What is the recommended approach for prescribing steroids?

How to Prescribe Steroids

Administer oral steroids as a single morning dose before 9 AM to align with the body's natural cortisol rhythm and minimize HPA axis suppression, using the lowest effective dose for the shortest duration necessary to control disease activity. 1

Initial Dosing Strategy

Dose Selection

• Start with disease-appropriate dosing: Initial doses typically range from 5-60 mg/day of prednisone depending on disease severity and type 1
• For asthma exacerbations: Use 40-60 mg/day as a single or two divided doses for 3-10 days 2
• For polymyalgia rheumatica: Start with 12.5-25 mg/day prednisone equivalent, with higher doses (within this range) for patients at high risk of relapse and lower doses for those with comorbidities like diabetes or osteoporosis 2
• For immune-related adverse events (Grade 2): Begin with 0.5-1 mg/kg/day orally 2
• For severe toxicities (Grade 3-4): Use 1-2 mg/kg/day, with Grade 4 requiring IV methylprednisolone initially 2

Timing of Administration

• Give steroids in the morning before 9 AM when adrenal cortex activity is maximal (between 2 AM and 8 AM) to minimize suppression of the HPA axis 1
• For patients experiencing behavioral side effects, afternoon dosing after school may be considered in children 3
• Administer with food or milk to reduce gastric irritation 1

Monitoring and Maintenance

Pre-Treatment Assessment

• Evaluate comorbidities before initiating therapy: hypertension, diabetes, glucose intolerance, cardiovascular disease, dyslipidemia, peptic ulcer, osteoporosis (especially recent fractures), cataracts, glaucoma risk factors, and chronic/recurrent infections 2
• Screen for tuberculosis with quantiferon or TST if planning to add additional immunosuppressive drugs for severe toxicity 2
• Female patients have higher risk of glucocorticoid side effects and should be monitored more closely 2

Ongoing Monitoring

• Follow-up schedule: Every 4-8 weeks in the first year, every 8-12 weeks in the second year, and as indicated during tapering or relapse 2
• Document continuously: Clinical response, laboratory markers, adverse events, and risk factors for relapse 2
• Ensure patients have rapid access to healthcare providers to report flares or adverse events 2

Tapering Protocols

Short-Course Therapy (≤2 Weeks)

• No taper required for courses lasting less than 10-14 days—steroids can be stopped abruptly 2, 3
• For asthma exacerbations treated for 3-10 days, discontinue from full dose without tapering 2

Long-Term Therapy Tapering

• Demonstrate stability for 1-3 months before initiating dose reduction 2, 4
• Reduce by 25-50% at each step for inhaled steroids in asthma, with reductions every 3 months 2, 4
• For polymyalgia rheumatica: Taper to 10 mg/day within 4-8 weeks initially, then decrease by 1 mg every 4 weeks until discontinuation 2
• Gradual tapering is essential for courses longer than 2 weeks to prevent adrenal insufficiency 3
• Initial taper of 25-33% at appropriate intervals once clinical response is achieved 3

Structured Taper Approach

• Reduce by 5 mg weekly until reaching 10 mg/day 3
• Then reduce by 2.5 mg weekly until reaching maintenance dose 3
• Never taper too rapidly to avoid recurrence or worsening of the underlying condition 2
• Taper should occur over at least 1 month for long-term therapy 2

Alternate-Day Therapy

When to Consider

• For long-term pharmacologic treatment to minimize undesirable effects including pituitary-adrenal suppression, Cushingoid state, withdrawal symptoms, and growth suppression in children 1
• Particularly useful for conditions like nephrotic syndrome and rheumatoid arthritis requiring prolonged therapy 1

Implementation

• Double the daily maintenance dose and administer every other morning 1
• If difficulty encountered, may triple or quadruple the daily dose given every other day 1
• Use only short-acting corticosteroids (prednisone, prednisolone, methylprednisolone, hydrocortisone) that produce adrenocortical suppression for 1.25-1.5 days 1
• Avoid dexamethasone and betamethasone for alternate-day therapy due to prolonged suppressive effects 1

Transition Strategy

• Once disease control is established on daily therapy, either: (a) change to alternate-day therapy then gradually reduce the alternate-day dose, or (b) reduce daily dose to lowest effective level then switch to alternate-day schedule 1
• For patients on long-term daily steroids, regular attempts should be made to transition to alternate-day therapy 1

Prophylaxis and Adjunctive Measures

Infection Prevention

• Prescribe trimethoprim/sulfamethoxazole 400 mg daily for patients on long-term immunosuppressive therapy to prevent opportunistic infections 2
• Consider this prophylaxis when steroid therapy is expected to be prolonged 2

Bone Protection

• Implement osteoporosis prevention measures for patients requiring long-term therapy 2
• Baseline and annual bone mineral density testing recommended for therapy exceeding 18 months 3

Gastric Protection

• Administer antacids between meals when large doses are used to help prevent peptic ulcers 1
• Consider dietary salt restriction in appropriate patients 1

Special Populations

Children

• Weight-based dosing: 1-2 mg/kg/day (maximum 60 mg/day) for most conditions 3
• For acute asthma: 1-2 mg/kg/day (20-40 mg/day) for 3-10 days 3
• For nephrotic syndrome: 2 mg/kg/day or 60 mg/m²/day (maximum 60 mg) until remission, then switch to alternate-day dosing 3
• Do not use actual body weight for obese children to avoid overdosing 3

Steroid-Dependent Patients

• Inhaled steroids are effective and can allow reduction of oral steroid dosage 2
• Use of spacer devices increases effectiveness of inhaled drugs 2

Critical Safety Considerations

Contraindications and Precautions

• Relative contraindications include uncontrolled diabetes, psychiatric conditions, severe osteoporosis 2
• Consider alternative agents (oral cyclophosphamide or calcineurin inhibitors) for patients with contraindications to high-dose steroids 2

Common Pitfalls to Avoid

• Do not prescribe "sparingly" or "thinly" for topical steroids of low-moderate potency—this contributes to steroid phobia and treatment failure 5
• Do not exceed 30 mg/day for initial PMR treatment—strongly recommend against doses >30 mg/day 2
• Do not use inhaled steroids ≤7.5 mg/day for PMR—conditionally discouraged 2
• Avoid abrupt withdrawal after long-term therapy—always taper gradually 1

Side Effect Management

• Monitor for steroid-related complications: glucose metabolism abnormalities, increased appetite, fluid retention, weight gain, facial flushing, mood alterations, hypertension, peptic ulcer, and rarely aseptic necrosis 2
• Side effects can occur at wide range of doses and vary by route of administration 6
• Lowest effective dose should be prescribed if oral steroids are unavoidable, as side effects may be present even on low doses (30% incidence reported at 5 mg/day prednisolone) 7

When to Discontinue or Modify

• Permanently discontinue for life-threatening (Grade 4) toxicity, severe recurring (Grade 3) toxicity, or moderate (Grade 2) toxicity not resolving in 3 months despite appropriate treatment 2
• Exception: Endocrinopathies controlled by hormone replacement do not require discontinuation even if Grade 4 2
• If lack of satisfactory clinical response after reasonable period, discontinue and transfer to other appropriate therapy 1