glucocorticoids

two types of corticosteroids and what each do

Mineralocorticoids - modulate Na+ & water balance

Glucocorticoids - influence CHO metabolism/other processes

Physiologic vs. Pharmacologic Effects

• Physiologic/Endogenous: treats endocrine disease and used for replacement for cortisol insufficiency (addison’s); in low doses its non-toxic

• pharmacologic: treats other conditions; suppressing inflammations; in high doses its toxic

what does high dose GC use cause

withdrawal symptoms and intense side effects

what is low dose GC use for 

physiologic replacement ~ primary endocrine disease more so for the Lack of cortisol

physiologic effects of glucocorticoids

1. metabolic 

2. cardiovascular

3. stress

4. water and electrolytes* (mineralocorticoid effects) [Most glucocorticoids have minimal mineralocorticoid activity] 

explain Glucocorticoid Effects: Metabolic

• affect carb metabolism which increases glucose 

• suppress protein synthesis 

• stimulate fat breakdown to cause redistribution in long term use which is cushing syndrome

explain Glucocorticoid Effects: cardiovascular

inc circulating RBCs and dec WBCs

explain Glucocorticoid Effects: stress

maintain bp and glucose levels

explain Glucocorticoid Effects: water and electrolytes

• Na/H20 retention 

• K excretion

• Ca excretion (bone density)  

ALL THREE OF THESE ARE THE MINERALOCORTICOID EFFECTS 

what are the 3 actions of glucocorticoids

1. Inhibit synthesis of chemical mediators like (prostaglandins, leukotrienes, histamine) → reduce inflammation/pain

2. Suppress phagocyte infiltration → reduce inflammation/pain

3. suppress lymphocyte proliferation → immunosuppressive effect

THESE ARE ALL NOT TOXICS AT PHYSIOLOGIC DOSE

Ex. adrenal insufficeny (addisions disease) mean low dose for replacement purposes only  

treatment goal for glucocorticoids

• pharmacologic dosing can cause severe toxicity in higher doses

• goal: create a therapeutic effect while keeping effect to a minimum 

• we want to produce a anti inflammatory and immunosuppressive effect 

what non endocrine conditions do pharmacologic treat 

1. Autoimmune (RA, SLE, MS, SLE)

2. Respiratory (Asthma, COPD)

3. Inflammatory Bowel Disease

4. Oncology (Leukemia, hodgkin’s Lymphoma)

5. Skin Conditions, Allergic Reactions BUT NOT ANAPHYLAXIS 

6. Head and Spinal Cord Injury

7. Suppression of Allograft Rejection (Transplant)

adverse effects of pharmacological use

1. iatrogenic Cushing Syndrome → buffalo hump, moon face, truncal obesity

2. Hyperglycemia

3. Gl Issues (Peptic Ulcer Disease) [High Risk for GI Ulceration and Bleeding esp w/ other medications]

4. Fluid / Electrolyte Imbalance (Na+/H2O Retention, K+ Loss)

5. Osteoporosis (LT Systemic Use)

6. Myopathy, Muscle Wasting

7. Increased Infection Risk (CAN MASK SIGN)

8. Ocular Issues (Cataracts, Glaucoma)

9. Delayed Wound Healing

10. Adrenal Insufficiency (If Discontinued Abruptly)

GC precautions with pt who have what medical conditions and w/ what drug interactions 

• HTN, Heart Failure, Renal Impairment

• DM, Osteoporosis, Glaucoma

• PUD / Gastritis

• K+ depleting diuretics like furosemide, tza

  • cause hypokalemia

• digoxin 

  • inc risk for toxicity/dysrhythmias

• NSAIDs

  • inc risk for GI bleeds

• insulin 

  • inc dose is needed to dec blood sugar

GC contradictions (a condition that makes a particular drug unsafe)

Systemic fungal infections

why should we taper GC

to dec adrenal suppression/crisis

GC route and examples of each

• systemic 

PO: Prednisone (Deltasone), Cortisone, hydrocortisone, prednisolone

IV : dexamethasone (Decadron)

• local:

Joint SONE: betamethaSONE, hydrocortiSONE, dexamethaSONE

topical: Triamcinolone, hydrocortisone

Inhalation: asthma, emphysema

-(MDI) Metered-Dose Inhaler (beclomethasone)

-(DPI) fluticasone

what are 4 general dosing guidelines

1. Highly Individualized, start low go slow (unless emergency)

2. Local Use Preferred Over Systemic→ fewer SE 

3. Take Before 9 AM (Mimic Diurnal Variation of cortisol)

4. Take w/ food/milk → dec GI effects 

5. TAPERRRRRR → PREVENT WITHDRAWAL AND ADREANAL INSUFFICIENCY (also do alt day therapy to reduce supression)

GC nurs considerations 

1. Id high risk pt and monitor for glucose 

2. 9am admin 

3. k+ supplements 

4. stomach protection with anti ulcer meds 

5. TAPERRRRR

6. prevent osteoporosis by bone density scan, Ca/vita D, (calcitonin and Bisphosphonate to prevent bone breakdown)

7. prevent/monitor for infection 

8. teach s/s of fluid/electrolyte imbalance

9. weekly weights→ notify if 5+ lbs