What investigations should be done for a patient on chronic steroid use who is physiologically normal?

Recommended Investigations for Patients on Chronic Steroid Therapy

For patients on chronic steroid therapy who are physiologically normal, regular monitoring should include blood glucose measurements, blood pressure checks, bone density assessment, and screening for adrenal insufficiency to prevent and manage steroid-related complications. 1

Blood Glucose Monitoring

• Fasting blood glucose and HbA1c should be monitored regularly, as steroid-induced hyperglycemia is common (occurring in up to 39.5% of patients on steroids) 1
• Random blood glucose measurements are more effective than fasting levels for detecting steroid-induced hyperglycemia, as peak hyperglycemia typically occurs 7-9 hours after steroid administration 1
• Consider more frequent monitoring in high-risk patients (those with pre-existing diabetes or elevated baseline glucose) 1
• Persistent hyperglycemia with two abnormal tests (random BGL ≥11.1 mmol/L on different occasions and/or newly elevated HbA1c ≥6.5%) with corticosteroid use is diagnostic of steroid-induced diabetes 1

Blood Pressure Monitoring

• Regular blood pressure measurements should be performed at each clinical visit 1
• Ensure proper technique: patient should be seated quietly for 5 minutes before measurement, no caffeine for 1 hour prior, and no smoking for 30 minutes prior 1
• Use appropriate cuff size (bladder should encircle at least 80% of arm length) 1
• Take at least two readings separated by time; if readings vary by >10 mmHg, take additional readings 1

Bone Health Assessment

• Baseline and periodic bone mineral density testing via DEXA scan, particularly for patients on prolonged therapy (>3 months) 1
• Consider vitamin D and calcium levels, especially in patients at higher risk for osteoporosis 1
• Screen for risk factors for osteoporosis including malnutrition, inflammation, smoking, and lack of weight-bearing exercise 1

Adrenal Function Monitoring

• For patients on chronic steroids, evaluate for symptoms of adrenal insufficiency, especially when tapering or discontinuing therapy 1
• Morning cortisol and ACTH levels should be checked if adrenal insufficiency is suspected 1
• Note that AM cortisol in patients on corticosteroids is not diagnostic as therapeutic steroids can affect the cortisol assay; hydrocortisone needs to be held for 24 hours and other steroids for longer before testing 1
• Consider standard dose ACTH stimulation test for indeterminate results (AM cortisol >3 mg/dL and <15 mg/dL) 1

Lipid Profile

• Regular monitoring of lipid profile (total cholesterol, HDL, LDL, triglycerides) 1
• Increased frequency of monitoring may be needed as steroid use is associated with hyperlipidemia (pooled prevalence of 8%) 2

Liver Function Tests

• Monitor liver enzymes (AST, ALT) and bilirubin periodically, especially if on other potentially hepatotoxic medications 1
• Consider more frequent monitoring if baseline abnormalities exist 1

Ophthalmologic Evaluation

• Regular eye examinations to screen for cataract formation and increased intraocular pressure 1
• More frequent monitoring for patients with pre-existing eye conditions 1

Infection Risk Assessment

• Screen for latent tuberculosis, hepatitis B, and Strongyloides stercoralis in high-risk patients before initiating long-term therapy (>4 weeks at >30 mg prednisone equivalent) 3
• Consider prophylaxis against Pneumocystis jirovecii pneumonia for patients on high-dose steroids (>30 mg prednisone equivalent) for >4 weeks or moderate doses (≥15 to <30 mg) for ≥8 weeks 3

Weight and Body Composition

• Regular weight measurements to monitor for steroid-induced weight gain (pooled prevalence of 13%) 2
• Waist circumference measurements to assess for central adiposity 2

Electrolyte Monitoring

• Periodic assessment of electrolytes, particularly sodium and potassium 1
• More frequent monitoring in patients with risk factors for electrolyte disturbances 1

Important Considerations

• The frequency of monitoring should be based on steroid dose, duration of therapy, and individual risk factors 1
• Patients on chronic steroids should be educated about potential complications and symptoms that warrant medical attention 1
• Patients should be advised to carry steroid alert cards or wear medical alert bracelets 1
• Consider education on stress dosing for sick days and emergency situations 1

By implementing these monitoring strategies, clinicians can identify and address steroid-related complications early, improving patient outcomes and quality of life.