What is the recommended dose and management for steroid-induced psychosis?

Management of Steroid-Induced Psychosis: Dosing Considerations and Treatment Approach

For patients with steroid-induced psychosis, the starting dose of steroids should be decreased, and when psychosis occurs, treatment with an atypical antipsychotic like risperidone (starting at 1-2 mg/day) is recommended while reducing the steroid dose to the minimum effective level. 1, 2, 3

Steroid Dosing to Prevent Psychosis

Risk Assessment and Prevention

• Steroid dose is the most significant risk factor for developing psychosis 4
• Initial steroid dosing should be modified in patients with:
  • History of psychosis: Reduce starting dose by up to 50% 1
  • Risk factors for psychosis: Consider lower starting doses and slower titration

Recommended Dosing Adjustments

• Standard starting dose for most conditions: 20-40 mg prednisone daily 1
• For patients with history of psychosis: Reduce to 10-20 mg daily initially 1
• Titrate to the lowest effective dose that provides symptom relief and disease control 1

Management of Active Steroid-Induced Psychosis

First-Line Approach

1. Reduce steroid dose to the minimum effective level if possible 5

   • Do not abruptly discontinue steroids if treating a serious underlying condition
   • Consider alternate-day dosing to reduce psychiatric side effects

2. Initiate antipsychotic medication 5, 3

   • Risperidone: Start at 1-2 mg/day (most evidence in this setting)
     • Can titrate by 0.5-1 mg increments every 24 hours as needed
     • Effective dose range: 1-4 mg/day
     • Maximum recommended dose: 6 mg/day 2
   • Monitor for extrapyramidal symptoms, which increase at doses >6 mg/day 6

Alternative Antipsychotics

• Quetiapine: Starting dose 300 mg/day, can increase to 900 mg/day if needed 7
• Haloperidol: Has been used successfully but carries higher risk of extrapyramidal symptoms 5
• Olanzapine: Initial target dose 7.5-10 mg/day 1

Special Populations

• Children/Adolescents: Lower doses of antipsychotics are required
  • Risperidone starting at 0.25-0.5 mg/day has been effective 3
  • Promethazine has been used successfully in very young children 8
• Elderly patients: Start with lower doses (risperidone 0.5 mg) and titrate more gradually 6

Monitoring and Follow-up

Clinical Monitoring

• Assess response within 1-2 weeks of antipsychotic initiation
• Most patients show improvement within 2 weeks and resolution within 4 weeks 7
• Monitor for:
  • Resolution of psychotic symptoms (hallucinations, delusions)
  • Extrapyramidal side effects
  • Metabolic effects (weight, blood glucose, lipids)

Duration of Antipsychotic Treatment

• Continue antipsychotic treatment until:
  • Steroid dose has been reduced to maintenance level
  • Psychotic symptoms have fully resolved
  • Then gradually taper antipsychotic over 2-4 weeks

Pitfalls and Caveats

• Do not abruptly discontinue steroids in patients with conditions requiring ongoing treatment
• Do not use budesonide in patients with cirrhosis or acute severe conditions as it may not reach the liver due to portal hypertensive shunts 1
• Avoid typical antipsychotics when possible due to higher risk of extrapyramidal side effects
• Remember that steroid-induced psychosis can manifest as inappropriate sexual behavior, especially in adolescents 7
• Consider prophylactic antipsychotic treatment in patients with previous episodes of steroid-induced psychosis who require repeated steroid courses 3

By following these guidelines, steroid-induced psychosis can be effectively managed while maintaining treatment of the underlying condition requiring steroid therapy.