What are the guidelines for using corticosteroids (CS) in the elderly?

Guidelines for Using Corticosteroids in the Elderly

Corticosteroid use in elderly patients should be limited to the shortest duration possible and at the lowest effective dose due to their significant risk profile, with careful monitoring for adverse effects and implementation of preventive measures when long-term use is unavoidable.

Key Principles for Corticosteroid Use in Elderly Patients

General Considerations

• Corticosteroid therapy choices should not be delayed when clinically indicated, but prolonged use should be avoided due to increased risk of adverse effects in elderly patients 1
• Elderly patients are more susceptible to corticosteroid-related complications due to age-related physiological changes and comorbidities 2
• Dose selection for elderly patients should be cautious, usually starting at the low end of the dosing range 2

Preferred Formulations

• Budesonide formulations are preferred over conventional systemic corticosteroids in elderly patients when appropriate for the condition (e.g., for ileocolonic or right-sided luminal Crohn's disease or left-sided ulcerative colitis) 1
• For localized conditions, topical formulations should be considered before systemic therapy 1
• When topical corticosteroids are needed for distal colonic disease, formulations with lower volume (such as foam) may be preferred in older patients with limited mobility or weak sphincter tone 1

Monitoring and Risk Management

Required Monitoring

• Regular assessment for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation, glaucoma, myopathy, and osteoporosis 1
• Monitoring of blood pressure, weight, intraocular pressure, and clinical evaluation for infections 2
• Assessment of hepatic and renal function before initiation of therapy 1
• Evaluation for psychosocial disturbances, thromboembolism, peptic ulcers, cataracts, and osteoporosis 2

Specific Risks in Elderly Patients

• Increased risk of diabetes mellitus, fluid retention, and hypertension 2
• Higher susceptibility to infections (39.3% of complications in elderly patients on long-term therapy) 3
• Greater risk of iatrogenic diabetes (16.7% of complications) 3
• Increased risk of arterial hypertension (13% of complications) 3
• Higher absolute risk of serious adverse events including sepsis (5.3-fold increase), venous thromboembolism (3.3-fold increase), and fractures (1.9-fold increase) within 30 days of initiating therapy, even at prednisone doses below 20 mg/day 4

Prevention of Complications

Osteoporosis Prevention

• For adults ≥40 years at very high fracture risk due to high-dose corticosteroid therapy (≥30 mg daily for ≥30 days) or cumulative dose ≥5 g over 1 year, PTH/PTHrP is conditionally recommended over anti-resorptive agents 1
• Oral bisphosphonates are strongly recommended over no treatment for osteoporosis prevention in high-risk elderly patients 1
• Any use of systemic corticosteroids should prompt consideration for measures to mitigate risk for osteoporosis 1

Gastrointestinal Protection

• Consider proton pump inhibitor or misoprostol for gastrointestinal protection in elderly patients on corticosteroids, especially if combined with NSAIDs 1

Minimizing Adverse Effects

• Administer a single morning dose early in the day to reduce adrenal suppression 5
• Implement dietary modifications—low calorie, low sodium, and high potassium 5
• Consider corticosteroid-sparing therapy when long-term treatment is required 1

Special Considerations

Inflammatory Bowel Disease

• Systemic corticosteroids should not be used for maintenance therapy in IBD in elderly patients 1
• Corticosteroid use for IBD maintenance therapy should be avoided due to potentially higher risk of adverse effects 1
• Budesonide may be preferred over conventional corticosteroids for specific IBD presentations in older patients 1

Asthma and COPD

• In elderly patients with asthma or COPD, inhaled corticosteroids at doses below 1000 μg are relatively well tolerated 6
• Higher doses of inhaled corticosteroids may affect hypothalamic-pituitary-adrenal function and bone turnover 6
• Spacer devices, often used in older patients who cannot operate metered dose inhalers, can potentiate the systemic effects of both corticosteroids and beta-2-agonists 6

Contraindications and Cautions

• Exercise extreme caution in elderly patients with diabetes, hypertension, osteoporosis, or history of infections 3
• Be aware of potential drug-drug interactions, particularly with medications commonly used in elderly patients 6
• Recognize the increased risk of serious adverse events even with short-term use (less than 30 days) 4

By following these guidelines and implementing appropriate monitoring and preventive measures, the risks associated with corticosteroid use in elderly patients can be minimized while maintaining therapeutic benefits.