Corticosteroid Therapy

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  • Created by: LBCW0502
  • Created on: 08-10-19 11:53
What are corticosteroids?
Any group of steroid hormones produced by adrenal cortex or made synthetically. Three main types - glucocorticoids, mineralocorticoids, sex hormones (androgens)
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Describe features of the adrenal glands
Suprarenal glands. Adrenal cortex (steroid hormone secretion, modulated by neuroendocrine pituitary hormones and RAAS). Adrenal medulla (catecholamines secretion e.g. noradrenaline and adrenaline, sympathetic NS)
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Outline the synthesis of steroid hormones
Steroid hormones derived from cholesterol. Pathways produce aldosterone, cortisol and androgens (testosterone, oestradiol)
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What are the endogenous steroid hormones?
Glucocorticoids and mineralocorticoids (and androgens)
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What is the function of glucocorticoids?
Affect carbohydrate, protein and fat metabolism. Anti-inflammatory and immunosuppressive activity
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What is the function of mineralocorticoids?
Affect fluid and electrolyte balance. Increase Na reabsorption and K loss in kidney. Passive reabsorption of water
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State features of the renin-angiotensin system (1)
In the outer zone of the adrenal cortex, renin is converted into angiotensinogen which is converted to ang I and ang II, leads to release of aldosterone (secreted in response to high K levels and activation of angiotensin receptors)
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State features of the renin-angiotensin system (2)
Mineralocorticoid activity, maintains fluid and electrolyte homeostasis. Inner zone of adrenal cortex (ACTH leads to secretion of cortisol)
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Describe the hypothalamic-pituitary-adrenal axis (1)
Circadian rhythm, CRH released from hypothalamus in response to stress, anterior pituitary released ACTH, cortisol secreted from adrenal glands, acts on tissues
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Describe the hypothalamic-pituitary-adrenal axis (2)
Cortisol has a negative feedback loop to hypothalamus and anterior pituitary to inhibit CRH and ACTH. Cortisol secreted in response to circadian rhythm and stressful situations (injury, infection, extreme temperature, exercise, hypoglycaemia)
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Describe the hypothalamic-pituitary-adrenal axis (3)
Has both glucocorticoid and mineralocorticoid activity. Enables body to cope
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Describe features of responses to stress (1)
Immediate response to stress, fight or flight response. Mediated by autonomic NS (adrenaline/noradrenaline). Long term effects mediated by corticosteroids. Mineralocorticoid (increase BP/blood volume, salt/water retention)
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Describe features of responses to stress (2)
Glucocorticoid (increase blood glucose and catabolism, fat/protein, decrease inflammatory response and immune response)
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Give examples of synthetic steroids
Hydrocortisone, methylprednisolone,triamcinolone, prednisolone, dexamethasone (anti-emetic given 30 mins before end of surgery), betamethasone, fludrocortisone
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What are the indications for corticosteroids? (1)
Anti-inflammatory/immunosuppressive therapy (control acute inflammatory reactions e.g. asthma attack/anaphylaxis, control chronic auto-immune/inflammatory disorders e.g. RA, IBD, prevention of organ rejection in transplants)
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What are the indications for corticosteroids? (2)
Replacement therapy (Addison's disease). Neoplastic disease. Anti-emetic
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Which drugs have a short duration of action?
Hydrocortisone and fludrocortisone
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Which drugs have an immediate duration of action?
Prednisolone and methylprednisolone
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Which drugs have a long duration of action?
Dexamethasone and betamethasone
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How do you know what dose to use? (1)
Depends on indication and acuity. Acute - high dose for short period of time, exacerbation of COPD, acute asthma, anaphylaxis
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How do you know what dose to use? (2)
Chronic - lowest dose possible that controls symptoms, morning administration reduces risk of adrenal suppression, IBD, chronic asthma
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What is Addison's Disease?
Acquired deficiency to produce corticosteroids. Requires both glucocorticoid and mineralocorticoid replacement lifelong. Androgen replacement not routinely used
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What is the treatment for Addison's Disease?
Glucocorticoid - hydrocortisone 15-30 mg/day in divided doses. Aim to resemble natural cycle of corticosteroid release. Mineralocorticoid - fludrocortisone 50-300 micrograms/day, depends on metabolism and exercise levels
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What is the adrenal crisis?
Severe physical stress (adrenal glands unable to supply extra corticosteroids). Leads to life-threatening symptoms (severe hypotension, hypovolaemic shock)
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How is an adrenal crisis treated?
IV hydrocortisone 100 mg every 6 hours. Fluid replacement. Fludrocortisone not required in an emergency
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What are the side effects of corticosteroids? (1)
Occurs with large loses/prolonged therapy. Shouldn't occur with replacement therapy. Diabetes/increase in blood glucose levels (increase gluconeogensis, decrease uptake of glucose into cells)
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What are the side effects of corticosteroids? (2)
Altered distribution of fat (fat stored in trunk/face/neck rather than limbs). Cushing's syndrome
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What are the side effects of corticosteroids? (3)
Increased susceptibility to infection (normal inflammatory/immune response suppressed, bone marrow not suppressed). Impaired wound healing (decrease in fibroblast activity). Hypertension (Na/H2O retention, increase blood volume/BP, Conn syndrome)
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What are the side effects of corticosteroids? (4)
Hypokalaemia (due to increase K loss via kidneys). Growth retardation in children (decrease protein synthesis)
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What are the side effects of corticosteroids? (5)
Osteoporosis (inhibition of OBs, increase OC activity, decrease Ca absorption from gut/Ca excretion by kidney, decrease bone density/increased risk of fractures). Altered mood/behaviour (euphoria, psychosis, depression, insomnia, mechanism unclear)
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What are the side effects of corticosteroids? (6)
Peptic ulceration (increased gastric acid secretion/COX inhibition, reduced production of protective mucus layer)
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What are the side effects of corticosteroids? (7)
Adrenal suppression (production of CRF, ACTH, endogenous steroids suppressed by administration of synthetic steroids, atrophy of adrenal cortex, sudden withdrawal of synthetic steroid can cause acute adrenal insufficiency)
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What are the side effects of corticosteroids? (8)
Muscle wasting/skin atrophy (increase protein breakdown/decrease protein synthesis). Cataracts and glaucoma, hoarseness with inhaled steroids (wasting of laryngeal muscles)
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What are the side effects of corticosteroids? (9)
Oral candida with inhaled steroids (need to rinse mouth after taking dose to reduce risk of oral thrush). Weight gain
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What are the clinical features of Cushing's syndrome?
Round face, hirsutism, hump, easy bruising, abdominal weight gain, stretch marks
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Describe features of a steroid treatment card (1)
Abrupt withdrawal after chronic/high dose treatment can lead to adrenal insufficiency
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Describe features of a steroid treatment card (2)
Gradual reduction of dose if - more than prednisolone 40 mg OD (or equivalent) for more than 1 week, treated for more than 21 days, taking doses at night, had short course within 1 year of long term treatment. Various reduction regimens
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Describe features of a steroid treatment card (3)
Patients carry steroid treatment card
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Are steroids in inhaled absorbed to a degree which is clinically relevant?
Very high doses of steroids in inhalers (use of topical or inhaled steroid therapy can have systemic risks e.g. case study - adrenal insufficiency due to inhaled steroid therapy prescribed for chronic asthma)
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Card 2

Front

Describe features of the adrenal glands

Back

Suprarenal glands. Adrenal cortex (steroid hormone secretion, modulated by neuroendocrine pituitary hormones and RAAS). Adrenal medulla (catecholamines secretion e.g. noradrenaline and adrenaline, sympathetic NS)

Card 3

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Outline the synthesis of steroid hormones

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Preview of the front of card 3

Card 4

Front

What are the endogenous steroid hormones?

Back

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Card 5

Front

What is the function of glucocorticoids?

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