What are the preparations for high-dose corticosteroid (corticosteroids) therapy?

From the Guidelines

Preparation for high-dose corticosteroid therapy should include a comprehensive pre-treatment assessment, including baseline measurements of blood pressure, weight, blood glucose, and electrolytes, as well as prophylaxis against Pneumocystis jirovecii pneumonia and gastric protection with a proton pump inhibitor. Before initiating therapy, patients should undergo these assessments to minimize the risk of adverse effects associated with high-dose corticosteroids, such as osteoporosis, cardiovascular disease, diabetes, weight gain, renal dysfunction, peptic ulcer disease, and hypertension, as reported in the study by Duru et al. 1.

Key Preparatory Measures

• Baseline measurements: blood pressure, weight, blood glucose, and electrolytes
• Prophylaxis against Pneumocystis jirovecii pneumonia with trimethoprim-sulfamethoxazole for patients receiving prednisone ≥20 mg daily for more than 4 weeks
• Gastric protection with a proton pump inhibitor, such as omeprazole 20 mg daily, to prevent peptic ulcer disease
• Bone protection with calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation, with consideration of bisphosphonates for those at high risk of osteoporosis
• Screening for latent tuberculosis and hepatitis B before starting therapy, as corticosteroids can reactivate these infections

Patient Education and Monitoring

Patients should be counseled about potential side effects, including mood changes, insomnia, increased appetite, fluid retention, and susceptibility to infections, as well as the importance of blood glucose monitoring, particularly for diabetic patients or those at risk, as corticosteroids cause insulin resistance and hyperglycemia 2. The most recent guideline from the American College of Rheumatology/vasculitis foundation recommends initiating treatment with high-dose oral glucocorticoids for patients with newly diagnosed giant cell arteritis, followed by tapering the glucocorticoid dose to avoid prolonged high-dose treatment and reduce toxicity 3.

Additional Considerations

The need for stress schemes with higher dosages has not been proven, although in some situations, they might be considered, and patients should be informed on the risk of adrenal insufficiency and know how to prevent it, as suggested by Duru et al. 1. The 2021 American College of Rheumatology/vasculitis foundation guideline also recommends that patients need education on stress dosing for sick days, use of emergency steroid injectables, when to seek medical attention for impending adrenal crisis, and a medical alert bracelet for adrenal insufficiency to trigger stress dose corticosteroids by EMS 3.

From the FDA Drug Label

The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases. The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. In situations of less severity lower doses will generally suffice, while in selected patients higher initial doses may be required More severe disease states usually will require daily divided high dose therapy for initial control of the disease process Once control has been established, two courses are available: (a) change to alternate day therapy and then gradually reduce the amount of corticoid given every other day or (b) following control of the disease process reduce the daily dose of corticoid to the lowest effective level as rapidly as possible and then change over to an alternate day schedule.

The preparations for high-dose corticosteroid therapy include:

• Initial suppressive dose: The initial dose should be continued until a satisfactory clinical response is obtained, usually 4-10 days.
• Dose variation: The initial dosage may vary from 5 mg to 60 mg per day, depending on the disease entity being treated.
• Disease severity: More severe disease states require daily divided high dose therapy for initial control, while less severe cases may suffice with lower doses.
• Alternate day therapy: After control is established, the patient can be switched to alternate day therapy, with gradual reduction of the corticoid dose every other day.
• Individualization: The therapy should be individualized and tailored to each patient, with careful consideration of the benefit-risk ratio 4, 5, 6.

From the Research

Preparations for High-Dose Corticosteroid Therapy

To prepare for high-dose corticosteroid therapy, several factors need to be considered:

• Monitoring of patients for adverse effects, including weight gain, osteoporosis, cataracts, hypertension, diabetes mellitus, dyspepsia, and psychiatric complaints 7
• Baseline monitoring of parameters such as weight, blood pressure, triglycerides, glucose, and urea and electrolytes before starting corticosteroids 7
• Screening and antimicrobial prophylaxis against tuberculosis, hepatitis B, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia (PJP) in patients scheduled to be on high-dose corticosteroids for >4 weeks or in patients chronically treated with moderate doses 8
• Consideration of the risk of infection, including progressive multifocal leukoencephalopathy (PML), with antimetabolites such as azathioprine and mycophenolate 8
• Monitoring of biomarker profiles in serum and bronchoalveolar lavage fluid, as well as whole blood transcriptome analysis to determine factors that influence the relationship between high-dose corticosteroids and outcome 9

Patient Assessment

Before starting high-dose corticosteroid therapy, patients should be assessed for:

• History of diabetes, as patients with a history of diabetes are more likely to experience multiple episodes of hyperglycemia 10
• Comorbid diseases, as patients with multiple comorbid diseases are more likely to experience adverse effects 7
• Duration of corticosteroid therapy, as longer duration of therapy is associated with a greater risk of adverse effects 7

Treatment Strategy

A treatment strategy for high-dose corticosteroid therapy should be based on:

• The pathophysiology of corticosteroid-induced hyperglycemia, focusing on diverse patterns of hyperglycemia induced by different formulations 11
• The mechanism of action of different corticosteroids, taking into account dosing and administration timing to predict the duration of therapy 11
• Treatment goals that differ slightly between transient and continuous use of corticosteroids, based on evidence from clinical practice guidelines of diabetes care both in ambulatory and hospital settings 11