The Many Uses of Steroids: From Bodybuilders to Critical Illness

1. The Many Uses of Steroids: From Bodybuilders to Critical Illness April Merrill, MS, APRN, CCNS

2. objectives • Identify the different categories of steroid medications • Identify the uses for steroid medications • Identify side-effects and precautions for steroid medications

3. 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

4. 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.

5. Steroid hormones • Adrenalcortical steroids • Progesterone & related steroids • Androgens • Estrogens • Bile acids & bile salts • Cholesterol

6. 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.

7. 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

9. Anabolic steroids Roids Juice Sauce Sloop

10. Natural ~ Bioactive Molecules promote cell division/ growth Testosterone Estrogen Cholesterol http://en.wikipedia.org/wiki/Testosterone What is an ‘anabolic steroid’? http://en.wikipedia.org/wiki/Cholesterol

11. What is a ‘synthetic’ anabolic? • Structural Definition • Not found in nature. • How they are prepared. • Semi-synthetic • Natural Source Materials • Synthetic Chemistry Derivation • Advantages • Cost • Highly variable structure

12. 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

13. 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 • Peliosishepatis • Skin • Acne and cysts • Oily scalp

14. ROID RAGE • Altered hormone levels • Inability to control behavior • Severe mood swings • Irritability • Violent aggression • Depression

15. Taking Anabolic steroids • Oral • Injection • Sanitation • Intramuscular injection • Avoidance • Nerves • Blood vessels • Sites • Deltoid in upper arm • Outer thigh • Buttocks

16. Legal and Moral Issues • Is it cheating? • Is it legal? • Is it worth it?

17. Detection Times • Nandrolonedecanoate- 18 mos. • Depo-testosterone- 3 mos. • Parabolan- 5 weeks • Andriol- 1 week • Clenbuterol- 4 days

18. Scientific Names • Oral • Oxymetholone • Oxandrolone • Methandrostenolone • Stanozolol • Injectable • Nandrolonedecanoate • NandrolonephenpropionateTestosterone cypionate • Boldenoneundecyclenate

19. ANDRIOL • Dosage- 8-16 40 mg caps daily • Street price- $1 for 40 mg • Half-life: 3-5 hrs

20. DANATROL • Dose- 200-400 mg daily • $2-3 per 200 mg cap • Lack of popularity • Slightly androgenic • Expensive

21. 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’

22. SUSTANON 250 • Dosage: 250-1000 mg/ week • Price: $10-30/ ml • Stacks well with any compound • Extreme anabolic tendencies • Good and bad • Injectables

23. 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

24. Cushing’s syndrome

25. Addison’s disease

26. 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.

27. 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

28. 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 disease • Allergic responses • Dermatologic (topical, oral) • Cancers • Organ transplant (immune system suppression) • Respiratory support in preterm infants • Decrease cerebral edema (suppress inflammation)

29. Actions • Background/overview • Metabolism • Mineralocorticoid effect (sodium retention) • Anti-inflammatory • Immunosuppressant

30. 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 Adverse Effects

32. 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

33. 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)

34. 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 route • Ex. Topical cream/ointment will have greater systemic effect if skin broken vs. intact

35. Corticosteroid Conversion On-line calculators: http://www.globalrph.com/corticocalc.htm http://www.medcalc.com/steroid.html

37. http://www.psoriasis.org/NetCommunity/Page.aspx?pid=469

38. 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

39. The end • Questions????