Ch 15 Corticosteroids

Front 1

Addison’s disease

Back 1

primary adrenocortical insufficiency with inadequate production of cortisol and aldosterone

Front 2

Addisonian crisis

Back 2

condition that mimics hypovolemic and septic shock; also known as adrenocortical insufficiency

Front 3

Aldosterone

Back 3

mineralocorticoid hormone secreted by the adrenal cortex to increase sodium reabsorption by the kidneys and indirectly regulate blood levels of potassium, sodium, and bicarbonate; also regulates pH, blood volume, and blood pressure

Front 4

Corticosteroid

Back 4

steroid hormones produced by the adrenal cortex; examples include androgens, glucocorticoids, and mineralocorticoids; also known as glucocorticoids or steroids.

Front 5

Cortisol

Back 5

the main glucocorticoid secreted as part of the body’s response to stress

Front 6

Cushing’s disease

Back 6

adrenocortical hyperfunction; may result from excessive corticotropin or primary adrenal tumor

Front 7

Glucocorticoid

Back 7

adrenal cortical hormone that protects the body against stress and affects protein and carbohydrate metabolism

Front 8

Immunosuppression

Back 8

suppression of the immune system

Front 9

Mineralocorticoid

Back 9

steroid hormone released by the adrenal cortex to promote sodium and water retention and potassium excretion

Front 10

Negative feedback mechanism

Back 10

when the output of a system affects the stimulus for the system (e.g., hormone secretion produces an effect that shuts off the stimulus for further hormone secretion)

Front 11

steroid

Back 11

lipid-soluble hormone produced by the gonadal organs or the adrenal cortex

Front 12

homeostasis

Back 12

Corticosteroid hormones affect almost all body organs and are extremely important in maintaining __________ when secreted in normal amounts.

Front 13

hypothalamus, the anterior pituitary, and adrenal cortex

Back 13

Corticosteroid secretion is controlled by the ________________, the ____________, and ___________ (the hypothalamic–pituitary–adrenal, or HPA, axis).

Front 14

stimuli that activate the hypothalamic-pituitary-adrenal, or HPA, axis

Back 14

low plasma levels of corticosteroids

pain

anxiety

trauma

illness

anesthesia

Front 15

corticotropin-releasing hormone or factor

Back 15

the stimuli cause the hypothalamus of the brain to secrete ______________ (known as CRH or CRF).

Front 16

corticotropin-releasing hormone or factor (known as CRH or CRF)

Back 16

___________________________ stimulates the anterior pituitary gland to secrete corticotropin.

Front 17

corticotropin

Back 17

__________ then stimulates the adrenal cortex to secrete corticosteroids.

Front 18

sympathetic nervous system (SNS)

Back 18

The stress response activates the _______________ to produce more epinephrine and norepinephrine and the adrenal cortex to produce as much as 10 times the normal amount of cortisol.

Front 19

synergistic interaction

Back 19

The _________ of these hormones (epinephrine, norepinephrine and cortisol) increases the person’s ability to respond to stress. However, the increased SNS activity continues to stimulate cortisol production (the main glucocorticoid secreted as part of the body’s response to stress) and overrules the negative feedback mechanism. Excessive and prolonged corticosteroid secretion damages body tissues.

Front 20

storage area

Back 20

In general, protein binding functions as a ____________ from which the hormones are released as needed. This promotes more consistent blood levels and more uniform distribution to the tissues.

Front 21

glucocorticoids, mineralocorticoids, and adrenal sex hormones

Back 21

The adrenal cortex produces approximately 30 steroid hormones, which are divided into ______________, _____________, and ______________.

Front 22

cholesterol

Back 22

Chemically, all corticosteroids are derived from _____________ and have similar chemical structures. However, despite their similarities, slight differences cause them to have different functions.

Front 23

Exogenous corticosteroids

Back 23

_________ are used as drugs in a variety of disorders. Their use must be closely monitored, because they have profound therapeutic and adverse effects.

Front 24

endogenous hormones

Back 24

To understand the effects of corticosteroids used as drugs (exogenous corticosteroids), it is necessary to understand the physiologic effects and other characteristics of the _________.

Front 25

Corticosteroid secretion

Back 25

_____________ is controlled by the hypothalamus, the anterior pituitary, and adrenal cortex (the hypothalamic–pituitary–adrenal, or HPA, axis).

Front 26

adrenal cortex

Back 26

The _________ ________ produces approximately 30 steroid hormones, which are divided into glucocorticoids, mineralocorticoids, and adrenal sex hormones.

Front 27

glucocorticoids

Back 27

Although the term “corticosteroids” actually refers to all secretions of the adrenal cortex, it is most often used to designate the ____________ , which are important in metabolic, inflammatory, and immune processes.

Front 28

Glucocorticoids

Back 28

_________ are secreted cyclically, with the largest amount being produced in the early morning and the smallest amount during the evening hours (in people with a normal day–night schedule).

Front 29

Mineralocorticoids

Back 29

a class of steroids that play a vital role in the maintenance of fluid and electrolyte balance through their influence on salt and water metabolism.

Front 30

Aldosterone

Back 30

the main mineralocorticoid and is responsible for approximately 90% of mineralocorticoid activity

Front 31

androgens; estrogens and progesterone

Back 31

The adrenal cortex secretes male (_________) and female (_______ and _________) sex hormones.

Front 32

Adrenal androgens

Back 32

_____________ increase protein synthesis (anabolism), which increases the mass and strength of muscle and bone tissue; they affect development of male secondary sex characteristics; and they increase hair growth and libido in women.

Front 33

Primary adrenocortical insufficiency (Addison’s disease)

Back 33

is associated with destruction of the adrenal cortex by disorders such as tuberculosis, cancer, or hemorrhage; with atrophy of the adrenal cortex caused by autoimmune disease or prolonged administration of exogenous corticosteroids; and with surgical excision of the adrenal glands. In this disorder, there is inadequate production of both cortisol and aldosterone.

Front 34

Secondary adrenocortical insufficiency

Back 34

produced by inadequate secretion of corticotropin, is most often caused by prolonged administration of corticosteroids. This condition is largely a glucocorticoid deficiency; mineralocorticoid secretion is not significantly impaired.

Front 35

Congenital adrenogenital syndromes and adrenal hyperplasia

Back 35

____________ result from deficiencies in one or more enzymes required for cortisol production. Low plasma levels of cortisol lead to excessive corticotropin secretion, which then leads to excessive adrenal secretion of androgens and hyperplasia (abnormal increase in number of cells).

Front 36

Androgen-producing tumors

Back 36

__________ of the adrenal cortex, which are usually benign, produce masculinizing effects.

Front 37

Adrenocortical hyperfunction (Cushing’s disease)

Back 37

__________ may result from excessive corticotropin or a primary adrenal tumor. Adrenal tumors may be benign or malignant. Benign tumors often produce one corticosteroid normally secreted by the adrenal cortex, but malignant tumors often secrete several corticosteroids.

Front 38

Hyperaldosteronism

Back 38

_______________ is a rare disorder caused by adenoma (a benign tissue from glandular tissue) or hyperplasia of the adrenal cortex cells that produce aldosterone. It is characterized by hypokalemia, hypernatremia, hypertension, thirst, and polyuria.

Front 39

glucocorticoids

Back 39

Exogenous corticosteroids, or _______________, are administered to treat disorders of the adrenal cortex or endocrine system.

Front 40

corticosteroids

Back 40

The administration of ____________ decreases the inflammatory symptoms and alters the immune response produced by nonendocrine disorders.

Front 41

hydrocortisone

Back 41

People once viewed _____________, a short-acting corticosteroid and an exogenous equivalent of endogenous cortisol, as the prototype corticosteroid drug.

Front 42

prednisone

Back 42

Now they consider _____________, an intermediate acting corticosteroid, to be the prototype corticosteroid.

Front 43

Prednisone (Apo-Prednisone, Deltasone)

Back 43

Glucocorticoid prototype

Front 44

Glucocorticoid other drugs in class

Back 44

Beclomethasone (QVAR, Beconase AQ)

Betamethasone (Celestone)

Betamethasone acetate and betamethasone sodium phosphate (Celestone Soluspan)

Budesonide (Pulmicort, Rhinocort, Entocort EC)

Cortisone

Dexamethasone (Decadron)

Dexamethasone acetate

Dexamethasone sodium phosphate (Decadron Phosphate)

Flunisolide (AeroBid, Nasarel)

Fluticasone (Flovent, Flonase)

Hydrocortisone (Cortaid)

Hydrocortisone (Cortef)

Hydrocortisone sodium phosphate

Hydrocortisone sodium succinate (Solu-Cortef)

Hydrocortisone retention enema (Cortenema)

Hydrocortisone acetate (Cortifoam)

Methylprednisolone (Medrol)

Methylprednisolone sodium succinate (Solu-Medrol)

Methylprednisolone acetate (Depo-Medrol)

Mometasone (Nasonex)

Prednisolone (Prelone)

Prednisolone acetate (Pred Forte)

Triamcinolone

Triamcinolone acetonide (Azmacort, Nasacort)

Triamcinolone hexacetonide (Aristospan)

Front 45

Fludrocortisone (Florinef)

Back 45

Mineralocorticoid prototype

Front 46

HPA axis

Back 46

The administration of exogenous corticosteroids suppresses the __________ ________. As a result, secretion of corticotropin decreases, causing atrophy of the adrenal cortex and decreased production of endogenous adrenal corticosteroids.

Front 47

inflammatory

Back 47

corticosteroid drugs act to inhibit the release, formation, or activation of various ___________ mediators.

Front 48

Inflammatory process

Back 48

Cellular responses to injury include the following: phospholipid in the cell membrane is acted on by phospholipase to release arachidonic acid, metabolism of arachidonic acid produces the inflammatory mediators prostaglandins and leukotrienes, lysosomal membrane breaks down and releases inflammatory chemicals (e.g., histamine, bradykinin, intracellular digestive enzymes), and white blood cells (WBCs) are drawn to the area and release inflammatory cytokines (e.g., interleukin-1 [IL-1] alpha).

Front 49

phospholipase A2

Back 49

Normally, when a body cell is injured or activated by various stimuli, the enzyme _________________ causes the phospholipids in cell membranes to release arachidonic acid. Free arachidonic acid is then metabolized to produce proinflammatory prostaglandins (see Chap. 14) and leukotrienes. At sites of tissue injury or inflammation, corticosteroids induce the synthesis of proteins that suppress the activation of phospholipase A2. This action, in turn, decreases the release of arachidonic acid and the formation of prostaglandins and leukotrienes.

Front 50

edema

Back 50

Anti-inflammatory agent of corticosteroid reduces capillary permeability and thus prevents leakage of fluid into the injured area and development of ____________. It also reduces the chemicals that normally cause vasodilation and tissue irritation.

Front 51

corticosteroid drugs

Back 51

Because the ___________________ affect virtually every aspect of inflammatory and immune responses, they are used in the treatment of a broad spectrum of diseases with an inflammatory or immunologic component.

Front 52

Allergic rhinitis (also called seasonal rhinitis, hay fever, and perennial rhinitis)

Back 52

a common problem for which corticosteroids are given by nasal spray, once or twice daily. The drugs decrease mucus secretion and inflammation. Therapeutic effects usually occur within a few days with regular use. Systemic adverse effects are minimal with recommended doses but may occur with higher doses, including adrenocortical insufficiency from HPA suppression.

Front 53

joint inflammation

Back 53

Corticosteroids are the most effective drugs for rapid relief of the pain, edema, and restricted mobility associated with acute episodes of _________ __________. They are usually given on a short-term basis. When inflammation is limited to three or fewer joints, the preferred route of drug administration is by injection directly into the joint. Intraarticular injections relieve symptoms in approximately 2 to 8 weeks, and several formulations are available for this route. However, corticosteroids do not prevent disease progression and joint destruction. As a general rule, a joint should not be injected more often than three times yearly because of risks of infection and damage to intraarticular structures from the injections and from overuse when pain is relieved.

Front 54

asthma

Back 54

Corticosteroids are commonly used in the treatment of _____________ because of their anti-inflammatory effects. In addition, corticosteroids increase the effects of adrenergic bronchodilators to prevent or treat bronchoconstriction and bronchospasm. The drugs increase the number of beta-adrenergic receptors and increase or restore responsiveness of beta receptors to beta-adrenergic bronchodilating drugs. Research indicates that responsiveness to beta-adrenergic bronchodilators increases within 2 hours and that numbers of beta receptors increase within 4 hours.

Front 55

5 to 10 days.

Back 55

In acute asthma or status asthmaticus unrelieved by inhaled beta-adrenergic bronchodilators, high doses of systemic corticosteroids are given orally or intravenously along with bronchodilators for approximately__________ to _______ days.

Front 56

1 to 3 days

Back 56

Although high doses of corticosteroid suppress the HPA axis, the suppression lasts for only _____ to _______ days, and other serious adverse effects are avoided. Thus, systemic corticosteroids are used for short-term therapy, as needed, and not for long-term treatment.

Front 57

flunisolide inhaler

Back 57

U.S. Food and Drug Administration (FDA) has issued a BLACK BOX WARNING ♦ for people who are transferred from systemically active corticosteroids to _______ _________ because deaths have occurred from adrenal insufficiency.

Front 58

lymphomas, lymphocytic leukemias, and multiple myeloma.

Back 58

Corticosteroids are commonly used in the treatment of __________ , lymphocytic __________ , and multiple __________.

Front 59

lymphocytes

Back 59

corticosteroids inhibit cell reproduction and are cytotoxic to __________. In addition to their anticancer effects in hematologic malignancies, corticosteroids are beneficial in treatment of several signs and symptoms that often accompany cancer

Front 60

Corticosteroids

Back 60

__________________ are used to treat anorexia, nausea and vomiting, cerebral edema and inflammation associated with brain metastases or radiation of the head, spinal cord compression, pain and edema related to pressure on nerves or bone metastases, graft-versus-host disease after bone marrow transplantation, and other disorders that occur in patients with cancer.

Front 61

COPD

Back 61

The authors found if patients with ___________ received systemic corticosteroids during acute exacerbations, the airflow limitations improved, relapses decreased, and length of hospital stays decreased.

Front 62

alternate-day therapy (ADT)

Back 62

Strategies to minimize HPA suppression and risks of acute adrenal insufficiency:

Using _________________, which involves titrating the daily dose to the lowest effective maintenance level, then giving a double dose every other day.

Front 63

growth

Back 63

A concern with children is __________ retardation, which can occur short term with small doses and administration by inhalation. Many children have a growth spurt when the corticosteroid is discontinued. Adult stature does not appear to be affected by inhaled corticosteroid therapy during childhood.

Front 64

older patients

Back 64

adverse effects such as mania, depression, psychosis, and delirium are extremely common in _____________ treated with corticosteroids.

Front 65

aggravated by corticosteroids in older adults

Back 65

heart failure, hypertension, diabetes mellitus, arthritis, osteoporosis, increased susceptibility to infection, concomitant drug therapy that increases risks of GI ulceration, and bleeding

Front 66

Use in patients with renal impairment

Back 66

In these patients, as in others, adverse effects of systemic corticosteroids may include infections, hypertension, glucose intolerance, obesity, cosmetic changes, bone loss, growth retardation in children, cataracts, pancreatitis, peptic ulcerations, and psychiatric disturbances.

Front 67

Use in Patients With Hepatic Impairment

Back 67

Metabolism of corticosteroids is slowed by severe hepatic disease, and corticosteroids may accumulate and cause signs and symptoms of hypercorticism. Use of prednisolone is preferred than prednisone

Front 68

Adrenal insufficiency

Back 68

__________ is the most clear-cut indication for use of a corticosteroid, and even a slight impairment of the adrenal response during severe illness can be lethal if corticosteroid therapy is not instituted.

Front 69

pneumocystosis

Back 69

Corticosteroids improve survival and decrease risks of respiratory failure with _______________ , a common cause of death in patients with AIDS.

Front 70

adrenocortical insufficiency

Back 70

corticosteroids adverse effects: fainting, weakness, anorexia, nausea, vomiting, hypotension, shock, and death (if untreated)

Front 71

Cushingoid features:

Back 71

“moon face” and buffalo hump due to the redistribution of fat

Front 72

Cardiovascular symptoms

Back 72

corticosteroids results in adverse reactions: hypotension, shock, hypertension, heart failure, thromboembolism, thrombophlebitis, fat embolism, and cardiac dysrhythmias

Front 73

diminished immunity

Back 73

corticosteroids results in adverse reactions: increased susceptibility to infection

Front 74

Endocrine effects

Back 74

corticosteroids results in adverse reactions: diabetes mellitus, hyperglycemia, and hypercholesterolemia; diminished T3 and T4 levels, resulting in hypothyroidism; reduced growth because of altered synthesis of DNA

Front 75

Fluid and electrolyte effects

Back 75

corticosteroids results in adverse reactions: fluid retention, hypokalemia, hypocalcemia

Front 76

integumentary effects

Back 76

corticosteroids results in adverse reactions: reddened skin, thinner skin, stretch marks, skin tears, delayed wound healing

Front 77

musculoskeletal effects

Back 77

corticosteroids results in adverse reactions: hypocalcemia, which places the patient at risk for osteoporosis and fracture development; serum hypocalcemia, which increases the release parathyroid hormone, increasing the loss of calcium from bone

Front 78

Ocular effects

Back 78

corticosteroids results in adverse reactions: cataracts and glaucoma

Front 79

Reproductive effetcs

Back 79

corticosteroids results in adverse reactions: amenorrhea or irregular menstrual cycles

Front 80

Licorice

Back 80

__________ increases the effects of corticosteroids, which may potentiate its effects; cautious use of this with corticosteroids is necessary.

Front 81

locally

Back 81

Corticosteroids can be given by several different routes to produce local or systemic effects, depending on the clinical problem. If feasible, these drugs should be given ____________ rather than systemically to prevent or decrease systemic toxicity.

Front 82

oral inhalation

Back 82

several formulations have been developed for _________ __________ in the treatment of asthma and for nasal inhalation in the treatment of allergic rhinitis.

Front 83

Parenteral

Back 83

______________ administration is indicated only for patients who are seriously ill or unable to take oral medications.

Front 84

sodium phosphate or sodium succinate salts

Back 84

For intramuscular or IV injections, sodium ____________ or sodium ___________ salts are used because they are most soluble in water.

Front 85

acetate salts

Back 85

For intraarticular or intralesional injections _____________ salts are used because they have low solubility in water and provide prolonged local action.

Front 86

Drugs That Increase the Effects of Corticosteroids

Back 86

Estrogens, oral contraceptives, ketoconazole, macrolide antibiotics (e.g., erythromycin)

Increase the effects of corticosteroids by inhibiting the enzymes that normally metabolize corticosteroids in the liver.

Diuretics (e.g., furosemide and thiazides)

Increase hypokalemia

Front 87

Drugs That Decrease the Effects of Corticosteroids

Back 87

Antacids and cholestyramine

Decrease the absorption of corticosteroids

Carbamazepine, phenytoin, rifampin

Induce microsomal enzymes in the liver and increase the rate at which corticosteroids are metabolized or deactivated

Front 88

stress or illness

Back 88

For people receiving chronic corticosteroid therapy, dosage must be increased during periods of __________ or _________. Some common sources of stress for most people include surgery and anesthesia, infections, anxiety, and extremes of temperature. Note that events that are stressful for one patient may not be stressful for another.

Front 89

hydrocortisone

Back 89

During major stress or severe illness, even larger doses are necessary. For example, a patient undergoing abdominal surgery may require 300 to 400 mg of ______________ on the day of surgery.

Front 90

100 mg

Back 90

During acute stress situations of short duration, such as traumatic injury or invasive diagnostic tests (e.g., angiography), a single dose of approximately _____________ mg of hydrocortisone immediately after the injury or before the diagnostic test is usually sufficient.

Front 91

Alternate-day therapy

Back 91

____________ , in which a double dose is taken every other morning, is usually preferred for other chronic conditions. This schedule allows rest periods so that adverse effects are decreased while anti-inflammatory effects continue.

Front 92

ADT

Back 92

_______________ seems to be as effective as more frequent administration in most patients with bronchial asthma, ulcerative colitis, and other conditions for which long-term corticosteroid therapy is prescribed.

Front 93

maintenance

Back 93

ADT is used only for ____________ therapy (i.e., clinical signs and symptoms are controlled initially with more frequent drug administration). ADT can be started after symptoms have subsided and stabilized.

Front 94

glucocorticoids

Back 94

Intermediate-acting ___________ (e.g., prednisone, prednisolone, methylprednisolone) are the drugs of choice for ADT.

Front 95

ADT

Back 95

-decreases susceptibility to infection and does not retard growth in children

- not usually indicated in patients who have previously received corticosteroids on a long-term basis

Front 96

Addison’s disease.

Back 96

Prescribers order hydrocortisone (Solu-Cortef) for the treatment of ________________

Front 97

Prednisone

Back 97

______________ is the drug of choice for nonendocrine disorders in which anti-inflammatory, antiallergic, antistress, and immunosuppressive effects are desired.

Front 98

dexamethasone

Back 98

Health care providers consider________________ (parenteral or oral) the corticosteroid of choice for cerebral edema associated with brain tumors, craniotomy, or head injury, because it is thought to penetrate the blood–brain barrier more readily and achieve higher concentrations in cerebrospinal fluids and tissues.

Front 99

medical alert bracelet

Back 99

Wear a special _______________ or tag or carry an identification card stating the drug being taken; the dosage; the prescriber’s name, address, and telephone number; and instructions for emergency treatment. If an accident or emergency situation occurs, health care providers must know about corticosteroid drug therapy to give additional amounts during the stress of the emergency.

Front 100

infection

Back 100

Avoid exposure to _____________ when possible. Avoid crowds and people known to have an infection. Also, wash hands frequently and thoroughly. These drugs increase the likelihood of infection, so preventive measures are necessary. Also, if infection does occur, healing is likely to be slow.

Front 101

weigh

Back 101

____________ frequently when starting corticosteroid therapy and at least weekly during long-term maintenance. An initial weight gain is likely to occur and is usually attributed to increased appetite. Later weight gains may be caused by fluid retention.

Front 102

oral; nasal

Back 102

Commonly used local applications are applied topically for skin disorders; by _________ inhalation for asthma; and by ___________ inhalation for allergic rhinitis. Although long-term use is usually well tolerated, systemic toxicity can occur if excess corticosteroid is inhaled or if occlusive dressings are used over skin lesions. Thus, a corticosteroid for local application must be applied correctly and not overused.

Front 103

Self- or Caregiver Administration

Back 103

Take an oral corticosteroid with a meal or snack to decrease GI upset.

If taking the medication once a day or every other day, take before 9:00 AM if taking multiple doses, take at evenly spaced intervals throughout the day.

When applying a corticosteroid to skin lesions, do not apply more often than ordered and do not cover with an occlusive dressing unless specifically instructed to do so.

Front 104

metered-dose inhaler

oral-inhalation corticosteroid

Back 104

1. Shake canister thoroughly.

2. Place canister between lips (both open and pursed lips have been recommended) or outside lips.

3. Exhale completely.

4. Activate canister while taking a slow, deep breath.

5. Hold breath for 10 seconds or as long as possible.

6. Wait at least 1 minute before taking additional inhalations.

7. Rinse mouth after inhalations to decrease the incidence of oral thrush (a fungal infection).

8. Rinse mouthpiece at least once per day.