Hypertension with corticosteroids

The corticosteroids are administered with caution in older adults because they are more likely to have preexisting conditions such as congestive heart failure, hypertension, osteo-poros s and arthritis which may be worsened by the use of such agents The nurse monitors older adults for exacerbation of existing conditionsduring corticosteroid therapy. In addition, lower dosages may be needed because of the effects of aging, such as decreased muscle mass renal function, and plasma volume. 

Speciai risk Use with caution in the following situations Nonspecific ulcerative colitis if there is a probability of impending perforation, abscess, or other pyogenic infection diverticulitis fresh intestinal anastomoses hypertension CHF thromboembolitic tendencies thrombophlebitis osteoporosis exanthema Cushing syndrome antibiotic-resistant infections convulsive disorders metastatic carcinoma myasthenia gravis vaccinia varicella diabetes mellitus hypothyroidism, cirrhosis (enhanced effect of corticosteroids). 

Adverse reactions of corticosteroids are frequent with the long-term immunosuppressive regimens which are often needed and include an increased risk of infections, Cushing-like symptoms, hypertension, hyperglycemia, osteoporosis, growth retardation in children and mental reactions such as dysphoria, psychosis and depression. 

Metyrapone is a competitive inhibitor of 11 beta hydroxylation in the adrenal cortex, and effectively inhibits cortisol production. It is used in low doses, titrated to achieve plasma cortisol levels as close as possible to normal day-time values. Occasionally it is used in higher doses combined with replacement corticosteroid treatment. Its main side effects relate to overdosage and resulting hypoadrenalism, but it can also cause hirsutism and hypertension, due to accumulation of precursor steroids. Ketoconazole is also sometimes used to suppress adrenal steroid production, but its potential for hepatotoxicity limits its... 

The first point is that treatment with steroids is generally palliative rather than curative, and only in a very few diseases, such as leukemia and nephrotic syndrome, do corticosteroids alter prognosis. One must also consider which is worse, the disease to be treated or possible induced hypercortisolism. The patient s age can be an important factor, since such adverse effects as hypertension are more apt to occur in old and infirm individuals, especially in those with underlying cardiovascular disease. Glucocorticoids should be used with caution during pregnancy. If steroids are to be employed, prednisone or prednisolone should be used, since they cross the placenta poorly. 

Transient elevations in blood pressure and heart rate occur with seizures, probably as a result of increased sympathetic stimulation that leads to increases in norepinephrine levels. Hypertension or increased pretreatment heart rate are strongly predictive of peak postictal change in both heart rate and blood pressure ( 38). Increased parasympathetic stimulation decreases the heart rate as a result of inhibition of the sinoatrial node. Stimulation of the adrenal cortex leads to increased plasma corticosteroids and stimulation of the adrenal medulla, which may also contribute to increases in blood pressure and heart rate. 

Corticosteroids should be used cautiously in the presence of congestive heart failure, myocardial infarction, hypertension, diabetes mellitus, epilepsy, glaucoma, hepatic disorders, osteoporosis, peptic ulceration, and renal impairment. Children are more susceptible to these adverse effects. To avoid cardiovascular collapse, steroids must be given slowly by intravenous injection. Large doses produce Cushing s syndrome (with moon face and sometimes hirsutism). 

CORTICOSTEROIDS VASODILATOR ANTI HYPERTENSIVES Risk of hyperglycaemia when diazoxide co-administered is with corticosteroids Additive effect both drugs have a hyperglycaemic effect Monitor blood glucose closely, particularly with diabetics... 

Corticosteroid-induced ocular hypertension appears to relate not only to the individual patient but to the specific steroid used. In general, dexamethasone 0.1%, betamethasone 0.1%, and prednisolone acetate appear more likely to induce significant lOP elevations than do fluorometholone alcohol and medrysone. Clinical studies with rimexolone and LE indicate that they have less potential to elevate lOP than does dexamethasone phosphate or prednisolone acetate. 

Because side effects can complicate the use of corticosteroids, a careful history and certain tests may be advisable, particularly if a patient may require prolonged ocular therapy. Steroids should be used with great caution in patients with diabetes mellitus, infectious disease, chronic renal feilure, congestive heart feilure, and systemic hypertension. Systemic administration is generally contraindicated in patients with peptic ulcer, osteoporosis, or psychoses. Topical steroids should be used with caution and only when necessary in patients with glaucoma. 

Induction of ocular hypertension after corticosteroid administration depends on the specific drug, the dose, the route and frequency of administration, and the corticosteroid responsiveness of the patient. Generally, patients with elevated lOP are asymptomatic, so examination with applanation tonometry is the key to diagnosis. If the patient shows a steroid responsiveness, the onset of lOP elevations is not immediate but occurs after approximately 2 weeks of use. However, it can occur many weeks later, and this time to onset is generally longer for systemic steroids. In responsive patients the level of lOP rise with systemic steroids averages approximately 60% of that produced by topically applied steroids. 

Contraindications to the use of adrenal steroids for suppressing inflammation are all relative, depending on the advantage to be expected. They should be used only for serious reasons if the patient has diabetes, a history of mental disorder or peptic ulcer, epilepsy, tuberculosis, hypertension or heart failure. The presence of any infection demands that effective chemotherapy be begun before the steroid, but there are exceptions (some viral infections, see above). Topical corticosteroid applied to an inflamed eye (with the very best of intention) can be disastrous if the inflammation is due to herpes virus. 

Ciclosporin-induced encephalopathy was precipitated by diltiazem in a 76-year-old white woman with corticosteroid-resistant aplastic anemia and thrombocjdope-nia, type 2 diabetes, and coronary artery disease, who was taking diltiazem for hypertension (28). She became comatose after 13 days of therapy with ciclosporin, and clinical examination and electroencephalography showed diffuse encephalopathy of moderate severity. Ciclosporin was withdrawn and she regained consciousness after 36 hours. 

Amphetamines have also been associated with a syndrome of acute kidney injury and rhabdomyolysis. Several series have described patients following intravenous injection of methamphetamine or phenmetrazine who presented with hyperactivity, fever, chills, sweats, abdominal cramps, diarrhea, and hypotension [177,178]. The patients have developed acute kidney injury which is usually oliguric and associated with classic rhabdomyolysis, similar to cases of cocaine-induced rhabdomyolysis. Several patients have had disseminated intravascular coagulation and liver function abnormalities as well. Methamphetamine abuse has also been associated with accelerated hypertension, unexplained chronic renal failure, acute lead poisoning (a common reagent used in its production utilizes lead acetate) and at least one case of biopsy proven interstitial nephritis the latter patient responded to intravenous corticosteroids but whether the nephritis was truly due to amphetamines remains unproven [179]. 

In addition to pituitary-adrenal suppression, prolonged therapy with corticosteroids can cause fluid and electrolyte disturbances, hypertension, hyperglycemia, and glycosuria. It also increases the susceptibility to infections including tuberculosis causes... 

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