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Long term corticosteroids

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Risk Prevention Action required if abnormal results
Fragility Fracture

applies to:

  • patients > 40 years who are currently taking or are frequent users of oral corticosteroids
  • patients < 40 years who are current or recent users of high-dose oral corticosterods for more than 3 months (high-dose defined as >/= 7.5mg prednisolone daily or equivalent)

 

consider

  • a fracture risk assessment preferably using Qfracture,
  • DXA in patients with clinical risk factors for osteoporosis and in whom antiosteoporosis treatment is being considered
  • If patient is considered to be at increased risk of a fragility fracture initiate treatment with an oral bisphosphonate
     

(SIGN recommend this applies to ALL patients taking oral corticosteroids)

Consider referral if fracture risk is high and/or BMD is decreasing
Corticosteroid induced osteoporosis
  • treatment for prevention of osteoporosis is recommended if:
    • a person is starting oral corticosteroids and is likely to be on these for a duration of at least 3 months;
    • if a person has been taking oral corticosteroids for the last 3 months and is aged over 65 years;
    • or if a person has a past history of a previous fragility fracture
  • if a person is aged less than 65 years and has no history of fragility fracture, but is likely to remain on corticosteroids for at least 3 months, then s/he should have his/her bone mineral density (BMD) measured using dual-energy X-ray absorptiometry (DXA) scanning (1)
    • osteoporosis prophylaxis is recommended if the T-score is -1.5 or less - this is because oral corticosteroid treatment leads to an increased risk of fracture over and above the effect of a low BMD (i.e. for a given BMD, there is a higher fracture risk in corticosteroid-induced osteoporosis than in postmenopausal osteoporosis)

 

more than three or four courses of corticosteroids taken in the previous 12 months is considered to be equivalent to more than 3 months of continuous treatment

  • if the intermittent courses of corticosteroid treatment are spread over a much longer term, then this is not regarded as such an important risk factor (1)
 
  • lifestyle measures are advised 
    • adequate dietary intake of calcium and vitamin D
    • regular exercise - various exercise measures including
      • low-impact, weight-bearing exercise e.g. walking
      • high-intensity strength training - targeting of the muscle groups around the hips, spine, and wrists
    • smoking cessation
    • avoidance of excessive alcohol intake

  • pharmacological treatment
    • daily calcium (1-1.2g) and vitamin D (800iu) supplements are indicated, particularly in individuals who have a poor intake such as the elderly, housebound or institutionalised. This supplementation however is generally regarded as an adjunct
    • therapy with an oral bisphosphonate represents the main form of therapy. 
new onset of diabetes 

typically 1 month after start of therapy

HbA1c 1or fasting glucose level at start of therapy then 1 month after and then every 3 months until patient is stabilised - monitor people with confirmed diabetes more closely

In patients with existing diabetes, oral antidiabetic drugs may need to be increased, or insulin therapy started

 

glaucoma and cataract optometrist examination at start and then every 6- 12 months; but earlier for those with symptoms of cataracts; early referral for intraocular pressure assessment if: personal/family history open angle glaucoma, diabetes, high myopia, connective tissue disease (particularly rheumatoid arthritis)  
hypertension  Monitor BP at every appointment Treat hypertension
dyslipidaemia Monitor triglycerides at start and then every 6–12 months  

Addison's disease

Adrenal suppression 

Potassium every 6–12 months 

hypokalaemia may present as cramping, weakness, malaise, and myalgias

 If adrenal suppression is suspected, biochemical testing of the HPA axis should be considered after steroid treatment has been reduced to a physiological dose.
GI disorders    
Growth supression Record height of children and adolescents regularly and plot on a growth chart Refer children and adolescents to a paediatrician if growth suppression is suspected
weight gain  BMI at start and then regularly

 

Offer weight management advice if necessary

 

Chicken pox 

Advise all those without a history of chickenpox who are taking systemic corticosteroids to avoid close contact with people who have chickenpox or shingles, and to seek urgent medical advice if they are exposed. Symptoms of and/or exposure to serious infections should also be assessed as corticosteroids are contraindicated in patients with untreated systemic infections.

 

 

Ensure that patient has been issued with a blue corticosteroid treatment card and that the treatment information is up to date

 

 Assessments on initaion

  • dyslipidaemia
  • diabetes
  • CVD
  • GI disorders
  • affective disorders
  • osteoporosis

 

 

 

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