Glucocorticoids and Mineralocorticoids

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.

Once administered, glucocorticoids act by binding to intracellular glucocorticoid receptors and then migrating into the nucleus to modify the expression of many different genes, including those involved in regulating inflammatory processes. Among their anti-inflammatory actions, glucocorticoids inhibit the release of pro-inflammatory molecules, such as prostaglandins and leukotrienes; prevent the activation and migration of immune cells; and increase the production and release of anti-inflammatory molecules.

Now, side effects of glucocorticoids are more common in clients receiving high doses for a prolonged period of time. Most side effects are related to excess glucocorticoid activity, which can result in iatrogenic Cushing syndrome. Common symptoms include mood changes; weight gain predominantly in the back of the neck between the shoulder blades and face, respectively termed buffalo hump and moon facies; skin atrophy and stretch marks; muscle weakness; hyperglycemia; and increased risk of infections.

Additionally, prolonged use of glucocorticoids can increase the risk of osteoporosis and pathological fractures, and inhibition of bone growth in children. Clients receiving glucocorticoids can develop ocular disorders, like cataracts and glaucoma, as well as peptic ulcer disease. Finally, when glucocorticoids are given at high doses, they can also act on mineralocorticoid receptors, causing sodium and water retention, which may result in hypertension and edema.

Glucocorticoids are contraindicated in clients with severe systemic fungal infections. Additionally, glucocorticoids should be used with caution in clients with infections such as varicella and tuberculosis, as well as in glaucoma, peptic ulcer disease, heart failure, diabetes mellitus, osteoporosis, or certain psychiatric conditions.

Now, switching gears, synthetic mineralocorticoids are used to treat conditions where mineralocorticoid levels are low, such as Addison disease and severe congenital adrenal hyperplasia. Additionally, they can be used to treat conditions like idiopathic orthostatic hypotension and severe septic shock. Now, synthetic mineralocorticoids include fludrocortisone, which can be taken orally.

Once administered, mineralocorticoids act primarily on intracellular mineralocorticoid receptors in the kidney tubules, where they favor the reabsorption of sodium and water, along with excretion of potassium and protons. It's important to note that mineralocorticoids can also cause moderate activation of glucocorticoid receptors.

Since mineralocorticoids cause sodium and water reabsorption, clients on fludrocortisone may experience fluid retention, hypertension, and edema, as well as worsening of pre-existing heart failure. Other common side effects include hypokalemia and hyperglycemia. Finally, by stimulating glucocorticoid receptors, clients may develop similar side effects to those of glucocorticoid use, including iatrogenic Cushing syndrome. Fludrocortisone should be used with caution in clients with uncontrolled hypertension, congestive heart failure, hypokalemia, and diabetes mellitus.

Now, when caring for a client with primary adrenal insufficiency who is prescribed hydrocortisone and fludrocortisone as part of their corticosteroid replacement regimen, begin your assessment by asking about their current symptoms, including fatigue, mood changes, orthostatic hypotension, muscle weakness, nausea, and salt cravings.

Next, assess their current weight, vital signs, hydration status, and other signs of adrenal insufficiency, such as hyperpigmentation of the skin. Then, review your client's most recent laboratory test results, including WBC, renal function, blood glucose, and electrolytes, especially potassium, sodium, and calcium; as well as diagnostic tests, including an ACTH stimulation test.

Okay, let's move on to client education. Explain to your client that the medications will help to replace their adrenal hormones, and ultimately decrease their current symptoms. Then, instruct them to take the fludrocortisone once daily in the morning; and the hydrocortisone twice each day. Let them know that the hydrocortisone therapy is meant to mimic the body's normal production of cortisol, so they should take the largest dose first thing in the morning, take the smaller dose in the early afternoon, and avoid taking the medication in the late afternoon or evenings, when cortisol levels normally decrease.

Be sure your client knows that they should not stop taking their medication abruptly. Also, ensure they understand that, during periods of high stress or illness, they will often need to increase their hydrocortisone dose adjustments in order to remain asymptomatic. Lastly, stress the importance of letting all their healthcare providers know they are on glucocorticoid replacement therapy, especially if they are to undergo any type of surgical procedure; and teach your client to wear medical alert identification at all times.

Next, let your client know about some side effects they may experience while taking these medications. Prompt them to report symptoms of too much glucocorticoid activity, which could cause accumulation of fat around the belly and upper back, as well as thinning of the skin, development of stretch marks or slow wound healing; as well as symptoms of hyperglycemia, which can cause increased hunger and thirst, along with increased urination and frequency. If your client has diabetes, remind them to check their blood glucose more often.

Then, teach your client to report symptoms of hypokalemia, which could manifest as muscle weakness or cramps, or feeling like their heart is beating irregularly; as well as symptoms of peptic ulceration, which could present as abdominal pain, throwing up blood that looks like coffee grounds, or passing black, tarry stools. Likewise, teach them to recognize and report symptoms of high blood pressure, such as really bad headaches or dizziness; or any change in their eyesight.

Lastly, encourage your client to adhere to lifestyle modifications that can help reduce the risk of steroid-induced osteoporosis, which includes a diet that has increased protein, as well as taking their prescribed calcium and vitamin D supplements daily.

Finally, while your client is being treated with a glucocorticoid and mineralocorticoid, closely monitor their laboratory test results, watch out for the development of side effects, and evaluate for the desired therapeutic effect of an absence of symptoms associated with adrenal insufficiency.

Alright, as a quick recap… Glucocorticoids and mineralocorticoids are endogenous hormones produced by the adrenal glands and are administered as replacement therapy in clients with impaired adrenal function.

Glucocorticoids act by binding to intracellular glucocorticoid receptors that modify the expression of many different genes, inhibit the release of pro-inflammatory molecules, prevent the activation of immune cells, and increase the production of anti-inflammatory molecules.

On the other hand, mineralocorticoids act primarily on intracellular mineralocorticoid receptors in the kidney tubules, causing reabsorption of sodium and water, along with excretion of potassium and protons.

Most side effects are related to excess glucocorticoid activity causing iatrogenic Cushing syndrome, which presents as mood changes, skin atrophy stretch marks; and weight gain predominantly in the back of the neck between the shoulder blades and face, respectively termed buffalo hump and moon facies. Other common side effects include electrolyte imbalances.

When caring for a client taking a glucocorticoid or mineralocorticoid, nursing considerations include performing a baseline assessment, monitoring for side effects, and evaluating for the desired therapeutic effects of the medication. Client teaching is focused on safe self-administration, learning to recognize and manage side effects, and when to contact the healthcare provider.