Practical considerations when prescribing long-term corticosteroids
Corticosteroids are associated with significant adverse effects and they must be slowly tapered rather than stopped
abruptly. The lowest effective dose should be used, then tapered and stopped as soon as possible.
The following practice points should be considered whenever a patient is prescribed corticosteroids long-term:9
- The patient’s co-morbidities and risk factors for adverse effects should be evaluated and managed where indicated,
these include; hypertension, diabetes, peptic ulcer, recent fractures, cataract/glaucoma, chronic infection, dyslipidaemia
and concurrent NSAID use
- During the course of treatment, monitor body weight and blood pressure, assess for peripheral oedema and heart failure
and test serum lipids, HbA1c (or fasting glucose in the first two months) depending on the individual patient’s
risk of adverse effects, dose and duration
- If the patient’s dose is ≥7.5 mg, daily, for more than three months, vitamin D supplementation is necessary,
along with adequate dietary calcium
- Bisphosphonates should be prescribed to patients with risk-factors for osteoporosis
- Patients treated with corticosteroids and NSAIDS should be given appropriate gastro-protective medicines, usually
a proton pump inhibitor
- Patients taking corticosteroid treatment for longer than one month, who need to undergo surgery, will require perioperative
management with adequate glucocorticoid replacement to overcome potential adrenal insufficiency
Tapering the dose
Tapering must be done carefully to avoid relapses of the condition and potential adrenal deficiency resulting from
hypothalamic-pituitary-adrenal axis (HPA) suppression. Higher doses of corticosteroid, e.g. 20 mg daily, for more than
three weeks, or bedtime dosing increase the likelihood of HPA axis suppression. Higher doses also increase the likelihood
of adverse affects. The taper is usually started as soon as symptoms are under control. The dose is reduced by 10% every
two to four weeks depending on the severity of symptoms, response to prednisone and the starting dose. The individual
condition being treated will alter the length of the taper, e.g. in a person with polymyalgia rheumatica, the course
of treatment is usually two to three years, with a gradual taper period. The dose of prednisone should be titrated against
the patient’s symptoms, not their acute phase response, i.e. the dose may not need to be increased when the CRP rises
if the patient remains asymptomatic.
The adverse effects of corticosteroid treatment
Adverse effects of corticosteroids include:10
- Skin changes and disorders, e.g. thinning and bruising, striae, acne, alopecia and hirsuitism
- Body composition changes, e.g. weight gain, Cushingoid features
- Ocular disorders, e.g. glaucoma and cataracts
- Cardiovascular disease
- Gastrointestinal disorders, e.g. dyspepsia, oesophagitis, gastritis, ulcers, bleeding
- Osteoporosis
- Central nervous system changes, e.g. mood changes, restlessness, depression, psychosis
- Diabetes
- Renal changes, e.g. hypertension and fluid retention
Older age, higher cumulative doses of corticosteroids and female sex increase the risk of adverse effects occurring.11
Preventing the adverse effects of corticosteroids
Vitamin D supplements should be prescribed alongside long-term corticosteroid treatment, in patients taking doses of
≥7.5 mg, daily, for more than three months.9 Colecalciferol* 1.25 mg, once monthly, is recommended for
vitamin D supplementation.10 Patients do not need their vitamin D levels to be tested, but if they have been,
and severe deficiency has been detected, a loading dose of one 1.25 mg tablet, daily for ten days is recommended.10 Calcitriol,
500 – 750 nanograms, daily, can be used instead of colecalciferol for patients with severe renal impairment.10
* Recommended International Non-proprietary Names (RINN or INN) spelling
Calcium supplementation is also recommended, but there have been concerns that calcium supplementation may increase
cardiovascular risk, particularly in older people.12, 13 General dietary advice may be more appropriate for
most people, and supplementation reserved for people in whom dietary calcium intake alone is insufficient. If calcium
supplementation is required, oral calcium carbonate 1.5 g, daily, can be considered.10
Ideally a bone-mineral density (BMD) scan of the lumbar spine and hip should be requested for patients when starting
long-term corticosteroids, however, this depends on the availability and funding of the local service, e.g. some services
require that patients have been taking corticosteroid treatment for three months before a scan is prioritised.2
Bisphosphonates should be considered in patients with a previous history of fragility fractures or reduced bone-mineral
density.6 Alendronate or zoledronic acid are recommended for most people who require a bisphosphonate for
corticosteroid-related osteoporosis prevention, based on patient preference and the expected length of corticosteroid
treatment.
Alendronate, 70 mg, once weekly, should be taken first thing in the morning, on an empty stomach, with a full glass
of water to ensure adequate absorption.10 The patient should then refrain from eating or taking other medicines
and remain upright (i.e. sitting or standing) for thirty minutes to minimise the risk of oesophageal irritation or erosion.
Zoledronic acid, 5 mg IV infusion over 15 minutes, once per year is an alternative.10 The patient should
be well hydrated prior to starting the infusion. The patient should have their renal function assessed prior to starting,
and be informed that dizziness and influenza-like symptoms are common after infusion.
The Special Authority requirements for the initial application for either alendronate or zoledronic acid require that:
- The patient is receiving systemic glucocorticosteroid treatment (≥5 mg per day prednisone equivalent) and has
already received or is expected to receive treatment for at least three months, and;
- The patient has documented BMD ≥1.5 standard deviations below the mean normal values in young adults (i.e. T-Score
≤1.5), or;
- The patient has a history of one significant osteoporotic fracture demonstrated radiologically, or;
- The patient has had a Special Authority approval for alendronic or zoledronic acid* (underlying cause – glucocorticosteroid
therapy) or raloxifene
* If either alendronate or zoledronic acid has been approved, and the other bisphosphonate is to be trialled,
then the patient is considered to have already meet the requirements for the new medicine.
If a funded bisphosphonate is required, but the patient does not meet the Special Authority requirements of alendronate
or zoledronic acid, etidronate disodium may be used, however, etidronate is significantly weaker than either alendronate
or zoledronic acid.
Etidronate disodium is prescribed at 400 mg, daily on and empty stomach, for 14 days, repeated every three months.
Risedronate, an alternative to alendronate, is to be listed on the Pharmaceutical
Schedule, without restrictions, from 1 September, 2013.