Management of long term high dose steroid therapy

Who to refer:

To diabetes liaison nurses (Diabetes.LiasonNurse@borders.scot.nhs.uk; phone 07973 631628)

• People with steroid-induced hyperglycaemia who may require insulin therapy i.e those not controlled on oral gliclazide as per guidance in Primary Care Management below, or in whom gliclazide is inappropriate.
• People with glucose levels > 20 mmol/l who are clinically unwell or in whom glucose levels remain above 20 mmol/l for three days in a row despite rapid uptitration of gliclazide as per guidance in Primary Care Management

If a patient is ketotic or running glucose levels above 30 mmol/l and is clinically unwell (i.e. concern regarding either DKA or HHS) then please refer for acute assessment under the general medicine take, but it is helpful if the diabetes nurses are also updated by email in this situation

To endocrinology for email advice (via email dr@borders.scot.nhs.uk)

• When advice required about interpretation of cortisol levels, or request for organisation of synacthen test, as per steroid withdrawal advice below. We expect to be able to give advice and assistance with interpretation remotely rather than bringing people to a formal endocrinology appointment for the majority

To endocrinology for clinic review (via SCI Gateway, routine referral)

• People with confirmed adrenal insufficiency lasting > 3 months who remain on steroids despite weaning attempts as per guidance in Primary Care management below. This would usually be after endocrine advice by email regarding cortisol levels as above

Who not to refer

• People whose steroid-induced hyperglycaemia can be managed with gliclazide
• People who cannot wean steroids down to 4 mg prednisolone or equivalent, or whose main issue with weaning below that level is reactivation of the condition for which steroids were started rather than steroid deficiency

Click for full size flowchart (Recommnedations for screening and monitoring for steroid induced diabetes)

Click for fullsize treatment Algorithm (Treatment Algorithm for hyperglycaemia in the context of steroid use)

STEROID WITHDRAWAL ADVICE

• NICE Guidelines (Adrenal insufficiency: identification and management) 2024 Section 1.9 covers managing glucocorticoid withdrawal to prevent adrenal insufficiency
  • Decisions to taper glucocorticoid should be made by the treating team
  • Suggested tapering regimens are outlined, including a faster taper for those who have been on glucocorticoids for 4 – 12 weeks and a slower taper for those on glucocorticoids for more than 12 weeks
  • Temporary symptoms including fatigue, reduction in appetite, low mood should be expected when tapering below physiological dose (e.g. 4mg).
  • If signs and symptoms of adrenal insufficiency develop below physiological dose (e.g. 4 mg) on faster weaning regimen then increase to double physiological dose (e.g. 8 mg) for 1 week then reduce to 4 mg prednisolone for 1 week then wean as per slower tapering regimen
• When weaning down and withdrawing long term steroids, patients who develop symptoms or signs of adrenal insufficiency on slow weaning can be risk stratified by a morning cortisol sample (brown tube, order on Trak or by handwritten form) taken prior to steroid dose and having omitted prednisolone the previous day. This should be done once prednisolone dose reaches 4mg or less. Prednisolone should be restarted after the blood test pending results.
• Interpretation of the 9 am cortisol is as per Table below

STEROID ‘SICK DAY RULES’

Patients prescribed steroids at >5mg/day prednisolone (or equivalent) for over 4 weeks are at risk of adrenal suppression and therefore may be at risk of adrenal crisis.

Patients at risk of adrenal crisis should be issued a STEROID EMERGENCY CARD  (found in patient information leaflet appendix 1 and can be found at www.endocrinology.org/adrenal-crisis or obtained from Pharmacy.

Sick day rule dosing for patients at risk of adrenal crisis is as follows (N.B. – if taking prednisolone 10mg daily or more, this is sufficient for rule 1 ‘moderate intercurrent illness’ cover and double dose not required)

Sick day rules

For perioperative and obstetric management please discuss with the anaesthetic team and consult national guidance (Management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency | Association of Anaesthetists – www.anaesthetists.org). 

• Borders Steroid Safety Bundle
• Patient information sheet in bundle document above
• Society for Endocrinology free steroid emergency card and guidance Adrenal crisis | Society for Endocrinology
• For perioperative and obstetric management please discuss with the anaesthetic team and consult national guidance (Management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency | Association of Anaesthetists– www.anaesthetists.org).