Glucocorticoids: Uses, Medications, & Action

• Glucocorticoids relieve pain and inflammation related to inflammatory and autoimmune disorders
• They manage skin disorders and allergic reactions
• They delay the progression of disorders like rheumatoid arthritis
• They prevent rejection after organ transplants
• They work as adjunctive therapy for some cancers
• Prototype medication: Prednisone

Other Medications

• Prednisolone
• Hydrocortisone
• Methylprednisolone
• Betamethasone
• Cortisone
• Dexamethasone
• Triamcinolone

Pharmacologic Action

• Corticosteroids are hormonal steroids from the adrenal cortex
• There are two types: glucocorticoids and mineralocorticoids
• Glucocorticoids (like cortisol) regulate carbohydrate, fat, and protein metabolism
• They're produced in response to stress to restore emotional stability
• Cortisol produces anti-inflammatory effects and suppresses the immune system.
• Mineralocorticoids (like aldosterone) promote sodium retention by the kidneys affecting fluid and electrolyte levels
• Glucocorticoids mimic cortisol, suppressing inflammation and the immune response
• They inhibit prostaglandin synthesis which decreases pain
• They decrease permeability of capillaries which decreases swelling
• They inhibit lysosomal activity which decreases inflammation
• They decrease lymphocyte production, which decreases the immune response
• Corticosteroids are the "steroidal" anti-inflammatory medication to which the 'non' in NSAIDs refers

Adverse Drug Reactions

• Glucocorticoids suppress adrenal function because the adrenal gland does not have to produce its own cortisol
• Hyperglycemia occurs due to effects on carbohydrate metabolism
• Myopathy (muscle weakness) occurs due to effects on protein metabolism
• Risk for peptic ulcer disease and GI distress increases due to inhibiting prostaglandin synthesis
• Increased susceptibility to infection occurs as they suppress the immune system
• Fluid and electrolyte imbalances can occur, causing fluid retention and swelling due to mineralocorticoid effects
• Redistribution of fat can occur, with increased fat in the face, torso, and upper back
• Fat decreases in the extremities can resulting in truncal obesity, moon face, and buffalo hump
• Osteoporosis occurs as calcium is drawn out of the bones
• Cataracts can develop over a long period

Interventions

• Monitor for adrenal insufficiency (hypotension, fatigue) during physical or emotional stress, consider larger dosage if these occur
• Monitor blood glucose levels, adjust insulin or hypoglycemic medication dosages for clients with diabetes mellitus accordingly
• Observe for GI bleeding (bloody vomitus, black, tarry stools)
• Implement gastric protective measures: give with food, consider analgesic substitute if client is taking an NSAID
• Observe for infection symptoms that may not include fever/inflammation (sore throat, fatigue, tachycardia, wound discharge)
• Initiate antimicrobial therapy as appropriate
• Monitor intake/output, watch for edema, lung crackles, unexplained weight gain (hypernatremia)
• Monitor for generalized weakness (hypokalemia)
• Monitor for Cushing-like effects (abdominal fat, buffalo hump, moon face); use lowest effective dose and alternate-day dosing
• Determine a regular schedule for ophthalmic examinations.

Administration

• Routes: oral, IV, IM, subcutaneous, topical, intranasal, inhalation
• For short-term oral use, give the largest dose on the first day, diminishing over the next 8 days
• For long-term use (10+ days), recommend alternate-day dosing to avoid adrenal gland suppression
• Taper the dose slowly in collaboration with the provider to determine the lowest effective dose
• Give supplemental doses as needed during times of stress.

Client Instructions

• Understand the effects these medications have on the body, and the implications of adrenal suppression
• For short-term therapy, carefully follow instructions, as daily doses may vary
• Use a calendar to keep track of medication days for alternate-day therapy
• Contact the provider when sick or under physical/emotional stress as dosages may need adjustment
• Do not stop taking the medication abruptly; gradually taper the dose when discontinuing it.
• Report hyperglycemia symptoms: polyphagia, polydipsia, polyuria
• Report muscle pain or weakness
• Consult the provider about using acetaminophen for pain and avoiding NSAIDs due to gastric irritation/ulceration potential
• Take medication with food to minimize gastric distress.
• Immediately report indigestion or bloody vomitus, as well as black, tarry stools (GI bleeding)
• Teach them about manifestations of infection that do not include fever and inflammation, such as a sore throat or a wound that has suspicious looking drainage.
• Report weight gain or edema (hypernatremia) and weakness (hypokalemia)
• Long-term therapy may cause changes in fat distribution: truncal obesity, moon-shaped face, buffalo hump
• Perform daily weight-bearing exercises and consume adequate calcium/vitamin D to help prevent osteoporosis
• Minimize eye exposure to sunlight and always wear sunglasses with ultraviolet protection
• Obtaining periodic eye examinations will help determine if cataracts are developing and reinforce the need to decrease the dose of the glucocorticoid to its lowest effective dose

Contraindications and Precautions

• Avoid in clients with systemic fungal infections or cataracts.
• Use with caution in clients with heart failure, peptic ulcer disease, diabetes mellitus, hypertension, renal dysfunction, myasthenia gravis, and osteoporosis.

Safety Alert

• Do not underestimate the potential for adverse drug reactions when given on a long-term basis
• Clients with osteoporosis experience greater bone loss because glucocorticoids suppress bone formation and the absorption of calcium from the intestines
• Mineralocorticoid effects increase sodium and water retention, increasing the severity of hypertension and heart failure
• Glucocorticoids inhibit prostaglandin synthesis thus decreasing the production of protective mucus in the stomach, increasing the risk for ulcers
• Clients with diabetes mellitus are more prone to hyperglycemia due to effects on glucose metabolism
• Muscle atrophy and weakness with long-term therapy exacerbates weakness in clients diagnosed with myasthenia gravis

Interactions

• Glucocorticoids prevent effective response to vaccines
• Live vaccine administration increases the risk for decreased antibody response and increased adverse effects
• Use with potassium-depleting diuretics (furosemide) increases hypokalemia risk
• Risk of digoxin-induced dysrhythmias increases with concurrent digoxin administration.
• Concurrent NSAID administration increases the risk of GI bleeding and ulceration
• The effects of insulin and oral hypoglycemics decrease in clients with diabetes.

Question Answer

• Increase serum glucose monitoring