dh206: pharmacology chapter 18: adrenocorticosteroids lisa mayo, rdh,bsdh copyright © 2011, 2007...
TRANSCRIPT
DH206: PharmacologyChapter 18: Adrenocorticosteroids
Lisa Mayo, RDH,BSDHCopyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Chapter 19 OutlineA&P ReviewHormone SecretionClassificationRoute of AdministrationMechanism of ActionPharmacological EffectsAdverse Rxns
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
AdrenocorticosteroidsUse in dentistry
Topically or systemically Treatment of oral lesions associated with
inflammatory disordersLong-term therapy: asthma or arthritis
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P Reviewhttp://www.youtube.com/watch?v=fF_3mJV3Yh0
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewAdrenal glands located on upper
surface of each kidneyOuter (next slide) & Inner layerInner layer (adrenal medulla)
Secretes catecholamine’s during fight-or-flight response
Epi is ONLY produced from the adrenal medulla = responsible for converting stored glycogen to glucose (glycogenolysis)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewOuter part: adrenal cortex has 3 layers
Each layer secretes steroid hormones 3 layers of the cortex
Layer of Cortex
Location
Hormone released
Function
Glomerulosa
Outer Aldosterone(mineralcortico-steroid)
Acts on kidney to ↑ absorption Na+, dump K+ & H+
Fasciculata Middle Cortisol Signals to body to ↑ glucose through gluconeogenesis or glycogenolysisBody secretes 20mg/day
Reticularis Inner Sex androgens (testosterone)
Male secondary characteristicsWomen’s only source of androgens
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewDeficiency/Adrenal gland not working properly: Addison’s disease
Effects from the 3 layers of the adrenal gland1. Aldosterone deficiency: Increase K+, metabolic acidosis
(H+ ↑), ↓Na+
2. Cortisol deficiency: Inadequate secretion of glucocorticoids, decrease glucose – when needed for flight or fight – will not have)
3. Testosterone deficiency Summary of what will happen to patient
Hyperkalemia (↑K+)Low BP (due to Na drop)Metabolic acidosis (H+ ↑)Hypoglycemia (decrease glucose)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewToo much hormone production from adrenal gland: Cushing’s Disease
Too much ACTH hormone from pituitary Your book sometimes calls this Cushing’s syndrome:
syndrome and disease are very different. Syndrome usually occurs due to exogenous steroid use
Will see the opposite effects as Addison’s Aldosterone: Decrease K+, H+, ↑Na+(↑ BP) Cortisol: Hyperglycemia Testosterone ↑ (secondary male characteristics) –
exogenous steroids can do this as well
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewHypothalamic-Anterior Pituitary Axis
A complex set of direct influences & feedback interactions among 3 endocrine glands1. Hypothalamus2. Pituitary gland3. Adrenal gland
Pituitary gland Often called the “master gland” of the endocrine
system Controls many other glands 2 lobes Located in the brain, attached to the hypothalamus
Hypothalamus controls the pituitary gland: connected by the portal system called Hypothalamic-Ant Pit Axis (see net slide)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
A&P ReviewHypothalamic-Anterior Pituitary Axis
Hypothalamus releases hormone CRH↓
Acts on Pituitary gland↓
ACTH hormone released↓
Influence adrenal gland↓
Adrenal gland releases its 3 hormones (aldosterone, cortisol, androgens)
Can also have a NEGATIVE FEEDBACK to help regulate hormone levels
SUMMARY: corticosteroids from adrenal gland controlled by hypothalamus & pituitary gland
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Hypothalamus stimulates release of hormones that affects many body organs
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Hormone SecretionKey Points
More cortisol & CRH are secreted during waking hours
When stressed – body needs more cortisol to copeWhen level of cortisol rises above normal:
ACTH/CRH release is inhibited: called NEGATIVE FEEDBACK
Steroids act like endogenous cortisol – they inhibit release ACTH/CRH Long-term steroid use – ACTH release is
suppressed for long periods thus atrophy occurs to adrenal gland
If steroid is stopped abruptly – relative steroid deficiency result – leads to adrenal crisis
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DRUG CLASSIFICATION
MineralocorticoidsGlucocorticoids
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Classification1. Glucocorticoids
Stimulate gluconeogenesis (make glucose) & lipolysis (fat breakdown)
Inhibit glucose uptake by cells (to increase blood plasma glucose)
Tx of inflammatory or allergic conditions (Book focuses on this category) – NEXT SLIDE
Drugs called corticosteroids
2. Mineralocorticoids (Aldosterone) Affect kidney: water & electrolyte composition Act on kidney in Loop of Henle Useful for patient with kidney issues Protype: fludrocortisone(Florinef)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Glucocorticoid UsesMEDICAL USES DENTAL USES
Asthma Oral lesions
RA Aphthous stomatitis
Lupus TMD
Addison’s Post-op surgery
Allergy Burning tongue
Transplant rejection Lichen planus
GI disorders (ulcerative colitis, Crohns, IBD)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Glucocorticoid UsesAntiinflammatory Suppress immune responses Palliative rather than curative
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Glucocorticoid AdministrationTopical
Useful for dental lesionsOralParental (IM, IV)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Mechanism of Action CorticosteroidsMost potent antiinflammatory agents availableAlmost every cell in the body has glucococortoid
receptors located in the cytoplasmCortisol (glucococortoid hormone) is hydrophobic –
requires active transport into a cell by a proteinOnce inside the cell – travels to nucleus & binds to
DNA
See next slide for picture
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Mechanism of Action Corticosteroids
Once inside cell 1. Controls rate of PRO synthesis 2. Controls release of histamine
Immunological Effects ↑ neutrophils ↓ inflammatory agents (prostaglandin, leukotriene,
macrophages)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Corticosteroid Drugs
Classified by duration of action – need to know which drugs fall into each category
p. 217, Table 18-2 Do NOT use this list, use next slide drugs..mistake in your book with Prednisone (listed as short-acting but is intermediate)
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Corticosteroid DrugsShort-ActingCortisone(Cortone)
Hydrocortisone(Cortisol, Cortef)
Intermediate-Acting (Useful in Dentistry)
Methylprednisolone(Medrol)
Prednisolone(Orapred, Prelone)
Prednisone(Meticorten, Deltasone) 1st line drug
Triamcinolone(Aristocort, Kenacort)Long-ActingBetamethasone(Celestone)
Dexamethasone(Decadron)
No contraindications
for EPI in LA
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Adverse RxnsRare in short-term useLong-term has many side effects due to
suppression of adrenal gland functionMetabolic changes (NBQ)
Moon faceBuffalo humpObesity, Weight gain
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Adverse RxnsHyperglycemia (NBQ)HypertensionOsteoporosisMood/behavior changesPoor-delayed healingImmune suppression: Candidiasis,
etc…Peptic ulcers
Corticosteroids ↑production of stomach acid & pepsin
No Aspirin & NSAIDs
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Adverse RxnsAdrenal crisis
Adrenal suppression with prolonged use (adrenal gland told not to release ACTH/CRH because patient getting from external source)
Body cannot respond correctly to stressful situation
Ex: dental phobia – steroid user body will not produce enough cortisol to respond to pt’s increased anxiety – crisis could occurPt may need additional steroids day of appt to
accommodate for this issue (Prednisone most commonly given)