Corticosteroids MCQs

Exogenous glucocorticoids act at the hypothalamus and pituitary to suppress the production of CRH and ACTH. As a result, adrenal production of endogenous corticosteroids is suppressed. On discontinuance, the recovery of normal hypothalamic-pituitary-adrenal function occurs slowly. Glucocorticoid doses must be tapered slowly, over several months, to prevent adrenal insufficiency. Reference: Basic & Clinical Pharmacology, Fourteenth Edition By Bertram G. Katzung Pg no. 712

A 21α-hydroxylase deficiency prevents normal synthesis of cortisol and aldosterone, and causes accumulation of cortisol precursors. The hypothalamic-pituitary system responds to the abnormally low levels of cortisol by increasing ACTH release. High levels of ACTH induce adrenal hyperplasia and excess production of adrenal androgens, which can cause virilization of females and prepubertal males. Glucocorticoid is administered to replace the missing mineralocorticoid and glucocorticoid activity and to suppress ACTH release, which removes the stimulus for excess adrenal androgen production. Reference: Basic & Clinical Pharmacology, Fourteenth Edition By Bertram G. Katzung Pg no. 715

Corticosteroids have been used to treat asthma since 1950 and are presumed to act by their broad anti-inflammatory efficacy, mediated in part by inhibition of production of inflammatory cytokines. They do not relax airway smooth muscle directly but reduce bronchial reactivity and reduce the frequency of asthma exacerbations if taken regularly. Their effect on airway obstruction may be due in part to their contraction of engorged vessels in the bronchial mucosa and their potentiation of the effects of β-receptor agonists, but their most important action is inhibition of the infiltration of asthmatic airways by lymphocytes, eosinophils, and mast cells. Reference: LANG’ Basic & clinical pharmacology by Bertram G. Katzung, Susen B. Masters and Anthony J. Trevor 12 th edition. Chapter 20- Drugs used in asthma by Dr. Homer A. Boushy, MD. Page no. 347

Answer is C (Dexamethasone): The treatment of choice for acute adrenal insufficiency is Glucocorticoid Replacement Therapy. In cases where the diagnosis of acute adrenal insufficiency is suspected (not confirmed) Dexamethasone is preferred as the initial steroid of choice because Dexamethasone does not compete with the cortisol assay. Cosyntropin stimulation testing may be performed while the patient is on treatment.

In acute adrenal insufficiency, there is loss of salt and water that is primarily due to reduced production of aldosterone. The loss of salt and water can lead to dehydration. A rational combination of drugs should include agents with complementary effects (i.e. a glucocorticoid and a mineralocorticoid). The combination with these characteristics is cortisol and fludrocortisone. (Note that although fludrocortisone may have sufficient glucocorticoid activity for a patient with mild disease, a patient in severe acute adrenal insufficiency needs a full glucocorticoid such as cortisol.) Reference: Basic & Clinical Pharmacology, Fourteenth Edition By Bertram G. Katzung Pg no. 710

Corticosteroids have mortality benefit in COVID 19 patients Patients with severe or critical COVID-19 develop an overstimulation of the immune system, which can be very harmful to their health. Corticosteroids reduce this overstimulation, which helps balance the immune system responses so that they are effective and do not cause damage to the person themselves.

Urgent treatment is often begun with an oral dose of 30-60 mg prednisone per day or an intravenous dose of 1 mg/kg methylprednisolone every 6-12 hours; the daily dose is decreased after airway obstruction has improved. In most patients, systemic corticosteroid therapy can be discontinued in 7-10 days, but in other patient's symptoms may worsen as the dose is decreased to lower levels. Reference: LANG' Basic & Clinical Pharmacology by Bertram G. Katzung, Susen B. Masters and Anthony J. Trevor, 12th Edition, Page Number-347.

Ketoconazole inhibits many types of cytochrome P450 enzymes. It can be used to reduce the unregulated overproduction of corticosteroids by adrenal tumors. Reference: Basic & Clinical Pharmacology, Fourteenth Edition By Bertram G. Katzung Pg no. 714