Is it advisable to still give corticosteroids (steroids)?

Steroid Administration Guidelines

Steroids should be tapered rather than abruptly discontinued, especially for patients who have been on steroids for more than 2-3 weeks, to prevent adrenal insufficiency and withdrawal symptoms. 1

When to Continue Steroids

Sepsis and Septic Shock

• For patients with septic shock who require vasopressors, steroids should be continued until vasopressors are no longer required 2
• Steroids should not be administered for sepsis in the absence of shock 2
• When administering steroids for septic shock, continuous infusion is preferred over repetitive bolus injections to avoid blood glucose fluctuations 2

Central Nervous System Cancers

• If a patient with CNS cancer is asymptomatic, steroids may be unnecessary 2
• For patients with extensive cerebral edema on imaging, careful assessment for subtle symptoms should be performed before discontinuing steroids 2
• The lowest effective dose of steroids should be used for the shortest time possible 2

Inflammatory Bowel Disease

• For IBD patients requiring surgery, steroids should be stopped preoperatively if possible, or dose minimized to reduce postoperative complications 2
• Patients on oral corticosteroids for more than 4 weeks prior to surgery should receive equivalent intravenous hydrocortisone while nil by mouth in the perioperative period 2

Immune Thrombocytopenia

• For adults with newly diagnosed ITP and platelet count <30 x 10^9/L who are asymptomatic or have minor mucocutaneous bleeding, steroids are recommended 2
• For adults with newly diagnosed ITP and platelet count ≥30 x 10^9/L who are asymptomatic or have minor mucocutaneous bleeding, observation rather than steroids is recommended 2
• Short courses (≤6 weeks including treatment and taper) are strongly recommended over prolonged courses 2

Tapering Guidelines

General Principles

• For patients on long-term steroid therapy, taper over 4-6 weeks or longer 1
• Initial reduction to physiologic dose (5-7.5 mg prednisone) can be done relatively quickly, followed by more gradual tapering 1
• For courses lasting more than 14 days, implement a more gradual taper to reduce the risk of adrenal insufficiency 1
• For high-dose therapy (>20 mg prednisone daily), tapering should be done more gradually, with a slow taper over 4-6 weeks or longer 1

Disease-Specific Tapering

• For septic shock: Taper when vasopressors are no longer required 2
• For ITP: Short course (≤6 weeks including treatment and taper) is strongly recommended 2
• For IBD: After complete resection of active disease, avoid inappropriate prolongation of steroids 2
• For eosinophilic esophagitis: After induction of clinicopathologic remission, topical corticosteroid therapy might need to be maintained, but long-term therapy must be individualized 2

Monitoring During Steroid Therapy

Side Effects to Monitor

• Hypertension
• Hyperglycemia
• Sleep and mood disturbances
• Gastric irritation or ulcer formation
• Glaucoma
• Myopathy
• Osteoporosis 2

Special Considerations

• Recovery time for normal HPA activity is variable depending upon dose and duration of treatment 3
• During recovery of the HPA axis, the patient is vulnerable to any stressful situation 3
• A single morning dose produces considerably less adrenal suppression compared to divided doses 3
• For patients on alternate-day therapy, it may be necessary to return to a full suppressive daily divided corticosteroid dose during acute flare-ups 3

Common Pitfalls and Caveats

1. Abrupt Discontinuation: Never abruptly stop steroids in patients who have been on therapy for more than 2-3 weeks due to risk of adrenal insufficiency 1, 3

2. Prolonged Use: Avoid prolonged courses (>6 weeks) of steroids when possible, as this increases risk of adverse effects without clear additional benefit 2

3. Perioperative Management: For non-emergency surgery, steroids should be minimized preoperatively to reduce postoperative complications 2

4. Monitoring Requirements: Ensure adequate monitoring for side effects regardless of duration or type of corticosteroid selected 2

5. Quality of Life Assessment: Conduct assessment of health-related quality of life (depression, fatigue, mental status) while patients are receiving corticosteroids 2

By following these guidelines, you can optimize the benefits of steroid therapy while minimizing potential adverse effects. The decision to continue or taper steroids should be based on the specific clinical scenario, underlying condition, duration of therapy, and patient-specific risk factors.