Farmakologi Kortikosteroid

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Text of Farmakologi Kortikosteroid

  • Kortikosteroid

  • Kortikosteroid

    Bentuk sintetik dari hormon yang disekresi oleh kortek

    adrenal.

    Esensial:

    Maintenan beberapa sistem terutama sistem

    kardiovaskular

    Berperan pada respon tubuh thd stress

    Mekanisme

    Supresi proses inflamasi, alergi dan sistem imun

    Dapat untuk prevensi dan tx asma dan artritis rematoid

  • Actions of corticosteroids are grouped:

    Glucocorticoid effects, including metabolic changes and anti-inflammatory actions.

    Mineralocorticoid effects, mainly retention of salt and water, together with loss of potassium and hydrogen ions.

  • Classification of Corticosteroids ORAL CORTICOSTEROIDS

    Glucocorticoid Effect Mineralocorticoid Duration of (dose equivalent) effect effect (in hours) SHORT ACTING Cortisone 25mg ++++ 8-12 hours Hydrocortisone 20mg ++++ 8-12 hours

    INTERMEDIATE-ACTING Prednisolone 5mg ++ 18-36 hours Triamcinolone 4mg - 18-36 hours Methylprednisolone 4mg - 18-36 hours Fludrocortisone - ++++ 24-36 hours

    LONG-ACTING Dexamethasone 750 micrograms - 36-54 hours Betamethasone 750 micrograms - 36-54 hours

  • HPA AXIS

  • Pharmacological Actions

    1. Carbohydrate

    2. Protein

    3. Lipid

    4. Electrolyte and H2O

    5. CVS

    6. Skeletal Muscle

    7. CNS

    8. Stomach

    9. Blood

    10. Anti-inflammatory

    11. Immunosuppressant

    12. Respiratory system

    13. Growth and Cell

    Division

    14. Calcium metabolism

  • Indikasi kortikosteroid:

    Kontrol gejala: Asthma, allergic rhinitis, rheumatoid arthritis and related connective

    tissue disorders, temporal arteritis, inflammatory bowel disease, inflammatory skin conditions, emesis following chemotherapy, chronic pain, anaphylactic shock

    Prevensi: Transplant rejection, respiratory distress in the newborn, cerebral

    oedema

    Treatment: Certain tumours, hypercalcaemia, some blood disorders, nephrotic

    syndrome

    Replacement therapy in Addisons disease (under-activity of the adrenal cortex)

  • Efek samping

    Dosis tinggi jangka pendek --- ES < dosis rendah jangka panjang

    Efek samping jangka panjang: Redistribusi lemak

    Hipertensi Intoleransi glukosa Gangguan penyembuhan luka

    Osteoporosis (bisa dicegah dg bifosfonat) Katarak Tukak lambung (Omeprazol, misoprostol) resiko infeksi Efek SSP, psikosis Hambatan pertumbuhan pada anak

    Cushings syndrome

  • Indikasi kortikosteroid:

    Kontrol simtom: Asthma, allergic rhinitis, rheumatoid arthritis and related connective

    tissue disorders, temporal arteritis, inflammatory bowel disease, inflammatory skin conditions, emesis following chemotherapy, chronic pain, anaphylactic shock

    Prevensi: Transplant rejection, respiratory distress in the newborn, cerebral

    oedema

    Treatment: Certain tumours, hypercalcaemia, some blood disorders, nephrotic

    syndrome

    Replacement therapy in Addisons disease (under-activity of the adrenal cortex)

  • Doses and Administration

    Regular medication reviews are needed to ensure doses are kept to the minimum necessary to manage the underlying condition.

    Inhaled beclomethasone, budesonide daily doses >800 mcg (adult)

    >400mcg (child) are associated with systemic (general) side effects. Side effects are seen at half these doses for fluticasone. Some high dose regimens include daily doses up to 2 mg and 1mg

    (fluticasone). Advice to patients should include:

    Keep to the same spacer device. Mouth rinsing may reduce candidiasis and systemic absorption.

    Pre-treatment with bronchodilator may reduce cough.

  • Doses and Administration

    Oral prednisolone. Side effects appear if daily dose >7.5 mg. Maintenance doses usually 2.5-15mg/ day. Severe disease may necessitate much higher doses.

    Administer as a single dose after breakfast, but before 9.00 am., with milk or food plus a full glass of water.

    Topical applications should avoid the face, and be free of occlusive dressings (including disposable nappies).

    Rectal administration may give erratic absorption and cause local pain and bleeding.

    If giving intramuscular injections, use each site only once and document.

  • Managing the Common Adverse Effects

    of Corticosteroids

    Short courses at high dosage for emergencies appear to cause fewer adverse effects than prolonged courses using lower doses.

    Many adverse effects, for example, those related to nutrition, only arise with long-term therapy.

  • INHALED CORTICOSTEROIDS

    (dose equivalent Time in circulation for adverse effects)

    Beclometasone 1000 micrograms - 19.5 hours

    Budesonide 1000 micrograms - 6.9 hours

    Fluticasone 500 micrograms - 43.2 hours

    propionate

    *calculated as 3 times the terminal half life.

    (Karch 2000, BNF 2002, Cave et al. 1999, Lipworth 1999)

  • Corticosteroids may affect:

    inflammatory and immune responses metabolic pathways:

    the starvation response + redistribution skin gastrointestinal tract bones muscles

    cardiovascular system central nervous system eyes reproductive system adrenal glands

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Increased risk of

    infections

    Teach good hand washing

    techniques

    Monitor body temperature at 5-6 p.m.

    daily

    Avoid exposure to infectious disease

    Contact doctor on exposure to

    chickenpox or measles.

    Caution with immunisations: avoid live

    vaccines (also for 6 months after

    discontinuation).

    SE

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Increase in appetite

    Encourage a well balanced, low calorie

    diet. Ask dietician to provide diet plan

    Monitor intake by asking patient to

    record intake for 24-hour periods.

    Weigh patient weekly

    Measure waist circumference

    regularly

    Potensi masalah

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Risk of dental caries

    Encourage scrupulous dental

    hygiene

    & low-sugar diet.

    Arrange 6 monthly dental

    inspections

    Consider using a mouthwash

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Risk of hypertension

    Foods rich in salt should be avoided,

    except with replacement regimens.

    Condiments and processed foods are

    high in sodium. Avoid salt-containing

    medicines e.g. some antacids. Avoid

    liquorice.

    Monitor blood pressure regularly.

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Risk of osteoporosis

    Encourage patient to eat foods high in

    calcium. Low fat dairy products are

    suggested.

    Suggest vitamin D supplementation,

    together with monitoring for vitamin D

    intoxication.

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Loss of potassium, causing

    muscle weakness,

    depression, constipation,

    cardiac complications.

    Venous blood samples to monitor

    electrolytes

    Encourage foods that are high in

    potassium e.g. raisins, bananas,

    meat.

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Nutrition

    Salt and water retention

    Limit salt intake.

    Fluid balance records and daily

    weighing are important during

    initiation of therapy

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Cardiovascular disease

    Hyperglycaemia / diabetes

    Increased cholesterol and

    triglycerides

    Congestive heart failure

    ? increased risks of

    thrombosis

    Monitor blood glucose concentrations

    regularly and if thrush appears on the

    skin

    Monitor lipid profile

    Observe for breathlessness. Monitor

    fluid retention. Minimise salt intake.

    Monitor full blood count

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Skin

    (particularly topical

    preparations)

    Increase in body hair and

    acne

    Poor wound healing

    Provide advice on managing acne

    Consult podiatrist regarding foot-care.

    Anticipate poor healing and contact

    wound care specialists promptly.

    Take swabs if healing delayed.

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Skin

    (particularly topical

    preparations)

    Thinning of the skin

    Increased vigilance of pressure areas.

    Evaluate pressure damage risk score

    regularly

    Avoid friction and shearing forces on

    the skin, for example, teach patients in

    the correct use of moving and handling

    aids (glide sheets) when moving along

    the bed/chair.

  • POTENTIAL PROBLEM

    SUGGESTED PREVENTION

    Skin

    (particularly topical

    preparations)

    Thinning of the skin

    Allow extra time for procedures

    involving tissue handling, such as

    transfer to hoist, care of infusion sites.

    Ensure good communication within

    the multidisciplinary team: for example,

    orthopaedic surgeons, and plaster

    technicians, or nurses applying

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