Glucocorticoids and mineralocorticoids: Nursing pharmacology

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GLUCOCORTICOIDS
DRUG NAME	cortisone; hydrocortisone (Cortef, A-Hydrocort)	prednisone (Deltasone, Liquid Pred, Meticorten, Orasone); prednisolone (Orapred, Prelone, Pediapred); methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol)	dexamethasone (Decadron, Dexasone, Solurex, Baycadron); betamethasone (Celestone, Celestone Soluspan, Betaject)
CLASS	Short-acting glucocorticoids	Intermediate-acting glucocorticoids	Long-acting glucocorticoids
MECHANISM of ACTION	Decrease inflammation by inhibiting the release of pro-inflammatory molecules, preventing the activation and migration of immune cells, and increasing the production and release of anti-inflammatory molecules
INDICATIONS	Hormone replacement therapy Inflammatory and autoimmune conditions (e.g., asthma, rheumatoid arthritis, inflammatory bowel disease, etc.) Prevention of organ transplant rejection Miscellaneous uses: treatment of chemotherapy-induced vomiting, hypercalcemia, adjuvant therapy in cancer
ROUTE(S) of ADMINISTRATION	Cortisone: PO Hydrocortisone: PO, IV, IM	Prednisone: PO Prednisolone: PO, IV, TOP Methylprednisolone: PO, IV, IM, IA	Dexamethasone: PO, IV, IM, IA Betamethasone: PO, IV, IM, IA, TOP
SIDE EFFECTS	HPA suppression Mood changes Weight gain and muscle weakness Osteoporosis Decreased bone growth rate in children Hypercortisolism
CONTRA-INDICATIONS & CAUTIONS	Systemic fungal infections Used with caution in clients with peptic ulcer disease, heart failure, severe viral or bacterial infections, psychiatric disorders, diabetes, osteoporosis, and glaucoma
NURSING CONSIDERATIONS	Encourage infection control practices Encourage medical alert bracelet Teach the client to monitor daily weights Monitor blood glucose

MINERALOCORTICOIDS
DRUG NAME	fludrocortisone (Florinef)
CLASS	Mineralocorticoids
MECHANISM of ACTION	Acts on the kidney tubules causing increased sodium and water retention, as well as increased loss of potassium and protons
INDICATIONS	Replacement therapy for adrenal insufficiency and congenital adrenal hyperplasia Refractory hypotension: idiopathic orthostatic hypotension, septic shock (off-label)
ROUTE(S) of ADMINISTRATION	PO
SIDE EFFECTS	Fluid retention Hypertension Edemas Hypokalemia Hyperglycemia
CONTRA-INDICATIONS & CAUTIONS	Used with caution in clients with uncontrolled hypertension, congestive heart failure, and hypokalemia

NURSING CONSIDERATIONS for
MINERALOCORTICOIDS

ASSESSMENT & MONITORING

Assessment

Current symptoms: fatigue, mood changes, orthostatic hypotension, muscle weakness, nausea, salt cravings
Weight
Vital signs
Hydration status
Presence of hyperpigmentation on the skin
Laboratory test results: WBC, renal function, blood glucose; electrolytes, especially potassium, sodium, and calcium
Diagnostic test results: ACTH stimulation test

Monitoring

Laboratory test results
Side effects
Evaluate for the desired therapeutic effect: absence of symptoms associated with adrenal insufficiency

CLIENT EDUCATION

Purpose of medication: to replace adrenal hormones and decrease symptoms
Take fludrocortisone once daily in the morning
Take hydrocortisone twice daily with food or milk
- Take largest dose first thing in the morning
- Smaller dose in early afternoon
- Do not take late in the day
- Will need additional hydrocortisone during high stress or illness
- Inform all healthcare providers about glucocorticoid replacement therapy
  - Glucocorticoid stress dosing prescribed during surgical procedures
- Do not abruptly stop taking medications
Medical alert medication
Side effects to report
- Excessive glucocorticoid activity
  - Accumulation of fat around the belly and upper back, thinning of the skin, development of stretch marks or slow wound healing
  - Hyperglycemia: increased thirst and hunger, along with passing a lot of urine
    - Diabetic clients: check blood glucose more often
  - Hypokalemia: muscle weakness or cramps, irregular heart beat
  - Peptic ulceration: abdominal pain, black, tarry stools, coffee ground emesis
  - Symptoms of high blood pressure: severe headache or dizziness
  - Visual changes
  - Steroid-induced osteoporosis
    - Lifestyle modifications: increased dietary protein, taking their prescribed calcium and vitamin D supplements

Transcript

Content Reviewers

Antonella Melani, MD,Lisa Miklush, PhD, RNC, CNS,Ashley Mauldin MSN, APRN, FNP-BC,Gabrielle Proper, RN, BScN, MN

Contributors

Kaylee Neff,Talia Ingram, MSMI, CMI

Glucocorticoids and mineralocorticoids are endogenous hormones normally produced by the adrenal glands. In clients with impaired adrenal function, these hormones can be administered as replacement therapy.

Synthetic glucocorticoids, also commonly known as corticosteroids, are medications that can be used in clients with decreased adrenal function, such as in adrenal insufficiency; this is also known as Addison disease, and specifically occurs when the adrenal glands don't make enough endogenous glucocorticoids, so these clients need hormone replacement therapy with synthetic glucocorticoids. In addition, glucocorticoids are used in the treatment of numerous inflammatory conditions, such as asthma, rheumatoid arthritis, and inflammatory bowel disease, as well as preventing organ rejection in transplant recipients.

Alright, now, based on the duration of action, synthetic glucocorticoids can be classified into three groups. The first group are short-acting glucocorticoids, such as cortisone and hydrocortisone. Cortisone needs to be converted into hydrocortisone in the liver in order to be active, so it can only be taken orally; while hydrocortisone can be given orally, intravenously, intramuscularly, and topically. The second group are intermediate-acting glucocorticoids, which include prednisone, prednisolone, and methylprednisolone. Prednisone can only be taken orally; while prednisolone can be administered orally, intravenously, or topically; and methylprednisolone can be given orally, intravenously, intramuscularly, or injected intra-articularly. The third and final group are long-acting glucocorticoids, which include betamethasone and dexamethasone. Both of these medications can be taken orally, intravenously, intramuscularly, or intra-articularly. In addition, betamethasone is also available for topical use.

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Glucocorticoids and mineralocorticoids: Nursing pharmacology

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