1. Glucocorticoids in Nonendocrine Disorders
Chapter 72
Glucocorticoids in Nonendocrine Disorders 1

2. Glucocorticoid Drugs
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 2

3. Glucocorticoids in Nonendocrine Disorders
Glucocorticoid physiology
Metabolic effects
Elevates blood glucose
Promotes storage of glucose in the form of glycogen
Reduces muscle mass
Decreases the protein matrix of bone
Causes thinning of the skin
Negative nitrogen balance
Lipolysis
Redistribution of fat: “Potbelly,” “moon face,” and “buffalo hump” 3

4. Glucocorticoids in Nonendocrine Disorders
Glucocorticoid physiology
Cardiovascular effects
Low levels of endogenous glucocorticoids: Capillaries become more permeable, vasoconstriction is suppressed, blood pressure falls
Glucocorticoids increase circulating red blood cells and polymorphonuclear leukocytes, and decrease lymphocytes, eosinophils, basophils, and monocytes 4

5. Glucocorticoids in Nonendocrine Disorders
Glucocorticoid physiology
Effects during stress
Physiologic stress (for example, surgery, infection, trauma, hypovolemia): Adrenal glands secrete large quantities of glucocorticoids and epinephrine
Result: Hormones help maintain blood pressure and blood glucose levels
Insufficient release of glucocorticoids: Hypotension and hypoglycemia occur
Very severe stress: Glucocorticoid insufficiency can result in circulatory failure and death 5

6. Glucocorticoids in Nonendocrine Disorders
Glucocorticoid physiology
Effects on water and electrolytes
Can exert actions like those of aldosterone
Can act on the kidney to promote retention of sodium and water while increasing urinary excretion of potassium
Net result is hypernatremia, hypokalemia, and edema
Most glucocorticoids used as drugs have very low mineralocorticoid activity 6

7. Glucocorticoids in Nonendocrine Disorders
Glucocorticoid physiology
Respiratory system in neonates
During labor and delivery: Adrenal glands of full-term infant release a burst of glucocorticoids
Effect: Maturation of the lungs
Preterm infant: Production of glucocorticoids is low
Preterm infant: High incidence of respiratory distress syndrome 7

8. Pharmacology of Glucocorticoids
Molecular mechanisms of action are different from those of other drugs
Glucocorticoid receptors are inside the cell
Glucocorticoids modulate the production of regulatory proteins rather than signaling pathways 8

9. Pharmacology of Glucocorticoids
Effects on metabolism and electrolytes
Anti-inflammatory and immunosuppressant effects
Major clinical applications of the glucocorticoids stem from their ability to suppress immune responses and inflammation
Therapeutic uses in nonendocrine disorders
Rheumatoid arthritis
Systemic lupus erythematosus
Inflammatory bowel disease
Miscellaneous inflammatory disorders 9

10. Pharmacology of Glucocorticoids
Therapeutic uses in nonendocrine disorders (Cont.)
Allergic conditions
Asthma
Dermatologic disorders
Neoplasms
Suppression of allograft rejection
Prevention of respiratory distress syndrome in preterm infants 10

11. Pharmacology of Glucocorticoids
Adverse effects
Adrenal insufficiency with prolonged administration
Osteoporosis with prolonged systemic therapy
Infection: PCP (Pneumocystis pneumonia)
Glucose intolerance: Hyperglycemia and glycosuria
Myopathy: Proximal muscles of the arms and legs are affected most 11

12. Pharmacology of Glucocorticoids
Adverse effects (Cont.)
Fluid and electrolyte disturbances: Sodium and water retention and potassium loss
Growth retardation: Can suppress growth in children
Psychologic disturbances 12

13. Pharmacology of Glucocorticoids
Adverse effects (Cont.)
Cataracts and glaucoma: Long-term glucocorticoid therapy
Peptic ulcer disease: Inhibit prostaglandin synthesis, augment secretion of gastric acid and pepsin, inhibit production of cytoprotective mucus, and reduce gastric mucosal blood flow 13

14. Pharmacology of Glucocorticoids
Adverse effects (Cont.)
Iatrogenic Cushing’s syndrome: Hyperglycemia, glycosuria, fluid and electrolyte disturbances, osteoporosis, muscle weakness, cutaneous striations, lowered resistance to infection; redistribution of fat produces a “potbelly,” “moon face,” and “buffalo hump”
Use in pregnancy and lactation 14

15. Pharmacology of Glucocorticoids
Drug interactions
Interactions related to potassium loss
Nonsteroidal anti-inflammatory drugs
Insulin and oral hypoglycemics
Vaccines 15

16. Pharmacology of Glucocorticoids
Contraindications and precautions
Patients with systemic fungal infections
Those receiving live virus vaccines
Use with caution in pediatric patients and in pregnancy/breast-feeding 16

17. Pharmacology of Glucocorticoids
Adrenal suppression
Why it can develop
Adrenal suppression and physiologic stress
Glucocorticoid withdrawal
Taper dosage over 7 days
Switch from multiple doses to single doses
Taper dosage to 50% of physiologic values
Monitor for signs of insufficiency 17

18. Glucocorticoid Routes of Administration
Oral, parenteral (IV, IM, subQ), and topical
Individual glucocorticoids differ in three ways:
Biologic half-life
Mineralocorticoid potency
Glucocorticoid potency 18

19. Glucocorticoid Dosage
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
Prolonged treatment with high doses is used only if disorder is life-threatening or has potential to cause permanent disability
Increased in times of stress
Gradual weaning
Alternate-day therapy
Administer before 0900 19

20. Question 1 A patient with systemic lupus erythematosus is prescribed
prednisone. It is most important for the nurse to monitor the patient for what?
A. Hypotension
B. Elevated potassium levels
C. Neck and back pain
D. Hypoglycemia
Answer: C
Rationale: Neck and back pain from a vertebral compression fracture may occur because of the development of osteoporosis as a result of glucocorticoid therapy. Other possible adverse effects of prednisone include hypertension, hypokalemia, and hyperglycemia.

21. Question 2
A patient has been prescribed pharmacologic doses of glucocorticoids. It is most important for the nurse to teach the patient to do what?
Increase intake of dietary sodium.
Take antibiotics to prevent infection.
Never abruptly withdraw therapy.
Have an eye examination every year.
Answer: C
Rationale: Abrupt withdrawal of glucocorticoids may cause adrenal insufficiency or an adrenal crisis. Infection should be prevented, but the use of antibiotics without a known infection is inappropriate. Sodium intake should be restricted while the patient is taking glucocorticoids. Eye examinations are recommended every 6 months for patients on glucocorticoid therapy.

22. Question 3
A patient has been receiving long-term prednisone therapy for treatment of rheumatoid arthritis. The chart indicates that the patient has developed Cushing’s syndrome. When performing a physical assessment, the nurse anticipates finding all but which manifestation of Cushing’s syndrome?
Hypoglycemia
Muscle weakness
Glucosuria
“Buffalo hump”
Answer: A
Rationale: Cushing’s syndrome is manifested by hyperglycemia, glycosuria, fluid and electrolyte disturbances, osteoporosis, muscle weakness, cutaneous striations, and lowered resistance to infection. Redistribution of fat produces a “potbelly,” “moon face,” and “buffalo hump.”