Glucocorticoids are commonly prescribed in the United Kingdom to manage a range of medical conditions for example inflammatory disorders and asthma exacerbations. Current estimates suggest that approximately 1% of the United Kingdom is prescribed a form of oral glucocorticoid for disease management. Drug delivery to the body for this class of medicine varies significantly and may include for instance oral, inhaled, nasal and topical administration.
Chronic use of glucocorticoids can negatively impact the hypothalamic pituitary-adrenal (HPA) axis. This in turn can lead to a reduction in the production of natural glucocorticoids from the adrenal glands. This effect arises from reduced corticotrophin-releasing hormone from the hypothalamus and adrenocorticotropic hormone from the pituitary gland. The sudden termination of exogenous glucocorticoid delivery to the body (i.e. by abrupt patient cessation) can cause adrenal insufficiency (AI), which may last from months to years. The presentation of AI is of great concern because patients are not able to mount a cortisol stress response when either acutely unwell, during invasive procedures or following trauma. The net effect of this may be adrenal crisis and ensuing hypotension with shock that can indeed be fatal.
Thus, there is a pressing need – and now a huge drive within the NHS - to ensure that all patients who are prescribed a long-term glucocorticoid product (e.g. 5mg Prednisolone or equivalent for longer than 4 weeks) receive a Steroid Emergency Card. Those patients receiving glucocorticoid therapy should always carry the card with them. Details within the card include the identity of the patient, key contact information, why the medication is prescribed, how to minimise risk associated with AI and where to seek further information. Moreover, a patient information leaflet should always be supplied whenever a systemic corticosteroid is prescribed or dispensed.
Patients should also be advised that chronic use of glucocorticoids can lead to increased susceptibility to infection (e.g. risk of severe chickenpox, unless already immune). Furthermore, the patient should be aware of the potential for mood and behaviour changes; especially when high doses are used. Here, the patient can become confused, irritable and suffer from delusion and suicidal ideations. It should be noted that these effects can also occur when glucocorticoid treatment is being withdrawn. Additional side effects arising from chronic glucocorticoid use include gastrointestinal, musculoskeletal along with ophthalmic effects which may be severe enough to warrant medical intervention.
Healthcare practitioners should therefore provide a Steroid Emergency Card with clear verbal instruction to those patients who receive medication such as:
· Chronic glucocorticoids at a dose equivalent / higher than Prednisolone 5mg
· Three or more short courses of high-dose oral glucocorticoids within the last 12 months and for 12 months after stopping
· Three or more intra-articular/intramuscular glucocorticoid injections within the last 12 months and for 12 months after stopping
· Repeated courses of Dexamethasone as an antiemetic in oncology regimens and for 12 months after stopping
· Extended courses of Dexamethasone (>10 days) for the treatment of severe COVID-19
· Inhaled steroids (i.e. >1000mcg/day Beclomethasone or >500mcg/day Fluticasone (or equivalent dose of another glucocorticoid)) and for 12 months after stopping
Further information may be located at: www.endocrinology.org/adrenal-crisis
