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Corticosteroids:, Adverse effects and contraindications of corticosteroids…
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Other uses:
Steroids with selective glucocorticoid action without Na+ and water retaining activity like
betamethasone and dexamethasone are used to decrease cerebral edema due to malignancies or TB.
Steroids are also useful in severe infective conditions like
TB meningitis and lepra reactions to tide over the acute crisis.
However these are contraindicated in intestinal(ileo-caecal) Tb due to the risk of perforation.
Significant decrease in the neurological deficits have been seen in spinal cord injury patients
treated with large doses of methylprednisolone within 8 hours.
Steroids can be used as a desperate measure in the septicemic shock.
Used in the treatment of sarcoidosis, in thrombocytopenia prednisolone used to decrease bleeding tendency.
Autoimmune hemolytic anemia treated with prednisolone.
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Effect on immunity:
these hormones suppress cell mediated immunity CMI more than humoral immunity.
Main effect is due to inhibition of recruitment of immune cells,
but they also inhibit the release of IL-1 and IL-2.
antibody production is affected at high doses and continuous administration of glucocorticoids results in catabolism of IgG.
Immunosuppressive effects of glucocorticoids is the basis of their use in graft rejection and various hypersensitivity reaction.
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Betamethasone can be given to accelerate the fetal lung maturation, if delivery is anticipated before 32 weeks of gestation.
In selected patients, antenatal steroid therapy decreases the incidence, severity and complications of respiratory distress syndrome
and decreases overall neonatal mortality and morbidity.
In addition, antenatal steroids may decrease the incidence of PDA, necrotizing enterocolitis and periventricular/intraventricular haemorrhage.
Betamethasone is the steroid of choice and two doses of 12mg are administered IM at an interval of 12 hours.
Alternatively, dexamethasone 6mg IM every 12 hourly four doses can be used.
Aldosterone
Major endogenous mineralocorticoid is aldosterone.
It acts in DCT of the kidney to cause reabsorption of Na+ and excretion of K+ and H+.
Thus the excess of mineralocorticoids can lead to
retention of sodium and water(hypertension and
edema), hypokalemia and alkalosis.
Addison’s disease
Whereas Addison’s disease(deficiency of adrenal corticosteroids) is characterized by hyperkalemia, acidosis and hypotension.
Aldosterone is also involved in causing myocardial remodelling associated with CHF
and the drugs blocking this effect
spironolactone, ACEI, ARBs and Beta blockers) decrease the mortality in patients with CHF.
Glucocorticoids:
Major endogenous glucocorticoid is hydrocortisone(cortisol).
Many of the effects of glucocorticoids are dose dependent
whereas some are permissive effects without these, many normal functions become deficient.
E.g. response of vascular and bronchial smooth muscle to catecholamines is diminished in the absence of cortisol.
Effect on metabolism:
Glucocorticoids are catabolic in nature
and thus cause breakdown of
carbohydrates(hyperglycemia), proteins(muscle wasting) and fat.
There is redistribution of fats deposition over face called moon face, mouth(fish mouth) and back called buffalo hump.
Whereas removal from the extremities is seen.
negative ca2+ balance
Glucocorticoids cause negative ca2+ balance by inhibiting intestinal absorption,
enhancing renal excretion
and causing loss of ca2+ from bones
and can predispose to osteoporosis.
Effect on CVS and CNS:
glucocorticoids prevent the increase in the permeability of capillaries.
These have mild euphoric effect
and high doses can lower seizure threshold.
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Dexamethasone suppression test: is used to test
the intactness of HPA axis function
and diagnosis of cushing’s syndrome.
corticosteroids can be useful in rheumatoid arthritis, osteoarthritis(intra-articular) and acute gouty arthritis when NSAID fails to provide pain relief.
These are also useful in inflammatory conditions of eye like conjunctivitis, iritis, iridocyclitis and keratitis.
However steroids are contraindicated in herpes simplex keratitis.
Corticosteroids are useful in the management of anaphylaxis(DOC is adrenaline), utricaria, angioedema and serum sickness.
These are used by inhalational route in chronic severe asthma
and IV hydrocortisone route is employed in acute severe asthma(status asthmaticus).
Skin conditions like phempigus vulgaris, exfoliative dermatitis and steven johnson syndrome also requires systemic steroid therapy.
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due to prominent lympholytic action in malignant cells,
steroids are essential component of the combination therapy of ALL and lymphomas(both Hodgkin as well as non-Hodgkin).
These are also useful in the CLL, multiple myeloma and breast carcinoma.
These can also be used with anti-neoplastic agents to decrease nausea and vomiting.
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