The corticosteroids are administered with caution in older adults because they are more likely to have preexisting conditions, such as congestive heart failure, hypertension, osteoporosis, and arthritis, which may be worsened by the use of such agents. The nurse monitors older adults for exacerbation of existing conditions during corticosteroid therapy. In addition, lower dosages may be needed because of the effects of aging, such as decreased muscle mass, renal function, and plasma volume.
ALTERNATE-DAY THERAPY. The alternate-day therapy approach to glucocorticoid administration is used in the treatment of diseases and disorders requiring long-term therapy, especially the arthritic disorders. This regimen involves giving twice the daily dose of the glucocorticoid every other day. The drug is given only once on the alternate day and before 9 AM. The purpose of alternate-day administration is to provide the patient requiring long-term glucocorticoid therapy with the beneficial effects of the drug while minimizing certain undesirable reactions (see Display 50-2).
Plasma levels of the endogenous adrenocortical hormones vary throughout the day and nighttime hours. They are normally higher between 2 AM and about 8 AM, and lower between 4 PM and midnight. When plasma levels are lower, the anterior pituitary releases ACTH, which in turn stimulates the adrenal cortex to manufacture and release glucocorticoids. When plasma levels are high, the pituitary gland does not release ACTH. The response of the pituitary to high or low plasma levels of glucocorticoids and the resulting release or nonrelease of ACTH is an example of the feedback mechanism, which may also be seen in other glands of the body, such as the thyroid gland. The feedback mechanism (also called the feedback control) is the method by which the body maintains most hormones at relatively constant levels within the bloodstream. When the hormone concentration falls, the rate of production of that hormone increases. Likewise, when the hormone level becomes too high, the body decreases production of that hormone.
Administration of a short-acting glucocorticoid on alternate days and before 9 AM, when glucocorticoid plasma levels are still relatively high, does not affect the release of ACTH later in the day, yet it gives the patient the benefit of exogenous glucocorticoid therapy.
THE PATIENT WITH DIABETES. Patients with diabetes who are receiving a glucocorticoid may require frequent adjustment of their insulin or oral hypoglycemic drug dosage. The nurse monitors blood glucose levels several times daily or as prescribed by the primary health care provider. If the blood glucose levels increase or urine is positive for glucose or ketones, the nurse notifies the primary health care provider. Some patients may have latent (hidden) diabetes. In these cases the cortico-steroid may precipitate hyperglycemia. Therefore all patients, those with diabetes and those without, should have frequent checks of blood glucose levels.
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