ADRENOCORTICOSTEROIDS CHAPTER 19 Adrenocorticosteroids = group of agents secreted by the adrenal cortex Dental uses Medical Uses Mechanism of release stress → hypothalamus releases CRF → pituitary releases ACTH → adrenal cortex releases hydrocortisone . Classification of Steroids glucocorticoids mineralcorticoids Disease States Addison’s disease Cushing’s syndrome Mechanism of Action steroid binds to receptor → forms steroid-receptor complex → complex enters nucleus, turns genes on/off anti-inflammatory Pharmacologic effects - palliative (not curative) glucocorticoids prednisone, methylprednisolone, triamcinolone 1. anti-inflammatory 2. suppress allergic reactions 3. suppress immune response mineralcorticoids 1. ↑ Na+ retention 2. ↑ K+ loss 3. ↑ edema, hypertension ADR’s Glucocorticooids (see fig 19-2, pg 243) 1. metabolic changes - look like Cushing’s syndrome (see fig. 19-3, pg 244) 2. infections - because of anti-inflammatory action 3. CNS - changes in personality and behavior (euphoria with high dose, depression with lower dose) 4. peptic ulcer - corticosteroids stimulate stomach acid 5. impaired wound healing / osteoporosis - impaired synthesis of collagen 6. ophthalmic effects - increased intraoccular pressure 7. electrolyte / fluid balance - can have some mineralcorticoid action 8. adrenal crisis - adrenal gland atrophies with prolonged use; can be lethal 9. dental effects a. slow healing of mucosal surfaces b. oral candidiasis with steroid inhalers (asthma) Medical Uses 1. Addison’s disease 2. Cushing’s syndrome (Rx, adrenal tumor, pituitary tumor) 3. autoimmune diseases a. rheumatoid arthritis b. collagen diseases 4. with chemotherapy in CA tx (anti-emetic/anti-nausea, and to reduce swelling which decreases pain) 5. asthma 6. emergencies - tx shock, tx adrenal crisis 7. tx inflammatory and allergic reactions (palliative only, not curative) (most common) Dental Uses 1. oral lesions - tx of noninfectious inflammatory diseases (most common) RAS 2. oral surgery - ↓ post-op edema, trismus, and pain (?) 3. pulp procedures (?) Dental Implications 1. GI - stimulate stomach acid, avoid Rx Salicylates (ASA) and NSAID’s 2. check BP - can exacerbate hypertension 3. glaucoma - avoid Rx anticholinergics 4. be aware of possible behavior changes 5. osteoporosis 6. infection - infection symptoms may be masked, pt. has decreased ability to fight infection 7. delayed wound healing - special care in suturing 8. adrenal crisis - only with severe stress 9. periodontal disease - interfere with body’s response to infection, osteoporosis Steroid supplementation most dental patients taking steroids having normal dental tx rendered DO NOT need additional steroids (see fig 19-4, pg 247) OTHER HORMONES CHAPTER 20 Hormones Pituitary Hormones (pituitary = “master gland”, hypophysis) Anterior (adenohypophysis) 1. GH growth hormone (somatotropin) gigantism acromegaly dwarfism 2. LH leutinizing hormone 3. FSH follicle stimulating hormone 4. TSH thyroid stimulating hormone (thyrotropin) 5. ACTH adrenocorticotropic hormone 6. PRL prolactin (leuteotropic hormone LTH) 7. β - lipotropin Posterior (neurohypophysis) 1. Vasopressin (antidiuretic hormone - ADH) 2. Oxytocin Thyroid Hormones Iodine-containing 1. T3 (tri-iodo-thyronine) 2. T4 (thyroxine) Hypothyroid child: cretinism adult: myxedema Hyperthyroid thyrotoxicosis Grave’s disease Plummer’s disease Hashimoto’s disease Calcitonin Pancreatic Hormones Insulin Glucagon Diabetes mellitus: def. abnormal carbohydrate metabolism with inappropriate hyperglycemia Type I (IDDM, juvenile onset) Type II (NIDDM, adult onset) Systemic complications Oral complications Management of DM patient Evaluation Medical emergencies Hypoglycemia Hyperglycemia Drugs used to manage diabetes (add’l resource: http://en.wikipedia.org/wiki/Anti-diabetic_medication) Type I Insulin: Lantus, Humalog, Humulin N, Humulin 70/30, Novolog Mix 70/30, Novolin 70/30 Type II Sulfonylureas: glimepiride, glyburide, glipizide (secretagogues) MA: ↑ release of insulin from beta cells, ↓ serum glucagon, ↑ insulin sensitivity in target tissues ADR’s: blood dyscrasias, GI, cutaneous, liver damage meglitinide derivatives (non-sulfonylurea secretagogues): repaglinide (Prandin) nateglinide (Starlix) MA: ↑ release of insulin from beta cells, ADR’s: must be taken with meals Biguanides: metformin MA: ↓ hepatic production of glucose, ↑ insulin sensitivity in target tissues ADR’s: GI, lactic acidosis thiazolidinediones (glitazones): Actos, Avandia MA: ↑ insulin sensitivity in target tissues ADR’s: weight gain, hepatotoxicity new drugs exenatide (Byetta) (secretagogue, incretin mimetic, glucagon-like peptide / GLP-1) MA: ↑ release of insulin from beta cells, ↓ serum glucagon, ↑ satiety ADR’s: GI, risk of hypoglycemia when used with other oral diabetic agents pramlintide (Symlin) (amylin analog) MA: modulation gastric emptying, prevent postprandial rise in plasma glucagon, ↑ satiety Amylin secreted along with insulin by pancreatic β- cells ADR’s: GI, risk of hypoglycemia when used with other oral diabetic agents DPP-4 inhibitors (Januvia / sitaglipton) MA: ↑insulin synthesis, oppose glucagon ADR’s: weight gain when used with sulfonylurea α-glucosidase inhibitors ( acarbose) MA: delay/prevent digestion of ingested carbohydrate (small intestine), delays glucose adsorption ADR’s: flatulence, GI Female Sex Hormones Estrogens: Premirin, Evista, Estradiol Progestins Oral contraceptives: NuvaRing, Loestrin 24 Fe Management of patient taking oral contraceptives: Drug interactions: Male Sex Hormones (testosterone) Other Agents clomiphene leuprolide tamoxifen danazol aromatase inhibitors .