Corticosteroids adrenal insufficiency

Corticosteroids Adrenal insufficiency, antiinflammatory agents, immunosuppressants Adrenal cortex... 

The recent CORTICUS trial (hydrocortisone vs placebo) does not support the routine use of corticosteroids in the management of septic shock. No difference in 28-d mortality was observed between groups, regardless of baseline relative adrenal insufficiency. Duration of shock was shorter in the hydrocortisone group however, an increased incidence of hyperglycemia, sepsis, and recurrent septic shock was observed. This section reflects the 2004 consensus guidelines... 

Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002 287 236-240. 

Prednisone -corticosteroid -leukocytosis -nausea and vomiting indigestion -anorexia or increased appetite -CNS effects (depression, anxiety, euphoria, insomnia, psychosis, confusion) -fluid retention -hyperglycemia -osteoporosis -acne -adrenal insufficiency with prolonged use... 

Corticosteroids can be initiated in septic shock when adrenal insufficiency is present or when weaning of vasopressor therapy proves futile. A daily dose equivalent to 200 to 300 mg hydrocortisone should be continued for 7 days. Adverse events are few because of the short duration of therapy. 

Close monitoring of 24-hour urinary free cortisol levels and serum cortisol levels are essential to identify adrenal insufficiency in patients with Cushing s syndrome. Steroid secretion should be monitored with all drug therapy and corticosteroid replacement given if needed. 

Corticosteroids are produced by the adrenal glands, and display two main types of biological activity. Glucocorticoids are concerned with the synthesis of carbohydrate from protein and the deposition of glycogen in the liver. They also play an important role in inflammatory processes. Mineralocorticoids are concerned with the control of electrolyte balance, promoting the retention of Na+ and CC, and the excretion of K+. Synthetic and semi-synthetic corticosteroid drugs are widely used in medicine. Glncocorticoids are primarily nsed for their antirhenmatic and anti-inflammatory activities, and mineralocorticoids are nsed to maintain electrolyte balance where there is adrenal insufficiency. 

Corticosteroids do not heal illnesses, but they are widely used in various conditions when it is necessary to utilize their anti-inflammatory, immunosuppressant, and mineralo-corticoid properties. In addition, they are used in replacement therapy for patients who have adrenal insufficiency. Corticosteroids can be used in vital situations for asthma, severe allergic reactions, and transplant rejections. They are effective in noninfectious granulomatous diseases such as sarcoidosis, collagen vascular disease, rheumatoid arthritis, and leukemia. Steroids are used as lotions, ointments, etc. in treating a number of dermatological and ophthalmologic diseases. 

Systemic Suppression of HPA function has occurred. Deaths caused by adrenal insufficiency have occurred during and after transfer from systemic to aerosol corticosteroids. 

Carefully observe infants born of mothers who have received substantial doses of corticosteroids during pregnancy for signs of adrenal insufficiency. 

Fludrocortisone acetate Synthetic corticosteroid with some glucocorticoid and potent mineralocorticoid activity Administered orally to treat primary adrenal insufficiency... 

Giving exogenous corticosteroids suppresses ACTH secretion which results in adrenal gland atrophy. Therefore glucocorticosteroid doses should be tapered off to allow the patient to adjust and prevent symptoms of adrenal insufficiency. For the short acting glucocorticosteroids an alternate day regimen should be considered to lower the risks for adrenal suppression. 

IV.a.1.9. Adrenal suppression. It results from inhibition of pituitary ACTH secretion, and some suppression of the normal adrenal response to stress may persist for years after stopping therapy. Rapid withdrawal of corticosteroid therapy can therefore precipitate dangerous acute adrenal insufficiency ( Addisonian crisis , with hypotension, vomiting, coma and ultimately death), and for this reason steroid treatment should always be reduced gradually, sometimes over many months, according to the dose and duration of therapy. 

In patients with longstanding hypothyroidism and those with ischemic heart disease, rapid correction of hypothyroidism may precipitate angina, cardiac arrhythmias, or other adverse effects. For these patients, replacement therapy should be started at low initial doses, followed by slow titration to full replacement as tolerated over several months. If hypothyroidism and some degree of adrenal insufficiency coexist, an appropriate adjustment of the corticosteroid replacement must be initiated prior to thyroid hormone replacement therapy. This prevents acute adrenocortical insufficiency that could otherwise arise from a thyroid hormone-induced increase in the metabolic clearance rate of adrenocortical hormones. 

Systemic corticosteroid effects from inhaled and nasal steroids inadequate to prevent adrenal insufficiency in patients withdrawn from corticosteroids abruptly... 

Monitor patients switched from chronicsystemic corticosteroids to avoid acute adrenal insufficiency in response to stress... 

Deaths due to adrenal insufficiency have occurred in asthma patients during and after transfer from use of long-term systemic corticosteroids to less systemically available inhaled corticosteroids. 

Zwaan CM, Odink RJ, Delemarre-van de Waal HA, Dankert-Roelse JE, Bokma JA. Acute adrenal insufficiency after discontinuation of inhaled corticosteroid therapy. Lancet 1992 340(8830) 1289-90. 

Grabner W. Zur induzierten NNR-Insuffizienz bei chirur-gischen Eingriffen. [Problems of corticosteroid-induced adrenal insufficiency in surgery.] Fortschr Med 1977 95(30) 1866-8. 

Patel L, Wales JK, Kibirige MS, Massarano AA, Couriel JM, Clayton PE. Symptomatic adrenal insufficiency during inhaled corticosteroid treatment. Arch Dis Child 2001 85(4) 330-4. 

Russell G. Inhaled corticosteroids and adrenal insufficiency. Arch Dis Child 2002 87(6) 455-6. 

Thus, in patients with Addison s disease or other forms of adrenal insufficiency, continuing oral administration of cortisone acetate or fludrocortisone acetate enables salt balance to be restored. Other corticosteriods and analogues that have been used in the hormonal control of sodium levels include aldosterone and deoxycortone acetate. Individual corticosteroids vary in the extent to which they possess the various hormonal activities so that combination therapy is usually required if, for example, mineral balances are to be maintained when corticosteroids are administered for their anti-inflammatory, antirheumatic or anti-allergic properties. 

Corticosteroids have a range of activity. They have potent antiinflammatory and immunosuppressive activity. Many synthetic drugs are available as corticosteroids. In appropriate doses, these are used as replacement therapy in adrenal insufficiency. The topical application of corticosteroids is safer when compared with systemic use. Corticosteroids should be used in smaller doses for the shortest duration of time. A high dose may be used for life-threatening syndromes or diseases. A tapering pattern of withdrawal should be followed to avoid complications of sudden withdrawal. Systemic therapy is indicated in a variety of conditions. These are administered by intraarticular injections with aseptic conditions for rheumatoid arthritis and osteoarthritis. In skin diseases, such as eczema, contact dermatitis, and psoriasis, corticosteroids are used topically. In some cases, steroids are combined with antimicrobial substances such as neomycin. 

Prednisolone - The stress of surgery causes an increase in plasma adrenocorticotrophic hormone and cortisol concentrations. Cortisol secretion can rise from 30 mg/day to 50 mg/day following minor surgery and 150 mg/day following major surgery. However, an abrupt withdrawal after a prolonged period may lead to acute adrenal insufficiency, hypotension or shock. Thus it is important to continue SC s corticosteroid therapy and additional intravenous hydrocortisone may be administered peri-operatively. 

Secondary adrenal insufficiency most commonly results from exogenous corticosteroid use, leading to suppression of the hypothalamic-pituitary-adrenal axis and decreased release of ACTH, resulting in impaired androgen and cortisol production. Mirtazapine and progestins (e.g., medroxyprogesterone acetate, megestrol acetate) have also been reported to induce secondary adrenal insufficiency. Secondary disease typically presents with normal mineralocorticoid concentrations. 

Because most adrenal crises occur because of glucocorticoid dose reductions or lack of stress-related dose adjustments, patients receiving corticosteroid-replacement therapy should add 5 to 10 mg hydrocortisone (or equivalent) to their normal daily regimen shortly before strenuous activities such as exercise. During times of severe physical stress (e.g., febrile illnesses, after accidents), patients should be instructed to double their daily dose until recovery. Treatment of secondary adrenal insufficiency is identical to primary disease treatment with the exception that mineralocorticoid replacement is usually not necessary. 

These agents have use in diagnosis of adrenal disease and in controlling excessive production of corticosteroids, e.g. by corticotropin producing tumours of the pituitary (Cushing s syndrome) or by adrenocortical adenoma or carcinoma where the cause cannot be removed. They must be used with special care since they can precipitate acute adrenal insufficiency. Some members inhibit other steroid synthesis. 

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