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BNSSG Adult Joint Formulary

6.2 Corticosteroid responsive conditions

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Last edited: 23-10-2024

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Corticosteroids (Systemic)

Glucocorticoid side-effects include diabetes and osteoporosis, which is a danger, particularly in the elderly, as it can result in osteoporotic fractures for example of the hip or vertebrae (see NICE CKS Osteoporosis - prevention of fragility fractures for recommendations); in addition high doses are associated with avascular necrosis of the femoral head. Muscle wasting (proximal myopathy) can also occur. Corticosteroid therapy is also weakly linked with peptic ulceration and perforation; and this risk is increased with concomitant NSAID (including low dose aspirin) use. There is no conclusive evidence that the use of enteric-coated preparations of prednisolone reduces the risk of peptic ulceration. Patients are also at risk of Psychiatric Reactions, see the BNF.

High doses of corticosteroids can cause Cushing's syndrome, with moon face, striae, and acne; it is usually reversible on withdrawal of treatment, but this must always be gradually tapered to avoid symptoms of acute adrenal insufficiency (important: see also Adrenal Suppression).

For further information on corticosteroids and monitoring see the CKS ‘Corticosteroids - oral’

Withdrawal

The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:

Recently received repeated courses (particularly if taken for longer than 3 weeks)
Taken a short course within 1 year of stopping long-term therapy
Other possible causes of adrenal suppression
Received more than 40mg daily prednisolone (or equivalent)
Been given repeat doses in the evening
Received more than 3 weeks' treatment (high dose inhaled steroid should be taken into consideration in these criteria)

Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and have received treatment for 3 weeks or less and are not included in the patient groups described above.

During corticosteroid withdrawal the dose may be reduced rapidly (e.g. 5mg per day) down to physiological doses (equivalent to prednisolone 7.5mg daily) and then reduced more slowly (e.g. 1-2mg per week). Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.

Link to NPSA Alert Steroid Emergency Card

Information on the NPSA alert can be found on the NHS England website: https://www.england.nhs.uk/2020/08/steroid-emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-adults/
Emergency Steroid Card is available to download as part of the resources developed by The Society for Endocrinology: https://www.endocrinology.org/adrenal-crisis/
Emergency Steroid Card can also be ordered from:
- NHS Forms at NHS Business Services Authority (NHS BSA) http://www.nhsforms.co.uk/
- Primary Care Support England (PCSE online) https://secure.pcse.england.nhs.uk/forms/pcsssignin.aspx
The guidance to accompany the Emergency Steroid Card produced by the Royal College of Physicians: Prevention and emergency management of adult patients with adrenal insufficiency can be found here
Guidance on issuing the Steroid Emergency Card in adults

6.2.1 Steroid Replacement Therapy

Recommended: (TLS Green)

Fludrocortisone (oral)

Mineralocorticoid

Hydrocortisone (oral)

Glucocorticoid

Hydrocortisone (Efmody^®) (TLS Amber Specialist Recommended)

For congenital adrenal hyperplasia in patients who are not adequately controlled or have experienced androgen excess with immediate release hydrocortisone. Only for use in patients who were established on Efmody whilst under the care of paediatric endocrinology to support continuity of care
Long-term use of Efmody^® permitted only if long-term benefit on hormone profile has been demonstrated.

6.2.2 Steroid Responsive Therapy

Recommended: (TLS Green)

Hydrocortisone (parenteral)

Hydrocortisone sodium succinate (Solucortef^®) (parenteral)

Prednisolone 5mg tablets (25mg tablets in specific patients) (oral) (TLS Green)

Plain tablets not enteric-coated

Betamethasone (parenteral) (TLS Green)

Dexamethasone (oral & parenteral) (TLS Blue)

Methylprednisolone (parenteral) (TLS Blue)

Methylprednisolone (oral) (TLS Blue)

For treatment of acute episodes of multiple sclerosis

Budesonide (Targeted-release) (TLS Red)

NICE TA973 Targeted-release budesonide for treating primary IgA nephropathy

6.2.3 Cushing's syndrome and disease

Beta-hydroxylase Inhibitors

Metyrapone (TLS Blue)

Management of Cushing's syndrome

Somatostatin analogues

Pasireotide (TLS Red)

As per NHS England Clinical Commissioning Policy 16052/P Pasireotide diaspartate: an injectable medical therapy for the treatment of Cushing's Disease

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