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Snapshot
  • A 68-year-old woman with a past medical history of polymyalgia rheumatica and migraines presents with sudden-onset, left-sided headache with radiation to her jaw.  She reports that this pain is not like her usual migraine pain. Laboratory testing reveals an elevated erythrocyte sedimentation rate. She is started on high-dose steroids to prevent permanent damage to her vision. (Giant cell arteritis)
Overview
  • Drugs
    • systemic
      • methylprednisolone
      • dexamethasone
      • prednisone
      • hydrocortisone
    • topical
      • triamcinolone
      • hydrocortisone
      • clobetasol
      • betamethasone
    • inhaled
      • fluticasone
      • budesonide
    • this list is not an exhaustive list as there are many different steroid options, particularly topical options
  • Mechanism of action
    • broad immunosuppressive effect, inhibiting multiple steps in the immune activation pathway
      • inhibits phospholipase A2, which prevents formation of arachidonic acid
      • inhibits NF-kB which is the transcription factor that results in production of inflammatory agents, including TNF-alpha
      • inhibition of cyclooxygenase-2
    • this result in ↓ leukotrienes, prostaglandins, and prostacyclins
  • Clinical use
    • any inflammatory process
      • drug reaction with eosinophilia and systemic symptoms (DRESS)
      • vasculitis
      • thyroid storm
      • inflammatory bowel disease
      • autoimmune diseases
      • cauda equina syndrome
    • immunosuppression
    • cancer chemotherapy
    • Addison disease
    • asthma
  • Adverse effects
    • hyperglycemia
      • diabetes
    • bone loss
      • osteoporosis
        • vertebral fractures
      • aseptic hip necrosis
      • ↓ skeletal growth in children
    • Cushing syndrome
      • buffalo hump
      • moon facies
      • truncal obesity
      • thin skin
      • striae
      • acne
    • psychiatric symptoms
      • findings
        • anxiety
        • panic attacks
        • insomnia
        • agitation
        • mania
        • psychosis
      • management
        • reducing the dose 
    • tertiary adrenal insufficiency
    • acute pancreatitis
    • lymphopenia
    • ↓ wound healing
    • cataracts

 

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