How to look after patients taking long term steroids

Diabetes & endocrinology
NHS Lothian

Audience

This guideline is aimed at all clinical health care professionals and nursing staff in NHS Lothian. It is designed to provide safe, practical guidance in the screening, diagnosis and management of complications related to long term high dose steroid therapy initiated in primary or secondary care.

Abbreviations

PPI = proton pump inhibitor, BGM = blood glucose monitoring, CGM = continuous blood glucose monitoring (such as dexcom or libre devices), BG = blood glucose, SU = sulphonylurea.

What to do when starting long term steroid therapy

  • PERFORM an HbA1c and warn patient of symptoms of hyperglycaemia
    • Hyperglycaemia is a potentially severe side effect of long-term steroid therapy particularly in the elderly and those with pre-existing diabetes.
    • See screening and treatment guidance (below). Give patient information sheet

  • PATIENT INFORMATION
  • GASTROPROTECTION
    • PPI therapy should not be given routinely but should be considered for people at high risk of gastrointestinal bleeding or dyspepsia. (e.g. previous GI bleed, known GORD/peptic ulcer disease, currently on anticoagulation or active cancer).

  • BONE PROTECTION
    • Bisphosphate should be considered to prevent vertebral fractures in men and women on prednisolone doses of 7.5 mg daily or greater (or equivalent) for three months or more. For those intolerant of bisphosphonates see SIGN guidance 142.

Screening, Monitoring and Managing Steroid Induced Diabetes – OUTPATIENT

For inpatients please refer to inpatient guidelines.

For outpatient steroid induced diabetes see this PDF.

Sick day rules for people taking long term steroids including hydrocortisone for adrenal insufficiency

See 'How to care for the unwell patient with adrenal insufficiency or taking long term steroids'

Safe long term steroid withdrawal advice

When weaning down and withdrawing long term steroids, patients can be risk stratified by a morning cortisol sample (brown tube, order on Trak or by handwritten form) taken prior to steroid dose. This should be done once prednisolone dose reaches 4mg or less.

RISK

MORNING CORTISOL (nmol/l)

ACTION

HIGH RISK

<275

Continue 4mg prednisolone and refer to endocrinology services. (If already in secondary care,  perform short synacthen test pre morning steroid dose if possible)

MODERATE RISK

275 - 425

Can stop prednisolone

Sick day dosing of 10mg prednisolone (or seek medical attention if unable to take) as per steroid emergency card for 3 months.

LOW RISK

>425

Can stop prednisolone.

Patient Information

Long Term Steroid Use Patient Information Leaflet