Adrenal Cortical Steroids – Clinical Overview
1. Introduction
Adrenal cortical steroids, commonly referred to as corticosteroids, are a class of steroid hormones produced by the adrenal cortex. They are critical for maintaining metabolism, immune response, electrolyte balance, and stress response. Clinically, synthetic corticosteroids are widely used for inflammation, autoimmune disorders, adrenal insufficiency, and certain cancers.
There are two main types:
- Glucocorticoids – primarily affect carbohydrate metabolism and immune response (e.g., cortisol, prednisone)
- Mineralocorticoids – primarily regulate sodium and water balance (e.g., aldosterone, fludrocortisone)
2. Pharmacology
2.1 Glucocorticoids
- Examples: Prednisone, Methylprednisolone, Dexamethasone, Hydrocortisone
- Mechanism: Bind to glucocorticoid receptors, modulate gene expression, and suppress pro-inflammatory cytokines
- Effects:
- Anti-inflammatory and immunosuppressive
- Increase gluconeogenesis → elevate blood glucose
- Promote protein catabolism and fat redistribution
- Modulate cardiovascular function by enhancing catecholamine sensitivity
2.2 Mineralocorticoids
- Examples: Aldosterone, Fludrocortisone
- Mechanism: Bind to mineralocorticoid receptors in kidney → increase sodium reabsorption and potassium excretion
- Effects:
- Maintain blood pressure and fluid balance
- Regulate electrolyte homeostasis
3. Clinical Uses
- Anti-inflammatory & Immunosuppressive
- Asthma, COPD exacerbations
- Rheumatoid arthritis, lupus, and other autoimmune disorders
- Allergic reactions and anaphylaxis
- Adrenal Insufficiency
- Addison’s disease
- Congenital adrenal hyperplasia
- Oncology
- Certain hematologic malignancies (e.g., lymphomas, leukemias)
- Reduce cerebral edema in brain tumors
- Other Uses
- Dermatologic conditions (eczema, psoriasis)
- Organ transplantation (prevent rejection)
4. Routes of Administration
- Oral – prednisone, dexamethasone
- Intravenous/IM – methylprednisolone, hydrocortisone
- Topical – creams, ointments, inhalers
- Intra-articular – joint injections
Route selection depends on disease severity, urgency, and site of action.
5. Adverse Effects
5.1 Short-term Use
- Hyperglycemia
- Fluid retention
- Mood changes (euphoria, insomnia, irritability)
- Increased susceptibility to infection
5.2 Long-term Use
- Cushingoid features (moon face, buffalo hump)
- Osteoporosis and fractures
- Muscle weakness (myopathy)
- Hypertension
- Cataracts and glaucoma
- Adrenal suppression → risk of adrenal crisis if abruptly stopped
6. Drug Interactions
- Anticoagulants: May alter effect of warfarin
- Diuretics: Risk of hypokalemia with loop or thiazide diuretics
- Vaccines: Immunosuppression may reduce vaccine efficacy
- NSAIDs: Increased risk of gastrointestinal ulcers
7. Dosing Considerations
- Glucocorticoids: Often tapered gradually after long-term therapy to prevent adrenal insufficiency
- Mineralocorticoids: Dosage titrated based on blood pressure, electrolytes, and plasma renin activity
- Timing: Morning dosing preferred to mimic circadian cortisol rhythm and reduce adrenal suppression
8. Special Populations
- Pregnancy: Some corticosteroids are considered relatively safe; monitor for gestational diabetes or hypertension
- Children: Chronic use may impair growth
- Elderly: Increased risk of osteoporosis, hypertension, and infections
9. Clinical Pearls
- Always use the lowest effective dose for the shortest duration to reduce adverse effects
- Monitor for electrolyte disturbances, bone health, blood sugar, and infection
- Abrupt discontinuation after long-term therapy can cause adrenal crisis → always taper
10. Summary
Adrenal cortical steroids are essential in modern medicine for their anti-inflammatory, immunosuppressive, and metabolic effects. While highly effective, they carry significant short- and long-term risks, requiring careful monitoring, dose adjustment, and patient education. Understanding the pharmacology, indications, and adverse effects is crucial for safe and effective therapy.
11. References
- Brunton LL, et al. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th Edition, 2021
- Furst DE. The rational use of corticosteroids in autoimmune and inflammatory diseases. Arthritis Rheum. 2005;52(7):1982–1991
- UpToDate: Overview of glucocorticoid therapy
- Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003;361:1881–1893
