Junior Doctor Tips - Managing Steroid Therapy: Understanding Side Effects and Safe Withdrawal
Patients on long-term steroid therapy often face a range of health challenges, from susceptibility to infections to various side effects. As medical professionals, it's crucial to understand these risks and manage steroid therapy effectively. In this article, we'll delve into the side effects of steroids, how to manage patients on steroids during illness, and the safe withdrawal of steroid therapy.
Understanding Steroid Side Effects
Steroids, whether for anti-inflammatory or immunosuppressive purposes, can have a significant impact on patients' health. Here are some common side effects to be aware of:
Mineralocorticoid Effects - Hypernatraemia & Hypokalaemia
Sodium and water retention leading to hypertension
Hypokalaemia (low potassium levels)
Glucocorticoid Effects - Hyperglycaemia & Hyperlipidaemia
Hyperglycemia and diabetes
Changes in fat distribution, leading to centripetal adiposity
Altered protein mobilisation resulting in conditions like osteoporosis, skin atrophy, striae, muscle wasting, and delayed wound healing
Psychiatric problems, ranging from subtle changes to paranoid psychosis, along with initial euphoria, sleep disturbances, and increased appetite
Increased vulnerability to infections, including candida, disseminated viral infections (measles, varicella zoster, herpes zoster), and bacterial infections
Other effects like peptic ulceration, acne, withdrawal reactions, ophthalmological issues (cataracts, glaucoma, papilloedema), and musculoskeletal problems (myopathy, fractures, osteonecrosis)
Managing Ill Patients on Steroids
Patients on long-term steroid therapy may require additional steroids during acute illness or stress, such as surgery or infection. Here's how to manage them effectively:
Assess whether the patient needs additional steroids based on their illness. Consult with the Endocrine team for guidance if necessary.
Prescribe hydrocortisone (25–100mg QDS or equivalent) in addition to the existing steroid dose if required.
Always remain vigilant for 'silent' infections in patients on high-dose steroids.
Never stop steroids abruptly in patients on long-term therapy, as it can precipitate an Addisonian crisis. Patients should carry a steroid card with them to inform healthcare professionals about their medication and dosage.
Treating Common Side Effects
Candida Infection: Prescribe nystatin lozenges/oral solution for oral/oesophageal infection. Clotrimazole (Canesten) cream/vaginal pessaries are usually given for vaginal infection. A stat dose of 150mg fluconazole can also help clear the infection. Fluconazole 50mg PO daily is useful for prophylaxis with high-dose steroids.
Cold Sores or Shingles: Patients with a history of cold sores or shingles should start high-dose acyclovir at the earliest sign of recurrence.
Reflux Symptoms: Prescribe ranitidine 150 mg BD for reflux symptoms. Avoid proton pump inhibitors (PPIs) unless there is a specific indication due to the risk of C. difficile.
Oropharyngeal candidiasis is one of the most common side-effects of steroid medication. Treatment is typically with Nystatin 100,000units qds for 7 days and continued for a further 48hrs after lesions have resolved.
Withdrawing Steroid Therapy
Gradual withdrawal of steroids is essential to prevent adverse reactions.
Here's a general guideline:
Reduce steroids from high doses by 5 mg of prednisolone (or equivalent) per week until reaching the equivalent of 10 mg prednisolone/day.
Afterward, reduce by 2.5mg/week until reaching 5 mg/day.
The rate of reduction depends on the duration of therapy. Longer therapy (>3 months) requires a slower taper, such as 1–2 mg/week.
Withdrawal reactions can include Addisonian crisis, arthralgia, mood changes, rhinitis, skin rashes, and weight loss. Morning irritability can be prevented by taking the daily dose twice a day (BD), though this may lead to Cushingoid symptoms.
Conclusion
In conclusion, managing patients on long-term steroid therapy requires vigilance, effective communication, and careful monitoring of side effects. By understanding the potential risks and following proper protocols, doctors can ensure the well-being of patients undergoing steroid treatment.
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