Steroids

Question 1

RA patient on steroids / immunomodulators

What is a steroid?

Layers of adrenal cortex?

Actions of aldosterone? (mineralocorticoid)

Actions of cortisol?

Draw the hypothalamic Pituitary Adrenal axis?

Answer 1

Organic compound that contains a characteristic arrangement of 4 cycloalkane rings that are joined together.

• Zona glomerulosa: aldosterone

• Zona fasciculata: cortisol

• Zona reticularis: sex hormones

• Na + reabsorption and K + excretion in DCT and collecting ducts

• Water balance: salt and water retention

• Acid base balance: metabolic alkalosis (excretion of K+ )

• Anti-insulin effect: increase blood glucose
• Stimulate gluconeogenesis: increase blood glucose
• Stimulate protein synthesis in the liver
• Stimulate lipolysis
• Metabolic effect as aldosterone
• Anti-inflammatory effect
• Immunosuppressive effect
• Control body stress response

Question 2

Advice to patients starting steroids?

Q: what concern regarding anasthesia in pt of steroids?

Complications of steroids

Answer 2

• They should not stop the drug suddenly. The drug should be tapered off slowly
• Make doctors aware that they are on steroids if they are admitted to hospital or prior to surgery (carry steroid card, wear medic alert bracelet
• There is increased possibility for infection, delayed wound healing

• Steroids may lead to osteoporosis with increased risk of fractures
• Steroids may lead to weight gain
• Steroids increase blood sugar, if diabetic you will encounter poor glycemic control, if not you can develop diabetes
• Steroids can lead to muscle weakness
• Steroids can lead to mood or behaviour changes
• Steroids increase the risk of peptic ulcers; do not take NSAID’s

Addisonian crisis
Chest infections
Electrolyte disturbances (hypokalemia)
DM, HTN

• Opportunistic bacterial and viral infections such as EBV, CMV –> leukemia, lymphoma
• Cushinoid features: obesity, muscle weakness, hirsutism, striae
• Cardiovascular: fluid retention, hypertension
• Endocrine: DM
• Musculoskeletal: osteoporosis, AVN, proximal myopathy

Question 3

Addisonian crisis

Cardinal features?

Management?

Answer 3

Acute reduction of the circulating steroids, primary if adrenal cortisol supply cannot meet body demand, or secondary to trauma, surgery, infection, sudden stop of exogenous steroids.

• Abdominal pain
• Nausea, vomiting
• Unexplained shock
• Hyponatremia, hyperkalemia

• CCRISP protocol
• ABC protocol
• IV steroids – immediate bolus of 100mg hydrocortisone IV or IM, followed by continuous intravenous infusion of 200mg over 24h
• IV fluids – rapid IV infusion of 1L of isotonic saline infusion within the first hour, followed by further IV rehydration as required
• Adjust metabolic disturbances

Question 4

How to prevent Addisonian crisis

Answer 4

If major surgery
Give hydrocortisone 100mg IV at induction f/b immediate infusion of 200mg over 24 hours
which covers both the intraoperative stress and the first 24 hours post-op, while the patient is nil by mouth.
Alternatively 6-8mg dead will cover 24 hours
After the first 24 hours:
“If the patient remains NPO but is stable, we can step down to Hydrocortisone 100 mg per 24 hours (either as continuous IV infusion or 50 mg IM every 6 hours).”
4. When oral intake resumes:
“Once the patient can tolerate orally, we resume the usual pre-surgical oral glucocorticoid dose.
If recovery is uncomplicated, return to the maintenance dose.
If recovery is delayed or stress persists, continue double the oral dose for up to a week before tapering.”

Body surface or intermediate surgery
“Intermediate surgery — 100 mg IV hydrocortisone at induction, 200 mg infusion over 24 hours, then double oral dose for 48 hours before resuming maintenance.”

Bowel procedures requiring laxatives/
enema
Continue normal glucocorticoid dose. Equivalent i.v. dose if prolonged nil by mouth
Treat as per primary adrenal insufficiency if concerned about hypothalamo-pituitary-adrenal axis function, and risk of adrenal insufficiency

Labour and vaginal delivery
Hydrocortisone 100 mg intravenously at onset of labour, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h-‘

Question 5

Correction of Hyperkalemia
Not in notes though

Answer 5

Step 1 – Stabilize the cardiac membrane:
• IV Calcium gluconate (10%) — 10 mL IV over 5–10 min.
→ Protects the heart but doesn’t lower K⁺.
(Repeat if ECG changes persist.)

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Step 2 – Shift potassium into cells:
• Insulin + Dextrose: 10 units regular insulin in 50 mL of 50% dextrose IV over 15–30 min.
• β₂-agonist (Salbutamol nebulization): 10–20 mg.
• Sodium bicarbonate (if acidotic): 50 mmol IV over 5 min.

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Step 3 – Remove potassium from the body:
• Loop diuretics (Furosemide): promotes renal excretion.
• Cation-exchange resins (Calcium resonium): oral or rectal.
• Hemodialysis: in refractory or severe cases, or renal failure.