The document discusses the pharmacology of steroids, including anabolic steroids, corticosteroids, estrogens, and progestins, detailing their mechanisms, uses, and adverse effects. Case studies illustrate practical applications of these steroids in clinical settings, along with specific hormone replacement therapies. Adverse effects of steroids range from virilization in women to cardiovascular complications and hormonal imbalances in both sexes.

1. CASE DISCUSSION SESSION-4
#CLINICAL_PHARMD_NURSING
COMPLETE LECTURE ON
STEROIDS
Dr. S P SRINIVAS NAYAK, PharmD, RPh, (Msc), (PGDND)
ASSISTANT PROFESSOR, DEPT. OF PHARMACY PRACTICE

2. INTRODUCTION
STEROIDS
1. Androgens (Anabolic Steroids)
2. Corticosteroids
3. Oestrogens and Progestins.

3. ANDROGENS (ANABOLIC STEROIDS)
Examples include
● testosterone,
● testosterone esters (propionate,enanthoate, and cypionate),
● danazol,
● fluoxymesterone,
● methyltestosterone,
● Oxandrolone(oral),
● Nandrolone (im),
● Stanozolol(oral),
● ethylestrenol(oral),
● oxymetholone,
● Methandrostenolone(im, oral),
● mesterolone, and boldenone

4. ANABOLIC STEROIDS
● Anabolic steroids promote protein synthesis and increase muscle
mass, resulting in weight gain.
● Testosterone is secreted by the testis and is the main androgen in the
plasma of men. In women, testosterone (in small amounts) is secreted
by the ovary and adrenal glands. Many of the androgens are modified
forms of testosterone
● Kinetics: Absorbed orally and from of injection site and undergoes
rapid first pass metabolism and quick metabolism respectively. In
order to retard the rate of absorption, testosterone esters in oil are
used which are less polar than the free steroid.
NOTE: Anabolic steroids enhance muscle strength and power; hence they are often misused by athletes. Their
use by athletes is prohibited. They can be detected in the urine by antidoping investigations.

5. ADVERSE EFFECTS
● Virilising effects:Results in masculinisation when taken by
women, characterised by hirsutism, acne, deepening of the voice,
menstrual irregularities, male pattern baldness,
prominent musculature, and hypertrophy of clitoris.
● Feminising effects: Seen in men who receive androgens, and is
characterised by gynaecomastia. This is because of conversion (by
aromatisation) of the androgen to oestrogen in extraglandular tissues

6. ● ■ Administration of anabolic steroids during gestation may result in
masculinisation of the urogenital sinus and clitoral hypertrophy.
Premature bone maturation and decreased birthweight have been
reported.
● ■ Growing children may develop pre-mature fusion of the epiphyses
of long bones, leading to permanent short stature.
● ■ Cystic acne, sebaceous cysts, furunculosis, and seborrheic
dermatitis have occurred in persons using anabolic steroids

7. LONG TERM USE OR AT TOXIC DOSES
● Oedema—Retention of water and sodium chloride leads to weight
gain and oedema.
■ Jaundice—Results from stasis and accumulation of bile in biliary
capillaries, There is elevation of bilirubin, ALT, AST
■ CVS effects—Hypertension and thrombotic complications (stroke,
myocardial infarction).
■ Endocrine effects—Testicular atrophy, low sperm count, sterility,
gynaecomastia.
■ Behavioural changes—Increased aggressiveness, iritability, psychosis.

8. CASE.1
● A 38 year old man k/c/o community aquired Pneumonia, DM2 and
HTN. Comes the GP with joint Pains and wants to grow his Body.
His treatment chart is followed with
Rx
Inj. Cefperazone 1g Once
Tab. Azithromycin 500mg
Tab. Glimepride 2mg
Tab metformin 500mg
tab,. Ramipril and
Tab. Oxondrolone 10mg
Inj. Pheniramine maleate 25mg
Question: Can we proceed Oxondrolone here? Why?

9. 2. CORTICOSTEROIDS
● Adrenal gland has cortex and medulla. Adrenal cortex secretes
steroidal hormones; adrenal medulla secretes adrenaline and
noradrenaline.
Hormones of adrenal cortex are Mineralocorticoids and Glucocorticoids
Dr spnayak

11. COSYNTROPIN STIMULATION TEST
OR STANDARD ACTH 1–24
STIMULATION TEST
● To evaluate the adrenal gland activity and its response to ACTH
● a synthetic form of ACTH called cosyntropin is administered
intramuscularly or intravenously at a dose of 0.25 mg, and the plasma
cortisol level is measured before and (30 minutes) after the test. An
increase in cortisol level to greater than 20 mg/100 ml indicates
normal response.

12. CLASSIFICATION OF GLUCOCORTICOIDS
● (a) Short acting (8–12 hours)
(i) Hydrocortisone(cortisol)
(ii) Cortisone
● Intermediate acting (12–36 hours)
(i) Prednisolone
(ii) Prednisone
(iii) methylPrednisone
(iv) Triamcinolone
● Long acting (36–72 hours)
(i) Betamethasone (IM,IV, ORAL)
(ii) Dexamethasone (IM, IV ORAL)
● Topical AND LOCAL: alclometasone, amcinonide, betamethasone, budesonide,
clobetasol, clocortolone, cortisol, desonide, desoximetasone, dexamethasone,
diflorasone, fluocinolone, fluocinonide, flurandrenolide, Fluticasone, halcinonide,
hydrocortisone, loteprednol. Beclomethasone.

13. ACTIONS OF GLUCOCORTICOIDS
LIPID METABOLISM: redistribution of body
fat that is deposited over the neck, face,
shoulder, etc. resulting in ‘moon face’,
‘buffalo hump’ and ‘fish mouth’ with thin limbs.
PROTEIN METABOLISM: Muscle wasting,
lympholysis, thinning of skin, osteoporosis,
growth retardation; wound healing inhibited.

14. Cardiovascular system
Glucocorticoids have sodium
and water retaining property
and cause HTN and CCF.
Calcium metabolism (anti-
vitamin D action)
Prolonged use may lead to
osteoporosis and pathological
fracture of vertebral bodies
CNS:
mental depression, irritability
and even psychosis. On the
other hand, euphoria,
insomnia, restlessness and
psychosis.

16. USES
Acute and chronic adrenal
insufficiency
Rheumatoid arthritis
Rheumatic fever
Allergic diseases
Bronchial asthma
Collagen diseases
Ocular diseases
Skin diseases
Organ transplantation
CONTRAINDICATIONS
1. Hypertension
2. Epilepsy
3. Diabetes mellitus
4. Psychosis
5. Peptic ulcer
6. Congestive cardiac failure
7. Tuberculosis
8. Renal failure
9. Herpes simplex keratitis
10. Glaucoma
11. Osteoporosis

17. CASE.2
● A 19-year-old man complains of anorexia, fatigue, dizziness, and
weight loss of 8 months’ duration. The examining physician
discovers postural hypotension and moderate vitiligo
(depigmented areas of skin) and obtains routine blood tests. She
finds hyponatremia, hyperkalemia, and acidosis and suspects
Addison’s disease. She performs a standard ACTH 1–24
stimulation test, which reveals an insufficient plasma cortisol
response, compatible with primary adrenal insufficiency. The
diagnosis of autoimmune Addison’s disease is made, and the
patient must start replacement of the hormones he cannot
produce himself.
● How should this patient be treated? What precautions should he
take?

18. ANSWER FOR CASE.2
The patient should be placed on replacement oral hydrocortisone at
10 mg/m2/d and fludrocortisone at 75 mcg/d. He should be given a
Medic Alert bracelet and instructions for minor and major stress
glucocorticoid coverage at 2 times and 10 times replacement of
hydrocortisone over 24 and 48 hours, respectively.
Explanation:
In primary adrenal insufficiency, about 20–30 mg of hydrocortisone
must be given daily, with increased amounts during periods of stress.
Although hydrocortisone has some mineralocorticoid activity, this
must be supplemented by an appropriate amount of a saltretaining
hormone such as fludrocortisone.

19. OESTROGENS
● Oestrogens are hormones secreted primarily by the ovarian follicles
and also by the adrenals, corpus luteum, placenta and testes.
● Oestrogens are readily absorbed through the skin and mucous
membranes. Following intramuscular administration of aqueous
suspensions or oil solutions, absorption begins promptly and
continues for several days.
Examples:
● oestradiol, ethinyl oestradiol, polyestradiol mestranol, quinestrol,
estrone, equilin, equilenin.. diethylstilbestrol, dienestrol, bisphenol A,
genistein.(non steroid molecules)

20. USES:
■ Oral contraceptive.
■ Hormone replacement therapy (in post-menopausal
women).
■ Treatment of ovarian dysgenesis (Turner’s syndrome).

21. PROGESTINS
● Progestins are hormones naturally secreted by the ovary mainly from the
corpus luteum during the second half of the menstrual cycle, from the
placenta during pregnancy, and from adrenal glands in both sexes.
● Progestins are used for a number of purposes, including treatment of
amenorrhoea, abnormal uterine bleeding, hypoventilation, contraception
(routine, as well as emergency contraception) and management of
bleeding during post-menopausal therapy.
● Progestins are used (with oestrogens) for hormone replacement therapy
in post-menopausal women, and (with or without oestrogens) for
contraception.

22. CASE.3
● A 25-year-old woman with menarche at 13 years and menstrual
periods until about 1 year ago complains of hot flushes, skin and
vaginal dryness, weakness, poor sleep, and scanty and infrequent
menstrual periods of a year’s duration. She visits her gynecologist,
who obtains plasma levels of follicle-stimulating hormone and
luteinizing hormone, both of which are moderately elevated. She is
diagnosed with premature ovarian failure, and estrogen and
progesterone replacement therapy is recommended. A dual-energy
absorptiometry scan (DEXA) reveals a bone density t-score of 2.5
SD, ie, frank osteoporosis.
● How should the ovarian hormones she lacks be replaced? What extra
measures should she take for her osteoporosis while receiving
treatment?

24. ANSWER
The patient should be advised to start daily transdermal estradiol
therapy (100 mcg/d) along with oral natural progesterone
(200mg/d) for the last 12 days of each 28-day cycle.
On this regimen, her symptoms should disappear and normal
monthly uterine bleeding resume. She should also be advised to
get adequate exercise and increase her calcium and vitamin D
intake as treatment for her osteoporosis.

25. THANK YOU