Corticosteroid Therapy Guidelines

Pre-Therapy Screening and Monitoring

• Before prescribing corticosteroids, patients should undergo tuberculin skin testing, blood pressure measurement, glycemic control assessment, serum potassium testing, and bone mineral density evaluation to minimize serious adverse effects 1, 2
• The American Thoracic Society recommends performing tuberculin skin testing before initiating steroid therapy, as steroids may suppress the immune response to skin tests 1
• Consider prophylaxis with trimethoprim/sulfamethoxazole for Pneumocystis carinii in high-risk patients receiving >15 mg prednisone daily for >3 weeks 1
• Consider isoniazid prophylaxis for patients with positive tuberculin skin tests or those at high risk 1
• Monitor serum potassium levels to detect electrolyte abnormalities and measure and document baseline blood pressure values 2

Calcium and Vitamin D Supplementation

• All patients starting corticosteroids should receive 800-1000 mg calcium and 800 IU vitamin D daily 2
• Arrange bone mineral densitometry as soon as possible, especially for high-risk patients (previous fracture, prolonged steroid use, age >40 years), and calculate 10-year fracture risk using the FRAX risk assessment tool (www.shef.ac.uk/FRAX) 2

Adrenal Function Testing

• When testing adrenal function, certain medications require specific washout periods:

  Medication	Washout Period
  Oral antihistamines	3-10 days
  Cetirizine	5-7 days
  Diphenhydramine	3 days
  Hydroxyzine	7-10 days
  Oral/intramuscular/intravenous steroids	3 days-2 weeks

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• Patients should not take oral steroids before ACTH stimulation testing and morning cortisol lab tests, as they will interfere with results and lead to inaccurate assessment of adrenal function 4
• AM cortisol in a patient on corticosteroids is not diagnostic, as therapeutic steroids can be detected in the cortisol assay, and hydrocortisone needs to be held for at least 24 hours and other steroids for longer before endogenous adrenal function can be accurately assessed 4

Patient Risk Assessment

• Screen for patients at increased risk of steroid complications, including previous fragility fracture, prolonged (>3 months) or repeated courses of steroids, age >40 years, diabetes or risk factors for diabetes, hypertension, history of peptic ulcer disease, and family history of osteoporosis 2

Ongoing Monitoring

• Regularly monitor blood pressure throughout treatment, and blood glucose, especially in those with risk factors for diabetes 2
• Repeat bone mineral density testing at 1 year for patients on long-term steroids, then every 2-3 years if stable, or annually if declining 2
• Consider monthly monitoring of morning cortisol and ACTH levels for 6 months, then every 3 months for 6 months, then every 6 months for 1 year in patients at risk for adrenal suppression 5

Discontinuation and Adrenal Insufficiency

• The HPA axis should be tested for recovery after 3 months of maintenance therapy with hydrocortisone in patients with adrenal insufficiency related to prior steroid use, as recommended by the American College of Clinical Oncology guidelines 4
• Different steroids require different washout periods, with hydrocortisone typically held for at least 24 hours, and other steroids, such as prednisone, requiring longer periods, according to the American College of Clinical Oncology guidelines 4
• Abruptly stopping steroids in patients on long-term therapy carries risks, including secondary adrenal insufficiency due to HPA axis suppression, and potentially precipitating adrenal crisis, emphasizing the need for consultation with endocrinology before testing, as implied by the American College of Clinical Oncology guidelines 4 and supported by 6
• To minimize risks, consideration should be given to consulting endocrinology before testing, using a carefully managed steroid taper before testing, ensuring patient education on symptoms of adrenal insufficiency, and having emergency protocols in place 6

Common Pitfalls to Avoid

• Failing to screen for tuberculosis before starting steroids, which can lead to reactivation of latent TB 1
• Not providing calcium and vitamin D supplementation, increasing osteoporosis risk 2
• Laboratory confirmation of adrenal insufficiency should not be attempted in patients given high-dose corticosteroids until treatment is ready to be discontinued, as exogenous steroids directly impact the hypothalamic-pituitary-adrenal (HPA) axis, suppressing endogenous cortisol production, cross-reacting with cortisol assays, and suppressing the normal ACTH response, according to the American College of Clinical Oncology guidelines 4