intermittent treatment every other day or every weekend.
AE: Skin atrophy, acne, abnormal pigmentation, purpura, delayed skin healing, photosensitivity, infection |
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Term
| What are the different dosing regimens for oral corticosteroids? |
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Definition
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Regimen
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Dosage*
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Clinical Application
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Adverse Effects
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Low Dose
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≤7.5mg
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Maintenance therapy
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Relatively few
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Alternate Day Dose
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>10mg
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Non-sx manifestations of mild-mod dx
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Few, less adrenal suppression
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Split daily Dose
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Variable
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Rapid control of active dx
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Dose dependent; ↑ AE
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Medium Dose
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>7.5 to ≤30mg
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Primary chronic conditions (mild-mod dx)
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Dose-dependent (considerable if tx for longer periods)
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High Dose
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>30 to ≤100mg
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Sub-acute diseases (active disease)
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Tx must be short-term, severe adverse effects
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Very High Dose
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>100mg
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Acute diseases or exacerbations
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Tx must be short-term, dramatic side effects
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IV Pulse Therapy
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≥250mg for one or a few days
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Severe or life threatening dx
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Low incidence
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Term
| What are examples of short acting, intermediate acting, and long acting corticosteroids, their doses, and half-lives? |
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Definition
Short acting:
Cortisone (25mg), HC (20mg) --> 8.5h half-life
Intermediate acting:
Prednisone, Prednisolone (5mg), Triamcinolone, Methylprednisolone (4mg) --> 18-36h half-life
Long-acting:
Dexamethasone (0.75mg), Betamethasone (0.6-0.75mg) --> 36-54h half-life
Mineralcorticoids are more potent in only short-acting glucocorticoids |
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Term
| When would you use once-daily dosing for steroids? |
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Definition
- Maintenance therapy or control of active disease
- Mimics normal cycle, administer in the morning
- May have to taper if pt. was on doses of >20mg/day for >2 weeks |
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Term
| When would alternate-day therapy be employed? |
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Definition
- Indicated for non-symptomatic manifestations of mild-moderate disease
- Minimizes suppresion of HPA axis
- Not recommended for initial therapy, mostly long-term |
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Term
| How would you figure out the alternate-day dosing? |
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Definition
- Before converting, minimum effective daily dose must be determined
- Optimum qod dose is 2.5-3x minimal daily dose
- For conversion from daily to qod, gradually increase on "on" days and decrease in "off" day dose.
- Taper dose by 5mg/week, increasing on "on" days and decreasing on "off" days |
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Term
| How do we effectively discontinue therapy? |
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Definition
nShort-term (<2 weeks) and also low doses (<20mg/day*)
–Okay to discontinue without tapering
nLong-term therapy must be tapered
–Decrease by 2.5-5mg q 3-7days
–Decrease by 2.5mg q 1-2 weeks
–Decrease by 5mg q 1-2 weeks if on alternate day dosing
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Term
| What are the systemic adverse effects of corticosteroid use? |
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Definition
Early Manifestations
nInsomnia
nEnhanced appetite
nWeight gain
nEmotional lability
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Sustained Therapy
nCushingoid habitus
nHPA suppression
nInfection
nOsteoporosis
nImpaired wound healing
Delayed Effects
nOsteonecrosis
nEcchymosis
nCataracts
nGrowth retardation
nFatty liver
nAtherosclerosis
Rare Effects
nPsychosis
nGlaucoma
nPancreatitis
nPseudotumor cerebri
Leukocytosis |
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Term
| What are contraindications and warnings of steroid use? |
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Definition
CI:
- Live vaccines
- Systemic fungal infections
- Hypersensitivity
Warnings:
- active infections
- diabetes
- Osteoporosis
- Peptic ulcer
- Electrolyte imbalances
- Stress, trauma, injury
- HPA Suppression |
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Term
| What is the monitoring involved with corticosteroid use? |
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Definition
nLabs - Including glucose, electrolytes, WBC
nStool test for occult blood loss
nDEXA
nGrowth and development
nCushingoid symptoms
nBlood pressure
nOphthalmologic exams
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