Steroids

1.) Adrenocorticosteroids are released from the:

a) Hypothalamus

b) Adrenal cortex

c) Kidneys

d) Pituitary gland

a) Hypothalamus

b) Adrenal cortex

c) Kidneys

d) Pituitary gland

2.) Adrenocorticotropin hormone (ACTH) is produced by the:

a) hypothalamus

b) adrenal cortex

c) kidneys

d) pituitary gland

a) hypothalamus

b) adrenal cortex

c) kidneys

d) pituitary gland

3.) Deficiency of adrenocorticosteroids is termed:

a) Addison disease

b) Adrenal crisis

c) Grave's disease

d) Cushing syndrome

a) Addison disease

b) Adrenal crisis

c) Grave's disease

d) Cushing syndrome

4.) Patients taking corticosteroids may have mucosal surfaces that are more _____ than other patients

a) stippled

b) fragile

c) pigmented

d) keratinized

a) stippled

b) fragile

c) pigmented

d) keratinized

5.) The most extensive use of corticosteroids is in the treatment of:

a) psychosis

b) osteoporosis

c) cancer chemotherapy

d) inflammatory and allergic conditions

a) psychosis

b) osteoporosis

c) cancer chemotherapy

d) inflammatory and allergic conditions

6.) For which type of oral lesion would glucocorticoids be contraindicated?

a) Erythema multiforme

b) Pemphigus vulgaris

c) Herpes labialis

d) Desquamative gingivitis

a) Erythema multiforme

b) Pemphigus vulgaris

c) Herpes labialis

d) Desquamative gingivitis

7.) Corticosteroids may mask the symptoms of an infection because corticosteroids increase a patient’s ability to fight infection.

a) Both the statement and reason are false

b) The statement is false and the reason is true

c) Both the statement and reason are true

d) The statement is true and the reason is false

a) Both the statement and reason are false

b) The statement is false and the reason is true

c) Both the statement and reason are true

d) The statement is true and the reason is false

8.) Once adrenal suppression occurs, the adrenal gland will never respond normally again.

a) True

b) False

a) True

b) False

9.) Most dental patients taking steroids who are having normal dental treatment rendered do not need additional corticosteroids

a) True

b) False

a) True

b) False

10.) Which of the following conditions may be exacerbated by corticosteroid use? (CHOOSE 4)

a) Hypertension

b) Hyperglycemia

c) Peptic ulcers

d) Hypotension

e) Osteoporosis

f) Hypoglycemia

a) Hypertension

b) Hyperglycemia

c) Peptic ulcers

d) Hypotension

e) Osteoporosis

f) Hypoglycemia

Which 2 endocrine glands control the production of adrenal hormones?

a.

b.

Which 2 endocrine glands control the production of adrenal hormones?

a. hypothalamus

b. pituitary gland

Where are the adrenal glands?

on top of the kidneys

A stimulus causes the _______________ to produce ______________________________ which then stimulates the ___________ gland to secrete ____________________________ which enters the bloodstream and stimulates the ___________ glands to release ____________ which then acts on the __________ gland to inhibit the release of _________ and the hypothalamus to inhibit the release of __________.

A stimulus causes the hypothalamus to produce CRH (corticotropin-releasing hormone) which then stimulates the pituitary gland to secrete ACTH (adrenocorticotropin hormone) which enters the bloodstream and stimulates the adrenal glands to release cortisol which then acts on the pituitary gland to inhibit the release of CRH and the hypothalamus to inhibit the release of ACTH.

Exogenous steroids inhibit the release of ________ and __________.

Exogenous steroids inhibit the release of CRH and ACTH.

The 2 main steroids produced in the body are _______________ and ________________.

The 2 main steroids produced in the body are mineralocorticoids and glucocorticoids.

Adrenal deficiency is called _____________________.

Adrenal deficiency is called Addison Disease.

Adrenal excess is called ______________________.

Adrenal excess is called Cushing Syndrome.

Name 4 drugs that will decrease steroid levels if taken concurrently:

a.

b.

c.

d.

Name 4 drugs that will decrease steroid levels if taken concurrently:

a. Carbamazepine (Tegretol)

b. Phenobarbital

c. Phenytoin (Dilantin)

d. Rifampin

Glucocorticosteroids are anti-_______________ and suppress the ______________ system.

Glucocorticosteroids are anti-inflammatory and suppress the immune system.

List 6 adverse effects of steroids:

a.

b.

c.

d.

e.

f.

List 6 adverse effects of steroids:

a. suppression of normal adrenal gland function

b. osteoporosis

c. hyperglycemia

d. hypertension

e. peptic ulcers

f. immune suppression, candidiasis, poor wound healing

What are the symptoms of rapid steroid withdrawal?

headache, fatigue, joint pain, nausea, vomiting, weight loss, fever, peeling of skin

TRUE or FALSE: Topical steroids are absorbed systemically.

TRUE

Diabetic patients may experience _________________ while taking steroids and may need additional ____________.

Diabetic patients may experience hyperglycemia while taking steroids and may need additional insulin.

_______________________________________ can happen with HIGH doses of steroids.

Adrenal insufficiency / Adrenal Crisis with atrophy of adrenal glands can happen with HIGH doses of steroids.

Hormone Production and Regulation: Endogenous Steroids

Regulation: hypothalamus and pituitary gland

• feedback loop: the hypothalamus and pituitary gland sense the amount of hormone in the blood and reduce/increase production of respective hormones to maintain balance (regulate hormones) in the bloodstream

Production: adrenal glands (produce endogenous steroid hormones)

• Endogenous steroids:

  • CRH: corticotropin-releasing hormone

  • ACTH: adrenocorticotropin hormone

  • Cortisol

• stimulus (e.g. stress) → hypothalamus produces CRH → pituitary gland secretes ACTH → adrenal glands release cortisol → acts on pituitary gland to inhibit release of CRH and hypothalamus to inhibit ACTH

Adrenocorticosteroids: Exogenous Steroids

Exogenous steroids act in the same way as cortisol by inhibiting the release of endogenous CRH and ACTH.

• long-term administration of endogenous steroids → suppression of ACTH release & atrophy of adrenal glands

  • Cushing Syndrome (long-term use of steroids; excessive steroids cause moon face, buffalo hump, truncal obesity, weight gain, muscle wasting)

• abrupt stop of exogenous steroids → steroid deficiency → adrenal crisis / Addison’s Disease

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Exogenous steroids are used topically, locally, and systemically for the treatment of inflammatory conditions.

• 2 Main Types:

  1. Mineralocorticoids (primarily aldosterone)

  2. Glucocorticoids

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Steroid Diseases:

• Addison Disease: DEFICIENCY of adrenocorticosteroids

• Cushing Syndrome: EXCESS of adrenocorticosteroids

Mineralocorticoids

Aldosterone: the primary mineralocorticoid that regulates fluid and electrolyte balance

• acts in the kidneys to regulate:

  • reabsorption of Na

  • excretion of K

  • water retention

  • BP (renin-angiotensin-aldosterone system)

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Exogenous Mineralocorticoids:

Fludrocortisone (Florinef): used for mineralocorticoid replacement in hypoadrenalism

Glucocorticoids

Glucocorticosteroids: produced in the adrenal cortex and have powerful anti-inflammatory and immunosuppressive effects

• control inflammation by stabilizing cells so that they do not release inflammatory initiators (still an unclear mechanism of action)

  • inhibit phospholipase A₂ → an enzyme that breaks arachidonic acid off of membrane phospholipids in pain response

  • increases neutrophils

  • decreases lymphocytes, monocytes, eosinophils, basophils → all WBCs

  • inhibits interleukin-2 → a cytokine that signals the immune system

  • inhibits histamine release → a hormone that promotes inflammation

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Exogenous Glucocorticoids

• Uses: palliative (NOT curative)

  • oral lesions: lichen planus, burning tongue, aphthous stomatitis, pemphigus vulgaris, erythema multiforme

  • long-term therapy for chronic systemic diseases: asthma, arthritis, COPD, allergic reactions, skin conditions (psoriasis, eczema, etc.)

• Administration: topical, oral, IM, IV

• Classified according to duration of action and degree of anti-inflammatory effects:

  • short-acting, intermediate-acting, long-acting

  • least anti-inflammatory: hydrocortisone (OTC)

  • most potent anti-inflammatory: betamethasone and dexamethasone

• Examples:

  • Hydrocortisone (Cortisol)

  • Prednisone (Deltasone)

  • Methylprednisolone (Medrol)

  • Triamcinolone (Kenalog)

  • Triamcinolone (Nasacort)

  • Mometasone (Nasonex)

  • Fluticasone (Flonase)

  • Fluticasone (Flovent)

  • Budesonide (Rhinocort)

Glucocorticosteroids: Adverse Effects, Drug Interactions

Adverse Effects: proportional to dose, frequency, time of administration, and duration

• hyperglycemia, especially in prediabetics (affects glucose metabolism)

  • causes breakdown of proteins and lipids into glucose → carbs are stored as glycogen to be converted back to glucose and deposited into the blood → high blood glucose levels

  • diabetics will need ADDITIONAL INSULIN when taking exogenous steroids

• immune suppression → opportunistic infections, masked symptoms

  • activation of latent TB with long-term glucocorticoid therapy → pts are given isoniazid

  • poor wound healing

  • candidiasis

• CNS effects: behavioral/personality changes; increasing doses: euphoria, agitation, psychoses; decreasing doses: depression

• suppression of normal adrenal gland function OR shutdown of adrenal glands (long-term use/abrupt discontinuation) → withdrawal OR Adrenal Crisis / Addison’s Disease

• Cushing Syndrome (long-term use of steroids; excessive steroids cause moon face, buffalo hump, truncal obesity, weight gain, muscle wasting)

• osteoporosis

• HTN

• peptic ulcers

Drug Interactions: decreased steroid levels when taken with…

• carbamazepine (Tegretol) (an anticonvulsant)

• phenobarbital (a barbiturate)

• phenytoin (Dilantin) (an anticonvulsant)

• Rifampin (an antibiotic used for TB)

Corticosteroid Withdrawal

• rapid withdrawal → headache, fatigue, joint pain, nausea, vomiting, weight loss, fever, peeling of skin

• HIGH-DOSE CHRONIC THERAPY (> 20 mg/day) IS ASSOCIATED WITH ADRENAL INSUFFICIENCY → corticosteroid replacement may be needed during periods of STRESS (extractions, perio surgery, implants, incision/drainage of infections, extensive restorations, etc.)

• Rule of Two’s (too conservative and not recommended)

  • 20mg cortisone/day for

  • 2 wks

  • within the last 2 yrs

  • the pt is at risk of Adrenal Crisis

Topical Glucocorticosteroids

Classified by potency (hydrocortisone is the LEAST potent and best to use in infants/children due to minimal systemic absorption)

• OTC topical: hydrocortisone 0.5% and 1%

• Dental Use:

  • Orabase with HCA (topical steroid for dentistry)

  • High Potency: fluocinonide gel 0.05% (Lidex, Lidex-E), clobetasol propionate 0.05% (Temovate)

  • Dexamethasone 0.5mg/5mL Oral Solution: 10mL (1mg) swished for 2 mins, 4x daily for 8 wks

Uses:

• skin/oral lesions: aphthous stomatitis, vesiculo-bullous diseases, burning mouth/tongue, ear/nose/throat conditions