C H A P T E R 3 6
Adrenocortical agents
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The glucocorticoids increase glucose production,
stimulate fat deposition and protein breakdown and
inhibit protein formation. They are used clinically to
block inflammation and the immune response and in
conjunction with mineralocorticoids to treat adrenal
insufficiency.
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Individuals receiving glucocorticoids need to be
protected from exposure to infection, have their
blood glucose monitored regularly and dietary
changes made as needed. They will also not heal well
because of the inhibition of protein formation.
KEY POINTS
and thereby minimise suppression of the
hypothalamic–pituitary axis.
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Space multiple doses evenly throughout the day
to try to achieve homeostasis.
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Use the minimal dose for the minimal amount of
time
to minimise adverse effects.
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Taper doses when discontinuing from high doses or
from long-term therapy
to give the adrenal glands
a chance to recover and produce adrenocorticoids.
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Arrange for increased dose when the person is
under stress
to supply the increased demand for
corticosteroids associated with the stress reaction.
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Use alternate-day maintenance therapy with short-
acting drugs whenever possible
to decrease the risk
of adrenal suppression.
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Do not give live virus vaccines when the person is
immunosuppressed
because there is an increased
risk of infection.
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Protect the person from unnecessary exposure
to infection and invasive procedures
because the
steroids suppress the immune system and the
person is at increased risk for infection.
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Assess the person carefully for any potential drug–
drug interactions
to avoid adverse effects.
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Provide thorough teaching, including measures to
avoid adverse effects, warning signs of problems
and the need for regular evaluation, including
blood tests,
to enhance knowledge of drug therapy
and promote compliance.
Explain the need to
protect from exposure to infections
to prevent
serious adverse effects.
Evaluation
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Monitor response to the drug (relief of signs and
symptoms of inflammation, return of adrenal
function to within normal limits).
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Monitor for adverse effects (increased susceptibility
to infections, skin changes, endocrine dysfunctions,
fatigue, fluid retention, peptic ulcer, psychological
changes).
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Evaluate the effectiveness of the teaching plan
(person can name drug, dosage, adverse effects to
watch for and specific measures to avoid them).
CRITICAL THINKING SCENARIO
Adrenocortical agents
THE SITUATION
M.W., a 48-year-old woman, was diagnosed with severe
rheumatoid arthritis 7 years ago. She has been retired, on
disability, from her job as an art teacher in the local high
school. Her pain is no longer controlled by aspirin, and
her doctor ordered 5 mg prednisone three times a day.
Over the next 4 weeks, M.W.’s symptoms were markedly
relieved; she was able to start painting again, and she
became much more mobile. She also noted that for the first
time in years she felt “really good”. Her appetite increased,
she was no longer fatigued and her outlook on life was
markedly improved. At her follow-up visit, M.W. had gained
4 kilograms; she had slight oedema in both ankles, and her
blood pressure was 150/92 mmHg. An inflamed, oozing
lesion was found on her right hand, which she stated
became infected a few weeks ago after she cut her hand
while peeling potatoes. Her range of motion and joints
were markedly improved. The doctor decided that M.W.
was past her crisis and that the prednisone should be
tapered to 5 mg/day over a 4-week period.
CRITICAL THINKING
Think about the pathophysiology of rheumatoid arthritis.
What
effects did the prednisone have on the process at work
in M.W.’s joints?
What effects does the adrenocorticoid steroid have on the
rest of M.W.’s body?
What can be expected to occur when a person is on
prednisone for a month?
What precautions should be taken?
What care interventions are appropriate for M.W. at this visit?
DISCUSSION
The most urgent problem for M.W. at this time is the
infected lesion on her hand.
