1. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Glucocorticoids in Nonendocrine Diseases

2. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.2 * Also known as corticosteroids and nearly identical to steroids produced by the adrenal cortex * Physiologic effects (low doses) Modulation of glucose metabolism in adrenocortical insufficiency * Pharmacologic effects (high doses) Suppression of inflammation

3. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.3 Glucocorticoid physiology * Metabolic effects * Cardiovascular effects * Effects during stress * Effects on water and electrolytes * Respiratory system in neonates

4. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.4 Molecular mechanisms of action different from those of other drugs * Glucocorticoid receptors are inside the cell. * Glucocorticoids modulate the production of regulatory proteins versus signaling pathways.

5. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.5 * Effects on metabolism and electrolytes * Anti-inflammatory & immunosuppressant effects * Therapeutic uses in nonendocrine disorders Rheumatoid arthritis Systemic lupus erythematosus Inflammatory bowel disease Miscellaneous inflammatory disorders

6. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.6 Therapeutic uses in nonendocrine disorders * Allergic conditions * Asthma * Dermatologic disorders * Neoplasms * Suppression of allograft rejection * Prevention of respiratory distress syndrome

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8. 8 Adverse effects * Adrenal insufficiency * Osteoporosis and resultant fractures * Infection * Glucose intolerance * Myopathy * Fluid and electrolyte disturbances * Growth retardation * Psychologic disturbances

9. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.9 Adverse effects * Cataracts and glaucoma * Peptic ulcer disease * Iatrogenic Cushing’s syndrome * Use in pregnancy and lactation Drug interactions * Interactions related to potassium loss * Nonsteroidal anti-inflammatory drugs * Insulin and oral hypoglycemics * Vaccines

10. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.10 Contraindications * Patients with systemic fungal infections * Those receiving live virus vaccines * Use with caution in pediatric patients and pregnancy/breast-feeding

11. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.11 Adrenal suppression * Why it can develop * Adrenal suppression and physiologic stress * Glucocorticoid withdrawal Taper the dosage over 7 days Switch from multiple doses to single doses Taper the dosage to 50% of physiologic values Monitor for signs of insufficiency

12. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.12 * Oral, parenteral (IV, IM, sc), and topical * Individual glucocorticoids differ in 3 ways Biologic half-life Mineralocorticoid potency Glucocorticoid potency

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14. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.14 * Highly individualized * Determined empirically (trial and error) No immediate threat – start low and slow Immediate threat – start high; decrease as possible * Long-time use – smallest effective amount

15. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.15 * Prolonged treatment with high doses only if disorder is life-threatening or has potential to cause permanent disability * Increase in times of stress * Wean gradually * Alternate-day therapy 15

16. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.16 You are assigned to the transplant clinic at the healthcare agency where you are doing a clinical rotation. Your instructor assigns you to care for Mr. O, 30 years old, who received a heart and lung transplant 6 weeks ago. He is single with a large extended family. He tells you, “I have six nieces and nephews. The oldest is 10, and the youngest is 8 months. I was so glad to see all of them when I went home. They really cheer me up.” Mr. O is taking multiple drugs to manage his health, including glucocorticoids. Your instructor asks you to develop a plan of care for him that focuses on minimizing the adverse effects of long-term glucocorticoid therapy.

17. Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.17 1. What do you identify as a priority piece of information to explain to Mr. O? 2. You review the information on adverse effects of glucocorticoid therapy; which two adverse effects would you not include in your plan of care for Mr. O? Remember, you need to teach him information related to his individual needs. 3. Did you pick up any vital information in your conversation with Mr. O that should be addressed? 17

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