Guidelines on Indications of Use
of Steroids
Annie Kung
Specialist in Endocrinology, Diabetes
& Metabolism
Types of Steroids
•
•
•
•
•
•
Replacement Therapy
glucocorticoid (hydrocortisone)
mineralocorticoid (fludrocortisone)
Anti-inflammatory Therapy
Short acting: hydrocortisone
Intermediate acting: prednisolone;
methylprednisolone; triamcinolone
• Long acting: dexamethasone
Chinese Translation for Steroid
From Google; English-Chinese Dictionary
Steroid 類固醇
Corticosteroid類固醇;皮質類固醇;
糖皮質激素;皮質激素
Hydrocortisone副腎荷爾蒙;腎上腺荷爾蒙
Routes of Administration
• Systemic : oral, transrectal, IV, IM
• Local: topical, intranasal, intraocular,
intraarticular
Availability of International Guidelines
on Use of Steroid
• No one-for-all guideline
• Glucocorticoid Replacement Therapy : Guidelines
published by Royal College of Physicians of
London, UK ; not available from Endocrine Society,
USA.
• Systemic Use of Glucocorticoid: Guidelines
available for EULAR (European League for
Rheumatology)
• Local Use of Steroid: guidelines on individual
disease, general guidelines not available
Royal College of Physicians of London Guidelines
on Glucocorticoid Replacement Therapy
•
•
•
•
•
•
•
Recommended Daily Dose for Glucocorticoid
Hydrocortisone (cortisol) 15-30mg
Cortisone acetate 25-37.5mg
Prednisolone 5-7.5mg
Dexamethasone 0.5mg
Recommended Daily Dose of Mineralocorticoid
Fludrocortisone 100-200mcg
Monitoring hydrocortisone replacement
• Hypoadrenalism is a rare condition and should
be managed by a specialist
• Biochemical monitoring enables detection of
minor degrees of under- or over-replacement
• Symptoms of hypo- or over-replacement are
vague
• 24 h urine free cortisol measurement should
be in the normal range; mid-day and evening
plasma cortisol should be >50nmol/l
Long-term Follow Up
• Regular review
• Steroid card/bracelet/medallion indicating the
diagnosis and replacement therapy
• Advice for concurrent illness management and
augmentation of replacement dose; IV
therapy for surgery/hospitalisation
• College of Physicians London, UK recommend
patients on glucocorticoid replacement longterm FU by endocrinologist
EULAR evidence-based
recommendations on the management
of systemic glucocorticoid therapy in
rheumatic diseases
J N Hoes et al, Ann Rheum Dis 2007;66:1560–1567
EULAR Expert Recommendation
• Top Number 1 Recommendation
• 1 a The ADVERSE effects of glucocorticoid therapy should be
considered and discussed with the patient before glucocorticoid
therapy is started
• 1 b This advice should be reinforced by giving information regarding
glucocorticoid management
• 1 c If glucocorticoids are to be used for a more prolonged period of
time, a ‘‘glucocorticoid card’’ is to be issued to every patient, with
the date of commencement of treatment, the initial dosage and the
subsequent reductions and maintenance regimens
Hoes et al Ann Rheum Dis 2007
EULAR Recommendation on Systemic Steroid
• Initial steroid dose/dosage reduction/long-term dosing
depends on underlying rheumatic disease, disease activity,
patient response
• Comorbidity should be evaluated: hypertension, DM,
peptic ulcer, fractures and osteoporosis, cataract/glaucoma,
infection, dyslipidaemia, NSAID
• Monitoring: body weight, BP, oedema, lipid, glucose, ocular
pressure, cardiac insufficiency
• Prevention of bone loss with antiresorptives+calcium+Vitamin D (assess of steroid
dose/duration/BMD)
• Children should be monitored for growth
• IV Steroid during surgery if systemic steroid is used for >1
month
• Gastric protection if concomittent use of NSAID
Intra-articular Steroid Injection
• First use dated back to 1951 by Hollander et al for arthritic joints;
evidence for effectiveness was based on anecdotal studies rather
than placebo-controlled trials
• Few facts but mostly opinions about diagnosis, which lesions to
treat, optimal steroid choice, dosage, injection techniques, intervals,
frequency
• Triamcinolone; methylprednisolone; dexamathesone.
• Insoluble/long-acting steroid remained in the joint, contact with
inflamed synovial surface, taken up by synovial cells and absorbed
into blood stream
• Similar side-effects as systemic steroids although the percentage of
patients having side-effects is less
• Recommendation: injection by trained personnel, e.g.
rheumatologist, orthopaedic surgeon, orthopaedic physiotherapists
practitioners in certain countries
Common Indications for Local Steroid Injection
•
•
•
•
•
•
•
•
Trigger finger
Carpel tunnel syndrome
De Quervain’s tenosynovitis
Joint Arthritis
Chronic spinal pain/facet joint pain
Sacroiliac joint arthritis
Osteoarthritis
Rheumatoid arthritis
Side-effects of Steroid Injection Therapy
•
•
•
•
•
Systemic Side-effects
Facial Flushing
Menstrual Irregularity
Hyperglycaemia
Suppress pituitaryadrenal axis
• Emotional upset
• Anaphylaxis
• Local Side-effects
• Post-injection flare of
pain
• Skin depigmentation
• Subcutaneous atrophy
• Bleeding
• Infection
• Steroid Arthropathy
• Tendon rupture/atrophy
• Soft tissue calcification
Frequency of Intra-articular Steroid
Injection
• Prolonged steroid injection is associated with
osteonecrosis
• Injection frequency into major joints in lower
limbs at no less than 3-4 month intervals. This
is based on consensus rather than evidence
• Joint sepsis is a known complication but rare
(1 in 17,000-77,000)
• Injection should be given by trained personnel
Use of Topical Corticosteroids according to
British National Formulary
• Indications: inflammatory condition of the skin other than infection.
• Common indications: eczema, contact dermatitis, insect sting,
eczema of scabies
• Contraindications: infection (bacteria/viral/fungal), rosacea
• Use of systemic and potent steroid in psoriasis should be avoided or
given only under specialist supervision
• BNF Formulary Guide: potency grouped as
Mild/Moderate/Potent/Very Potent
• Potent topical steroid should generally be avoided on the face and
skin flexures except under special circumstances by specialist
supervision
• Intralesional steroid injection should be reserved by severe
cases/localised lesions, eg keloid scars, hypertrophic lichen planus,
alopecia areata
Side-effects with topical Steroid
•
•
•
•
•
•
•
•
Spread/worsening of untreated infection
Thinning of skin
Irreversible striae and telangiectasia
Contact dermatitis
Perioral dermatitis
Acne, worsening of acne rosacea
Depigmentation
hypertichosis
Caution with Topical Steroid
• No more frequently than twice daily, apply thinly
to the affected area only
• Use the least potent formulation which is fully
effective
• Avoid prolonged use on the face and keep away
from eyes
• Caution in children and during pregnancy
• Suppression of pituitary adrenal axis and even
cause Cushing’s syndrome with prolonged use in
large area