Corticosteroid induced osteoporosis

• see the Osteoporosis section for guidance on prevention and treatment of glucocorticoid-induced osteoporosis

Withdrawal

The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:

• recently received repeated courses (particularly if taken for longer than 3 weeks)
• taken a short course within 1 year of stopping long-term therapy
• other possible causes of adrenal suppression
• received more than 40mg daily prednisolone (or equivalent)
• been given repeat doses in the evening
• received more than 3 weeks' treatment (high dose inhaled steroid should be taken into consideration in these criteria)

Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and have received treatment for 3 weeks or less and are not included in the patient groups described above.

During corticosteroid withdrawal the dose may be reduced rapidly (e.g. 5mg per day) down to physiological doses (equivalent to prednisolone 7.5mg daily) and then reduced more slowly (e.g. 1-2mg per week). Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.

Adrenal suppression

To compensate for a diminished adrenocortical response caused by prolonged corticosteroid treatment, any significant intercurrent illness, trauma or surgical procedure requires a temporary increase in corticosteroid dose (determined by starting dose), or if already stopped, a temporary re-introduction of corticosteroid treatment. Anaesthetists must therefore know whether a patient is taking or has been taking a corticosteroid, to avoid a precipitous fall in blood pressure during anaesthesia or in the immediate post-operative period.

Addison's disease

In the management of Addison's disease, physiological replacement is best achieved with a combination of hydrocortisone and the mineralocorticoid fludrocortisone (see section 6.3.1 Replacement therapy); hydrocortisone alone does not usually provide sufficient mineralocorticoid activity for complete replacement.

Hypopituitarism

In the management of hypopituitarism, which is more common, hydrocortisone alone may often prove sufficient.

The optimum daily dose is determined on the basis of clinical and biochemical response.

If a patient is suffering with an infection which leaves them bed-bound, the glucocorticoid should be doubled for several days. If the patient is vomiting, then the use of intramuscular hydrocortisone is indicated.

Glucocorticoid therapy

Glucocorticoids, notably prednisolone, are used as anti-inflammatory agents in many areas of medicine. These drugs suppress the response of B cells of the immune system and affect the inflammatory process at an early stage.

Adrenal suppression and increased risk of infection can occur whilst taking these drugs and the steroid warning card should be issued with all prescriptions.

Live vaccines should be avoided with immunosuppressive doses.

Equivalent anti-inflammatory doses of corticosteroids

Prednisolone 5mg =

• Betamethasone 750mcg
• Deflazacort 6mg
• Dexamethasone 750mcg
• Hydrocortisone 20mg
• Methylprednisolone 4mg
• Triamcinolone 4mg

Patients on long-term corticosteroid treatment should carry a steroid treatment card which gives guidance on minimising risk and provides details of prescriber, drug, dosage and duration of treatment.

Prednisolone

• Tablets 1mg, 5mg (£1.60 = 10mg daily)
• Soluble tablets 5mg (£89.60 = 10mg daily)
• Oral solution sugar free 10mg/ml (£55.50 = 30ml)
• Tablets 25mg

Notes

1. Oral solution 10mg/ml 30ml container. For patients unable to use standard tablets and when total treatment course exceeds 150mg (equivalent to more than 30 soluble 5mg tablets)
2. Enteric coated tablets are not included in the formulary, however it is recognised that very occasional use may be appropriate when compliance with non-EC coated tablets cannot be obtained. Enteric-coated tablets cost more than the non-coated formulation and are not licensed for reducing the risk of dyspepsia or GI-bleeding.
3. Enteric coated prednisolone tablets should not be prescribed for patients with inflammatory bowel disease.
4. Prednisolone 25mg tablets are more expensive and are intended only for use in chemotherapy regimens that use very high dose steroids.

Hydrocortisone

• Tablets 10mg, 20mg (£1.86 = 30 x 10mg)
• Injection 25mg/ml
• Injection 100mg/ml (£2.12 = 1ml amp)

Notes

1. COVID-19 – treatment with corticosteroids (CAS alert, 03 September 2020): includes criteria for treatment of patients with severe or critical COVID-19 with corticosteroids, and dose schedules

Dexamethasone

• Tablets 500micrograms, 2mg (£3.19 = 2mg x 50)
• Oral solution sugar free 2mg/5ml (£42.30 = 150ml)
• Injection 3.8mg/ml (£2.00 = 1ml amp)

Notes

1. COVID-19 – treatment with corticosteroids (CAS alert, 03 September 2020): includes criteria for treatment of patients with severe or critical COVID-19 with corticosteroids, and dose schedules

Betamethasone

• Soluble tablets sugar free 500micrograms (£19.75 = 100 tablets)
• Solution for injection 4mg/ml (£22.47 = 1ml amp)

Methylprednisolone sodium

• Tablets 2mg, 4mg, 16mg, 100mg
• Solu-Medrone injection 40mg, 125mg, 500mg, 1g (£4.75 = 125mg vial)

Notes

1. MHRA Drug Safety Update (October 2017): Methylprednisolone injectable medicine containing lactose (Solu-Medrone 40 mg): do not use in patients with cows' milk allergy
   1. Solu-Medrone 40 mg uses lactose produced from cows' milk as an excipient and may contain trace amounts of milk proteins; other strengths of Solu-Medrone do not contain lactose
   2. serious allergic reactions have been reported in patients allergic to cows' milk proteins
   3. do not use injectable methylprednisolone medicines that contain lactose in patients with a known or suspected allergy to cows' milk
   4. if a patient's symptoms worsen or any new allergic symptoms occur, allergic reaction to cows' milk proteins should be suspected; stop administration of the product and treat the patient's condition accordingly
2. Solu-Medrone 40 mg Powder for Injection has been reformulated as lactose-free formulation (replaced by sucrose). Pfizer will stop distributing lactose-containing product from 9th December 2020 and it will no longer be available once stock is depleted. Care should be taken to select appropriate product whilst both available.