Learning Outcomes
By the end of this section, you should be able to:
- 26.4.1 Identify the characteristics of glucocorticoid and mineralocorticoid drugs used to treat adrenal disorders.
- 26.4.2 Explain the indications, actions, adverse reactions, contraindications, and interactions of glucocorticoid and mineralocorticoid drugs used to treat adrenal disorders.
- 26.4.3 Describe nursing implications of glucocorticoid and mineralocorticoid drugs used to treat adrenal disorders.
- 26.4.4 Explain the client education related to glucocorticoid and mineralocorticoid drugs used to treat adrenal disorders.
Glucocorticoids
Glucocorticoids and mineralocorticoids are two types of steroid hormones that are produced by the adrenal cortex and play distinct roles in regulating the body’s metabolism, fluid balance, and stress response. Glucocorticoids are produced in response to stress and help regulate metabolism and the immune system.
The primary glucocorticoid in the body is cortisol. Cortisol helps regulate glucose uptake in other tissues—such as muscles and fat—and has an anti-inflammatory and immunosuppressive effect, making it an important medication in the treatment of many inflammatory and autoimmune disorders and in preventing transplantation rejection. Nurses should note that there are many corticosteroids within this class of drugs, and they vary by potency, route of administration, and other non-anti-inflammatory activity. These properties help the health care provider choose the appropriate corticosteroid agent to prescribe for the client. Synthetic glucocorticoids—such as prednisone, dexamethasone, and hydrocortisone—are commonly used in medicine to treat conditions such as asthma, rheumatoid arthritis, and inflammatory bowel disease.
Although glucocorticoids can be effective at treating certain conditions, they can have significant toxic effects over time that limit use. As such, their use is typically reserved for short-term treatment of acute conditions or as a last resort for long-term conditions that have not responded to other treatments. Short-term use is tapered quickly to avoid rebound symptoms. Long-term use also requires tapering due to HPA axis suppression resulting in inadequate cortisol production.
Cortisone Acetate
Cortisone acetate is a glucocorticoid that also has salt-retaining properties. It is indicated for use with primary or secondary adrenocortical insufficiency, hypercalcemia associated with cancer, rheumatic disorders, collagen disorders, allergic states, inflammatory bowel disorders, and various respiratory, hematologic, integumentary, and neoplastic disorders. Adverse effects include fluid retention, sodium retention, hypertension, muscle weakness, osteoporosis, headache, and weight gain.
Hydrocortisone
Hydrocortisone, a synthetic form of cortisol, is a short-acting glucocorticoid that is used to reduce inflammation and swelling in the body. Hydrocortisone is used to treat a variety of conditions including skin disorders, allergic reactions, asthma, arthritis, and certain types of cancer. It can be applied topically, as a cream or ointment, and has ophthalmic, otic, and rectal routes available. Adverse effects include headache, dizziness, nausea, weight gain, mood changes, increased blood pressure, hyperglycemia, difficulty sleeping, dry skin, acne, skin irritation, and increased risk of infections.
Clinical Tip
Hydrocortisone Administration
Systemic administration of steroids is often recommended to take place in the morning to avoid insomnia (Hodgens & Sharman, 2023).
Methylprednisolone
Methylprednisolone is an intermediate-acting synthetic glucocorticoid that is used as an anti-inflammatory and immunosuppressant. It is commonly used to treat a variety of inflammatory and autoimmune conditions. Methylprednisolone—available in oral, injectable, and topical forms—works by binding to glucocorticoid receptors in the cells of the body, which leads to a reduction in the release of inflammatory molecules, such as cytokines, and inhibits the immune response and decreases inflammation. Dosing is based on the condition being treated and the severity of symptoms.
Prednisolone
Prednisolone, an intermediate-acting synthetic form of cortisol, is used to decrease inflammation and to treat a variety of conditions including rheumatic conditions, allergic reactions, asthma, and certain types of cancer. The medication comes in an oral form and as an injectable. Adverse effects include increased glucose levels, injection site reactions, weight gain, and mood changes.
Prednisone
Prednisone is an intermediate-acting steroid medication and a synthetic form of cortisol used to reduce inflammation. Like prednisolone, it is used in the treatment of a variety of conditions including asthma, allergic reactions, rheumatic disorders, respiratory disorders, and certain types of cancer. Adverse effects include weight gain, mood changes, increased blood sugar levels, and osteoporosis.
Betamethasone
Betamethasone is a long-acting synthetic cortisol that reduces inflammation and swelling in the body and is used to treat various disorders including skin and inflammatory disorders such as rheumatoid arthritis. Adverse effects include skin irritation, increased risk of infection, and elevated blood glucose levels.
Dexamethasone
Dexamethasone is a long-acting synthetic form of cortisol that is used to reduce inflammation in the body and may also be used as an immunosuppressant. Dexamethasone, which comes in an oral and injectable form, is used to treat numerous disorders including rheumatic, respiratory, asthma, and allergic reactions. This drug is also used in the diagnosis of Cushing’s syndrome as a suppressive test. Adverse effects include increased risk of infection, weight gain, irritability and mood changes, increased blood sugar levels, GI upset, and osteoporosis.
Table 26.6 lists common glucocorticoids and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Cortisone acetate (Cortison, Cortisyl) |
Typical dose: 25–300 mg orally daily depending on the specific disease entity being treated. |
| Hydrocortisone (Cortisporin, Cortizone, Solu-Cortef, Proctocort) |
Topical cream: Depends on formulation, typically 1%, 3–4 times daily. IV: 100–500 mg; dose extremely variable based on client and indication. |
| Methylprednisolone (Medrol, Solu-Medrol) |
Typical dose: 4–200 mg daily depending on the specific disease entity being treated. Routes include oral (dose-pack, tablets, solution), intravenous, intra-articular, and intramuscular. |
| Prednisolone (Millipred, Omnipred, Prelone) |
Typical dose: 5–60 mg orally daily depending on the specific disease entity being treated. |
| Prednisone (Deltasone) |
Typical dose: 5–60 mg orally daily depending on the specific disease entity being treated. |
| Betamethasone (Celestone, Betaject) |
Typical dose for injectable: 0.25–0.9 mg/day intravenously or intramuscularly. |
| Dexamethasone (Decadron, Dexasone) |
Typical dose: 0.5–9 mg daily depending on the specific disease entity being treated. Routes include oral, intravenous, intra-articular, and intramuscular. |
Adverse Effects and Contraindications
Short-term adverse effects include insomnia, hunger, and mood changes. Long-term adverse effects include weight gain, high blood pressure, osteoporosis, hyperglycemia, skin atrophy (topical application), iatrogenic Cushing’s syndrome, and increased risk of infection.
Glucocorticoids are contraindicated in clients with hypersensitivity to any component of the formulation, those who have an active systemic fungal infection, or those with uncontrolled hyperglycemia.
Table 26.7 is a drug prototype table for glucocorticoids featuring methylprednisolone. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Synthetic glucocorticoid Mechanism of Action Binds to glucocorticoid receptors, decreasing the release of inflammatory molecules and inhibiting the immune response |
Drug Dosage Typical dose: 4–200 mg daily depending on the specific disease entity being treated. Routes include oral (dose-pack, tablets, solution), intravenous, intra-articular, and intramuscular. |
| Indications Inflammatory conditions Autoimmune disorders Therapeutic Effects Decreases inflammation Suppresses the immune response |
Drug Interactions Oral anticoagulants Aspirin Food Interactions No significant interactions |
| Adverse Effects Weight gain High blood pressure Osteoporosis Increased risk of infection Skin atrophy Hyperglycemia/glycosuria |
Contraindications Hypersensitivity Systemic active fungal infections Caution: May increase risk of infection |
Mineralocorticoids
Mineralocorticoids are a type of steroid hormones that are produced by the adrenal cortex and are involved in regulating the body’s fluid balance and electrolyte levels. The primary mineralocorticoid in the body is aldosterone.
Disorders of mineralocorticoid production or activity can lead to imbalances in fluid and electrolyte levels: two such conditions exist. The first is hyperaldosteronism, which is characterized by excess aldosterone production. An excess of aldosterone causes an increase in blood pressure and serum sodium levels along with a decrease in serum potassium levels. The other condition is hypoaldosteronism, which is characterized by insufficient aldosterone production. Hypoaldosteronism leads to a decrease in blood pressure and serum sodium levels along with an increase in serum potassium levels.
Aldosterone
Aldosterone works by binding to mineralocorticoid receptors in the cells of the kidneys, which increases the reabsorption of sodium ions and the excretion of potassium ions. This leads to an increase in blood volume and blood pressure. In addition to regulating fluid and electrolyte balance, aldosterone plays a role in the renin-angiotensin-aldosterone system (RAAS). The RAAS is a complex hormonal system that helps to regulate blood pressure by controlling the balance of sodium and water in the body.
Fludrocortisone
Fludrocortisone is a synthetic adrenocortical steroid that binds to mineralocorticoid receptors in the cells of the kidneys and supports fluid and electrolyte balance within the body. This medication is used to treat primary and secondary adrenocortical insufficiency in Addison’s disease. Adverse effects include hyperglycemia, hypokalemia, hypertension, muscle weakness, and impaired wound healing. It is contraindicated in clients with fungal infections and hypersensitivity.
Adverse Effects and Contraindications
Common adverse effects of mineralocorticoid drugs include fluid retention because they promote sodium and water reabsorption in the kidneys; hypokalemia where symptoms include muscle weakness, fatigue, irregular heartbeat, and muscle cramps; elevated blood pressure; gastrointestinal disturbances such as stomach discomfort, nausea, and diarrhea; and mood and behavioral changes such as mood swings, irritability, or anxiety.
Contraindications include hypersensitivity to the drug or any of its components, systemic fungal infections, heart failure, and severe kidney impairment. Mineralocorticoids can suppress the immune system and worsen systemic fungal infections; heart failure is contraindicated because these drugs can cause fluid retention and lead to worsening of fluid volume overload; and severe kidney impairment can occur in clients with kidney disease as these drugs are excreted through the urine and can cause further renal insufficiency.
Table 26.8 is a drug prototype table for mineralocorticoids featuring fludrocortisone acetate. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Mineralocorticoid Mechanism of Action Binds to mineralocorticoid receptors in the cells of the kidneys, which increases the reabsorption of sodium ions and the excretion of potassium ions, helping to regulate fluid and electrolyte balance |
Drug Dosage For salt-losing adrenogenital syndrome: Typical dose: 0.1–0.2 mg orally daily. For Addison’s disease: Usual dose: 0.1 mg orally daily, although dosage ranging from 0.1 mg 3 times a week to 0.2 mg daily has been employed. |
| Indications Primary and secondary adrenocortical insufficiency in Addison’s disease Treatment of salt-losing adrenogenital syndrome Therapeutic Effects Generalized extracellular fluid volume expansion |
Drug Interactions Amphotericin B Potassium-depleting diuretics Digitalis glycosides Oral anticoagulants Antidiabetic drugs Aspirin Barbiturates Phenytoin Rifampin Anabolic steroids Vaccines Estrogen Food Interactions No significant interactions |
| Adverse Effects Edema Cardiac enlargement Potassium loss Muscle weakness Abdominal distention Impaired wound healing Growth suppression Hyperglycemia Urticaria |
Contraindications Systemic fungal infections Hypersensitivity Caution: May mask infections |
Nursing Implications
The nurse should do the following for clients who are taking glucocorticoids and mineralocorticoids:
- Educate the client regarding glucocorticoid and mineralocorticoid therapy.
- Assess the client’s knowledge about signs and symptoms of over- and undertreatment, adverse reactions, and contraindications and clarify any gaps in knowledge.
- Monitor vital signs and electrolytes, especially sodium and potassium, renal function, glucose levels, serum aldosterone levels, serum cortisol levels, and bone density test, closely.
- Report any abnormalities or symptoms such as weight gain, edema, crackles, jugular vein distention, fever, tachycardia, tachypnea, shortness of breath, or a change in mental status to the health care provider.
- Provide client teaching regarding the drug and when to call the health care provider. See below for additional client teaching guidelines.
Client Teaching Guidelines
The client taking a glucocorticoid or mineralocorticoid should:
- Take drugs as prescribed by their health care provider.
- If using the drug systemically, avoid people who are sick—especially those who have chickenpox, measles, or tuberculosis—because they are at an increased risk of contracting the condition.
- Report signs of fluid volume overload such as a weight gain of 2 pounds in 3 days or 5 pounds in a week.
- Limit salt intake.
- Report symptoms of infection, such as a fever greater than 100.4°F, a fast heartbeat, fast breathing, and symptoms of electrolyte imbalances such as weight gain, edema, a change in mental status, or shortness of breath and symptoms of cardiovascular issues including jugular vein distention, tachycardia, and/or palpitations to the health care provider.
The client taking a glucocorticoid or mineralocorticoid should not:
- Stop taking this medication without consulting with the health care provider because this drug must be tapered to decrease adverse effects.
FDA Black Box Warning
Corticosteroids
Injection into the epidural space of the spine may result in rare but serious adverse events including loss of vision, stroke, paralysis, and death.