THE MANY USES OF STEROIDS:

FROM BODYBUILDERS

TO CRITICAL ILLNESS

April Merrill, MS, APRN, CCNS

OBJECTIVES Identify the different categories of

steroid medications

Identify the uses for steroid medications

Identify side-effects and precautions for steroid medications

WHAT ARE HORMONES? 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

WHAT ARE STEROIDS? 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.

STEROID HORMONES Adrenalcortical steroids Progesterone & related steroids Androgens Estrogens Bile acids & bile salts Cholesterol

PROGESTERONE & RELATED STEROIDS 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.

ANDROGENS 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

ANABOLIC STEROIDS

Roids

Juice

Sauce

Sloop

WHAT IS AN ‘ANABOLIC STEROID’? Natural ~ Bioactive Molecules

promote cell division/ growth

Testosterone

Estrogen

Cholesterol

http://en.wikipedia.org/wiki/Testosterone

http://en.wikipedia.org/wiki/Cholesterol

WHAT IS A ‘SYNTHETIC’ ANABOLIC? Structural Definition

Not found in nature. How they are prepared.

Semi-syntheticNatural Source MaterialsSynthetic Chemistry Derivation

AdvantagesCostHighly variable structure

USES 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

SIDE EFFECTS 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

ROID RAGE Altered hormone levels

Inability to control behavior

Severe mood swings

Irritability

Violent aggression

Depression

TAKING ANABOLIC STEROIDS

Oral Injection

Sanitation Intramuscular injection

Avoidance Nerves Blood vessels

Sites Deltoid in upper arm Outer thigh Buttocks

LEGAL AND MORAL ISSUES

Is it cheating?

Is it legal?

Is it worth it?

DETECTION TIMES Nandrolone decanoate- 18 mos.

Depo-testosterone- 3 mos.

Parabolan- 5 weeks

Andriol- 1 week

Clenbuterol- 4 days

SCIENTIFIC NAMES

Oral

Oxymetholone

Oxandrolone

Methandrostenolone

Stanozolol

Injectable

Nandrolone decanoate

Nandrolone phenpropionateTestosterone cypionate

Boldenone undecyclenate

ANDRIOL

Dosage- 8-16 40 mg caps daily

Street price- $1 for 40 mg

Half-life: 3-5 hrs

DANATROL

Dose- 200-400 mg daily

$2-3 per 200 mg cap

Lack of popularity Slightly androgenic Expensive

METHYLTESTOSTERONE 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’

SUSTANON 250

Dosage: 250-1000 mg/ week Price: $10-30/ ml Stacks well with any compound Extreme anabolic tendencies

Good and bad Injectables

ANABOLIC REFERENCES www.steroid.com www.bodybuilding.com www.steroidworld.com www.wikipedia.com www.wrestlingusa.com www.anabolicsmall.com www.steroids.com www.pharmaeurope.com

CUSHING’S SYNDROME

ADDISON’S DISEASE

ADRENALCORTICAL STEROIDS

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.

SPECIFIC DRUGS 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

INDICATIONS 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 diseaseAllergic responsesDermatologic (topical, oral)CancersOrgan transplant (immune system suppression) Respiratory support in preterm infantsDecrease cerebral edema (suppress

inflammation)

ACTIONS Background/overview Metabolism Mineralocorticoid effect (sodium

retention) Anti-inflammatory Immunosuppressant

ADVERSE EFFECTS 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

DRUG INTERACTIONS 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

ADRENAL SUPPRESSION 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)

POTENCY OF TOPICAL CORTICOSTEROIDS Potency can vary greatly between

various drugs, preparations (cream vs. ointment), and routes of administration

Systemic absorption also varies based on routeEx. Topical cream/ointment will have greater

systemic effect if skin broken vs. intact

CORTICOSTEROID CONVERSIONOn-line calculators:

http://www.globalrph.com/corticocalc.htm

http://www.medcalc.com/steroid.html

Class/Potency Brand Name Generic

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

NURSING IMPLICATIONS 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

THE END Questions????