Drug Safety Update
October 2017: Methylprednisolone injectable medicine containing lactose (Solu-Medrone 40mg) do not use in patient's with cows milk allergy
August 2017: Corticosteroids: rare risk of central serious chorioretinopathy with local as well as systemic use.
December 2016: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
September 2007: Corticosteroids: early psychiatric side-effects
FOR DETAILED INFORMATION ON SAFETY ISSUES WHEN PRESCRIBING CORTICOSTEROIDS, REFER TO THE BNF using the links below.
Important safety information
During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy develops and can persist for years after stopping. Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency (AI), hypotension, or death. 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, or if already stopped, a temporary reintroduction of corticosteroid treatment. 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.
Treatment Cessation in Adults
Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension or death. Withdrawal can also be associated with fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.
The magnitude and speed of dose reduction in corticosteroid withdrawal should be determined on a case-by–case basis, taking into consideration the underlying condition that is being treated, and individual patient factors such as the likelihood of relapse and the duration of corticosteroid treatment. Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:
- received more than 40 mg prednisolone (or equivalent) daily for more than 1 week;
- received ≥ prednisolone 5 mg (or equivalent) daily for 3 weeks or longer across all routes of administration (oral, topical, inhaled, intranasal, intra-articular);
- been given repeat doses in the evening;
- 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 including patients with an established or suspected diagnosis of primary AI (e.g. Addison's disease, congenital adrenal hyperplasia (CAH), bilateral adrenalectomy or adrenal haemorrhage) or patients with an established or suspected diagnosis of AI due to hypopituitarism due to hypothalamo-pituitary disease who are either on permanent glucocorticoid replacement or require glucocorticoid replacement during illness or stress such as a surgical procedure.
Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above.
During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more slowly. Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.
National guidelines and the latest steroid card can be downloaded here https://www.endocrinology.org/adrenal-crisis
Management of patients receiving corticosteroids in primary care (treatment principles also apply in secondary care), revised Nov 2017
NG 191: COVID-19 rapid guideline: managing COVID-19 - includes latest advice on use of corticosteroids for COVID patients
Corticosteroids should be prescribed as a single dose in the morning after breakfast to avoid excessive suppression of the pituitary-adrenal function.
Prednisolone plain tablets are the most commonly used corticosteroids. The uncoated tablets achieve quicker and more predictable plasma levels and are the formulation of choice.
Prednisolone EC/gastro-resistant tablets: there is little data to support the idea that enteric-coated prednisolone causes less gastric irritation compared with uncoated tablets. The absorption of the EC tablets can be delayed and the timing of a meal in relation to taking the tablets can cause wide variations is plasma levels. EC tablets should not be prescribed routinely. The EC tablets may be useful for long-term treatment of conditions such as rheumatoid arthritis.
Hydrocortisone is used for adrenal replacement and also for short term use by IV injection for emergency management of a range of conditions.
Methylprednisolone is mainly used IV for specific conditions where short term high dose therapy is needed.