As a well-rounded health care provider, you know that corticosteroid therapy is indicated in all of the following conditions except:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Systemic lupus erythematosus
D. Acute spinal cord injury
Correct Answer: A. Osteoarthritis
Osteoarthritis is not an indication for corticosteroid therapy. It has an inflammatory component, but the disease is not severe enough to suppress the immune system. Lupus, spinal injury, and rheumatoid arthritis are conditions that require suppression of the immune system in order for the client to survive.
Option B: The desired immune-suppressing and anti-inflammatory effects of corticosteroids can also predispose patients to infection. A meta-analysis of 2000 patients found that the infection rate is significantly higher in patients using systemic corticosteroids when the daily dose was 10 mg/day. The immunosuppressive effect is impacted not just by the dosage but also by the patient’s age, underlying disorders, and any concomitant use of biologic or non-biologic disease-modifying anti-rheumatic drugs. In particular, patients on corticosteroids are susceptible to invasive fungal and viral infections.
Option C: The genomic mechanism of action is the classically understood mechanism mediated through the glucocorticoid receptor, which leads to most of the anti-inflammatory and immunosuppressive effects. The glucocorticoid receptor is located intracellularly within the cytoplasm and upon binding trans-locates rapidly into the nucleus where it affects gene transcription and causes inhibition of gene expression and translation for inflammatory leukocytes and structural cells such as epithelium. This action leads to a reduction in proinflammatory cytokines, chemokines, and cell adhesion molecules, as well as other enzymes involved in the inflammatory response.
Option D: The non-genomic mechanism occurs more rapidly and is mediated through interactions between the intracellular glucocorticoid receptor or a membrane-bound glucocorticoid receptor. Within seconds to minutes of receptor activation, a cascade of effects is set off, including inhibition of phospholipase A2, which is critical for the production of inflammatory cytokines, impaired release of arachidonic acid, and regulation of apoptosis in thymocytes. Corticosteroids at high concentrations will also inhibit the production of B cells and T cells.