What are the patient-centered care approaches for glucocorticoids (corticosteroids) administration across the lifespan?

From the Guidelines

Glucocorticoid therapy requires a patient-centered approach across the lifespan, with a focus on minimizing adverse effects and maximizing therapeutic benefits, as emphasized by the most recent guidelines 1.

Key Considerations

• For infants and children, medications like prednisolone (0.5-2 mg/kg/day) are commonly used for conditions such as asthma or inflammatory disorders, with careful monitoring of growth and development 1.
• Adolescents require special attention to medication adherence and body image concerns, while adults typically receive prednisone (5-60 mg daily depending on condition), with monitoring for metabolic effects and bone health 1.
• Elderly patients often need lower doses (typically 25-50% reduction) due to decreased drug clearance and increased risk of side effects like osteoporosis, requiring calcium (1200-1500 mg daily) and vitamin D (800-1000 IU daily) supplementation 1.

Patient Education and Monitoring

• Healthcare providers should employ shared decision-making, educate patients about potential side effects including mood changes, weight gain, and increased infection risk, and develop tapering schedules when discontinuing therapy to prevent adrenal insufficiency 1.
• Regular monitoring of blood pressure, blood glucose, bone density, and electrolytes is essential across all age groups, with frequency determined by dose, duration, and individual risk factors 1.

Special Considerations

• Patients on glucocorticoid therapy should be monitored for body weight, blood pressure, peripheral oedema, cardiac insufficiency, serum lipids, blood and/or urine glucose, and ocular pressure, depending on individual patient risk, glucocorticoid dose, and duration 1.
• The use of glucocorticoids in patients with diabetes requires careful consideration of the impact on blood glucose levels and adjustment of insulin therapy as needed 1.

From the FDA Drug Label

Since complications of treatment with glucocorticoids are dependent on the size of the dose and the duration of treatment, a risk/benefit decision must be made in each individual case as to dose and duration of treatment and as to whether daily or intermittent therapy should be used Growth and development of infants and children on prolonged corticosteroid therapy should be carefully observed. Special consideration should be given to patients at increased risk of osteoporosis (e.g., postmenopausal women) before initiating corticorticosteroid therapy. To minimize the risk of glucocorticoid-induced bone loss, the smallest possible effective dosage and duration should be used. Patients should be warned not to discontinue the use of corticosteroids abruptly or without medical supervision Patients with moderate to severe liver disease should be monitored for increased signs and/or symptoms of hypercorticism.

The patient-centered care for glucocorticoids across the lifespan involves:

• Monitoring for signs and symptoms of hypercorticism and adrenal axis suppression during treatment
• Careful observation of growth and development in infants and children on prolonged corticosteroid therapy
• Special consideration for patients at increased risk of osteoporosis before initiating corticosteroid therapy
• Minimizing the risk of glucocorticoid-induced bone loss by using the smallest possible effective dosage and duration
• Warning patients not to discontinue corticosteroid use abruptly or without medical supervision
• Monitoring patients with moderate to severe liver disease for increased signs and/or symptoms of hypercorticism 2
• Supplementation with a systemic glucocorticosteroid is recommended in situations where patients are subject to surgery or other stress situations 3
• Screening patients for hepatitis B infection before initiating immunosuppressive treatment with budesonide extended-release tablets 3
• Chemoprophylaxis for patients with latent tuberculosis or tuberculin reactivity during prolonged budesonide extended-release tablets therapy 3

From the Research

Patient-Centered Care for Glucocorticoids Across the Lifespan

• Glucocorticoids have been used to manage rheumatoid arthritis (RA) since the 1940s, with their efficacy in controlling disease activity and delaying joint damage well established 4, 5, 6.
• However, long-term use of glucocorticoids, particularly at higher doses, is not advisable due to their adverse effects, and recent guidelines recommend using them only as bridging therapy or at the lowest dose possible for the shortest time possible 4, 7, 6.
• The risk-benefit balance of glucocorticoid therapy varies across patients, with some studies suggesting a favorable balance for low-dose therapy in senior patients 4 and others highlighting the need for stronger evidence to guide treatment decisions 7.
• Provider preference is a significant predictor of long-term glucocorticoid use, with variability in prescribing practices among rheumatologists raising concerns about quality of care 7.
• The use of glucocorticoids in critical care settings is also controversial, with some studies suggesting their potential benefits in certain conditions, such as severe acute respiratory distress syndrome or septic shock, but also highlighting the need for better biomarkers to determine which patients will benefit from therapy 8.

Considerations Across the Lifespan

• Glucocorticoid therapy should be individualized, taking into account the patient's age, disease severity, and comorbidities 4, 6.
• Patients with RA should be closely monitored for adverse effects, and glucocorticoid doses should be tapered or discontinued when possible 4, 7.
• Education and support are essential for patients on long-term glucocorticoid therapy, with healthcare providers playing a crucial role in promoting adherence and minimizing risks 5, 6.
• Further research is needed to clarify the optimal use of glucocorticoids in RA management, including the benefit-risk ratio of low-dose therapy and the optimal duration of bridging therapy 6.