Steroids

Steroids MOA

• Increase blood glucose

  • gluconeogenesis

  • counteracting with insulin

• Increase sodium and water retention

• Regulate/ Suppress the immune system

2 Major types of exogenous corticosteroids

• Glucocorticoids

  • anti-inflamatory

  • ex: Dexamethasone

• Mineralocorticoids

  • Sodium and water retention, increase BP

  • ex: Hydrocortisone

Mineralocorticoid Effects

Aldosterone like effects

• increase serum sodium

• increase water retention

• increase blood pressure

Mineralocorticoid Indicatione

Hypotension (sever)

• septic shock

Ant-inflammatory corticosteroids effects

• Inhibition of lymphocyte proliferations

  • T cells

  • B cells

• Inhibition of interleukin production

• Inhibition of capillary permeability to leukocytes

• Inhibit prostaglandin production

• Reduce the inflammation

Corticosteroids in Least to most Relative Anti-inflammatory Activity

Cortisone: 0.5

Hydrocortisone: 1.0

Prednisone: 4.0

Prednisolone: 4.0

Triamcinolone: 5.0

Methylprednisolone: 5.0

Betamethasone: 25

Dexamethasone: 25-30

Corticosteroid Relative Mineralocorticoid Activity

Cortisone: 0.8

Hydrocortisone: 1.0

Prednisone: 0.8

Prednisolone: 0.8

Triamcinolone: 0

Methylprednisolone: 0

Betamethasone: 0

Dexamethasone: 0

Corticosteroids Indications

Autoimmune diseases

• Rheumatoid arthritis

• Sjorgen’s disease

• Post - organ transplantation

• Anaphylactic reactions

• Asthma

• Allergic rhinitis

• Traumatic injuries and inflammation

• Shock and critically ill pts

• Post traumatic/ surgical treatment: to reduce the inflammation

  • removal of impacted mand. molar tooth

Steroid ADR: Cardiovascular

Hypertension

• water and sodium retention

• inhibition of prostaglandin synthesis

• increase renal excretion of potassium

• short term effect, reversible

Steroid ADR: Infections

• due to impaired cell mediated immunity

• both T & B cells are affected

• more w/ cumulative dose

  • bacterial, fungal and viral infections

Steroid ADR: GI

• gastrointestinal perforations, fistulas

• oropharyngeal and esophageal candidiasis

  • common in post- transplant pt if no appropriate prophylactic regimen

• Peptic Ulcer Disease (PUD)

  • due to inhibition of prostaglandin synthesis

  • cumulative dose

  • risk factors: concurrent NSAID use

Steroid Induced Osteoporosis

• decrease calcium GI absorption

• increase calcium renal excretion

• decrease androgen and estrogen production

• inhibition of osteoblasts proliferation

• inhibition of osteocytes proliferation and induction their apoptosis

• stimulation of osteoclasts bone resorption activities

prevention of corticosteroid induced osteoporosis

Calcium vitamin/ supplements

Steroid ADRs: Ophthalmic

Glaucoma

• increase intraocular pressure (IOP)

• dose and duration dependent

• most common with: betamethasone, dexamethasone

• mod: prednisone

• lease: hydrocortisone

• reversible except for the optic nerve damage

Cataract

• irreversible: surgery correction

Steroid ADRs: Dermatological

• Acne: disappear w/ discontinuation

• cutaneous and subcutaneous atrophy

• delayed wound healing

Steroids: Cushing Syndrome

Caused by high doses over long period of time

• redistribution of body fat

  • dorsocervical and supraclavicular

  • moon facing

  • central obesity

  • poor wound healing

  • easily bruising

  • hypertension

Prevention: follow up, monitor, evaluate indication and consider discontinuation if possible

Steroids: Adrenal suppresion

• HPA axis suppression: reduced cortisol response

• High dose steroids more than a week

• In many pts both cushing’s and adrenal suppression

• Prevention: tapering off meds