Adrenocorticosteroids — MCQs
Escape phenomenon in mineralocorticoid excess occurs due to:
Which of the following is a short-acting glucocorticoid?
Which of the following has the least glucocorticoid activity?
What is the primary mechanism by which steroids exert their anti-inflammatory action?
Which of the following is the drug of choice for Addison's disease?
A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?
A 42-year old man with history of alcohol dependency presents with progressive abdominal distension. Abdominal examination reveals a shifting dullness. Which one of the following is the most appropriate drug to relieve this abdominal distension?
Which of the following potassium-sparing diuretics was the first to be shown to reduce cardiac mortality in chronic heart failure patients?
Which of the following steroids possesses maximum glucocorticoid activity?
Preferred first-line drug for infantile spasms is –
Adrenocorticosteroids Indian Medical PG Practice Questions and MCQs
Question 1: Escape phenomenon in mineralocorticoid excess occurs due to:
- A. Angiotensin II
- B. Renin
- C. Mineralocorticoid-like action of cortisol
- D. ANP (Atrial Natriuretic Peptide) (Correct Answer)
Explanation: ***ANP (Atrial Natriuretic Peptide)*** - The **escape phenomenon** in mineralocorticoid excess is an adaptive mechanism where initial sodium and water retention is followed by a return to near-normal sodium balance, primarily due to increased release of **ANP**. - **ANP** promotes natriuresis (sodium excretion) and diuresis (water excretion), counteracting the effects of prolonged mineralocorticoid action. *Angiotensin II* - **Angiotensin II** stimulates aldosterone secretion and promotes sodium and water reabsorption, directly opposing the "escape" from mineralocorticoid-induced fluid retention. - Its actions would exacerbate, rather than mitigate, the effects of mineralocorticoid excess. *Renin* - In mineralocorticoid excess, high sodium and fluid volume typically **suppress renin secretion**, which would lead to decreased angiotensin II and aldosterone production. - Suppressed renin is a *consequence* of mineralocorticoid excess, not the mechanism for escape. *Mineralocorticoid-like action of cortisol* - While **cortisol** can exert mineralocorticoid effects, especially at high concentrations or in conditions like apparent mineralocorticoid excess, it would perpetuate rather than resolve the issues of sodium and water retention. - The escape phenomenon describes the body's adaptation *despite* the continued presence of mineralocorticoid activity.
Question 2: Which of the following is a short-acting glucocorticoid?
- A. Dexamethasone
- B. Hydrocortisone (Correct Answer)
- C. Fludrocortisone
- D. Aldosterone
Explanation: ***Hydrocortisone*** - **Hydrocortisone** (Cortisol) is considered a **short-acting glucocorticoid** with a biological half-life of 8-12 hours [1]. - It has both **glucocorticoid** and significant **mineralocorticoid activity**, mimicking the natural adrenal hormone [1], [4]. *Fludrocortisone* - **Fludrocortisone** is a synthetic corticosteroid with potent **mineralocorticoid activity** and some glucocorticoid effects [2]. - It is used primarily for its **mineralocorticoid effects** in conditions like Addison's disease for salt retention. *Dexamethasone* - **Dexamethasone** is a **long-acting glucocorticoid** with a biological half-life of 36-72 hours [1]. - It possesses potent **glucocorticoid activity** but negligible mineralocorticoid effects. *Aldosterone* - **Aldosterone** is a **mineralocorticoid hormone** produced by the adrenal glands, not a glucocorticoid [1], [3]. - Its primary role is to regulate **sodium and potassium balance** and blood pressure [3].
Question 3: Which of the following has the least glucocorticoid activity?
- A. Fludrocortisone
- B. Cortisone (Correct Answer)
- C. Dexamethasone
- D. Betamethasone
Explanation: ***Cortisone*** - **Cortisone has the LEAST glucocorticoid activity** among the options listed. - It is a **prodrug** that must be converted to **hydrocortisone (cortisol)** by 11β-hydroxysteroid dehydrogenase in the liver to become active. - Its glucocorticoid potency is approximately **0.8** relative to hydrocortisone (when hydrocortisone = 1). - Due to variable hepatic conversion, it has **lower and less predictable glucocorticoid effects** compared to other agents. *Fludrocortisone* - Primarily used for its **potent mineralocorticoid activity** (125× that of hydrocortisone). - However, it retains **significant glucocorticoid activity** approximately **10-15 times** that of hydrocortisone. - Despite being marketed as a mineralocorticoid, its glucocorticoid potency is **considerably higher than cortisone**. *Dexamethasone* - **Highly potent synthetic glucocorticoid** with negligible mineralocorticoid activity. - Glucocorticoid potency is approximately **25-30 times** that of hydrocortisone. - Long duration of action (36-72 hours) and excellent CNS penetration. *Betamethasone* - **Highly potent synthetic glucocorticoid**, structurally similar to dexamethasone (differs only in stereochemistry at C-16). - Glucocorticoid potency is approximately **25-30 times** that of hydrocortisone. - Minimal mineralocorticoid activity, with similar clinical applications to dexamethasone.
Question 4: What is the primary mechanism by which steroids exert their anti-inflammatory action?
- A. Phospholipase A2 (Correct Answer)
- B. Myeloperoxidase
- C. Cyclooxygenase
- D. Lipoxygenase
Explanation: ***Phospholipase A2*** - Steroids exert their primary anti-inflammatory action by inducing the synthesis of **lipocortin-1 (annexin-1)**, which then inhibits **phospholipase A2 (PLA2)**, an enzyme crucial for the release of **arachidonic acid** from cell membrane phospholipids. - By blocking PLA2, steroids prevent the formation of all subsequent inflammatory mediators derived from arachidonic acid, including **prostaglandins**, **leukotrienes**, and **thromboxanes**. - This represents the most **upstream** mechanism of steroid anti-inflammatory action, affecting multiple downstream pathways simultaneously. *Cyclooxygenase* - **Cyclooxygenase (COX)** enzymes, specifically COX-1 and COX-2, are responsible for converting arachidonic acid into **prostaglandins** and **thromboxanes**. - While steroids ultimately reduce COX activity by limiting substrate availability, their direct and primary inhibition is not on COX itself but at an earlier step in the inflammatory cascade. *Lipoxygenase* - The **lipoxygenase (LOX)** pathway converts arachidonic acid into **leukotrienes**, which are potent mediators of inflammation, particularly in asthma and allergic reactions. - Steroids do inhibit the formation of leukotrienes indirectly by blocking their precursor, arachidonic acid, but their direct target is not LOX itself. *Myeloperoxidase* - **Myeloperoxidase** is an enzyme found primarily in **neutrophils** and macrophages, playing a role in oxidative stress and microbial killing by producing hypochlorous acid (bleach). - While steroids can modulate immune cell function, their direct anti-inflammatory mechanism is not through the inhibition of myeloperoxidase activity.
Question 5: Which of the following is the drug of choice for Addison's disease?
- A. Hydrocortisone (Correct Answer)
- B. Betamethasone
- C. Dexamethasone
- D. Prednisolone
Explanation: ***Hydrocortisone*** - **Hydrocortisone** is the **glucocorticoid of choice** for Addison's disease because it most closely mimics the body's natural cortisol in terms of **potency and duration of action**. - It is preferred for **physiological replacement therapy** due to its short half-life (8-12 hours), allowing for dosing schedules that mimic the normal circadian rhythm of cortisol secretion. - While hydrocortisone has **some mineralocorticoid activity**, it is usually **combined with fludrocortisone** (a synthetic mineralocorticoid) to provide complete hormone replacement in Addison's disease. - The typical regimen is hydrocortisone **15-25 mg/day in divided doses** plus fludrocortisone **0.05-0.2 mg/day**. *Betamethasone* - **Betamethasone** is a **potent long-acting synthetic glucocorticoid** with **minimal mineralocorticoid activity**. - Its **long duration of action** and high potency make it unsuitable for daily physiological replacement therapy, as it increases the risk of **cushingoid side effects** and cannot mimic normal cortisol circadian rhythm. *Dexamethasone* - **Dexamethasone** is a **very potent long-acting glucocorticoid** with **no mineralocorticoid activity**. - Its **very long half-life (36-72 hours)** makes precise titration for physiological replacement extremely difficult and increases the risk of **overreplacement and cushingoid features**. - It is not suitable for routine replacement therapy in Addison's disease. *Prednisolone* - **Prednisolone** is an intermediate-acting glucocorticoid that can be used as an **alternative to hydrocortisone** for replacement therapy. - However, **hydrocortisone remains preferred** because its pharmacokinetic profile more closely matches physiological cortisol secretion. - Like hydrocortisone, prednisolone also requires **supplementation with fludrocortisone** for complete mineralocorticoid replacement.
Question 6: A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?
- A. Insulin only
- B. Hydrocortisone only (Correct Answer)
- C. Both
- D. None of the options
Explanation: ***Hydrocortisone only*** - Patients on chronic **high-dose steroid therapy** (>5 mg prednisolone daily for >3 weeks) are at risk of **adrenal insufficiency** during surgical stress due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. - **Hydrocortisone stress dose** (100 mg IV at induction, followed by 50 mg every 8 hours) is the **most essential and immediate requirement** to prevent **adrenal crisis** during major surgery. - Hydrocortisone has both glucocorticoid and mineralocorticoid activity, mimicking the body's natural cortisol response to surgical stress. *Insulin only* - While steroids can cause **hyperglycemia** requiring insulin management, this is a **secondary concern** compared to preventing life-threatening **adrenal crisis**. - Insulin addresses a metabolic complication but does not protect against **inadequate cortisol response** to surgical stress. - **Without stress-dose steroids**, the patient risks hemodynamic collapse regardless of glucose control. *Both* - Although **both** medications might eventually be needed if hyperglycemia develops, the question asks for the **most essential** requirement. - **Hydrocortisone is non-negotiable** and must be given prophylactically; insulin is only needed if blood glucose is elevated. - Prioritizing both equally misses the critical time-sensitive need for **adrenal axis support**. *None of the options* - This is incorrect because patients on chronic high-dose steroids undergoing major surgery **absolutely require stress-dose steroid coverage**. - Failure to administer hydrocortisone can result in **acute adrenal crisis** with severe hypotension, shock, and potential mortality. - Modern guidelines confirm the need for perioperative steroid supplementation in high-risk patients.
Question 7: A 42-year old man with history of alcohol dependency presents with progressive abdominal distension. Abdominal examination reveals a shifting dullness. Which one of the following is the most appropriate drug to relieve this abdominal distension?
- A. Lactulose
- B. Spironolactone (Correct Answer)
- C. Propranolol
- D. Octreotide
Explanation: **Spironolactone** - **Spironolactone** is an **aldosterone antagonist**, which is the **first-line diuretic** used in the management of **ascites** due to **cirrhosis**, often developing secondary to alcohol dependency. - It works by blocking aldosterone receptors in the **renal collecting duct**, leading to increased sodium and water excretion while conserving potassium, effectively reducing fluid accumulation. *Lactulose* - **Lactulose** is a non-absorbable disaccharide primarily used to treat and prevent **hepatic encephalopathy** by reducing ammonia levels. - It does not directly relieve abdominal distension caused by ascites, and its use is unrelated to fluid overload. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** used to reduce **portal pressure** and prevent **variceal bleeding** in patients with cirrhosis. - While it addresses a complication of chronic liver disease, it does not directly manage or relieve ascites. *Octreotide* - **Octreotide** is a **somatostatin analog** used to treat complications like **acute variceal bleeding** or **hepatic encephalopathy** by reducing splanchnic blood inflow. - It is not indicated for the management of ascites or relief of abdominal distension caused by fluid accumulation.
Question 8: Which of the following potassium-sparing diuretics was the first to be shown to reduce cardiac mortality in chronic heart failure patients?
- A. Spironolactone (Correct Answer)
- B. Amiloride
- C. Triamterene
- D. Eplerenone
Explanation: ***Spironolactone*** - **Spironolactone** was the first potassium-sparing diuretic shown to reduce **cardiac mortality** in patients with **chronic heart failure** in the **RALES trial** (Randomized Aldactone Evaluation Study). - Its beneficial effects in heart failure are primarily attributed to its **aldosterone receptor antagonist** properties, which counteract the harmful effects of aldosterone on the myocardium and vasculature, rather than just its diuretic effect. *Amiloride* - **Amiloride** is a potassium-sparing diuretic that works by directly inhibiting **epithelial sodium channels (ENaC)** in the collecting duct. - While it helps in potassium conservation, it has not been shown to significantly reduce cardiac mortality in chronic heart failure patients in clinical trials. *Triamterene* - **Triamterene** is another potassium-sparing diuretic that also directly inhibits **ENaC** in the collecting duct, similar to amiloride. - Like amiloride, it is used to prevent hypokalemia but lacks evidence for significant **cardiac mortality reduction** in chronic heart failure. *Eplerenone* - **Eplerenone** is a selective **aldosterone receptor antagonist**, similar to spironolactone, with fewer hormonal side effects. - While it has been shown to reduce **cardiac mortality** in chronic heart failure (e.g., in the EMPHASIS-HF trial), it was introduced later than spironolactone and was not the *first* to demonstrate this benefit.
Question 9: Which of the following steroids possesses maximum glucocorticoid activity?
- A. Prednisolone
- B. Aldosterone
- C. Dexamethasone (Correct Answer)
- D. Cortisol
Explanation: ***Dexamethasone*** - **Dexamethasone** is a synthetic glucocorticoid with high potency, making it one of the steroids with the **maximum glucocorticoid activity** [1], [2]. - It exhibits a much longer duration of action and significantly greater anti-inflammatory effects compared to natural glucocorticoids like cortisol [2]. *Prednisolone* - **Prednisolone** is a synthetic glucocorticoid that has approximately four times the anti-inflammatory potency of cortisol [1]. - While potent, it does not reach the glucocorticoid activity levels of dexamethasone. *Cortisol* - **Cortisol** is the body's primary natural glucocorticoid, involved in stress response and metabolism [2]. - Its glucocorticoid activity serves as a baseline for comparing the potencies of other synthetic corticosteroids [2]. *Aldosterone* - **Aldosterone** is primarily a mineralocorticoid, not a glucocorticoid, with its main role being the regulation of electrolyte and water balance [2]. - It possesses minimal to no glucocorticoid activity.
Question 10: Preferred first-line drug for infantile spasms is –
- A. ACTH
- B. Ethosuximide
- C. Vigabatrin (Correct Answer)
- D. Carbamazepine
Explanation: ***Vigabatrin*** - **Vigabatrin** is considered the preferred first-line treatment for infantile spasms, particularly effective for both **cryptogenic** and **symptomatic** cases, and especially for cases associated with **tuberous sclerosis complex (TSC)**. - It works by irreversibly inhibiting **GABA transaminase**, increasing GABA levels in the brain, thereby suppressing seizures with fewer long-term side effects compared to ACTH. *ACTH* - **ACTH** is also an effective first-line treatment for infantile spasms and may be preferred in certain clinical scenarios or when vigabatrin is **contraindicated** or **unavailable**. - Its mechanism of action is not fully understood but may involve **steroid receptors**, suppression of inflammatory cytokines, and modulation of neuronal excitability. *Ethosuximide* - **Ethosuximide** is the drug of choice for **absence seizures** (petit mal seizures), not infantile spasms. - It acts by blocking **T-type calcium channels** in the thalamus, which are crucial for the generation of absence seizures. *Carbamazepine* - **Carbamazepine** is primarily used for **focal (partial) seizures** and **tonic-clonic seizures**, not infantile spasms. - It works by blocking **voltage-gated sodium channels**, stabilizing inactivated states and preventing repetitive neuronal firing.
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