clinical corticosteroids and cushings

cause of hypersecretion of glucocorticoids

adrenal hyperfunction

causes of adrenal hyperfunction(4)

-more common in women

-overproduction of ACTH (adenocorticotropic hormone)

-ACTH-independant adrenal corticol tumour

-rare ectopic CRH-secreting tumour

2 causes of overproduction of ACTH and which is more common

-pituitary disease (80%)

-ectopic ACTH-secreting tumour

what do causes of adrenal hyperfunction cause (3)

hypercortisolism/cushing’s disease/cushing’s syndrome

primary difference between cushing’s disease and cushing’s syndrome in terms of their causes

-disease- associated with excess pituitary ACTH secretion(hypercortisolism)

-syndrome- can be caused by other tumours or prolonged glucocorticoid therapy

what do both ACTH-dependant and independant causes of adrenal hyperfunction produce

hypercortisolism

what pattern of cortisol levels is seen in plasma and urine for cushing’s disease/syndrome?

high plasma and urine cortisol with loss of diurnal variation

how do plasma ACTH levels differ between a pituitary/ectopic ACTH-secreting tumour vs an adrenal tumour

plasma ACTH levels are HIGH if due to pituitary/ectopic acth-secreting tumour (low cortisol) and LOW/undetectable if due to adrenal tumour (high cortisol)

diagnostic tests for hypersecretion (3)

-measure cortisol in fluids

-’overnight dexamethasone suppression test’

-metyrapone

in what fluids(3) is cortisol measured to test for hypersecretion and when are levels especially high?

-blood urine saliva

-levels high especially in evening/nigh (midnight test)

how does the ‘overnight dexamethasone suppression test’ work?

normally it inhibits cortisol production for 24 hours (would not work with hypersecretion/cushings)

what is metyrapone and what is its normal effect on cortisol production

-competitive inhibitor of 11b hydroxylase

-normally inhibits cortisol production (would not with hypersecretion/cushings)

some features of cushing’s disease/syndrome

-moon face

-red cheeks

-skinny arms and legs, increased abdominal fat (fat distributed here)

-obesity

-thinning of skin

-buffalo hump

-osteoporosis

what’s the primary surgical treatment for cushing’s disease/syndrome(3) and what follows it?

surgical removal of the pituitary or ectopic (lung) or adrenal tumour plus corticosteroid replacement therapy for life (with gradual discontinuation of synthetic glucocorticoids)

when and how is metyrapone used in patients with cushing’s

given orally

used in patients with ectopic ACTH-secreting tumours (eg bronchial carcinomas) that aren’t amendable to surgery

also used to control symptoms before surgery

common side effects with metyrapone

nausea, vomiting, dizziness, headache, hypotension, sedation

what is osilodrostat, how is it administered, whats it specifically for and what specific pt population requires extra care

-11bhydroxylase inhibitor oral

indicated for endogenous cusings disease only

patients of asian origin

what is ketoconazole, hows it given, whats it specifically for and mech of action

oral anti-fungal

endogenous cushing’s disease

inhibits several steroid synthesis enzymes

what is pasireotide, hows it administered and when is it used

somatostatin analogue, administered via subcutaneous or intramuscular (s.c,i.m) routes and used when surgery has failed or is inappropiate

side effects of corticosteroids (7) see more deets for each side effect on slides

central serous chorioretinopathy(CSC) - retinal disorder

elevation of plasma glucose

osteoporosis

growth retardation in children

immunosuppression

psychiatric reactions

adrenal suppression

advice for pts taking corticosteroids via any route in terms of CSC

report any blurred vision/other visual disturbances

what does high blood glucose trigger in those with low pancreas reserve + why is blood glucose high? (2)

type 2 diabetes

increased gluconeogenesis and insulin antagonism

patients on corticosteroids and with type 1 diabetes and at risk of diabetes need to…

monitor carefully/observe

patients on corticosteroids and with type 2 diabetes may need…

drug doses adjusted

what happens in osteoporosis

increased osteoclast, decreased osteoblast activity and reduced calcium absorption

who should be considered for bone-protective therapy (3)

women and men 70 or over or

with previous fragility fracture or

taking high doses of glucocorticoids (7.5mg or more of prednisolone)

what if not eligible for bone-protective therapy

fracture probability (incl. premeno women and younger men)

what to take for osteoporosis

bisphosphates, calcium and vit d WITH HRT for women/testosterone for men

when is growth retardation in children seen

high doses inhaled steroids for asthma/low doses for systemic administration

what infectious diseases in particular should be avoided (immunosuppression)

-chickenpox/shingles

-measles

what to give patient if never had chickenpox/not immune

passive immunisation with varicella-zoster immunoglobulin

measles - what to use for prophylaxis

normal immunoglobulin

what to do with dose if patient experiences psychiatric reactions

reduce dose/discontinue steroid

in terms of psychiatric reactions, who should we take care prescribing high doses of systemic corticosteroids to

those with a past history of psychiatric reactions including family history

adrenal suppression - 2 weeks of treatment

not an issue, after 2 weeks, body is able to quickly recover and steroid production continues

adrenal suppression - after 3 weeks of treatment, what happens to adrenal cortex and what does this cause. what is pt at risk of if they stop steroids suddenly after this timeframe has passed?

adrenal cortex shrinks, endogenous steroid production stops

adrenal crisis

is aldosterone production affected by long term steroids and why

aldosterone production is mainly controlled by angiotensin II and Na+

adrenal crisis treatments to be given asap

i.v hydrocortisone

i.v saline for CV system

what to do with pt with infection on steroids

steroid may need increasing (suggest double dose in times of ‘stress’)

what to do about risk of drastic fall in BP during/after op (2) (they’re on steroids)

-EXTRA dose of hydrocortisone as pre-med

-EXTRA doses of hydrocortisone in following 2-3 days

what to do about pt on steroids and vomitting

may need i.v hydrocortisone

when is gradual withdrawal of corticosteroid treatment required

if course is OVER 3 weeks

why is gradual withdrawal of treatment required if course is longer than 3 weeks (2)

-prevents flare up of disease

-prevents withdrawal symptoms

examples of stress (3)

infection, trauma, surgery

what to do if pt experiences stress after stopping corticosteroid n why (up to 3 mnths later and or taking 10mg prednisolone)

additional corticosteroid cover is needed to compensate for any potential adrenal suppression

when is steroid (blue) treatment card required

long term (over 3 week) treatment

what does steroid (blue) treatment card contain (2)

precautions to minimise risk of adverse effects

details of prescriber, drug, dosage and duration of treatment

purpose of steroid emergency card (red card)

support early recognition of adrenal crisis