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CORTICOSTEROIDS
Dr Mayur Chaudhari
Assistant Professor
Department of Pharmacology
Government Medical College, Surat
Steroids are fast catching up with antibiotics
as the most abused class of drugs today

2
HISTORY
 1855 – Thomas Addison
 1856 – Charles-Edouard Brown-Sequard
 1932 – Harvey Cushing

 1936 – Edward Kendall & ...
 The adrenal produces various classes of hormones,
each of which aid in dealing with the stress faced by
animals and peop...
LEARNING OBJECTIVES
 Biosynthesis
 Actions
 Pharmacokinetics and Preparations

 Uses
 Dosage schedule and withdrawal
...
ANATOMY

6
BIOSYNTHESIS OF ADRENAL
HORMONES
Mineralocorticoids

Glucocorticoids

Sex Hormones

11-OH Pregnenolone

Dehydroepiandroste...
REGULATION
 Synthesized and Released
under influence of ACTH
and Pituitary.

 Regulated by CRH from
hypothalamus

and

b...
HPA AXIS

9
REGULATION
Circadian rhythm

10
MECHANISM OF ACTION

11
ACTIONS
• Effect on Na+
Mineralocorticoid • Effect on K+
• Fluid Balance

Glucocorticoid

• Carbohydrate
• Protein and Fat...
MINERALOCORTICOID ACTIONS
 Enhanced absorption of Na+ from DT
 increased excretion of K+ and H+.

 Similar action on co...
EXTREMES OF ALDOSTERONE
 Dilutional hypernatremia,
 Hyperkalamia, acidosis,
 massive loss of Na+ and decreased EFC volu...
GLUCOCORTICOID ACTIONS
CARBOHYDRATE METABOLISM
 Glycogen deposition in liver
 Gluconeogenesis
 Inhibit glucose utilizat...
PROTEIN METABOLISM
 Breakdown of protein
 Mobilize Amino Acid from peripheral tissues
 Muscle wasting, lympholysis, los...
FAT METABOLISM
 Permissive action due to Glucagon, Growth
Hormone, Adrenaline and Thyroxine – Lipolysis.
 Increased brea...
CALCIUM METABOLISM
 Inhibition of intestinal absorption and promotion
of excretion
 Loss of calcium from bone.
 Negativ...
WATER EXCRETION AND STOMACH
 Maintain normal GFR
 In adrenal insufficiency capacity is lost – water
intoxication
 Gastr...
CARDIOVASCULAR SYSTEM
 Permissive role on pressor effect with Adr and
angiotensin
 Maintain tone of arterioles and myoca...
SKELETAL MUSCLES
 Hypocorticism: Decreased work capacity,
weakness
 Hypercorticism: Excess Mineralocorticoid
.Hypokalemi...
CENTRAL NERVOUS SYSTEM
 Mild euphoria, increased motor activity
 Insomnia, hypomania or depression
 Apathy, depression ...
LYMPHOID TISSUE
 Destruction of lymphoid tissue – modest in normal
persons
 In presence of malignancy of lymphatic cells...
INFLAMMATION
 Prevent migration of leucocytes
 Prevent chemotaxis and lysosomal enzyme synthesis
 Diminish production o...
INFLAMMATION
 Suppress inflammatory response to all noxious stimuli at all
stages
 Cardinal signs of inflammation inhibi...
IMMUNOLOGICAL ACTION
 Inhibit function of macrophages, Reduce ability to
respond to antigen
 Inhibit activation of cytot...
IMMUNOLOGICAL ACTION
 Impair immunological competence
 Suppress all types of hypersensitization and allergy.
 Suppressi...
MISCELLANEOUS
 Uricosuric action
 Nonspecific antipyretic

 Structural and functional maturation of fetal
lung

28
PHARMACOKINETICS
 Therapeutically given by various routes – orally,
IM, IV, topically
 Hydrocortisone undergoes high fir...
PHARMACOKINETICS
 Synthetic steroids have to undergo reduction in
liver to active compounds
 Metabolized in liver and ex...
HYDROCORTISONE
 Rapid but short acting with significant
Mineralocorticoid activity
 Used for replacement therapy, shock,...
PREDNISOLONE
 More potent than hydrocortisone, more GC activity
 Intermediate duration of action
 Less HPA axis suppres...
METHYLPREDNISOLONE
 More potent and more selective
 Retention enema in ulcerative colitis
 Pulse therapy in non respons...
TRIAMCINOLONE
 Potent and selective glucocorticoid
 Used as intraarticular injection

DEXAMETHASONE
 Potent and highly ...
FLUDROCORTISONE
 Potent mineralocorticoid having some GC activity
 Replacement therapy in Addison’s disease
 Congenital...
THERAPEUTIC USES
 Physiologic doses of Corticosteroids are used for
replacement therapy
 Supraphysiologic doses are used...
REPLACEMENT THERAPY
Adrenal insufficiency – acute/chronic
 Abrupt withdrawal of steroid therapy
 Chronic infections – Tu...
REPLACEMENT THERAPY
ACUTE ADRENAL INSUFFICIENCY
 IV Hydrocortisone/ Dexamethasone bolus f/b infusion
 Monitor CVP

 Sho...
REPLACEMENT THERAPY
CONGENITAL ADRENAL HYPERPLASIA
 Hydrocortisone 0.6 mg/kg in divided doses
 Fludrocortisone 10-20 µg/...
MUST KNOW
 Biosynthesis and Regulation of Corticosteroids
 Mechanism of action of Corticosteroids
 Name of commonly use...
3/09/13
99.16,100,34.62,56,39,38,33,78,94,71,17,29,44,37,81,92,48,10,66,9
,70,73,21,75,58,53,60,27,20,19,14,22,88,52,89,5,...
CORTICOSTEROIDS
Dr Mayur Chaudhari
Assistant Professor
Department of Pharmacology
Government Medical College, Surat
OBJECTIVES
 Pharmacotherapy
 Adverse Effects

 Contraindications

43
GENERAL PRINCIPLES
 Single dose is not harmful
 Short Courses
 Long term use – Hazardous
 Initial Dose – According to ...
Pharmacotherapy
45
ARTHRITIDES
 Rheumatoid Arthritis
 Osteoarthritis
 Rheumatic fever
 Gout

46
COLLAGEN DISEASES
 Systemic Lupus Erythematous
 Nephrotic Syndrome
 Glomerulonephritis

47
SEVERE ALLERGIC REACTIONS
 Anaphylaxis
 Angioneurotic edema
 Urticaria
 Serum Sickness
 Allergic conjunctivitis

 Al...
AUTOIMMUNE DISEASES
 Hemolytic anemia
 Idiopathic thrombocytopenic purpura
 Active chronic hepatitis

49
BRONCHIAL ASTHMA
 Status asthmaticus
 Acute asthma exacerbation
 Severe chronic asthma

50
LUNG DISEASES
 Aspiration pneumonia
 Pulmonary edema
 Lung maturation in fetus

51
INFECTION
 Severe tuberculosis
 Lepra reaction
 Bacterial meningitis
 Pneumocystis carinii pneumonia

52
EYE DISEASES
 Allergic conjunctivitis
 Iritis
 Iridocyclitis
 Keratitis

53
SKIN DISEASES
 Eczema
 Pemphigus vulgaris
 Exfoliative dermatitis
 Steven Johnson Syndrome

54
INTESTINAL DISEASES
 Ulcerative colitis
 Crohn’s Disease

 Coeliac Disease

55
 CEREBRAL OEDEMA
 NEUROCYSTICERCOSIS
 MALIGNANCIES
 ORGAN TRANSPLANT

 SKIN ALLOGRAFT
56
 SEPTIC SHOCK
 THYROID STORM

 PITUITARY ADRENAL AXIS FUNCTION

57
ADVERSE EFFECTS

58
MINERALOCORTICOID
 Na+ and water retention
 Edema
 Hypokalemic alkalosis
 Progressive rise in BP

59
GLUCOCORTICOID
 Cushing’s habitus
 Fragile skin, Purple Striae
 Hyperglycemia
 Muscular Weakness

 Delayed healing
60
 Susceptibility to infection
 Peptic Ulceration
 Osteoporosis

 Posterior Sub capsular cataract
 Glaucoma
 Growth Re...
 Psychiatric Disturbances
 HPA Axis Suppression

62
CONTRAINDICATIONS
 Peptic ulcer
 Diabetes mellitus
 Hypertension
 Viral and fungal infections

 Tuberculosis
63
CONTRAINDICATIONS
 Osteoporosis
 Herpes simplex keratitis
 Psychosis
 Epilepsy
 Congestive heart failure

 Renal Fai...
SUMMARY
 Guidelines for use of glucocorticoids
 Pharmacotherapy
 Adverse effects
 Contraindications

65
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Pharmacology of corticosteroids

Presentation for Medical undergraduates for teaching pharmacology. It deals with Physiology of steroid hormones and their action along with agents which are used therapeutically with their action, adverse effects and therapeutic uses.

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Pharmacology of corticosteroids

  1. 1. CORTICOSTEROIDS Dr Mayur Chaudhari Assistant Professor Department of Pharmacology Government Medical College, Surat
  2. 2. Steroids are fast catching up with antibiotics as the most abused class of drugs today 2
  3. 3. HISTORY  1855 – Thomas Addison  1856 – Charles-Edouard Brown-Sequard  1932 – Harvey Cushing  1936 – Edward Kendall & Tadeus Reichstein.  1949 – Phillip Hench  1954 – Aldosterone  1955 - ACTH 3
  4. 4.  The adrenal produces various classes of hormones, each of which aid in dealing with the stress faced by animals and people almost daily.  At least two of these groups – Glucocorticoids and Mineralocorticoids are necessary for life .  Corticosteroids or corticoids refer to natural glucoand mineralo-corticoids and their synthetic analogues. 4
  5. 5. LEARNING OBJECTIVES  Biosynthesis  Actions  Pharmacokinetics and Preparations  Uses  Dosage schedule and withdrawal  ADRs and Contraindications  Precautions during therapy  Contraindications 5
  6. 6. ANATOMY 6
  7. 7. BIOSYNTHESIS OF ADRENAL HORMONES Mineralocorticoids Glucocorticoids Sex Hormones 11-OH Pregnenolone Dehydroepiandrosterone DHEA Cholesterol ACTH Pregnenolone 11 α OH 11 α OH 17,20 lyase 11-OH Progesterone 17,20 lyase Progesterone 11- Deoxy Corticosterone Androstenodione 11- Deoxy Cortisol Testosterone Cortisol Corticosterone AT II Dihydrotestosterone Aldosterone Estradiol 7
  8. 8. REGULATION  Synthesized and Released under influence of ACTH and Pituitary.  Regulated by CRH from hypothalamus and by feedback levels of blood concentrations 8
  9. 9. HPA AXIS 9
  10. 10. REGULATION Circadian rhythm 10
  11. 11. MECHANISM OF ACTION 11
  12. 12. ACTIONS • Effect on Na+ Mineralocorticoid • Effect on K+ • Fluid Balance Glucocorticoid • Carbohydrate • Protein and Fat • Other Activities 12
  13. 13. MINERALOCORTICOID ACTIONS  Enhanced absorption of Na+ from DT  increased excretion of K+ and H+.  Similar action on colon, sweat gland and salivary gland. 13
  14. 14. EXTREMES OF ALDOSTERONE  Dilutional hypernatremia,  Hyperkalamia, acidosis,  massive loss of Na+ and decreased EFC volume  Positive Na+ balance, expansion of ECF,  Increased plasma Na, hypokalemia, alkalosis hypertension  myocardial fibrosis 14
  15. 15. GLUCOCORTICOID ACTIONS CARBOHYDRATE METABOLISM  Glycogen deposition in liver  Gluconeogenesis  Inhibit glucose utilization  Hyperglycemia  Insulin resistance, DM like state 15
  16. 16. PROTEIN METABOLISM  Breakdown of protein  Mobilize Amino Acid from peripheral tissues  Muscle wasting, lympholysis, loss of osteoid from bone  Thinning of skin  Excess urea production – Negative nitrogen balance  Increase uric acid excretion 16
  17. 17. FAT METABOLISM  Permissive action due to Glucagon, Growth Hormone, Adrenaline and Thyroxine – Lipolysis.  Increased breakdown of triglycerides.  Redistribution of body fat – Moon face, Buffalo Hump, Fish Mouth. 17
  18. 18. CALCIUM METABOLISM  Inhibition of intestinal absorption and promotion of excretion  Loss of calcium from bone.  Negative calcium balance  Spongy bones – more sensitive. 18
  19. 19. WATER EXCRETION AND STOMACH  Maintain normal GFR  In adrenal insufficiency capacity is lost – water intoxication  Gastric acid and pepsin secretion enhanced  Aggravate peptic ulcer 19
  20. 20. CARDIOVASCULAR SYSTEM  Permissive role on pressor effect with Adr and angiotensin  Maintain tone of arterioles and myocardial contractility  Adrenal insufficiency leads to low cardiac output and arteriolar dilatation and poor response to adrenaline  Cardiovascular collapse – along with mineralocorticoids 20
  21. 21. SKELETAL MUSCLES  Hypocorticism: Decreased work capacity, weakness  Hypercorticism: Excess Mineralocorticoid .Hypokalemia – Weakness.  Excess glucocorticoid : Muscle wasting, weakness and myopathy 21
  22. 22. CENTRAL NERVOUS SYSTEM  Mild euphoria, increased motor activity  Insomnia, hypomania or depression  Apathy, depression and psychosis in Addison’s disease.  Maintenance of perceptions and excitability of neurons  Lowers seizure threshold 22
  23. 23. LYMPHOID TISSUE  Destruction of lymphoid tissue – modest in normal persons  In presence of malignancy of lymphatic cells – lytic actions are significant (apoptosis) – used in lymphomas (Basis of Use)  Minor effects on haemoglobin and RBCs – protect against haemolysis of RBCs – Increase in number of RBCs  Decreases the numbers of circulating lymphocytes, monocytes, eosinophils and basophils but increases Polymorphs 23
  24. 24. INFLAMMATION  Prevent migration of leucocytes  Prevent chemotaxis and lysosomal enzyme synthesis  Diminish production of PGs, LTs, PAF and histamine release  Stabilize lysosomal membrane preventing spillage of lysosomal enzymes 24
  25. 25. INFLAMMATION  Suppress inflammatory response to all noxious stimuli at all stages  Cardinal signs of inflammation inhibited  Root cause remain intact  Favor spread of infection  Interfere with healing and scar formation  Silent perforation 25
  26. 26. IMMUNOLOGICAL ACTION  Inhibit function of macrophages, Reduce ability to respond to antigen  Inhibit activation of cytotoxic T lymphocytes, cause lysis of T Lymphocytes  Effects of complement are inhibited  Prevent Homograft rejection 26
  27. 27. IMMUNOLOGICAL ACTION  Impair immunological competence  Suppress all types of hypersensitization and allergy.  Suppression of CMI – delayed hypersensitivity, graft rejection  Inhibit release of IL1 from macrophages, IL2 formation  Suppression of natural killer cell 27
  28. 28. MISCELLANEOUS  Uricosuric action  Nonspecific antipyretic  Structural and functional maturation of fetal lung 28
  29. 29. PHARMACOKINETICS  Therapeutically given by various routes – orally, IM, IV, topically  Hydrocortisone undergoes high first pass metabolism  Oral bioavailability of synthetic corticoids is high  Both, endogenous and therapeutically administered GC are bound to Corticosteroid Binding Globulin (CBG) 29
  30. 30. PHARMACOKINETICS  Synthetic steroids have to undergo reduction in liver to active compounds  Metabolized in liver and excreted in urine  Exogenously administered hydrocortisone has t1/2 of 1.5 Hrs 30
  31. 31. HYDROCORTISONE  Rapid but short acting with significant Mineralocorticoid activity  Used for replacement therapy, shock,  Status asthmaticus and adrenal insufficiency  Topically and as enema for ulcerative colitis 31
  32. 32. PREDNISOLONE  More potent than hydrocortisone, more GC activity  Intermediate duration of action  Less HPA axis suppression  Used for allergic, inflammation  autoimmune diseases, malignancy 32
  33. 33. METHYLPREDNISOLONE  More potent and more selective  Retention enema in ulcerative colitis  Pulse therapy in non responsive RA  Renal transplant, pemphigus  Minimal suppression of HPA axis. 33
  34. 34. TRIAMCINOLONE  Potent and selective glucocorticoid  Used as intraarticular injection DEXAMETHASONE  Potent and highly selective, long acting  Marked HPA suppression  Inflammatory and allergic condition  Shock, cerebral edema. 34
  35. 35. FLUDROCORTISONE  Potent mineralocorticoid having some GC activity  Replacement therapy in Addison’s disease  Congenital adrenal hyperplasia  Idiopathic hypotension 35
  36. 36. THERAPEUTIC USES  Physiologic doses of Corticosteroids are used for replacement therapy  Supraphysiologic doses are used for their antiinflammatory effects  immunosuppressive effects In organ transplant patients and those with autoimmune disorders 36
  37. 37. REPLACEMENT THERAPY Adrenal insufficiency – acute/chronic  Abrupt withdrawal of steroid therapy  Chronic infections – Tuberculosis  Autoimmune adrenal disease  Surgery, Hemorrhage and AIDS Congenital adrenal hyperplasia  Congenital disorder due to deficiency of 21-hydroxylse enzyme – no cortisol but ACTH – increased androgen production 37
  38. 38. REPLACEMENT THERAPY ACUTE ADRENAL INSUFFICIENCY  IV Hydrocortisone/ Dexamethasone bolus f/b infusion  Monitor CVP  Short term infusion of dopamine CHRONIC ADRENAL INSUFFICIENCY  Hydrocortisone orally  If needed ad fludrocortisone 38
  39. 39. REPLACEMENT THERAPY CONGENITAL ADRENAL HYPERPLASIA  Hydrocortisone 0.6 mg/kg in divided doses  Fludrocortisone 10-20 µg/kg if salt wasting persist 39
  40. 40. MUST KNOW  Biosynthesis and Regulation of Corticosteroids  Mechanism of action of Corticosteroids  Name of commonly used Glucocorticoids  Anti-inflammatory and immunosuppressive actions of Glucocorticoids 40
  41. 41. 3/09/13 99.16,100,34.62,56,39,38,33,78,94,71,17,29,44,37,81,92,48,10,66,9 ,70,73,21,75,58,53,60,27,20,19,14,22,88,52,89,5,2,86,68,69,28,45, 8,13,26,41,32,54,82,74,98,11,3,47,93,55,91,63,49,30,15,95,64,96,77 ,18,101,76 06/09/13 38,99,16,100,52,40,35,71,78,94,89,86,5,69,2,28,53,58,75,21,70,33, 73,60,92,66,9,37,27,20,19,88,22,14,34,56,62,13,45,85,7,36,49,46,1 1,98,54,50,59,82,3,18,47,30,51,15,23,63,57,61,91,12,93,101,96,95,6 7 41
  42. 42. CORTICOSTEROIDS Dr Mayur Chaudhari Assistant Professor Department of Pharmacology Government Medical College, Surat
  43. 43. OBJECTIVES  Pharmacotherapy  Adverse Effects  Contraindications 43
  44. 44. GENERAL PRINCIPLES  Single dose is not harmful  Short Courses  Long term use – Hazardous  Initial Dose – According to severity  No abrupt withdrawal  Local Therapy 44
  45. 45. Pharmacotherapy 45
  46. 46. ARTHRITIDES  Rheumatoid Arthritis  Osteoarthritis  Rheumatic fever  Gout 46
  47. 47. COLLAGEN DISEASES  Systemic Lupus Erythematous  Nephrotic Syndrome  Glomerulonephritis 47
  48. 48. SEVERE ALLERGIC REACTIONS  Anaphylaxis  Angioneurotic edema  Urticaria  Serum Sickness  Allergic conjunctivitis  Allergic Rhinitis 48
  49. 49. AUTOIMMUNE DISEASES  Hemolytic anemia  Idiopathic thrombocytopenic purpura  Active chronic hepatitis 49
  50. 50. BRONCHIAL ASTHMA  Status asthmaticus  Acute asthma exacerbation  Severe chronic asthma 50
  51. 51. LUNG DISEASES  Aspiration pneumonia  Pulmonary edema  Lung maturation in fetus 51
  52. 52. INFECTION  Severe tuberculosis  Lepra reaction  Bacterial meningitis  Pneumocystis carinii pneumonia 52
  53. 53. EYE DISEASES  Allergic conjunctivitis  Iritis  Iridocyclitis  Keratitis 53
  54. 54. SKIN DISEASES  Eczema  Pemphigus vulgaris  Exfoliative dermatitis  Steven Johnson Syndrome 54
  55. 55. INTESTINAL DISEASES  Ulcerative colitis  Crohn’s Disease  Coeliac Disease 55
  56. 56.  CEREBRAL OEDEMA  NEUROCYSTICERCOSIS  MALIGNANCIES  ORGAN TRANSPLANT  SKIN ALLOGRAFT 56
  57. 57.  SEPTIC SHOCK  THYROID STORM  PITUITARY ADRENAL AXIS FUNCTION 57
  58. 58. ADVERSE EFFECTS 58
  59. 59. MINERALOCORTICOID  Na+ and water retention  Edema  Hypokalemic alkalosis  Progressive rise in BP 59
  60. 60. GLUCOCORTICOID  Cushing’s habitus  Fragile skin, Purple Striae  Hyperglycemia  Muscular Weakness  Delayed healing 60
  61. 61.  Susceptibility to infection  Peptic Ulceration  Osteoporosis  Posterior Sub capsular cataract  Glaucoma  Growth Retardation  Foetal abnormality 61
  62. 62.  Psychiatric Disturbances  HPA Axis Suppression 62
  63. 63. CONTRAINDICATIONS  Peptic ulcer  Diabetes mellitus  Hypertension  Viral and fungal infections  Tuberculosis 63
  64. 64. CONTRAINDICATIONS  Osteoporosis  Herpes simplex keratitis  Psychosis  Epilepsy  Congestive heart failure  Renal Failure 64
  65. 65. SUMMARY  Guidelines for use of glucocorticoids  Pharmacotherapy  Adverse effects  Contraindications 65

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