Steroid Treatment in Oral Cancer Patient

1. Steroid Treatment in Oral Cancer Patient Oral Maxillofacial section, VGH-Tpe Reporter: 王奕凱 Supervisor: 高壽延 主任 雷文天 醫師

2. Introduction • Clinical application of corticosteroid • Complication of corticosteroid • Dental uses of corticosteroid • Management of corticosteroid-use dental patients

3. Introduction • Adrenal gland: Cortex and Medulla • Adrenal cortex: 3-layer Outer: zona glomerulosa: Middle: zona fasciculata Inner: zona reticularis

6. Structure

7. Physiopharmacology of corticosteroids • 其基本構造包含17個碳做骨架核,常用之 類固醇共有 21 個碳原子。在位置1,2 間改為雙鍵, 即成 Prednisolone, 其抗發炎作用增強四倍, 如Ｃ16再改為甲基,Ｃ9 改為氟離子,則成 Dexamethasone , 抗發炎作用 增加30倍而鈉滯留作用消失

8. Regulation: HPA axis

9. Functions of corticosteroid • Regulation of carbohydrate, fat, protein • Anti-inflammation action by inhibit lysosome, prostaglandin, cytokines release. • Regulate the function of lekocyte. • Increase gluconeogenic, proteolysis, lipolysis and blood sugar

10. Clinical application of steriod • Immunosuppressive: Rheumatoid arthritis, SLE, organ transplantation, asthma… • Anti-inflammation: hepatitis, dermatoses, mucositis, post-op edema… • Analgesia: reduction of pain • Replacement for adrenal insufficiency

11. Clinical application

13. Complication of corticosteroid

14. Adverse effect of corticosteroids • Receive long-term, high-dose steroid • Hypertension, heart failure • Osteoporosis, DM, impaired wound healing, metal depression and psychosis • Peptic ulcer, Cataract, glaucoma, growth suppression, hypocalcemia, PTH increased • Cushing syndrome • Secondary adrenal insufficiency

15. Complications of corticosteroids treatment

17. Dental uses of corticosteroids • Topical use: non-infections, ulcerative diseases in oral cavity. Inhibit the inflammatory reaction, redness and edema • Systemic use: third molar extraction, pre-prosthetic surgery, reconstructive oral surgery, orthognatic surgery

18. condition administration 不建議使用於herpetic infections

19. Nincort ointment • Acute and chronic oral lesions • 成分：0.1% triamcinolone acetonide 3.5 g/ tube (17.5 mg cortisol/tube) • 用法： apply a small dab (about ¼ inch ) to the lesion at bed time, or 2- 3times a day after meals

20. Dexaltin ointment • Indication: inflammation manifestation of corticosteroid-responsive dermatoses in oral cavity • 成分： 0.1% dexamethasone 5g / tube ( 133 mg cortisol/ tube )

21. PBK solution • Indication: oral ulcer • 成分： susp 100ml/ bot prednisolone 100mg(400mg cortisol) benadryl 8.33 mg kaopectin 33.33 mg • 用法：gargling in mouth for 5 min. 5-10 ml Bid

22. Management of corticosteroid-use dental patientsPrevent adrenal crisis

24. Adrenal crisis( acute adrenal insufficiency) • Hypotension • Severe weakness • Progressive mental confusion • Nausea and vomiting • Abdominal, lower back or leg pain • Hyperthermia • Hypoglycemia • Hyperkalemia • Improve CAD • Loss of consciousness • Coma • death

25. Dental patient taking steroid supplementation not required • Patient taking low dose (<20 mg of cortisol daily) • Patient taking large dose: for less than 2 weeks for minor dental procedure with minimal stress

26. Dental patient taking steroid supplementation required • Patient taking large dose: for greater than 2 weeks for extensive major or stressful dental procedure ＃ Double usual daily dose on the day before, the day of, and the day after surgery ＃ Appt in the morning ＃ Good pain control ＃ Resume normal maintenance dose post-op 2 days.

27. Dental patient taking steroid supplementation required • If the patient received at least 20mg of cortisol for more than 2 weeks within past year ＃60mg cortisol(or equivalent) the day before and the day of surgery at morning ＃ On first 2 post-op days, 40mg cortisol ＃ Then take 20mg cortisol thereafter, until post-op 6 days.

28. Management of adrenal crisis • Place the patient in a supine position with leg elevated • 200 mg hydrocortisone IV stat repeated as necessary • Oxygen and CPR if necessary • Transportation to a medical facility as soon as possible

29. Thanks for your attention