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 long-term 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 anti-resorptives+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 pituitary-adrenal 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