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Kortikosteroid

Kortikosteroid
Kortikosteroid
Kortikosteroid

Kortikosteroid

Kortikosteroid  Bentuk sintetik dari hormon yang disekresi oleh kortek adrenal.  Esensial:  Maintenan beberapa

Bentuk sintetik dari hormon yang disekresi oleh kortek adrenal.

Esensial:

Maintenan beberapa sistem terutama sistem kardiovaskular

Berperan pada respon tubuh thd stress

Mekanisme

Supresi proses inflamasi, alergi dan sistem imun

Dapat untuk prevensi dan tx asma dan artritis rematoid

Actions of corticosteroids are grouped:

Actions of corticosteroids are grouped:  Glucocorticoid effects, including metabolic changes and anti-inflammatory

Glucocorticoid effects, including metabolic changes and anti-inflammatory actions.

Mineralocorticoid effects, mainly retention of salt and water, together with loss of potassium and

hydrogen ions.

Classification of Corticosteroids ORAL CORTICOSTEROIDS

Classification of Corticosteroids ORAL CORTICOSTEROIDS

Glucocorticoid Effect (dose equivalent)

Mineralocorticoid

effect

Duration of effect (in hour

SHORT ACTING

 

Cortisone

25mg

++++

8-12 hours 8-12 hours

Hydrocortisone

20mg

++++

INTERMEDIATE-ACTING

 

Prednisolone

5mg

++

18-36 hours

Triamcinolone

4mg

-

18-36 hours 18-36 hours 24-36 hours

Methylprednisolone

4mg

-

Fludrocortisone

-

++++

LONG-ACTING

Dexamethasone

750 micrograms 750 micrograms

-

36-54 hours 36-54 hours

Betamethasone

-

HPA AXIS
HPA AXIS
   

Pharmacological Actions

 
 

1.

Carbohydrate

8. Stomach

2.

Protein

9. Blood

3.

Lipid

10. Anti-inflammatory

4.

Electrolyte and H 2 O

11. Immunosuppressant

5.

CVS

12. Respiratory system

6.

Skeletal Muscle

13. Growth and Cell Division

7.

CNS

 

14. Calcium metabolism

Indikasi kortikosteroid:

Indikasi kortikosteroid:  Kontrol gejala:  Asthma, allergic rhinitis, rheumatoid arthritis and related connective

Kontrol gejala:

Asthma, allergic rhinitis, rheumatoid arthritis and related connective

tissue disorders, temporal arteritis, inflammatory bowel disease,

inflammatory skin conditions, emesis following chemotherapy, chronic pain, anaphylactic shock

Prevensi:

Transplant rejection, respiratory distress in the newborn, cerebral oedema

Treatment:

Certain tumours, hypercalcaemia, some blood disorders, nephrotic syndrome

Replacement therapy in Addison’s disease (under-activity of the adrenal cortex)

disorders, nephrotic syndrome  Replacement therapy in Addison’s disease (under -activity of the adrenal cortex)

Efek samping

Efek samping  Dosis tinggi jangka pendek --- ES < dosis rendah jangka panjang  Efek

Dosis tinggi jangka pendek --- ES < dosis rendah jangka panjang Efek samping jangka panjang:

Redistribusi lemak

Hipertensi

Intoleransi glukosa

Gangguan penyembuhan luka

Osteoporosis (bisa dicegah dg bifosfonat)

Katarak

Tukak lambung (Omeprazol, misoprostol)

resiko infeksi

Efek SSP, psikosis

Hambatan pertumbuhan pada anak

misoprostol) • ↑ resiko infeksi • Efek SSP, psikosis • Hambatan pertumbuhan pada anak Cushing ’

Cushings

syndrome

Indikasi kortikosteroid:

Indikasi kortikosteroid:  Kontrol simtom:  Asthma, allergic rhinitis, rheumatoid arthritis and related connective

Kontrol simtom:

Asthma, allergic rhinitis, rheumatoid arthritis and related connective

tissue disorders, temporal arteritis, inflammatory bowel disease,

inflammatory skin conditions, emesis following chemotherapy, chronic pain, anaphylactic shock

Prevensi:

Transplant rejection, respiratory distress in the newborn, cerebral oedema

Treatment:

Certain tumours, hypercalcaemia, some blood disorders, nephrotic syndrome

Replacement therapy in Addison’s disease (under-activity of the adrenal cortex)

disorders, nephrotic syndrome  Replacement therapy in Addison’s disease (under -activity of the adrenal cortex)

Doses and Administration

Doses and Administration  Regular medication reviews are needed to ensure doses are kept to the

Regular medication reviews are needed to ensure doses are kept to the

minimum necessary to manage the underlying condition.

Inhaled beclomethasone, budesonide daily doses >800 mcg (adult) >400mcg (child) are associated with systemic (general) side effects.

Side effects are seen at half these doses for fluticasone.

Some ‘high dose’ regimens include daily doses up to 2 mg and 1mg (fluticasone).

Advice to patients should include:

Keep to the same spacer device.

Mouth rinsing may reduce candidiasis and systemic absorption.

Pre-treatment with bronchodilator may reduce cough.

Mouth rinsing may reduce candidiasis and systemic absorption.  Pre-treatment with bronchodilator may reduce cough.

Doses and Administration

Doses and Administration  Oral prednisolone. Side effects appear if daily dose >7.5 mg. Maintenance doses

Oral prednisolone. Side effects appear if daily dose >7.5 mg. Maintenance doses usually 2.5-15mg/ day. Severe disease may necessitate much higher doses.

Administer as a single dose after breakfast, but before 9.00 am., with milk or food plus a full glass of water.

Topical applications should avoid the face, and be free of occlusive

dressings (including disposable nappies).

Rectal administration may give erratic absorption and cause local pain and bleeding.

If giving intramuscular injections, use each site only once and document.

Managing the Common Adverse Effects

of Corticosteroids

Managing the Common Adverse Effects of Corticosteroids  Short courses at high dosage for emergencies appear

Short courses at high dosage for emergencies appear to cause fewer adverse effects than prolonged courses using lower doses.

Many adverse effects, for example, those related to

nutrition, only arise with long-term therapy.

INHALED CORTICOSTEROIDS

INHALED CORTICOSTEROIDS (dose equivalent Time in circulation for adverse effects)  Beclometasone  Budesonide 

(dose equivalent Time in circulation for adverse effects)

Beclometasone

Budesonide

Fluticasone

propionate

1000 micrograms 1000 micrograms 500 micrograms

-

-

-

19.5 hours 6.9 hours 43.2 hours

*calculated as 3 times the terminal half life.

(Karch 2000, BNF 2002, Cave et al. 1999, Lipworth 1999)

Corticosteroids may affect:

Corticosteroids may affect:  inflammatory and immune responses  metabolic pathways:  the starvation response +

inflammatory and immune responses

metabolic pathways:

the starvation response + redistribution

skin

gastrointestinal tract

bones

muscles

cardiovascular system

central nervous system

eyes

reproductive system

adrenal glands

 muscles  cardiovascular system  central nervous system  eyes  reproductive system  adrenal

SE

SE POTENTIAL PROBLEM SUGGESTED PREVENTION Increased risk of infections Teach good hand washing techniques

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Increased risk of infections

Teach good hand washing techniques Monitor body temperature at 5-6 p.m. daily Avoid exposure to infectious disease Contact doctor on exposure to chickenpox or measles. Caution with immunisations: avoid live vaccines (also for 6 months after

discontinuation).

to chickenpox or measles. Caution with immunisations: avoid live vaccines (also for 6 months after discontinuation).

Potensi masalah

Potensi masalah POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Encourage a well balanced, low calorie diet.

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Nutrition

Encourage a well balanced, low calorie diet. Ask dietician to provide diet plan

Increase in appetite

Monitor intake by asking patient to record intake for 24-hour periods.

Weigh patient weekly

Measure waist circumference regularly

by asking patient to record intake for 24-hour periods. Weigh patient weekly Measure waist circumference regularly
POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Encourage scrupulous dental hygiene & low-sugar diet.
POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Encourage scrupulous dental hygiene & low-sugar diet.

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Nutrition

Encourage scrupulous dental

hygiene

& low-sugar diet.

Risk of dental caries

Arrange 6 monthly dental inspections

Consider using a mouthwash

& low-sugar diet. Risk of dental caries Arrange 6 monthly dental inspections Consider using a mouthwash
POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Foods rich in salt should be avoided, except with replacement
POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Foods rich in salt should be avoided, except with replacement

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Nutrition

Foods rich in salt should be avoided, except with replacement regimens.

Risk of hypertension

Condiments and processed foods are

high in sodium. Avoid salt-containing medicines e.g. some antacids. Avoid liquorice.

Monitor blood pressure regularly.

high in sodium. Avoid salt-containing medicines e.g. some antacids. Avoid liquorice. Monitor blood pressure regularly.
 
 

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Nutrition

Encourage patient to eat foods high in

calcium. Low fat dairy products are

Risk of osteoporosis

suggested.

Suggest vitamin D supplementation, together with monitoring for vitamin D

intoxication.

POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Venous blood samples to monitor electrolytes Loss of potassium,
POTENTIAL PROBLEM SUGGESTED PREVENTION Nutrition Venous blood samples to monitor electrolytes Loss of potassium,

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Nutrition

Venous blood samples to monitor electrolytes

Loss of potassium, causing muscle weakness, depression, constipation, cardiac complications.

Encourage foods that are high in potassium e.g. raisins, bananas, meat.

depression, constipation, cardiac complications. Encourage foods that are high in potassium e.g. raisins, bananas, meat.
POTENTIAL PROBLEM Nutrition Salt and water retention SUGGESTED PREVENTION Limit salt intake. Fluid
POTENTIAL PROBLEM Nutrition Salt and water retention SUGGESTED PREVENTION Limit salt intake. Fluid

POTENTIAL PROBLEM

Nutrition

Salt and water retention

SUGGESTED PREVENTION

Limit salt intake.

Fluid balance records and daily weighing are important during initiation of therapy

PREVENTION Limit salt intake. Fluid balance records and daily weighing are important during initiation of therapy
POTENTIAL PROBLEM SUGGESTED PREVENTION Cardiovascular disease   Hyperglycaemia / diabetes Monitor blood
POTENTIAL PROBLEM SUGGESTED PREVENTION Cardiovascular disease   Hyperglycaemia / diabetes Monitor blood

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Cardiovascular disease

 

Hyperglycaemia / diabetes

Monitor blood glucose concentrations regularly and if thrush appears on the skin

Increased cholesterol and triglycerides

Monitor lipid profile

Congestive heart failure

Observe for breathlessness. Monitor fluid retention. Minimise salt intake.

? increased risks of thrombosis

Monitor full blood count

Monitor fluid retention. Minimise salt intake. ? increased risks of thrombosis Monitor full blood count
POTENTIAL PROBLEM SUGGESTED PREVENTION Skin (particularly topical preparations) Provide advice on managing acne
POTENTIAL PROBLEM SUGGESTED PREVENTION Skin (particularly topical preparations) Provide advice on managing acne

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Skin (particularly topical preparations)

Provide advice on managing acne

Consult podiatrist regarding foot-care.

Increase in body hair and acne

Anticipate poor healing and contact wound care specialists promptly.

Poor wound healing

Take swabs if healing delayed.

poor healing and contact wound care specialists promptly. Poor wound healing Take swabs if healing delayed.
POTENTIAL PROBLEM SUGGESTED PREVENTION Skin (particularly topical preparations) Thinning of the skin Increased
POTENTIAL PROBLEM SUGGESTED PREVENTION Skin (particularly topical preparations) Thinning of the skin Increased

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Skin (particularly topical preparations)

Thinning of the skin

Increased vigilance of pressure areas. Evaluate pressure damage risk score regularly

Avoid friction and shearing forces on the skin, for example, teach patients in the correct use of moving and handling aids (glide sheets) when moving along the bed/chair.

for example, teach patients in the correct use of moving and handling aids (glide sheets) when
POTENTIAL PROBLEM SUGGESTED PREVENTION Skin (particularly topical preparations) Allow extra time for procedures involving

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Skin (particularly topical preparations)

Allow extra time for procedures involving tissue handling, such as transfer to hoist, care of infusion sites.

Thinning of the skin

Ensure good communication within the multidisciplinary team: for example, orthopaedic surgeons, and plaster technicians, or nurses applying plaster casts, need to be aware that the patient is prescribed corticosteroids, and adjust treatment, if possible.

POTENTIAL PROBLEM Gastrointestinal Tract Irritation of stomach and oesophagus SUGGESTED PREVENTION Take
POTENTIAL PROBLEM Gastrointestinal Tract Irritation of stomach and oesophagus SUGGESTED PREVENTION Take

POTENTIAL PROBLEM

Gastrointestinal Tract

Irritation of stomach and oesophagus

SUGGESTED PREVENTION

Take oral corticosteroids with food or milk

Observe and test stools for blood loss

SUGGESTED PREVENTION Take oral corticosteroids with food or milk Observe and test stools for blood loss
POTENTIAL PROBLEM SUGGESTED PREVENTION Bones Osteoporosis (see nutrition above) Encourage moderate exercise Bone
POTENTIAL PROBLEM SUGGESTED PREVENTION Bones Osteoporosis (see nutrition above) Encourage moderate exercise Bone

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Bones Osteoporosis (see nutrition above)

Encourage moderate exercise

Bone densiometry assessments

Consider HRT

Growth

Plot height and weight on centile charts at regular intervals.

Bone densiometry assessments Consider HRT Growth Plot height and weight on centile charts at regular intervals.
POTENTIAL PROBLEM SUGGESTED PREVENTION Muscles Routine exercise may help to prevent or decrease muscle weakness.
POTENTIAL PROBLEM SUGGESTED PREVENTION Muscles Routine exercise may help to prevent or decrease muscle weakness.

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Muscles

Routine exercise may help to prevent or decrease muscle weakness.

Muscle weakness

Cramps

Assess activities such as rising from a chair

Monitor respiratory function

Check electrolytes if cramps occur

Assess activities such as rising from a chair Monitor respiratory function Check electrolytes if cramps occur
POTENTIAL PROBLEM SUGGESTED PREVENTION Mental health   Monitor behaviour. Emotional changes such as
POTENTIAL PROBLEM SUGGESTED PREVENTION Mental health   Monitor behaviour. Emotional changes such as

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Mental health

 

Monitor behaviour.

Emotional changes such as moodiness, depression, euphoria or hallucinations

Consider the possibility of steroid psychosis and refer as necessary.

Steroid abuse/ dependence

Refer patients who resist dose reductions.

of steroid psychosis and refer as necessary. Steroid abuse/ dependence Refer patients who resist dose reductions.
POTENTIAL PROBLEM SUGGESTED PREVENTION Eyes (particularly eye drops or if creams applied close to  
POTENTIAL PROBLEM SUGGESTED PREVENTION Eyes (particularly eye drops or if creams applied close to  

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Eyes (particularly eye drops or if creams applied close to

 

eyes)

Regular eye examinations are

Increased intraocular pressure and glaucoma Cataracts or clouding of

important to detect changes before permanent eye damage occurs. Arrange appointments on initiation of therapy, after 6 months, then at

vision

least yearly.

Infections

occurs. Arrange appointments on initiation of therapy, after 6 months, then at vision least yearly. Infections
POTENTIAL PROBLEM SUGGESTED PREVENTION Reproductive system   Delayed puberty Offer reassurance
POTENTIAL PROBLEM SUGGESTED PREVENTION Reproductive system   Delayed puberty Offer reassurance

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Reproductive system

 

Delayed puberty

Offer reassurance

Changes in menstrual cycle

Advise clients of potential problems

Impotence

puberty Offer reassurance Changes in menstrual cycle Advise clients of potential problems Impotence
POTENTIAL PROBLEM SUGGESTED PREVENTION Administer medication before 9.00 am. Adrenal suppression/ insufficiency: Persists

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Administer medication before 9.00 am.

Adrenal suppression/ insufficiency:

Persists 3 months- years after discontinuation

Monitor pulse, blood pressure, electrolytes and glucose regularly. Repeat checks if bruises appear.

After 1 week’s use, advise against sudden discontinuation of therapy.

Advise wearing a medical-alert bracelet to inform emergency workers of medication

Control of Glucocorticoid Secretion

(The hypothalamic/pituitary/adrenal (HPA) axis)

Secretion (The hypothalamic/pituitary/adrenal (HPA) axis) Corticosteroids administered as medications constantly
Secretion (The hypothalamic/pituitary/adrenal (HPA) axis) Corticosteroids administered as medications constantly

Corticosteroids administered as medications constantly inhibit CRH & ACTH secretion. The adrenal cortex eventually shrinks and may fail to synthesise any hormones, even in response to extreme stress, such as surgery or infection.

In health, when there is not stress, cortisol suppresses secretion of

CRH and ACTH by a negative feedback mechanism

POTENTIAL PROBLEM SUGGESTED PREVENTION Supervise gradual withdrawal of therapy Withdrawal of therapy Supervise transition

POTENTIAL PROBLEM

SUGGESTED PREVENTION

Supervise gradual withdrawal of therapy

Withdrawal of therapy

Supervise transition from oral to inhaled

administration and conversion to alternate day therapy.

Continue to monitor patients for possible adrenal insufficiency for a year after discontinuation.

Ensure that patient always carries a 'steroid card'

Cautions and contra-indications

Cautions and contra-indications  When administering corticosteroids, caution is needed in some  circumstances: 

When administering corticosteroids, caution is needed in some

circumstances:

Presence of infections. Infections may 'flare up', including HIV/AIDS, previous TB, wound infection, Herpes simplex.

Conditions which will be exacerbated: hypertension, diabetes, heart failure, osteoporosis, glaucoma, epilepsy, mood disorders, pressure

sores.

Conditions where potassium loss will prove dangerous: liver failure.

Situations where muscle weakening could be problematic: Recent

myocardial infarction, muscle wasting, elderly, bedridden.

Cautions and contra-indications

Cautions and contra-indications  Masking of serious symptoms: peptic ulcer, inflammatory bowel disease, pneumonia 

Masking of serious symptoms: peptic ulcer,

inflammatory bowel disease, pneumonia

Corticosteroids worsen cardiovascular risk factors. Their long-term use should be carefully evaluated

in patients already at high risk of stroke or heart

attack.

Lower doses are needed in patients unable to eliminate drugs at the normal rate:

hypothyroidism, liver failure, renal failure, elderly.

Cautions and contra-indications

Cautions and contra-indications  Pregnancy. The risks of intrauterine growth retardation with repeated courses of

Pregnancy. The risks of intrauterine growth retardation

with repeated courses of intra-muscular corticosteroids are

administered to prevent respiratory distress of the new- born are currently under investigation. When cortIcosteroids are administered for severe maternal disease, the benefits are likely to outweigh any risks. Most

prednisolone (unlike dexamethasone) is inactivated by the

placenta.

Breastfeeding: avoid if >40mg prednisolone /day (or equivalent) administered. Doses below those causing

systemic side effects are considered safe.

Interactions (Not a complete list)

Interactions (Not a complete list)  Corticosteroids interact with many other drugs.  Some drugs intensify

Corticosteroids interact with many other drugs.

Some drugs intensify the adverse reactions of corticosteroids:

Increased risk of gastro-intestinal bleeding: alcohol, anticoagulants, aspirin, NSAIDs

Increased fluid retention and hypertension: beta2 agonists, NSAIDs, sodium-containing preparations, oestrogens, liquorice, ginseng, some Asian herbal mixtures Increased potassium depletion: beta2 agonists, diuretics, digoxin, laxatives

Interactions (Not a complete list)

Interactions (Not a complete list)  The effects of some drugs and appliances are antagonised: anti-

The effects of some drugs and appliances are antagonised: anti-

epileptics, anti-diabetics, anti-hypertensives, growth hormone, intra-

uterine contraceptive devices.

The dose of corticosteroids is effectively reduced by:

co-administration with antacids, within 2 hours

carbamazepine, phenytoin, rifampicin, theophylline

The dose of corticosteroids is effectively increased by:

erythromycin, ketoconazole, itraconazole, ciclosporin, some anti-virals

corticosteroids is effectively increased by:  erythromycin, ketoconazole, itraconazole, ciclosporin, some anti-virals