Different types of Steroids

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Logic Behind Why we Use the steroids we use 

1) Duration of Action

2) Anti - inflammatory effects verse salt - retaining effects


Pathophysiology

HPA axis CRH (hypothalamus) -> ACTH (Anterior Pituitary) -> Adrenal Cortex (Glomerulosa - Mineralocroticoids, Fasciculata - glucocorticoids, Reticularis - sex hormones)

Corticosteroids 

Mineralocorticoids



Typical Steroids: 

Betamethasone: celestone diprolene, luxiq

Cortisone: cortisone acetate

Dexamethasone: decadron

Fludrocortisone: florinef

Hydrocortisone

Methylprednisolone: medrol

Prednisolone: orapred, pediapred

Prednisone

Triamcinolone: Kenalog, Nasacort, aristospan


Intuitively Think about where each of these are used why?

Hydrocortisone short acting Stress dose steroids has anti inflammatory and has salt retaining to bring up the map too

  • Stress dose steroids 20 to 50 mg/m^2/day in 3 to 4 doses
  • 25 mg of hydrocortisone every eight hours for 24 hours
  • Anti-inflammatory or immunosuppressive 2.5 to 10mg/kg/day
  • Myxedema Coma: 100mg q8hrs IV, random cortisol


Prednisone - want mostly anti-inflammatory effect

COPD

40 to 60 mg daily for 5 to 7 days; administer in 1 or 2 divided doses

10 to 60 mg/day given in a single daily dose or in 2 to 4 divided doses; Low dose: 2.5 to 10 mg/day; High dose: 1 to 1.5 mg/kg/day (usually not to exceed 80 to 100 mg/day).

The following dose taper example is from the commercially available tapered-dosage product:

Day 1: Administer 30 mg on day 1 as 10 mg at breakfast, 5 mg at lunch, 5 mg at dinner, and 10 mg at bedtime.

Day 2: Administer 25 mg on day 2 as 5 mg at breakfast, 5 mg at lunch, 5 mg at dinner, and 10 mg at bedtime.

Day 3: Administer 20 mg on day 3 as 5 mg at breakfast, 5 mg at lunch, 5 mg at dinner, and 5 mg at bedtime.

Day 4: Administer 15 mg on day 4 as 5 mg at breakfast, 5 mg at lunch, and 5 mg at bedtime.

Day 5: Administer 10 mg on day 5 as 5 mg at breakfast and 5 mg at bedtime.

Day 6: Administer 5 mg on day 6 as 5 mg at breakfast.

methylprednisolone 40-60mg q6,q8,q12, q24: 40 to 60 mg daily for 5 to 14 days



Pulse Dose steroids mostly antiinflammatory effect

solumederol (methylprednisolone) 1gram daily x3 days



hydrocort

stress dose steroids


fludrocortisone: adrenal insufficiency, congenital adrenal hyperplasia, orthostatic hypotension, postural orthostatic tachycardia syndrome (POTS), septic shock inadequate response to fluid resuscitation and vasopressor therapy

septic shock inadequate response 0.05 mg daily for 7 days until glucocorticoid is discontinued whichever is first



1. Choosing Between Different Types of Steroids

  • Question: What are three guiding principles for selecting the appropriate corticosteroid?
  • Answer:
    • Consider glucocorticoid activity (anti-inflammatory effect) and mineralocorticoid activity (impact on salt and water retention).
    • Recognize that glucocorticoid and mineralocorticoid activities generally exist on opposite ends of the spectrum.
    • Factor in each steroid’s half-life and potency to match the needs of the clinical situation.

2. Understanding Glucocorticoid Activity

  • Question: How should glucocorticoid activity influence steroid choice?
  • Answer: Glucocorticoid activity reflects the anti-inflammatory potency of a steroid. For intense inflammatory situations, such as ARDS or brain metastases, high-potency glucocorticoids like dexamethasone ("the bazooka") are preferred for maximal anti-inflammatory effect.

3. Understanding Mineralocorticoid Activity

  • Question: How does mineralocorticoid activity impact steroid selection?
  • Answer: Steroids with higher mineralocorticoid activity, like hydrocortisone, are preferred when fluid and salt retention are beneficial, as in septic shock or adrenal insufficiency. Fludrocortisone, though high in mineralocorticoid activity, is not typically used in septic shock due to sufficient mineralocorticoid effect from hydrocortisone alone.

4. Mnemonic for Steroid Strength: "High Powered MD"

  • Question: How can clinicians remember the spectrum of glucocorticoid potency and mineralocorticoid activity across steroids?
  • Answer: The mnemonic “High Powered MD” helps recall the order from hydrocortisone (H) to dexamethasone (D), with glucocorticoid activity increasing along this spectrum and mineralocorticoid activity decreasing. Hydrocortisone has the most mineralocorticoid activity, while dexamethasone has none.

5. Importance of Steroid Half-Life and Potency

  • Question: Why do half-life and potency matter in steroid choice?
  • Answer: Longer half-life and high-potency steroids, like dexamethasone, suppress the HPA axis more extensively, making short-acting steroids (like hydrocortisone) preferable in conditions like adrenal insufficiency where mimicking natural cortisol rhythms is essential.

6. Considerations in Clinical Scenarios

  • Question: How does understanding steroid properties guide treatment for specific conditions?
  • Answer:
    • High glucocorticoid steroids like dexamethasone are used for acute inflammatory conditions (e.g., ARDS, COVID-19 with pulmonary involvement) where strong anti-inflammatory action is needed.
    • Steroids with both glucocorticoid and some mineralocorticoid effect (prednisone, methylprednisolone) are commonly used in COPD and asthma, avoiding excessive fluid retention.
    • Hydrocortisone is chosen for septic shock due to its combined glucocorticoid and mineralocorticoid actions, assisting with blood pressure support.

7. Balancing Fluid Retention Concerns in Certain Conditions

  • Question: Why might prednisone or methylprednisolone be chosen over hydrocortisone in COPD or asthma?
  • Answer: Prednisone and methylprednisolone have higher glucocorticoid effects with minimal mineralocorticoid activity, reducing the risk of fluid retention. This is especially important for patients with heart failure or respiratory issues.

8. Hydrocortisone for Shock and Adrenal Insufficiency

  • Question: Why is hydrocortisone often preferred in septic shock and adrenal insufficiency?
  • Answer: Hydrocortisone offers a balance of glucocorticoid and mineralocorticoid activity, supporting blood pressure and fluid status, essential in managing septic shock and adrenal crises.

9. The Unique Role of Fludrocortisone

  • Question: How does fludrocortisone differ from other steroids?
  • Answer: Fludrocortisone has the highest mineralocorticoid activity, with mild glucocorticoid effects. It is primarily used for conditions needing strong mineralocorticoid support, like primary adrenal insufficiency.

10. Steroid Half-Life and HPA Axis Suppression

  • Question: How does the steroid’s half-life impact its effect on the HPA axis?
  • Answer: Long-acting steroids (e.g., dexamethasone) suppress the HPA axis more due to prolonged activity, risking adrenal suppression. Short-acting steroids like hydrocortisone are preferred for adrenal insufficiency to mimic natural cortisol rhythms and reduce suppression.

1. Why is Hydrocortisone a Good Choice for Physiologic Dosing?

  • Question: Why is hydrocortisone often chosen for dosing that mimics natural physiology?
  • Answer: Hydrocortisone is a direct analog of the body’s natural cortisol, allowing for a close match to physiologic secretion. Its short half-life also enables dosing two to three times a day, mimicking the body’s natural cortisol production cycle, and it can be dosed more frequently if needed for stress dosing, as in cases of adrenal insufficiency.

2. Steroid Conversion Factors

  • Question: What are common conversion factors used between different steroids?
  • Answer: A standard conversion includes:
    • 1 mg dexamethasone ≈ 4 mg methylprednisolone ≈ 5 mg prednisone ≈ 20 mg hydrocortisone. This conversion allows for switching between steroids while maintaining similar potency.

3. Balancing Steroid Strength and HPA Axis Suppression

  • Question: Why choose steroids with lower potency and shorter half-life when possible?
  • Answer: Lower-potency, short-acting steroids like hydrocortisone reduce the risk of HPA axis suppression and adrenal insufficiency, as the body’s cortisol rhythm can continue functioning with shorter intervals of endogenous suppression.

4. Side Effects of Long-Term Steroid Use

  • Question: What are common long-term side effects of steroids?
  • Answer: Chronic use can lead to weight gain, osteoporosis, hyperglycemia, infection risk, dyslipidemia, and increased cardiovascular risk. Additionally, long-term use can result in avascular necrosis (AVN), with some studies noting AVN rates ranging from 4-40%.

5. Risks of Short Steroid Courses (Steroid Bursts)

  • Question: Do short courses of steroids (bursts) increase risk of serious side effects?
  • Answer: Yes. Recent studies indicate that even short courses (14 days or less) can increase risks of GI bleeding, sepsis, and heart failure, though the absolute risk is small. For instance, a large study in Taiwan found these risks in a young, generally healthy population taking steroids for conditions like URIs and bronchitis.

6. Prophylaxis for Infection Risk

  • Question: At what point should PJP prophylaxis be considered for patients on steroids?
  • Answer: PJP prophylaxis is generally started for patients on a prednisone equivalent of 20 mg daily for over one month, but the underlying condition also affects this decision. For example, patients with ANCA vasculitis are at a higher risk and may need prophylaxis at lower doses compared to other conditions like lupus.

7. GI Prophylaxis with Steroids

  • Question: When is GI prophylaxis indicated for patients on steroids?
  • Answer: While the association between steroids alone and ulcers is debated, the risk of GI bleeding increases significantly when steroids are combined with NSAIDs. In such cases, PPIs are recommended for GI protection.


Key Question and Answer Points on Steroid Management and Prophylaxis

  1. When should GI prophylaxis be given to patients on steroids?

    • Answer: According to Dr. Beth Wallace, GI prophylaxis is recommended for patients on steroids if they are also on NSAIDs or blood thinners, have a history of ulcers, or experience GI symptoms (e.g., GERD) from steroids. Prophylaxis is more likely to be considered in older patients as well. Options include PPIs or H2 blockers.

  2. Why are calcium and vitamin D important for patients on chronic steroids?

    • Answer: Calcium and vitamin D supplementation is used to help prevent glucocorticoid-induced osteoporosis. Chronic steroid use reduces calcium absorption and increases urinary excretion, contributing to bone loss. Although calcium and vitamin D improve bone density, they have not shown a significant reduction in non-traumatic fractures.

  3. When should bisphosphonates be prescribed for patients on steroids?

    • Answer: Bisphosphonates are recommended for patients over 40 on high-dose steroids (≥30 mg/day prednisone initially or a cumulative dose of ≥5 g in a year) and for others based on their FRAX score if they’re on ≥2.5 mg/day prednisone for over three months.

  4. What is the suggested approach to tapering steroids?

    • Answer: For steroids taken for less than seven days, stopping without tapering is usually safe. For prolonged use, a rapid taper can be done until the dose reaches approximately 20 mg prednisone equivalent, after which a slower taper is recommended. Switching to shorter-acting steroids like hydrocortisone can help avoid HPA axis suppression.

  5. What are the risks of multiple steroid bursts over time?

    • Answer: Multiple courses of short steroid bursts, especially in conditions like COPD or chemotherapy, increase the risk of adrenal insufficiency. Studies have shown that frequent short courses can suppress the adrenal glands, making tapering beneficial even for short bursts if used repeatedly.

  6. How can steroid withdrawal syndrome affect tapering?

    • Answer: Steroid withdrawal syndrome can present as fatigue, malaise, dizziness, and depression, distinct from adrenal insufficiency or the underlying disease. Patients should be advised to take it easy during tapering to avoid exacerbating these symptoms, and clinicians may need to adjust the taper based on symptom severity.

  7. When does the risk of adrenal insufficiency increase with steroid use?

    • Answer: Patients on >5 mg prednisone daily for over two weeks are at moderate risk for adrenal insufficiency, with higher risk after four weeks or more. Physiologic cortisol levels (around 10-15 mg/day hydrocortisone equivalent) can guide when adrenal recovery is expected during tapering.

  8. What are important considerations when counseling patients reluctant to stop steroids?

    • Answer: Patients may resist stopping steroids due to familiarity and perceived safety. Clinicians can explain that although steroids are effective, they act broadly and disrupt many immune functions, unlike more targeted therapies that may provide safer long-term control of inflammation.


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