Adrenocorticosteroids = Group of Agents Secreted by the Adrenal Cortex

Adrenocorticosteroids Chapter 19

Adrenocorticosteroids = group of agents secreted by the adrenal cortex

Dental uses

Medical Uses

Mechanism of release

stress → hypothalamus releases CRF → pituitary releases ACTH → adrenal cortex releases hydrocortisone

. Classification of Steroids

glucocorticoids

mineralcorticoids

Disease States

Addison’s disease

Cushing’s syndrome

Mechanism of Action

steroid binds to receptor → forms steroid-receptor complex → complex enters nucleus, turns genes on/off

anti-inflammatory

Pharmacologic effects - palliative (not curative)

glucocorticoids prednisone, methylprednisolone, triamcinolone

1. anti-inflammatory

2. suppress allergic reactions

3. suppress immune response

mineralcorticoids

1. ↑ Na+ retention

2. ↑ K+ loss

3. ↑ edema, hypertension

ADR’s

Glucocorticooids (see fig 19-2, pg 243)

1. metabolic changes - look like Cushing’s syndrome (see fig. 19-3, pg 244)

2. infections - because of anti-inflammatory action

3. CNS - changes in personality and behavior

(euphoria with high dose, depression with lower dose)

4. peptic ulcer - corticosteroids stimulate stomach acid

5. impaired wound healing / osteoporosis - impaired synthesis of collagen

6. ophthalmic effects - increased intraoccular pressure

7. electrolyte / fluid balance - can have some mineralcorticoid action

8. adrenal crisis - adrenal gland atrophies with prolonged use; can be lethal

9. dental effects

a. slow healing of mucosal surfaces

b. oral candidiasis with steroid inhalers (asthma)

Medical Uses

1. Addison’s disease

2. Cushing’s syndrome (Rx, adrenal tumor, pituitary tumor)

3. autoimmune diseases

a. rheumatoid arthritis

b. collagen diseases

4. with chemotherapy in CA tx (anti-emetic/anti-nausea, and to reduce swelling which decreases pain)

5. asthma

6. emergencies - tx shock, tx adrenal crisis

7. tx inflammatory and allergic reactions (palliative only, not curative) (most common)

Dental Uses

1. oral lesions - tx of noninfectious inflammatory diseases (most common) RAS

2. oral surgery - ↓ post-op edema, trismus, and pain (?)

3. pulp procedures (?)

Dental Implications

1. GI - stimulate stomach acid, avoid Rx Salicylates(ASA) and NSAID’s

2. check BP - can exacerbate hypertension

3. glaucoma - avoid Rx anticholinergics

4. be aware of possible behavior changes

5. osteoporosis

6. infection - infection symptoms may be masked, pt. has decreased ability to fight infection

7. delayed wound healing - special care in suturing

8. adrenal crisis - only with severe stress

9. periodontal disease - interfere with body’s response to infection, osteoporosis

Steroid supplementation

most dental patients taking steroids having normal dental tx rendered DO NOT need additional steroids (see fig 19-4, pg 247)

OTHER HORMONES Chapter 20

Hormones

Pituitary Hormones (pituitary = “master gland”, hypophysis)

Anterior (adenohypophysis)

1. GH growth hormone (somatotropin)

gigantism

acromegaly

dwarfism

2. LH leutinizing hormone

3. FSH follicle stimulating hormone

4. TSH thyroid stimulating hormone (thyrotropin)

5. ACTH adrenocorticotropic hormone

6. PRL prolactin (leuteotropic hormone LTH)

7. β - lipotropin

Posterior (neurohypophysis)

1. Vasopressin (antidiuretic hormone - ADH)

2. Oxytocin

Thyroid Hormones

Iodine-containing

1. T3 (tri-iodo-thyronine)

2. T4 (thyroxine)

Hypothyroid

child: cretinism

adult: myxedema

Hyperthyroid

thyrotoxicosis

Grave’s disease

Plummer’s disease

Hashimoto’s disease

Calcitonin

Pancreatic Hormones

Insulin

Glucagon

Diabetes mellitus: def. abnormal carbohydrate metabolism with inappropriate hyperglycemia

Type I (IDDM, juvenile onset)

Type II (NIDDM, adult onset)

Systemic complications

Oral complications

Management of DM patient

Evaluation

Medical emergencies

Hypoglycemia

Hyperglycemia

Drugs used to manage diabetes (add’l resource:

Type I

Insulin: Lantus, Humalog, Humulin N, Humulin 70/30, Novolog Mix 70/30, Novolin 70/30

Type II

Sulfonylureas: glimepiride, glyburide, glipizide (secretagogues)

MA: ↑ release of insulin from beta cells, ↓ serum glucagon, ↑ insulin sensitivity in target

tissues

ADR’s: blood dyscrasias, GI, cutaneous, liver damage

meglitinide derivatives (non-sulfonylurea secretagogues):

repaglinide (Prandin) nateglinide (Starlix)

MA: ↑ release of insulin from beta cells,

ADR’s: must be taken with meals

Biguanides: metformin

MA: ↓ hepatic production of glucose, ↑ insulin sensitivity in target tissues

ADR’s: GI, lactic acidosis

thiazolidinediones (glitazones): Actos, Avandia

MA: ↑ insulin sensitivity in target tissues

ADR’s: weight gain, hepatotoxicity

new drugs

exenatide (Byetta) (secretagogue, incretin mimetic, glucagon-like peptide / GLP-1)

MA: ↑ release of insulin from beta cells, ↓ serum glucagon, ↑ satiety

ADR’s: GI, risk of hypoglycemia when used with other oral diabetic agents

pramlintide (Symlin) (amylin analog)

MA: modulation gastric emptying, prevent postprandial rise in plasma glucagon,

↑ satiety Amylin secreted along with insulin by pancreatic β- cells

ADR’s: GI,risk of hypoglycemia when used with other oral diabetic agents

DPP-4 inhibitors (Januvia / sitaglipton)

MA: ↑insulin synthesis, oppose glucagon

ADR’s: weight gain whenused with sulfonylurea

α-glucosidase inhibitors ( acarbose)

MA: delay/prevent digestion of ingested carbohydrate (small intestine), delays glucose adsorption

ADR’s: flatulence, GI

Female Sex Hormones

Estrogens: Premirin, Evista, Estradiol

Progestins

Oral contraceptives: NuvaRing, Loestrin 24 Fe

Management of patient taking oral contraceptives:

Drug interactions:

Male Sex Hormones (testosterone)

Other Agents

clomiphene

leuprolide

tamoxifen

danazol

aromatase inhibitors