What are the management strategies for patients on chronic corticosteroid (steroid) therapy who are at risk of developing infections?

From the Guidelines

Patients on chronic steroids with concern for developing infection should receive appropriate vaccinations, including annual influenza jab with inactivated vaccine, pneumococcal polysaccharide conjugate vaccines, and COVID-19 vaccinations, as recommended by national guidance 1. To minimize the risk of infection, it is crucial to follow vaccination guidelines, which include:

• Annual influenza jab with inactivated vaccine (subcutaneous) instead of live vaccine (nasal spray) for patients on corticosteroids
• Pneumococcal polysaccharide conjugate vaccines (Prevenar13) as per national guidance
• COVID-19 vaccinations according to current recommendations for people with Duchenne muscular dystrophy and/or on long-term steroids Additionally, patients on chronic steroids should be aware of the increased risk of infection due to the immunosuppressive effects of steroids, which can inhibit inflammatory responses and T-cell function 1. Key considerations for preventing infections in patients on chronic steroids include:
• Hand hygiene
• Avoiding sick contacts
• Receiving appropriate vaccinations
• Monitoring for signs of infection, such as fever, cough, or shortness of breath
• Prompt treatment of infections with antimicrobial therapy targeted to the specific infection It is also essential to consider the risk of opportunistic infections, such as pneumocystis jiroveci pneumonia, and take prophylactic measures as needed 1. Overall, a comprehensive approach to infection prevention and management is necessary to minimize the risk of morbidity and mortality in patients on chronic steroids.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection The rate of infectious complications increases with increasing corticosteroid dosages. Monitor for the development of infection and consider prednisone tablets withdrawal or dosage reduction as needed.

To manage chronic steroids with concern for developing infection, monitor patients closely for signs of infection and consider withdrawal or dosage reduction of prednisone as needed. Key considerations include:

• Screening for infections such as hepatitis B, tuberculosis, and fungal infections before initiating treatment
• Avoiding exposure to varicella and measles in non-immune patients
• Prophylaxis with varicella zoster immune globulin or immunoglobulin in case of exposure to varicella or measles
• Consultation with physicians with expertise in managing hepatitis B regarding monitoring and consideration for hepatitis B antiviral therapy 2

From the Research

Management of Chronic Steroids with Concern for Developing Infection

• The use of chronic steroids can increase the risk of developing infections, particularly pneumocystis pneumonia (PCP) 3, 4, 5, 6.
• Studies have shown that prophylactic use of trimethoprim-sulfamethoxazole (TMP-SMX) can reduce the incidence of PCP in patients with rheumatic diseases receiving high-dose steroids 3.
• The efficacy and safety of low-dose TMP-SMX for PCP prophylaxis have been evaluated in several studies, with results suggesting that low-dose TMP-SMX is as effective as conventional-dose TMP-SMX with a lower incidence of adverse events 4, 5, 6.
• A systematic review and meta-analysis found that low-dose TMP-SMX was associated with a significant decrease in adverse reactions and similar mortality rates compared to conventional-dose TMP-SMX 6.
• The pharmacology and complications of steroids, including the risk of infection, are well-established 7.
• Patients receiving chronic steroids should be monitored closely for signs of infection, and prophylactic measures such as TMP-SMX should be considered in high-risk patients 3, 4, 5, 6.

Prophylaxis and Treatment Options

• TMP-SMX is a commonly used prophylactic agent for PCP in patients receiving chronic steroids 3, 4, 5, 6.
• Low-dose TMP-SMX has been shown to be effective and safe for PCP prophylaxis in patients with rheumatic diseases receiving moderate-to-high-dose glucocorticoids 5.
• The choice of prophylaxis and treatment options should be individualized based on patient risk factors and medical history 3, 4, 5, 6.

Adverse Events and Safety Considerations

• Adverse events associated with TMP-SMX, such as nausea and hyponatremia, are common but can be reduced with low-dose therapy 4, 5, 6.
• Serious adverse events, such as Stevens-Johnson syndrome, are rare but can occur with TMP-SMX therapy 3.
• Patients receiving chronic steroids should be monitored closely for signs of adverse events, and prophylactic measures should be adjusted accordingly 3, 4, 5, 6.