Steroids

Question 1

Steroids complications? (remember all of it)

Answer 1

Metabolic: HTN, dyslipidaemia, weight-gain, diabetes, increased CV risks, HPA axis suppression

Bone: Osteoporosis, Avascular necrosis, fractures

Infections***

Cushingoid appearance: Buffalo hump, body changes, weight gain, think skin, bruising

3 P‘s: Proximal myopathy, PUD, Psychiatric disturbances.

Eye: cataract, glaucoma

Question 2

What are the key 4 aspects of managing steroid complications you should discus in the long case? (start with initial spiel)

Answer 2

” I am concerned about the impact of corticosteroids on this patient’s general health. In particular, I am concerned about his future risk of developing glucocorticoid-induced diabetes, osteoporosis and proximal myopathy which may threaten his already vulnerable mobility”

**Prevention of diabetes and CV risk factor control

**Bone health & Falls prevention (given proximal myopathy)

Infection prevention

Stress dosing in the context of chronic HPA axis suppression

Question 3

How would you manage his bone health in the face of anticipated corticosteroid use?

Answer 3

1. Annual height measurement
2. BMD at baseline and after 1yr (if >5mg/d)
3. Maintain optimal Ca and Vit-D level: calcium >1.2g/day
4. Antiresorptive therapy if T-score <-1.5 (not -2.5 if on steroids)
5. Terliparatide is also effective in improving BMD and reducing # in steroid-induced OP
6. Reduce steroids ASAP if possible, to minimise the risk.

Question 4

How should you manage the risk of adrenal supression due to supra-physiological glucocorticoid use?

Answer 4

“I think the risk of adrenal suppression is low/high for this patient.”

_Significant ris_k: a total of >3 weeks in the last 6 months or ≥2 weeks of continuous use

Checking early AM cortisol would be helpful (should WH evening and morning dose before), but I note that normal level does not rule out HPA axis suppression → confirm with short SynACTHen test

Stress dose steroids if develops acute illness

Question 5

How would you manage the risk of steroid-induced diabetes? (not diabetic yet)

Answer 5

Non-pharm

• Educate: about the risk, ask patient to monitor for symptoms of hyperglycaemia
• Monitoring: Patient needs to check the BGLs on day 3 then weekly
  
  • Before breakfast
  • 2h post-lunch and dinner
  • If daily dose is tapered down to <15mg → can check less frequently
• Life-style measures: exercise, weight-loss, diet - reduce sugar intake, smoking/ETOH

Pharm

• Consider if the patient is still off-target (~fasting <7, post-prandial <11), despite lifestyle measures
• If BGL <15 → OHG likely to control it
• If BGL >15 → insulin is probably required. Commence with Metformin + Insulin.

Move on to spiel for browny points

• For morning daily dose of steroids: I would use intermediate-acting insulin as BGL usually goes up between 1200-2000 then fall overnight (hence intermediate regime will have maximal effect during this time)
• BD Dexamethasone for example → different patterns of hyper so insulin regime needs to be tailored (e.g. basal + bolus)
• Involve endocrinology given this complexity
• But I would usually consider
  
  • Pre-breakfast Protaphane
  • Pre-lunch Actrapid (adj according to 2hr post-prandial BGL) + Protaphne (dose adj based on pre-dinner BGL)
  • Pre-dinner Actrapid (nut usually not needed)

Question 6

What is an appropriate tapering regime for patients who are at risk or who have evidence of HPA-axis suppression? (you want to stop it all together)

Answer 6

Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to 7.5 mg of prednisone per day) is reached; slower tapering of GC therapy may be recommended if risk of disease relapse is a concern

Then switch to hydrocortisone 20mg mane

Gradually reduce hydrocortisone by 2.5mg over weeks to months and re-assess based on morning cortisol, and if required, ACTH simulation test

Question 7

What is your approach to wean off this patient’s steroids?

Answer 7

Goals: achieving maximum desired therapeutic benefit with minimum dose.

Challenge:

• HPA suppression
• Symptoms of HPA suppression without biochemical evidence
• psychological dependence
• disease recurrence

Dose reduction: decrease by 5-10% every 1-4 weeks

Monitoring:

• SynACTHen - is the test of choice. 1mcg (not 250mcg - as 1mcg is more reflective of physiological concentration) of SynACTHen then bloods before, 20min and 30min after injection (easier in outpatient setting compared with 250mcg regime)
• If >500, essentialy rules it out
• Monitor disease activity.
• If HPA axis suppression (<100), maintain current dose, repeat the test 2-3 month after

Question 8

Short term use of steroids - 50mg OD 3 weeks - would you taper?

Answer 8

No. Even if at a fairly high dose, doesn’t require tapering. HPA suppression due to gluticorticoid use of this duration will not persist and is highly unlikely to have any clinical consequence. However, in frail, very ill patient, reasonable to be more cautious.