DH206: Pharmacology
Chapter 18: Adrenocorticosteroids
Lisa Mayo, RDH,BSDH
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Chapter 19 Outline
 A&P Review
 Hormone Secretion
 Classification
 Route of Administration
 Mechanism of Action
 Pharmacological Effects
 Adverse Rxns
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Adrenocorticosteroids
 Use in dentistry
Topically or systemically
 Treatment of oral lesions associated with inflammatory
disorders
 Long-term therapy: asthma or arthritis

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A&P Review
http://www.youtube.com/watch?v=fF_3mJV3Yh0
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A&P Review
 Adrenal glands located on upper surface
of each kidney
 Outer (next slide) & Inner layer
 Inner layer (adrenal medulla)
 Secretes catecholamine’s during fightor-flight response
 Epi is ONLY produced from the
adrenal medulla = responsible for
converting stored glycogen to glucose
(glycogenolysis)
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A&P Review
 Outer part: adrenal cortex has 3 layers


Each layer secretes steroid hormones
3 layers of the cortex
Layer of
Cortex
Location
Hormone
released
Function
Glomerulosa
Outer
Aldosterone
Acts on kidney to ↑ absorption Na+,
(mineralcortic dump K+ & H+
o-steroid)
Fasciculata
Middle
Cortisol
Reticularis
Inner
Sex androgens Male secondary characteristics
(testosterone) Women’s only source of androgens
Signals to body to ↑ glucose through
gluconeogenesis or glycogenolysis
Body secretes 20mg/day
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A&P Review
Deficiency/Adrenal gland not working properly: Addison’s disease
 Effects from the 3 layers of the adrenal gland
1.
Aldosterone deficiency: Increase K+, metabolic acidosis (H+ ↑),
↓Na+
2.
Cortisol deficiency: Inadequate secretion of glucocorticoids,
decrease glucose – when needed for flight or fight – will not have)
3.
Testosterone deficiency
 Summary of what will happen to patient
 Hyperkalemia (↑K+)
 Low BP (due to Na drop)
 Metabolic acidosis (H+ ↑)
 Hypoglycemia (decrease glucose)
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A&P Review
Too much hormone production from adrenal gland: Cushing’s Disease
 Too much ACTH hormone from pituitary
 Your book sometimes calls this Cushing’s syndrome: syndrome and disease
are very different. Syndrome usually occurs due to exogenous steroid use
 Will see the opposite effects as Addison’s
 Aldosterone: Decrease K+, H+, ↑Na+(↑ BP)
 Cortisol: Hyperglycemia
 Testosterone ↑ (secondary male characteristics) – exogenous steroids
can do this as well
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A&P Review
Hypothalamic-Anterior Pituitary Axis
 A complex set of direct influences & feedback interactions
among 3 endocrine glands
1.
Hypothalamus
2.
Pituitary gland
3.
Adrenal gland
 Pituitary gland
 Often called the “master gland” of the endocrine system
 Controls many other glands
 2 lobes
 Located in the brain, attached to the hypothalamus
 Hypothalamus controls the pituitary gland: connected by the
portal system called Hypothalamic-Ant Pit Axis (see net slide)
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A&P Review
Hypothalamic-Anterior Pituitary Axis
Hypothalamus releases hormone CRH
↓
Acts on Pituitary gland
↓
ACTH hormone released
↓
Influence adrenal gland
↓
Can also have
a NEGATIVE
FEEDBACK
to help
regulate
hormone levels
Adrenal gland releases its 3 hormones
(aldosterone, cortisol, androgens)
SUMMARY: corticosteroids from adrenal gland controlled by
hypothalamus & pituitary gland
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
Hormone Secretion
Key Points
 More cortisol & CRH are secreted during waking hours
 When stressed – body needs more cortisol to cope
 When level of cortisol rises above normal: ACTH/CRH release
is inhibited: called NEGATIVE FEEDBACK
 Steroids act like endogenous cortisol – they inhibit release
ACTH/CRH
 Long-term steroid use – ACTH release is suppressed for
long periods thus atrophy occurs to adrenal gland
 If steroid is stopped abruptly – relative steroid deficiency
result – leads to adrenal crisis
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Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.
DRUG CLASSIFICATION
Mineralocorticoids
Glucocorticoids
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Classification
Glucocorticoids
1.




Stimulate gluconeogenesis (make glucose) & lipolysis (fat breakdown)
Inhibit glucose uptake by cells (to increase blood plasma glucose)
Tx of inflammatory or allergic conditions (Book focuses on this
category) – NEXT SLIDE
Drugs called corticosteroids
Mineralocorticoids (Aldosterone)
2.




Affect kidney: water & electrolyte composition
Act on kidney in Loop of Henle
Useful for patient with kidney issues
Protype: fludrocortisone(Florinef)
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Glucocorticoid Uses
MEDICAL USES
DENTAL USES
Asthma
Oral lesions
RA
Aphthous stomatitis
Lupus
TMD
Addison’s
Post-op surgery
Allergy
Burning tongue
Transplant rejection
Lichen planus
GI disorders (ulcerative
colitis, Crohns, IBD)
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Glucocorticoid Uses
 Antiinflammatory
 Suppress immune responses
 Palliative rather than curative
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Glucocorticoid Administration
 Topical
 Useful for dental lesions
 Oral
 Parental (IM, IV)
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Mechanism of Action Corticosteroids
 Most potent antiinflammatory agents available
 Almost every cell in the body has glucococortoid receptors
located in the cytoplasm
 Cortisol (glucococortoid hormone) is hydrophobic – requires
active transport into a cell by a protein
 Once inside the cell – travels to nucleus & binds to DNA
See next slide for picture
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Active
Transport
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Mechanism of Action Corticosteroids
 Once inside cell
1.
2.
Controls rate of PRO synthesis
Controls release of histamine
 Immunological Effects


↑ neutrophils
↓ inflammatory agents (prostaglandin, leukotriene,
macrophages)
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Corticosteroid Drugs
 Classified by duration of action – need to know which
drugs fall into each category
 p. 217, Table 18-2 Do NOT use this list, use next slide
drugs..mistake in your book with Prednisone (listed as
short-acting but is intermediate)
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Corticosteroid Drugs
Short-Acting
Cortisone(Cortone)
Hydrocortisone(Cortisol, Cortef)
Intermediate-Acting (Useful in Dentistry)
No
contraindications
for EPI in LA
Methylprednisolone(Medrol)
Prednisolone(Orapred, Prelone)
Prednisone(Meticorten, Deltasone)
1st line drug
Triamcinolone(Aristocort, Kenacort)
Long-Acting
Betamethasone(Celestone)
Dexamethasone(Decadron)
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Adverse Rxns
 Rare in short-term use
 Long-term has many side effects due to suppression of
adrenal gland function
 Metabolic changes (NBQ)
 Moon face
 Buffalo hump
 Obesity, Weight gain
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Adverse Rxns







Hyperglycemia (NBQ)
Hypertension
Osteoporosis
Mood/behavior changes
Poor-delayed healing
Immune suppression: Candidiasis, etc…
Peptic ulcers
 Corticosteroids ↑production of stomach acid &
pepsin
 No Aspirin & NSAIDs
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Adverse Rxns
 Adrenal crisis



Adrenal suppression with prolonged use (adrenal gland
told not to release ACTH/CRH because patient getting
from external source)
Body cannot respond correctly to stressful situation
Ex: dental phobia – steroid user body will not produce
enough cortisol to respond to pt’s increased anxiety –
crisis could occur
 Pt may need additional steroids day of appt to
accommodate for this issue (Prednisone most commonly
given)
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Drug Interactions
Drug interactions due to liver metabolism by the CYP3A4
enzyme
1) Insulin drugs
2) Carbamazepine(Tegretol)
3) Phenytoin(Dilantin)
4) Rifampin (TB drug)
5) Phenobarbital
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