Steroid Use In Clinical Practice DR. TIN WIN AUNG Consultant Endocrinologist Department of Diabetes & Endocrinology North Okkalapa General & Teaching Hospital Outlines ◼ Overview of Steroids → What are steroids? →Steroidogenesis, Regulation, Physiological & Adverse Effects ◼ Steroids use in Clinical practice → Classification → Topical Steroids → Inhaled Corticosteroids → Systemic Corticosteroids → Prevention & Treatment of Complications of using CS What are steroids? ◼ Steroids (short for corticosteroids) are synthetic drugs that closely resemble cortisol, a hormone that your adrenal glands produce naturally. ◼ Corticosteroids are different from the male hormone-related steroid compounds that some athletes use. Corticosteroids ◼ Corticosteroids divided into: –Glucocorticoids –Mineralocorticoids Endogenous Steroidogenesis Regulation of Cortisol Secretion ◼ Three major mechanisms control ACTH release and the Cortisol secretion (1) Negative feedback mechanism →ACTH from anterior pituitary (2) Diurnal variation →Levels are the highest in the morning on waking and the lowest in the middle of evening. (3) Stress- physical (trauma, surgery, exercise) - psychological (pain, anxiety, apprehension) - physiological (nausea, fever and hypoglycemia) The Role of Cortisol in Regulation of HPA Axis 20 mg/day Plasma Cortisol -140- 700 nmol/l (Ref: range) Glucocorticoids Physiological Effects Carbohydrate metabolism ↑gluconeogenesis and conserve glucose for use during stress or starvation. Protein metabolism catabolic effect → negative nitrogen balance with muscle wasting, osteoporosis, growth slowing, skin atrophy, increased capillary fragility, bruising and striae. → Delayed wound healing Fat deposition → ↑on shoulders, face and abdomen. Anti-inflammatory and immunosuppressive effects → ↓ recruitment and function of inflammatory cells and vascular permeability at the site of inflammation. → Inhibit prostaglandin and leucotriene synthesis by inhibiting the release of arachidonic acid from the phospholipids. Use as anti-inflammatory and immunosuppressive agents Maintainance of blood pressure → enhances the vascular reactivity to other vasoactive substances such as nor- epinephrine and angiotensin-II Anti-vitamin D action → ↓ calcium absorption from the gut and ↑ urinary calcium excretion, → useful in treatment of hypercalcemia in sarcoidosis and vitamin D intoxication. Fluid and electrolyte balance Renal excretion of urate is increased Systems Adverse Effects Cautions/Comments Fluid/Electrolyte Sodium Retension Caution in CHF/hypertension disturbances Edema ↓ Salt intake ↑ Potassium exerction Potassium supplements ↑ Calcium excretion ↑ risk of osteoporosis, Ca supplements Gastrointestinal Gastric Irritation Risk ↑ with ↑doses & prolonged use. N, V, Wt loss/ Wt gain Use PPI only in long term high dose Abd distension, Peptic ulcer steroid therapy Endocrine Hypercortisolism (Cushingoid state) Associated with long term use even at Secondary adrenal insufficiency lower dosages Menstrual difficulties: Amenorrhea, post-menopausal bleeding Precipitation of diabetes mellitus Glucose Intolerance: hyperglycemia Others Insomnia Psychiatric disturbances Immunosuppression Cataracts / Glaucoma Hirsutism/ Acne Classification of Corticosteroids Classification of Synthetic Corticosteroids by Chemical Structure Progesterone-type Hydrocortisone- Methasone-type Acetonides & type related Flugestone Alclometasone Fluorometholone Chloroprednisone Beclomethasone Amcinonide Medrysone Cloprednol Betamethasone Budesonide Prebediolone acetate Fludrocortisone Clobetasol Ciclesonide Progestrin→ Fluocinolone Clobetasone Deflazacort cyproterone acetate Fluprednisolone Dexamethasone Desonide Medroxyprogesterone Methylprednisolone Diflucortolone Formocortal acetate Prednisolone Fluclorolone Flunisolide Prednisone Flumetasone Halocinonide Tixocortol Fluticasone Triamcinolone Triamcinolone Meprednisone acetonide Paramethasone Ulobetasol Other Cortivazol Classification of Corticosteroids by Route of Administration ❑ Topical ❑ Oral →creams ❑ Parental →IV/ IM ❑ Inhalation- Aerosol →ointments ❑ Others →lotions, mousses, → Intrarticular →shampoos → ocular, nasal, rectal (enema), in ear or spinal →gels or tapes Steroid Use in Clinical Practice Common clinical uses of systemic corticosteroids Allergy and •Moderate to severe asthma exacerbations/ Acute exacerbations of COPD respirology • Allergic rhinitis • Atopic dermatitis • Urticaria/angioedema • Anaphylaxis/ Food and drug allergies • Hypersensitivity pneumonitis • Sarcoidosis • Acute and chronic eosinophilic pneumonia • Interstitial lung disease Dermatology •Pemphigus vulgaris • Acute, severe contact dermatitis Endocrinology • Adrenal insufficiency • Congenital adrenal hyperplasia Gastroenterology • Ulcerative colitis/ Crohn’s disease • Autoimmune hepatitis Hematology •Lymphoma/leukemia • Hemolytic anemia • Idiopathic thrombocytopenic purpura Rheumatology/ • Rheumatoid arthritis/ Systemic lupus erythematosus immunology • Polymyalgia rheumatica • Polymyositis/dermatomyositis • Polyarteritis/ Vasculitis Ophthalmology • Uveitis • Keratoconjunctivitis Other • Organ Transplant • Multiple sclerosis • Nephrotic syndrome • Chronic active hepatitis • Cerebral edema PRESCRIBING CORTICOSTEROIDS ◼ In non-endocrine disorders, GCs are commonly given in pharmacologic (therapeutic) doses to suppress inflammation ◼ In endocrine disorders, corticosteroid doses are often given at or close to physiologic doses (rather than in therapeutic ranges) Topical Corticosteroids Potency Ratings of Topical Corticosteroids Ultra high Augmented betamethasone dipropionate 0.05% (I) Clobetasol propionate 0.05%, Diflorasone diacetate 0.05% Fluocinonide 0.1%, Flurandrenolide 4 mcg per m2 Halobetasol propionate 0.05% High Amcinonide 0.1% (II) Betamethasone dipropionate 0.05% Desoximetasone, Diflorasone diacetate 0.05% Fluocinonide 0.05%, Halcinonide 0.1% Medium to Amcinonide 0.1% High Betamethasone dipropionate 0.05% (III) Fluticasone propionate 0.005% Triamcinolone acetonide 0.5% Medium Betamethasone valerate , Desoximetasone 0.05% (IV and V) Fluocinolone acetonide 0.025%, Fluticasone propionate 0.05% Hydrocortisone butyrate 0.1%/probutate 0.1%/valerate 0.2% Triamcinolone acetonide 0.025%/ acetonide 0.1% Low Alclometasone dipropionate 0.05%, Desonide 0.05% (VI) Fluocinolone 0.01%, Hydrocortisone butyrate 0.1% Least potent Hydrocortisone 1%, 2.5% (VII) http://www.factsandcomparisons.com Indications of topical corticosteroids Disorders very responsive to topical Disorders less responsive to topical corticosteroids corticosteroids (remission with low to medium topical CS) (high potency steroids at higher CS) •Atopic dermatitis •Dscoid lupus erythematosus •Seborrheic dermatitis •Psoriasis of palms and soles •Lichen simplex chronicus •Necrobiosis lipoidica diabeticorum •Pruritus ani •Sarcoidosis •Later phase of allergic contact dermatitis •Lichen striatus •Later phase of irritant contact dermatitis •Pemphigus •Nummular eczematous dermatitis •Familial benign pemphigus •Stasis dermatitis •Vitiligo •Psoriasis •Granuloma annularae Is Corticosteroid cream safe? ◼ In most cases, topical steroids are safe and well tolerated if used correctly. ◼ People who experience side effects usually are not using steroid creams properly. ◼ Applying the cream or ointment thinly and evenly to the affected areas on the skin is important. ◼ This minimizes the amount absorbed through the skin into the body Clobetasol propionate (0.05%) ◼ Use of 2g/day → ↓ morning cortisol level after a few days ◼ Use over 100 g/week or 100-300 g/week →features of Cushing’s $ and symptoms of adrenal insufficiency. ◼ Allenby et al (1987) Clobetasol propionate > 50 g/week→ Adrenal suppression Recommended dose- Not more than 50 g/week for Not more than 2 weeks ◼ Cushing’s $ was also reported with the use of relatively low potent topical steroid triamcinolone acetonide (0.1%) of 38 g daily under occlusion for ~ 4 years Tips for use of Topical steroids ◼ Once or twice-daily application is recommended for most preparations ◼ More frequent administration does not provide better results ◼ Chronic application of topical steroids →tolerance & tachyphylaxis. ◼ Ultra-high-potency steroids should not be used for > 3 weeks continuously. ◼ If a longer duration is needed, the steroid should be gradually tapered to avoid rebound symptoms, and treatment should be resumed after a steroid-free period of at least one week. Inhaled Corticosteroids Major ICS ◼ beclomethasone dipropionate (Half life- 15 hrs) ◼ fluticasone propionate (Half life- 14 hrs) ◼ Budesonide (Half life- 2 to 3 hrs) ◼ mometasone furoate (Half life- 5 to 8 hrs) Newer generations of ICS ◼ ciclesonide (Half life 0.71 hrs) ◼ Flunisolide (Half life 1-2 hrs) Relative ICS potencies ◼ mometasone > fluticasone propionate > ciclesonide > beclomethasone monoproprionate > budesonide EVIDENCE FOR SYSTEMIC ABSORPTION OF ICS ◼ ~ 10% to 20% of a dose of ICS → respiratory tract ◼ 80% to 90% →swallowed and absorbed through the GI tract. ◼ Most of the drug that is swallowed will undergo first-pass metabolism and does not enter the systemic circulation. ◼ The ICSs in current use have a high first pass metabolism, exceeding 99% in the case of fluticasone propionate. Extent of absorption is determined by ◼ inhaler device ◼ particle size ◼ deposition site, pharmacokinetic and physicochemical properties of the drug (lipophilicity) ◼ The rate of dissolution of different ICSs in human bronchial fluid → 6 min for budesonide → 5 hours for beclomethasone → 8 hours for fluticasone ICS & HPA