1
Q
What is the function of the adrenal glands in regards to steroid production?
A
Secrete mineralcorticoids, glucocorticoids, and sex hormones
2
Q
Where are the adrenal glands located?
A
Sit on top of the kidneys
3
Q
What are the two main areas of the adrenal glands?
A
Cortex and Medulla
4
Q
What composes the cortex of the adrenal glands?
A
Zona Glomerulosa
Zona Fasciculata
Zona Reticularis
(GFR on top of kidneys)
5
Q
Describe the pathway of hormone synthesis in the zona Glomerulosa?
A
Cholesterol –> Desoxycorticosterone –> Corticosterone –> 18-Hydroxyxosterone –> Aldosterone
6
Q
What is the main steroid product of the zona glomerulosa?
A
Aldosterone
7
Q
Describe the pathway of hormone synthesis zona fasci?
A
Cholosterol –> Prenolene –> Progesterone –> 17-Hydroxyprogesterone –> 11-Deoxycortisol –> Cortisol
8
Q
What is the main steroid product of the Zona Fasci?
A
Cortisol
9
Q
Describe the pathway of hormone synthesis in the zona reticularis?
A
Cholesterol –> 17-Hydroxypregnenolone –> Dehydroepiandrosterone –> Androstenedione –> Testosterone
10
Q
What cholesterol is used for steroid synthesis?
A
LDL Cholesterol
11
Q
Where is testosterone mainly produced? In Who?
A
Testosterone can be produced in the Zonba reticularis; however, in males, most testosterone is synthesized in the testes
- Little testosterone production in the female ovaries
12
Q
What does cortisol regulate in the body?
A
- Mediate the stress response
- Help regulate metabolism
- Help regulate the inflammatory process
- Help regulate the immune system
13
Q
When is cortisol released? What does it help restore?
A
Cortisol is released in response to stress and also helps to restore hormone levels when stress resolves
14
Q
Describe the physiologic pathway of short term stress?
A
Hypothalmus –> Nerve Impulse –> Spinal Cord –> Preganglionic Symapthetic Fibres –> adrenal Medulla (Secretes amino-acid based hormones) –> Catecholamines (epinephrine and norepinephrine)
15
Q
What is the physiologic response of short term stress?
A
- Increased heart rate
- Increased blood pressure
- Liver converts glycogen to glucose and releases glucose to blood
- Changes in blood floe patterns leading to decreased digestive system activity and urine output
- Increased metabolic rate
- bronchodilation
16
Q
Describe the physiologic pathway of prolonged stress?
A
Stress –> Hypothalamus –> CRH (corticotropin-releasing hormone) –> Corticotroph cells of anterior pituitary –> ACTH –> Adrenal Cortex ( secretes steroid hormones) –> Releases Mineralcorticoids and Glucocorticoids
17
Q
In the long term stress response, mineralcorticoids function to:
A
Retention of sodium and water by kidneys
Increased blood volume and blood pressure
18
Q
In long term stress, glucocorticoids function to:
A
- Proteins and fats converted to glucose or broken down for energy (muscle wasting)
- Increased blood glucose
- Suppression of the immune system
19
Q
What controls the production and secretion of cortisol?
A
HPA Axis
20
Q
What is the main function of the HPA axis?
A
Control the production and secretion of cortisol by the hypothalamus-pituatary-adrenal (HPA) axis
21
Q
Describe the HPA axis pathway?
A
Circadian Regulation and/or stressors (hypoglycemia, hypotension, surgery, fever, injury)
V
Hypothalmus
V
Pituatary (acted on by vasopressin and pro-inflammatory cytokines)
V
ACTH
V
Adrenals
V
Cortisol (exhibits negative inhibition on the hypothalamus and pitautary to inhibit cortisol release)
22
Q
In the HPA axis pathway, cortisol exhibits ________ on the pitauatary and hypothalmus to…..
A
Negative Inhibition
- Inhibits its own release, when cortisol levels are high, the cortisol inhibits further production
23
Q
What are the main actions of glucocorticoids?
A
They suppress inflammatory and immunological responses
24
Q
Describe the basics of inflammation? What are its purposes?
A
- Inflammation is a process whereby WBC’s and other mediators protect against foreign substances
- The inflammatory process serves several purposes initially (e.g. removal of damaged cells) but may eventually become counterproductive (e.g. edema impedes blood flow)
25
Describe the inflammatory response
Stimulus --> Antigen-Antibody Response
V V
Release of Inflammatory Mediators
and
Cell Mobilization --> Increased Capillary Permeability
V V
Edema, Erythema, and Pruritis
26
How do corticosteroids exert an anti-inflammatory effect? (Specific)
- Alter cytokine release
- Blocking increased capillary permeability
- Causing less vasoactive substance release
- Inhibits leukocyte and macrophage migration/adhesion
- Interfering with phagocytosis
27
When corticosteroids are used pharmacologically, they exert an anti-inflmmatory response by..... (Basic)
- Impede the inflammatory process
28
How do corticosteroids exhibit immunosuppressive effects? (specific)
- Alter the cell function of specific genes
- Affect the function of WBC's
- Inhibit T-cell activation
- Inhibit IL's, cytokines, gamma-interferon, and TNF-alpha synthesis
29
What are the actions of corticosteroids?
Anti-inflammatory
Immunosuppressive
Anti-mitotic
Anti-tumour
Anti-emetic
30
How do corticosteroids exhibit anti-mitotic activity? When is this useful?
Inhibit DNA synthesis and epidermal cell turnover
- Useful in psoriasis
31
How do corticosteroids exhibit anti-tumour effects? When is this useful?
May be related to inhibition of glucose transort or induction of cell death in immature lymphocytes
- useful in cancer (used in certain chemo regimens)
32
How do corticosteroids exhibit anti-emetic effects? When would this be beneficial?
May be due to a blockade of cerebral innervation of the emetic center
- Block the emetic effects of chemo therapeutic agents
33
In asthma, what is the standard of care?
Inhaled corticosteroids
34
In atopic dermatitis, what is the standard of care?
Topical corticosteroids
35
In transplant induction, what is standard of care?
All will use a corticosteroid
36
In rheumatoid arthritis, how many in % will a corticosteroid?
- 30-40% will use (up to 75% will use at some time in their life)
37
What are the two types of corticosteroid dosage forms? Examples?
Local Agents:
- Otic
-Opthalmic
-Inhaled
-Topical
Systemic Agents:
- Injectables
-Oral
38
Why would you want to use an agent locally as opposed to systemically?
Fewer side effects
39
Opthalmic and Otic corticosteroids are available as.....
Drops, ointments, emulsions and intravitreal implants
40
In regards to the eyes and ears, corticosteroids often come in combination with.....
Anti-biotics
41
Opthalmic/Otic corticosteroids are used for:
Redness, itching, swelling and pain
42
What is the main issue with opthalmic and otic eye drops?
Correct delievery technique
43
Nasal Inhaled steroids uses:
Rhinitis
Polyps
Sinusitis
44
What is an issue with inhaled nasal corticosteroids?
Installation technique
45
What are the pros and cons of metred-dose inhalers?
Pros - Portability
Cons - Inhalation technique
- Always guessing how many doses are left
46
What are some device pros and cons with dry powders for inhalation?
Pros:
Actuation
Portable
Shows remaining doses
Cons:
Powder despostion in mouth
requires good lung function
Age restrictions (large strong deep breth, children often can’t do this)
47
What is a combo inhaled product composed of? When are they often used?
Corticosteroid and Beta-2 Adrenergic Agonist (LABA)
- Often used in COPD
48
Solutions for inhalation are referred to as:
Nebulizers
49
What is an example of a solution for inhalation?
Budesonide
50
What are some pros of nebulizers?
Reasonable lung delievery when cannot generate sufficient flow rate
Easy for infants (mask)
Young Children
51
What are some cons of nebulizers?
Time consuming (10-15 min/dose)
Expensive
Non-portable equipment
False sense of superiority
52
What are the topical corticoidsteroids dosage forms? What is the rating of their strengths/potency?
Lotions < Creams < Gels < Ointments
53
When are lotions most useful?
Least occlusive, non-greasy
- Useful for axillia, foot, groin, large, hairy areas and acute weeping lesions
54
When are creams useful?
Medium occlusion
- Cosmetically most acceptable
Suitable for non-acute/wet lesions, intertriginous areas (skin folds)
55
When are gels useful?
Non-greasy, non-occlusive
- Quick drying, can apply to face, hairy areas
- Do not leave residue, useful on scalp or hairy areas
- Irritating
56
When are ointments useful?
Most occlusive
- Greasy; for very dry, scaly or hyperkeratized skin area, palms and soles
57
What is the rating scale of corticosteroids? What does each category indicate for usage?
Potency - Scale of 1 -7
Group 1 - Ultra-high Potency
Group 2,3 - High Potency
--> Generally limit to daily-BID dosing and limit length of therapy
--> Avoid use on large areas, thin skin areas, skin folds, and face
--> Caution in young children/infants
--> Suitable for short term intermittent usage (< 2-4 week usage)
Group 4,5 - Mid-potency
--> Suitable for intermittent long-term usage
--> Chronic use in thick skin areas is suitable
--> Avoid on thin skin areas (e.g. face)
Group 6,7 - Low potency
--> Safest in infants, children and elderly or for larger areas or higher risk areas (e.g. face, perianal, eyelids)
--> Caution still required
--> Suitable for maintenance of chronic conditions after initial control obtained
--> often applied BID-QID, less frequent (OD -BID) if ongoing
58
What are the main corticosteroid creams and their respective potency?
Clobetasol propionate 0.05% - 1
Betamethasone Dipropionate 0.05% - 3
Betamethasone Valerate 0.1% (Fucibet: beta 0.1% + fuscidic acid 2%) - 5
Hydrocortisone 2.5% (1% and 0.5% OTC) - 7
59
What are the main corticosteroid ointments and their respective potency?
Clobetasol propionate 0.05% - 1
Betamethasone dipropionate 0.05% - 2
Betamethasone Valerate 0.1% - 3
Betamethasone Valerate 0.05% - 5
Hydrocortisone (1% or 0.5 % OTC) - 7
60
What are the main corticosteroid lotions/solutions and their respective potency?
Clobetasol Propionate (0.05% Scalp Lotion, 0.05% topical spray) - 1
Betamethasone Dipropionate 0.05% Lotion - 3-5
Betamethasone Valerate (0.1% Scalp lotion, 0.1% lotion, 0.05% lotion) - 5-6
61
Non-steroidal corticosteroids:
Tacrolimus, Pimecrolimus - Calcineurin Inhibitor
Crisaborole 2% oint - PDE0- 4 Inhibitor
Roflumilast 0.3% - PDE0-4 Inhibitor
62
What factors influence the cutaneous penetration of corticosteroids?
- Moisture of skin (more absorbed when wet)
- Heat
- Potency of the steroid
- Dosage form
63
What are some forms of dosage forms used for rectal usage? What factor is important in considering what dosage form to use? What sx are they used to tx?
Enemas, Rectal ointments, supposoitories, rectal foams
- Depends on how far you need to go into the colon (ulcerative cholitis vs hemmrhoids)
- For inflammation, itching and discomfort
64
What are the common corticosteroids for enemas?
- Betamethasone
- Budesonide
- Hydrocortisone
65
What is the common corticosteroid for rectal ointments?
Hydrocortisone
66
What is the common corticosteroid for suppositories?
Hydrocortisone
67
What is the common corticosteroid rectal foams?
Hydrocortisone
68
What are the different types of injectable systemic corticosteroids?
Intravenous, Intramuscular, Intralesional, Intra-articular
69
What are examples of intravenous corticosteroids?
Hydrocortisone
Methylprednisolone
70
When is an IV corticosteroid used over another dosage form?
Used when a faster onset or high doses are required
71
What are some examples of intramuscular corticosteroids?
Betamethasone Acetate/sodium phosphate
Dexamethasone Sodium phosphate
Methylprednisolone
Triamcinolone
72
What are the two PK effects of intramuscular corticosteroids?
- Have a delayed onset
- Provide depot effects (sustained action) --> Pain relief varies from person to person
73
What is an example of an intralesional corticosteroids?
Triamcinolone Acetonide
74
What are some examples of an intra-articular corticosteroids?
Triamcinolone
Betamethasone
Methylpredinsolone
75
What is the main difference between intra-articular and intramuscular corticosteroids?
Intra-articular corticosteroids have a quicker onset of action and shorter duration of action
76
What are the usual sites of intra-articular corticosteroid administration?
Hip, knee, ankle, shoulder, elbow, wrist
77
What technique should be used when administering an intra-articular corticosteroid?
Aseptic technique very important
78
How frequently can a joint be injected? Why?
- No firm answer
- No more than 2-4x per year
- Anymore and mechanical disruption in site can cause more damage
79
Describe oral corticosteroid absorption. Result in regards to doasge form?
Exhibit rapid and complete absorption from the gut
Oral doses are equivalent to IV
80
What is the conversion of an IV corticosteroid dose to an oral dose? Why?
Oral doses are equivalent to IV
Exhibit rapid and complete absorption from the gut
81
What are the corticosteroids found in tablets?
Betamethasone
Cortisone
Dexamethasone
Hydrocortisone
Methylprednisolone
Prednisone
Triamcinolone
82
What commercially oral solutions of corticosteroids are available?
Prednisolone (pediapred)
83
What type of oral dosage form is Budesonide found in? What is each one used to treat?
Tablets --> Ulcerative colitis
Capsules --> Chron's Disease
84
Define a physiologic dose. What is a physiological dose used for?
Used to replace deficiencies (what the body will normally produce in a day)
- A dose equivalent to the amount of cortisol excreted by the adrenal cortex per day
85
The amount of cortisol excreted by the adrenal cortex per day is equivalent to _______ prednisone
5 mg of prednisone per day
86
Define pharmacological dose
a dose used to treat disease states and provide supportive therapy
87
What is considered a "low dose" or "maintenance dose"of prednisone?
5-15 mg per day
88
What is considered a "moderate dose" of prednisone?
0.5 mg/kg/day
89
What is considered a high dose of prednisone?
1-3 mg/kg/day
90
What is considered a "high or massive dose" of prednisone?
15-30 mg/kg/day
91
What are the common adverse effects of opthalmic corticosteroids?
- Stinging, redness
- Tearing, burning
- Secondary infection (immune-suppressant, more at risk of infection)
92
What is a more serious a/e of opthlamic corticosteroids?
Formation of cataracts or glaucoma
93
What are some adverse effects of oral inhalation corticosteroids? How can they be minimized?
Oral Thrush
Dry Mouth
Difficulty Swallowing
Dysphoria (voice change)
--> Rinse your mouth out
94
What are some common adverse effects of nasal corticosteroids? How can they be minimized?
Rhinorhhea
Burning
Sneezing
Bloody Nose
-->Point away from nasal septum
95
What are some adverse effects of topical corticosteroids?
- Burning
- Irritation
- Skin atrophy
- Tachyphylaxis (use for long time, effect starts to wear off)
- Telangiectasia (spider veins)
96
What are some systemic complications and adverse effects of oral corticosteroids?
Euphoria
Beign Intercranial HTN
Cataracts
Moon Face with red plethoric cheeks
Buffalo Hump
HTN
Thinning of skin
Increased abdominal fat
Avascular necrosis of femoral head
Easy Bruising
Poor Wound Healing
Thin arms and legs; muscle wasting
97
CNS effects of corticosteroids are real and depend on the ________ (main factor). They may be ______ or _______.
Dose Related
May be Chronic or Acute
98
What are the manifestations of CNS effects of corticosteroids?
Early Phase:
- Euphoria
- Insomnia
- Restlessness
- Memory Impairment
Late Phase: -->: Chronic Usage
- Altered Mood
- Depression
- Mania
- Psychosis
99
Are CNS effects of corticosteroids permanent?
No - When you discontinue this meds, these manifestations will often abide/disappear
100
What are the two worrisome opthalmic adverse effects? Why do these occur? What dosage forms do they occur with?
Cataracts and Glaucoma
--> Corticosteroids cause an increase in intraoccular pressure that may cause or worsen cataracts and glaucoma
- Adverse effects of both topical and oral; however, worse with topical
101
The risk cataracts and glaucoma depend on.....
The dose, strength and length of treatment
102
What are the risk factors for cataracts with corticosteroids? There is an increased risk at what dose and duratio of prednisone? Counselling tip?
- Daily dose, cumulative dose, duration, age
- Increased risk with oral prednisone > 15 mg/d x 1 year
- Long term corticosteroid users should have routine eye exams as damage is irreversible
103
What is the difference between corticosteroid inducaed glaucoma and cataracts?
Cataract damage is irreversible whereas glaucoma (goes away) subsides when agent is d/c
104
What are the risk factors for glaucoma induced by corticosteroids?
- Pre-existing POAG (Glaucoma)
- Diabetes
- Family hx of glaucoma
- RA (Rheumatoid Arthritis)
105
When does glaucoma due to corticosteroids occur? Is the damage irreversible?
- Typically occurs within the first few weeks
- Subsides when agent is d/c
106
Hypercortisolism presents with ___________ features because__________
Cushingoid Features
- Alters normal fat distribution
107
In regards to hypercortisolism, fat distribution presents as......
- Fat redistribution from the periphery to the trunk
108
Can hyperocortilosim occur with corticosteroids?
YES
- Exogenous steroids increase steroid levels
109
Hypercortisolism fat redistribution presents as_________ such as.......
Centripetal Obesity
- Moon Face
- Buffalo Hump
- Protuberant Abdomen
110
Face/Back (Cushingoid Features) occurs when? What does it depend on? Is it permanent?
- Can occur in the first couple months; dose and duration dependent
- Discontinued --> Will often resolve
111
What is a common G.I. adverse effect of corticosteroids? Counselling tip?
Causes G.I. Upset
- Take with food
112
What are some common G.I. adverse effects of oral corticosteroids? Any drug interactions important to realize?
- Dyspepsia
- GI upset
- Increased risk of peptic ulcer disease when used in conjunction with NSAID's (more at increased risk, not uncommon to use both together)
113
What are the main endocrine adverse effects of corticosteroids?
Glucose intolerance
Sodium/water retention
Increased Appetite
114
What is glucose intolerance in regards to corticosteroids? Describe the physiology of how corticosteroids can cause glucose intolerance?
Use of corticosteroids can cause an increase in blood glucose
- Mainly by: increased gluconeogenesis and decreased ultilization of glucose by the tissues
- Also has effects on glucagon (increases) and catecholamines (increases)
115
Glucose intolerance effects severity? Typically are related to what?
- Increases in blood glucose are normally mild
- Typically are dose related
116
Increases in blood glucose are seen with what dose of prednisone?
Doses > or = to 15 mg/day
117
Does corticosteroids only cause an increase in blood glucose in people with diabetes?
- Increase in blood glucose can occur in those with or without diabetes
118
How long does corticosteroid induced elevated BG last for?
- Elevated BG may persist for months upon d/c
119
How does sodium/water retention occur with corticosteroids?
- Occurs due to a variety of actions corticosteroids have on the kidney and vasculature
120
Sodium/water retention is a more common a/e of what corticosteroids?
- corticosteroids with greatest mineralcorticoid activity are most likely to cause fluid retention
121
What are some factors that pre-dispose someone on corticosteroids to sodium/water retention?
- Age
- History of high blood pressure
122
Are sodium/water retention adverse effects permanent?
- Usually resolves upon d/c of corticosteroids
123
Increased appetite due to corticosteroid usage is usually seen with what dose?
High dose therapy
124
In children, what is a primary concern of corticosteroids? What determines these effects?
- All CS's can affect growth patterns in children; the effects are dose-dependent and mainly with oral dosage forms
125
All CS's can affect growth patterns. True or False
True
126
CS's have many effects which could have an effect on growth. Examples include:
Decreasing osteoblasts
Decreased GH secretion
Competitively inhibiting insulin receptors
127
What type of CS's have the most pronounced affect on final height?
- Oral Therapy
128
Are the studies for growth retardation in CS's usage in children profound? What should a pharmacist consider?
- Can occur in kids but good studies are lacking
- Consider the risk:benefit ratio
- Another good reason to use the lowest dose for the shortest duration
129
Compare growth retardation in oral CS's to inhaled CS's. Is inhaled progressive?
- Oral - 4 cm in one study
- Inhaled - Cochran review - 0.5 cm less growth in the first year --> less so in subsequent years, not cumulative, and may not affect final adult height
130
Is CS's growth retardation permenant?
Not necessarily
- May catch up when come off of the steroid
131
What is the HPA axis? What does it do?
- A connection between the brain and adrenal glands
- The body's main stress system
- It releases cortisol to activate a response to stress
132
The human body's main stress system is:
HPA-axis
133
What is the physiologic secretion of the HPA-axis?
Normal Secretion: 10-20 mg/day of cortisol
134
Cortisol secretion follows a ________ cycle
Diurnal
135
When are endogenous levels of cortisol the highest? When is it the lowest?
- Endogenous levels of cortisol are highest at 7-8 am
- Decreases throughout the day and lowest at midnight
136
Does cortisol cortisol secretion fluctuate? If so, when?
- Yes
- In periods of acute stress, there will be increased release (up to 10 fold release)
- i.e. illness, stress, surgery
137
Describe the process of HPA axis suppression.
- The HPA axis is under negative feedback control by endogenous cortisol
- Hence, when exogenous corticosteroids are administered, these cause negative feedback of CRH and ACTH
- Result is the suppression of the HPA axis
138
What is a main counselling tip for oral CS usage?
A patient who is taking enxogenous CS --> This cortisol is being ingested orally --> Disrupts this cycle. --> Inhibits this loop here --> No more CRH and ACTH telling the adrenals to release cortisol --> That is okay as long as people continue to take their corticosteroids
If suddenly under stress, body will not have the capability t produce more when they need more
CANNOT STOP TAKING THE MEDICATION SUDDENLY
Stressful situation --> May require more corticosteroid
139
If HPA-axis suppression is present, what will happen if the steroids are abruptly stopped or if the patient becomes severely ill?
- Hypotension
- Hypoglycemia
- Flue like sx: fatigue, N/V, chills, fever, myalgia
- Weight loss
- Confusion
140
What are some of the factors that predict the occurrence of HPA-axis supression?
- Dose
- Type of steroid
- Interval (10 mg QID does not equal 40 mg OD)
- Duration
-Route
- Time of rhythym (want to follow circadian rhythym - dose it in the morning)
141
In regards to interval of dosing, what is an important point to understand in regards to dosing of CS's?
- There is more HPA axis suppression if dosed throughout the day than once daily
142
When should oral CS's be dosed? Why?
- IN THE MORNING (when endogenous cortisol levels are the highest)
143
In regards to HPA axis supresison, at what doses does it occur for maintenance doses? How long does suppresion last for?
Maintenance Dosing = Long term use
Prednisone:
5-15 mg/day = variable
>15 mg/day = invariably (suppression) occurs
May take weeks to >1 year for HPA-axis to return to normal when d/c chronic steroids
144
In regards to HPA-axis suppression, at what doses does it occur for short term doses?
Maybe:
1 mg/kg/day x 2 weeks
15-40 mg/day x1-4 weeks
No:
15-40mg/day x 5-7 days
145
When is screening for HPA-axis suppression recommended?
- Screening has been recommended for those who take oral CS's for > 2 consecutive weeks or >3 cumulative weeks in the previous 6 months
146
If HPA axis suppression occurs, how long till it fully recovers?
- Between 1 to 3 years after cessation of exogenous steroids
- In order to determine if HPA-axis suppression/recovery, a blood test can be performed: the SST (short Synacthen test) --> Synthetic ACTH given and plasma cortisol levels measured at 0, 30, 60 mins to see if it rises
- NO CLEAR GUIDANCE ON WHEN TO PERFORM HPA-AXIS TESTING --> BASED OFF CLINICAL JUDGEMENT
147
What is the occurence of adrenal insufficiency? Is it easy to predict? What is a recommendation for testing a pt for HPA-axis suppression?
- CS's used by 15 of the population and risk of adrenal insufficiency is 1 to 60%
- Difficult to predict who will be insufficient or not
- Sx's of mild insufficiency are often non-desriptive
- Options; Test, taper and see what happens, or stop and see what happens
- Therefore: pt's with unexplained sx's after steroid withdrawal should be tested for HPA axis suppression
148
In regards to immune system a/e of CS's, what is the main worry? At what doses does this occur?
- Increased susceptibility to infections
- May see increased susceptibility to:
i) Viral Infections (variecella zoster)
ii) Bacterial Infections (Cellulitis)
iii) Fungal infections (candida)
- Typically does not occur in doses <10 mg/day (prednisone) or cumulative dose <700 mg
149
What are some a/e associated with the skin/connective tissue with oral CS's? How does CS's cause these sx?
- Acne (topical and oral)
- Bruising
- Thin Skin - typically rversible (chronic effecr, but will resolve)
- Striae - Not reversible
- Impaired wound healing
- CS's inhibit epidermal cell division and DNA synthesis
150
What are some a/e of CS's associated with bone? When do these a/e occur?
OSTEOPOROSIS
- CS's have multiple effects on bones:
i) Protein catabolism
ii) Osteoblast Inhibition
iii) GH inhibition
iv) Decreased Ca2+ absoprtion
v) Decreased renal calcium reabsorption
- Bone loss with CS's occurs most rapidly in first 3 months and peaks at 6 months
151
Bone loss associated CS's a/e correlate to ________ and ________
Dose and Duration
152
At what doses does risk of bone fracture increase? Duration?
Risk of fracture increases with doses as low as 2.5-7.5 mg/day
Systemic therapy >2-3 months is a major risk factor for bone loss (and fracture)
153
What % of pt's will develop osteoporosis with chronic tx?
- 30-50% will develop osteoporosis with chronic tx
154
In regards to bone health, what is a clinical practice tip that should be brought up to the pt and physician?
- A fracture risk assesment should be performed on all adults initiating or continuing glucocorticoid therapy > or = to 2.5 mg/day for > 3 months
155
What counselling tips should be provided to a pt about protecting bone health? What population?
Adults > or = 40 yrs old at moderate or high risk:
- Optimize Calcium/Vit.D/Lifestyle
- Strongly recommend osteoporosis tx (e.g. with a bisphosphonate - preventative tx)
156
CS's can also cause ________ along with osteoporosis
OSTEONECROSIS
157
What is osteonecrosis? What Increases the risk? When do Sx occur? Counselling?
- Death of bone tissue due to impaired blood supply
- Risk increases with both dose and duration of CS's
- Symptoms usually develop after a few months to a few years
- Long term users should be asked about joint pain/range of motion
158
CS's a/e of muscle? Dose? Sx?
Muscle (myopathy)
- Muscle weakness may occur which may be due to dcreased protein synthesis in the muscle (CS's have catabolic effects)
- More common with prolonged courses of high dose CS's (at prednisone doses > or = to 10 mg/day
- Characterized by arm and leg weakness after several weeks to months of use
159
What are some long term s/e's in kids? When do they occur? What is the most common and serious a/e?
Weight gain (most common)
Growth retardation
Cushingoid features
Infection --> Most serious a/e
At least 15 days of tx
160
What are some short course s/e of CS's in kids? Are serious a/e's common?
- Vomitting (most common a/e for quitting)
- Behavioural changes
- Sleep disturbances
Serious AE's are uncommon
161
Short term use of CS's is most commonly used for:
However, short term use is associated with.....
- Most commonly for: URTI, spinal conditions, allergies, LRTI
- Associated with higher rates of sepsis, VTE, and fracture (even though low dose, low time)
162
Does short term use of CS's mitigate all the risks of them?
NO
163
Do CS's have a role in COVID-19/ If so, which one?
Systemic CS's improve clinical outcomes and decrease mortality in hospitalized patients requiring oxygen
Recommended Dose: DEX 6 mg od for up to 10 days
PHARM 253 Exam 1
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