Corticosteroids in Practice

Give an example of a mineralcorticoid

Fludrocortisone

What is the brand name of Fludrocortisone?

Florinef

What are indications for mineralcorticoids?

Replacement for adrenocortical insufficiency (Addison’s disease)

salt-losing syndrome (increases NA reabsorption)

Unlabeled: Severe orthostatic hypotension

What is the MOA of mineralocorticoids?

Causes Na resorption → increase in BP

mimics aldosterone

What are AE of mineralocorticoids?

fluid imbalance

hypokalemia (K wasting)

edema

Increase in BP

CHF

What is a normal daily dose for fludrocortisone?

0\.1 - 0.2 mg PO daily

What is the MOA of glucocorticoids?

binds to intracellular receptors & alters protein synthesis

inhibit leukocyte traffic & access to site of inflammation

When are glucocorticoids or steroids indicated?

any disease involving inflammation

Rheum dis, Respiratory dis, renal dis, GI dis, hepatic dis, MS, ect

What are the 4 most common routes of administration for steroids?

1. oral
2. IV
3. topical
4. intra-articular

When are topical glucocorticoids indicated?

Psoriasis, eczema, atopic dermatitis, vitiligo, contact dermatitis, ect

When would a low potency glucocorticoid be appropriate?

thin skin

acute inflammatory lesions (diaper rash/eczema behind ear)

What is the main SE of topical glucocorticoids?

skin atrophy

acne

abnormal pigmentation

purpura (broken blood vessels)

delayed skin healing

photosensitivity

infection\* - fungal

When would a medium or high potency topical glucocorticoid be used?

Chronic use

Hyperkeratotic (thick skin)

lichenified lesions

What are 3 very high potency options for glucocorticoids?

Clobetasol propionate

halobetasol propionate

betamethasone dipropionate

Strength: 0.05%

What are high potency options for glucocorticoids?

Bertamethasone dipropionate/valerate

Fluocinonide

triamcinolone acetonide

Strength: 0.2- 0.05%

What are low potency options for glucocorticoids?

Dexamethason, flucinolone, hydrocortisone (OTC)

strength: 2.5-0.01%

When would an ointment be appropriate?

thick lichenified lesion, enhance penetration drug

“meaty plaques”

When would a cream be appropriate?

acute and subacute dermatoses; moist skin and interiginous areas

rash in groin/ under boobas

When would solutions, gels & sprays be appropriate?

Scalp, where non-oil based vehicles are needed

How long should medium-high to very high potent topicals be used?

< 3 weeks

irreversible skin atrophy

How long should a medium potency in areas of thin skin be used?

less than 2 weeks

\

How long and what product should be used for diaper rash?

lowest potency for 3-7 days

With chronic use how should treatment proceed?

intermittent treatment preferred

every other day, weekends only

What are the 2 short-acting oral glucocorticoid options, their T 1/2 life, and potency?

Cortisone

Hydrocortisone

T 1/2: 8-12 hrs

GC

What are the 2 intermediate acting oral glucocorticoid options, their T 1/2 life, with greater glucocorticoid activity than mineralocorticoid?

Prednisone

Prednisolone

T 1/2: 18-36 hrs

GC>>>MC

What are the 2 intermediate acting oral glucocorticoids that express glucocorticoid activity?

Methylprednisone

Triamcinolone

T 1/2: 18-36 hrs

What are the 2 long acting oral glucocorticoids, their T 1/2 life, and their potency?

Dexamethasone

Betamethasone

T 1/2: 36-54 hrs

GC

What is the conversion ratio of prednisone to methylprednisone?

5:4

When is a taper required for oral glucocorticoids?

if received therapy >2 weeks AND doses >20mg/day

When should oral glucocorticoids be taken?

the morning to mimic normal cycle

can cause insomina

What is considered low dose therapy, when is it used, and what AE are there?

What is split daily dosing used, what are the AE?

rapid control of active disease

dose dependent, increase in AE

What is a medium dose of oral corticosteroids, when is it used, and what are the AE?

>7.5 mg to

Approximately how much prednisone do we naturally produce per day?

5 mg of prednisone

For RA patients what is the highest dose of prednisone they should recieve?

20 mg

What is a high dose of oral corticosteroids, when it is used, and the AE?

>30 to

What is a very high dose of oral corticosteroids, when is it used, and the AE?

> 100mg

acute disease/exacerbations, usually inpt or hospital

Tx must be short-term, dramatic SE

* in outpt >100 mg not give esp if pt never had it before
* should live in a bubble bc high risk of infection
* CNS effects (psychosis, insomnia, depression)

What is a IV pulse therapy of corticosteroids, when is it used, and the AE?

>250 mg for one or a few days

sever/ life-threating disease

low incidence of AE

When converting to alterante-day dosing what is generally the rule of thumb?

2\.5-3x the minimal daily dose

requires gradual increase in on days with concurrent decrease on off day dose

Give an example of a split day dosing pack?

Medrol dosepak (methylprednisolone)

When is it okay to stop glucocorticoid therapy without a taper?

Short term (

Give examples of tapering schedules for long-term therapy?

decrease by 2.5-5mg q 3-7 weeks

decrease by 2.5 mg q 1-2 weeks

decrease by 5 mg q 1-2 weeks if alternate day dosing

How can we minimize risk of HPA axis suppression when tapering glucocorticoids?

Use lowest effect dose

administer in the morning (prevent insomnia)

alternate-day dosing when appropriate

D/C therapy ASAP

What corticosteroids is more common in oncology?

Dexamethasone

no taper when used for nausea

What corticosteroids are more common in rheum?

prednisone and methylprednisolone

What are early manifestations of systemic adverse effects from systemic glucocorticoids?

Insomnia

Enhanced appetite

Weight gain

Emotional liability

Leukocytosis

Hyperglycemia

What are sustained AE of systemic glucocorticoid therapy?

Cushingoid habitus

HPA suppression

Infection

Osteoporosis

Impaired wound healing

What are delayed AE of systemic glucocorticoid therapy?

Osteonecrosis

Ecchymosis (bruising)

Cataracts

Growth retardation

Fatty liver

\*Atherosclerosis

What are rare AE of systemic glucocorticoid therapy?

Psychosis

Glaucoma

Pancreatitis

Pseudotumor cerebri

What are counter indications for glucocorticoid therapy?

Live vaccines (>20mg of prednisone for more than 2 weeks do NOT)

systemic fungal infections → PCP prophylaxis w/ high doses of Bactrium

Hypersensitivity

What are some warnings for glucocorticoid use?

Active infections

DM

Osteoporosis

Peptic ulcer

Electrolyte imbalances

Stress, Trauma, or surgery

HPA suppression

What drug causes reduced elimination and metabolism of prednisone?

Ketoconazole (strong CYP 3A4 inhibitor)

What drugs causes increased elimination and metabolism of prednisone?

Phenytoin

Carbamazepine

Rifampin

Phenobarbital

What should be monitored if the patient is on Furosemide and glucocorticoids?

Check Potassium (K)

What should be monitored with concurrent Amphotericin B and glucocorticoids?

Check Potassium (K)

What occurs with concurrent use of glucocorticoids and aspirin?

may decrease serum aspirin levels

What should be monitored during glucocorticoid therapy?

Labs (glucose, electrolytes, WBC)

Stool test for occult blood loss

DEXA scan

Growth & development

blood pressure

Ophthalmologic exams

What should a patient do if they miss a dose?

Daily: take ASAP (skip if close to next dose)

QOD: take ASAP, ski that day and take the next morning

When does glucocorticoid-induced osteoporosis occur and when should they be treated?

w/in first 6-12 months of therapy

decrease bone formation w/ increase bone resorption

osteoporosis trxt may be needed for prednisone doses btwn (5-7.5mg daily)

What is the target supplementation of Vitamin D and Calcium in adults taking> 2.5/day for > 3 months?

Calcium: 800-1000mg/day

Vitamin D: 600-800 mg/day

What is the next step if supplementation of Calcium and Vitamin D is not enough to prevent glucocorticoid-induced osteoporosis?

Oral bisphosphonates (moderate to high risk)

Alendronate, ibandronate → stand 1 hr after & take with empty stomach and water