Steroids: 5 Pearls Segment

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Pearl 1:  How do you choose which steroid to order?

1. 1. Order steroids based on a spectrum that uses three guiding principles!
      1. Three guiding principles:
         1. Glucocorticoid (anti-inflammatory) activity
         2. Mineralocorticoid activity
         3. Potency & half-life
      2. Steroid spectrum:
         1. Hydrocortisone → Prednisone → Methylprednisolone → Dexamethasone
         2. Mnemonic: High Powered MD
   2. Glucocorticoid (anti-inflammatory/immunosuppressive) activity:
      1. Activity increases along spectrum
      2. Example: Dexamethasone has the HIGHEST glucocorticoid activity (our “bazooka gun”). Used in emergencies to decrease inflammation (cord compression or brain metastasis).
   3. Mineralocorticoid activity:
      1. Activity decreases along spectrum
      2. Increases fluid retention and blood pressure
      3. Example: Hydrocortisone has relatively more mineralocorticoid activity. Used in septic shock.
      4. Note: Fludrocortisone is an exception!
         1. HIGHEST mineralocorticoid activity
         2. Mild glucocorticoid activity
   4. Potency & half-life:
      1. Activity increases along spectrum
      2. Example: Hydrocortisone has LOWER potency & half-life. Used in adrenal insufficiency (more closely mimics natural cortisol production).
      3. TIP: Lower potency & half-life are preferred
         1. Less hypothalamus pituitary adrenal (HPA) axis suppression
         2. Reduced risk of adrenal insufficiency
   5. Conversion Factors:
      1. 1 mg of dexamethasone =
         1. 4 mg of methylprednisolone
         2. 5 mg of prednisone
         3. 20 mg of hydrocortisone
      2. TIP: To estimate steroids in prednisone equivalents:
         1. Multiply by 5 if starting with dexamethasone
         2.  Divide by 5 if starting  with hydrocortisone

Pearl 2: What have studies shown in terms of dose and duration for worrisome complications?

1. 6. Avascular Necrosis (AVN):
      1. How often?  4-40% rate of AVN in various conditions
      2. When?
         1.  Most cases occur after 1 year of being on steroids
         2. Earliest recognized case of AVN:
            1. After one month of 16 mg/day of oral methylprednisolone or a cumulative dose of about 570 mg
      3. Reference: One dose pack of methylprednisolone contains about 84 mg over 6 days.
   7. Immunosuppression:
      1. Large scale population and claims data have shown a small but significant increase in infection risk
      2. When?
         1. Short steroid bursts for asthma or COPD
         2. Prednisone less than 5 mg in patients with RA
      3. Reminder: Any amount of steroid is immunosuppressive to a degree
         1. Taking  3-4 mg of prednisone = taking a TNF-inhibitor in terms of the increase in infection risk!

Pearl 3: What types of prophylaxis should be started in patients on steroids and when?

1. 8. PJP Prophylaxis:
      1. Who? Those on equivalent of prednisone 20 mg or greater
      2. How long? Longer than one month
      3. For who? All patients on steroids
      4. The threshold to wait 1 month to start PJP ppx may change  if patients are on other immunosuppressive drugs or depending on the patient’s disease (ex. ANCA vasculitis)
   1. GI Ulcer Prophylaxis: 
      1. What? H2 blocker or PPI

1. 9. 2. For who? Patients who are on NSAIDs or blood thinners, have a history of ulcers, or develop symptoms of reflux
   10. Osteoporosis and Fracture Prophylaxis:
       1. Steroid induced osteoporosis is very common!
          1.  Fracture risk increases even on 2.5 to 7.5 mg of prednisone daily for 1-3 months

1. 1. 2. What? Vitamin D and calcium
         1. How long? Daily for 1-3 months
         2. For who? All patients on steroids for >3 months
         3. Impact? Increases bone mineral density, but no change in fracture risk
      3. What? Bisphosphonates
         1. For who?
            1. All patients ≥40 on  high dose glucocorticoids (prednisone ≥ 30 mg/day or cumulative dose ≥ 5 gm in 1 year)
            2. All patients on prednisone ≥ 2.5mg/day for > 3 months
               1. NOTE: For these patients, calculate a FRAX score to determine need for bisphosphonates
         2. Impact? Reduced fracture risk

Pearl 4: In which patients should we wean steroids vs. stop abruptly and how should we do so?

1. 11. Weaning steroids:
       1. When? No clear guideline
          1.  Consider duration of steroid of use when deciding to taper
             1. Frequent, short steroid courses
                1. Example:  Patients with COPD who receive frequent steroid bursts or patients receiving steroids with their chemotherapy regimens.
                   1. 10-15% of patients …developed adrenal insufficiency if steroids are not tapered!
             2. Long courses of steroids
                1. If the patient is on high dose steroids
                   1. Wean to lower levels rapidly
                   2. Slow taper at 20 mg prednisone to prevent withdrawal
                2. Can transition to hydrocortisone
                   1. It’s half-life is similar to physiologic cortisol production
                   2. It has a shorter half life, which the body’s HPA axis time to “wake up” and encourages endogenous steroid production (unlike consistent HPA suppression with longer acting steroids)

1. 50. Abruptly stop steroids:
       1. When? No clear guideline
          1. Consider duration of steroid use when deciding to abruptly stop
             1. Can feel comfortable stopped if < 7 - 14 days of steroid course
             2. Infrequent, short steroid course
                1. Example: Patient with infrequent asthma OR a 2-3 day course of stress dose steroids

Pearl 5: What factors limit steroid weaning?

1. 1. Recurrence of the disease that was being treated by steroids
   2. When should we consider adrenal insufficiency in a wean?
      1. Average daily cortisol production is equivalent to 10-15 mg of hydrocortisone or prednisone 2.5-3.5 mg
         1. Low risk if <2 weeks
         2. Moderate risk if taking equivalent of 5 mg of prednisone for >2-4 weeks
         3. Higher risk if on 5 mg of prednisone equivalent for >4 weeks
   3. Steroid Withdrawal Syndrome:
      1. Can affect up to 80% of patients
      2. Fatigue, malaise, anxiety, and myalgia
      3. Not associated with adrenal insufficiency
   4. Some patients may be hesitant to transition to biologics if they have been on steroids for a while and it works for them!
      1. This can be an opportunity to counsel and partner with your patient!

Contributors

Shreya Trivedi, MD, ACP Member – Editor
Jason Freed, MD – Host, Editor
Casey Kim, MD – Host, editor, MOC questions
Jeffrey Fish, MD - Guest
Beth Wallace, MD - Guest
Afreen Shariff, MD – Guest*
Michael Weintraub, MD - Guest

Reviewers

Nick Mark, MD
Katherine Wysham, MD

*Dr. Shariff is a consultant with BMS and Merck

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  June 28, 2023

Expiration Date: June 27, 2026

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