1. April Merrill, MS, APRN, CCNS

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

3.  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

4.  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.

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

6.  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.

7.  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

9. Roids Juice Sauce Sloop

10.  Natural ~ Bioactive Molecules  promote cell division/ growth  Testosterone  Estrogen  Cholesterol http://en.wikipedia.org/wiki/Testosterone http://en.wikipedia.org/wiki/Cholesterol

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

12.  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 http://www.steroidabuse.com/how-anabolic-steroids-work.html

13.  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

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

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

16.  Is it cheating?  Is it legal?  Is it worth it?

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

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

19.  Dosage- 8-16 40 mg caps daily  Street price- $1 for 40 mg  Half-life: 3-5 hrs

20.  Dose- 200-400 mg daily  $2-3 per 200 mg cap  Lack of popularity  Slightly androgenic  Expensive

21.  Dosage: 25-50 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’

22.  Dosage: 250-1000 mg/ week  Price: $10-30/ ml  Stacks well with any compound  Extreme anabolic tendencies  Good and bad  Injectables

23.  www.steroid.com  www.bodybuilding.com  www.steroidworld.com  www.wikipedia.com  www.wrestlingusa.com  www.anabolicsmall.com  www.steroids.com  www.pharmaeurope.com

26.  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.

27.  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

28.  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)

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

30.  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

32.  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

33.  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)

34.  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

35. On-line calculators: http://www.globalrph.com/corticocalc.htm http://www.medcalc.com/steroid.html

37. 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 http://www.psoriasis.org/NetCommunity/Page.aspx?pid=469

38.  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

39.  Questions????