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Kortikosteroid
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
(dose equivalent)
SHORT ACTING Cortisone Hydrocortisone
25mg 20mg
INTERMEDIATE-ACTING Prednisolone 5mg Triamcinolone 4mg Methylprednisolone 4mg Fludrocortisone 750 micrograms 750 micrograms
++ ++++
-
HPA AXIS
Pharmacological Actions
1. Carbohydrate 8. Stomach 9.
2. Protein
3. Lipid 4. Electrolyte and H2O
Blood
10. Anti-inflammatory 11. Immunosuppressant 12. Respiratory system 13. Growth and Cell
5. CVS
6. Skeletal Muscle 7. CNS
Division
14. Calcium metabolism
Indikasi kortikosteroid:
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 Addisons disease (under-activity of
Efek samping
Dosis tinggi jangka pendek --- ES < dosis rendah jangka
Redistribusi lemak
Hipertensi
Intoleransi glukosa Gangguan penyembuhan luka
Cushings syndrome
Indikasi kortikosteroid:
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 Addisons disease (under-activity of
>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.
Maintenance doses usually 2.5-15mg/ day. Severe disease may necessitate much higher doses. milk or food plus a full glass of water.
Administer as a single dose after breakfast, but before 9.00 am., with
Rectal administration may give erratic absorption and cause local pain
to cause fewer adverse effects than prolonged courses using lower doses.
Many adverse effects, for example, those related to
INHALED CORTICOSTEROIDS
(dose equivalent Time in circulation for adverse effects)
cardiovascular system central nervous system eyes reproductive system adrenal glands
SE
POTENTIAL PROBLEM
SUGGESTED PREVENTION
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).
Potensi masalah
POTENTIAL PROBLEM SUGGESTED PREVENTION Encourage a well balanced, low calorie diet. Ask dietician to provide diet plan Monitor intake 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. Arrange 6 monthly dental inspections Consider using a mouthwash
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Nutrition
Risk of hypertension
Foods rich in salt should be avoided, except with replacement regimens. Condiments and processed foods are high in sodium. Avoid salt-containing medicines e.g. some antacids. Avoid liquorice. Monitor blood pressure regularly.
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Encourage patient to eat foods high in calcium. Low fat dairy products are suggested. Suggest vitamin D supplementation, together with monitoring for vitamin D intoxication.
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Nutrition Loss of potassium, causing muscle weakness, depression, constipation, cardiac complications. Venous blood samples to monitor electrolytes Encourage foods that are high in potassium e.g. raisins, bananas, meat.
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Nutrition
Limit salt intake. Fluid balance records and daily weighing are important during initiation of therapy
POTENTIAL PROBLEM Cardiovascular disease Hyperglycaemia / diabetes Increased cholesterol and triglycerides Congestive heart failure ? increased risks of thrombosis
SUGGESTED PREVENTION
Monitor blood glucose concentrations regularly and if thrush appears on the skin Monitor lipid profile Observe for breathlessness. Monitor fluid retention. Minimise salt intake. Monitor full blood count
POTENTIAL PROBLEM
Skin (particularly topical preparations) Increase in body hair and acne Poor wound healing
SUGGESTED PREVENTION
SUGGESTED PREVENTION
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.
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Allow extra time for procedures involving tissue handling, such as transfer to hoist, care of infusion sites. 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
SUGGESTED PREVENTION
Take oral corticosteroids with food or milk Observe and test stools for blood loss
POTENTIAL PROBLEM
SUGGESTED PREVENTION
POTENTIAL PROBLEM
SUGGESTED PREVENTION
Routine exercise may help to prevent or decrease muscle weakness. Assess activities such as rising from a chair Monitor respiratory function Check electrolytes if cramps occur
SUGGESTED PREVENTION
POTENTIAL PROBLEM
Eyes (particularly eye drops or if creams applied close to eyes) Increased intraocular pressure and glaucoma Cataracts or clouding of vision Infections
SUGGESTED PREVENTION
Regular eye examinations are important to detect changes before permanent eye damage occurs. Arrange appointments on initiation of therapy, after 6 months, then at least yearly.
SUGGESTED PREVENTION
Offer reassurance Changes in menstrual cycle Advise clients of potential problems Impotence
POTENTIAL PROBLEM
Monitor pulse, blood pressure, electrolytes and glucose regularly. Repeat checks if bruises appear. After 1 weeks use, advise against sudden discontinuation of therapy. Advise wearing a medical-alert bracelet to inform emergency workers of medication
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
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'
Conditions where potassium loss will prove dangerous: liver failure. Situations where muscle weakening could be problematic: Recent
Their long-term use should be carefully evaluated in patients already at high risk of stroke or heart attack. eliminate drugs at the normal rate:
with repeated courses of intra-muscular corticosteroids are administered to prevent respiratory distress of the newborn 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.
equivalent) administered. Doses below those causing systemic side effects are considered safe.
corticosteroids:
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