April Merrill, MS, APRN, CCNS

 Identify the different categories of steroid medications  Identify the uses for steroid medications  Identify side-effects and precautions for steroid medications

 Hormones- secreted by cells to regulate the activity of other cells.  Growth  Development  Behavior  Reproduction  Coordinates the production, use and storage of energy.  Homeostasis  Nutrition  Metabolism  Excretion  Water and salt balance

 The term steroid refers to any synthetic (man made) or naturally occurring fat (lipid) soluble compound that has a physiological response.  Steroids are hormones derived from cholesterol and differ only in the ring structure and side chains attached to it.

 Adrenalcortical steroids  Progesterone & related steroids  Androgens  Estrogens  Bile acids & bile salts  Cholesterol

 Progestogens (also known a progestins) such as progesterone  Produced from the corpus luteum in normal menstrual cycle  Estrogens, including estradiol and estrone  produced primarily by developing follicles in the ovaries, the corpus luteum, and the placenta  promote the development of female secondary sexual characteristics, such as breasts  involved in the thickening of the endometrium and other aspects of regulating the menstrual cycle.

 Testosterone  primarily secreted in the testes of males and the ovaries of females  plays a key role in the development of male reproductive tissues such as the testis and prostate  promotes secondary sexual characteristics such as increased muscle, bone mass and the growth of body  Prevents osteoporosis

Roids Juice Sauce Sloop

 Natural ~ Bioactive Molecules  promote cell division/ growth  Testosterone  Estrogen  Cholesterol

 Structural Definition  Not found in nature.  How they are prepared.  Semi-synthetic  Natural Source Materials  Synthetic Chemistry Derivation  Advantages  Cost  Highly variable structure

 Anabolic steroids are synthetic versions of testosterone, the body’s natural sex hormone. They assist athletes by facilitating efforts to gain strength and muscle mass for increased muscular endurance, power and speed. Stimulation of:  Sexual development  Growth  Puberty  Bone marrow  Appetite  Muscle Mass  Stamina

 Hormonal System  Men Infertility Breast development Shrinking of the testicles  Women Enlargement of the clitoris Excessive growth of body hair  Both Sexes  Male-pattern baldness  Muscoloskeletal System  Short stature  Tendon rupture  Cardiovascular System  Heart attacks  Enlargement of the left ventricle  Liver  Cancer  Peliosis hepatis  Skin  Acne and cysts  Oily scalp

 Altered hormone levels  Inability to control behavior  Severe mood swings  Irritability  Violent aggression  Depression

 Oral  Injection  Sanitation  Intramuscular injection Avoidance Nerves Blood vessels  Sites Deltoid in upper arm Outer thigh Buttocks

 Is it cheating?  Is it legal?  Is it worth it?

 Nandrolone decanoate- 18 mos.  Depo-testosterone- 3 mos.  Parabolan- 5 weeks  Andriol- 1 week  Clenbuterol- 4 days

 Oral  Oxymetholone  Oxandrolone  Methandrostenolone  Stanozolol  Injectable  Nandrolone decanoate  Nandrolone phenpropionate Testosterone cypionate  Boldenone undecyclenate

 Dosage mg caps daily  Street price- $1 for 40 mg  Half-life: 3-5 hrs

 Dose mg daily  $2-3 per 200 mg cap  Lack of popularity  Slightly androgenic  Expensive

 Dosage: mg/ day  Price: 2 50 mg tablets for $1  First oral steroid  Works well; bad side effects and high cost  Potent androgen  Prone to ‘roid rage’

 Dosage: mg/ week  Price: $10-30/ ml  Stacks well with any compound  Extreme anabolic tendencies  Good and bad  Injectables

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 Glucocorticoids- cortisol  controls carbohydrate, fat and protein metabolism  anti-inflammatory by preventing phospholipid release, decreasing eosinophil action  Mineralocorticoids-aldosterone  controls electrolyte and water levels, mainly by promoting sodium retention in the kidney.

 Prednisone (Deltasone)  Methylprednisolone (Solumedrol IM/IV)  Cortisone  Betamethasone (Diprolene)  Dexamethasone (Decadron)  Hydrocortisone (Solucortef IM/IV)  Prednisolone  Triamcinolone (Azmacort, Nasacort, Kenalog)  Fluticasone (Flovent, Flonase, Advair*)  Budesonide (Pulmicort, Rhinocort, Symbicort*) * Combination product

 Replacement; Addison’s disease (low dose)  Non-endocrine (high dose)  Rheumatoid arthritis / SLE / other inflammation (po, intra-articular injection)  Asthma (oral, inhaled, IV)  Inflammatory bowel disease  Allergic responses  Dermatologic (topical, oral)  Cancers  Organ transplant (immune system suppression)  Respiratory support in preterm infants  Decrease cerebral edema (suppress inflammation)

 Background/overview  Metabolism  Mineralocorticoid effect (sodium retention)  Anti-inflammatory  Immunosuppressant

 Adrenal insufficiency  Osteoporosis  Infection  Glucose intolerance  Muscle wasting  Fluid and electrolyte imbalance  Edema, HTN, muscle weakness, dysrhythmias  Growth suppression  Depression/suicide  “roid rage”  Cataracts, glaucoma  Peptic ulcer  Iatrogenic Cushing’s syndrome  Thin skin

 Digoxin, thiazide / loop diuretics due to hypokalemia  NSAIDs due to GI bleeding  Insulin and oral hypoglycemics due to hyperglycemia  Vaccines due to immunosuppression  No live vaccines

 Need for additional doses during stress if replacement  Tapering if not replacement  DO NOT ABRUPTLY STOP (with exceptions)  Alternate day dosing  Theoretically there is less endogenous corticosteroid suppression (via feedback)

 Potency can vary greatly between various drugs, preparations (cream vs. ointment), and routes of administration  Systemic absorption also varies based on route  Ex. Topical cream/ointment will have greater systemic effect if skin broken vs. intact

On-line calculators:

Class/PotencyBrand NameGeneric CLASS 1—Superpotent Clobex Lotion/Spray/Shampoo, 0.05% Clobetasol propionate Diprolene Ointment, 0.05% Betamethasone dipropionate CLASS 2—Potent Lidex Cream/Gel/Ointment, 0.05% Fluocinonide CLASS 3—Upper Mid- Strength Lidex-E Cream, 0.05%Fluocinonide CLASS 4—Mid-Strength Kenalog Cream/Spray, 0.1% Triamcinolone acetonide CLASS 5—Lower Mid- Strength Capex Shampoo, 0.01%Fluocinolone acetonide CLASS 6—Mild Aclovate Cream/Ointment, 0.05% Alclometasone dipropionate CLASS 7—Least Potent Cortaid Cream/Spray/Ointment Hydrocortisone

 Give with food  Give before 9 am to mimic circadian rhythm  Contraindicated if systemic fungal infection  Caution with pregnancy or lactation, HTN, heart disease, renal failure, GI irritation, DM

 Questions????