What are the risks and necessary precautions for a patient taking supraphysiologic doses of steroids, including sick-day rules, infection precautions, vaccination guidance, skin and wound care, and bone health management?

Counseling Patients on Supraphysiologic Steroid Therapy

Patients on supraphysiologic doses of steroids require comprehensive education on sick-day rules (doubling the dose during illness), emergency injectable hydrocortisone kits, medical alert identification, infection precautions including live vaccine avoidance, meticulous wound care, and aggressive bone health management with calcium and vitamin D supplementation.

Sick-Day Rules and Emergency Management

All patients must understand "sick-day rules": double your regular steroid dose during any febrile illness, vomiting, diarrhea, or significant physiological stress. 1 This is non-negotiable education that prevents adrenal crisis.

• Provide an emergency hydrocortisone injection kit (100 mg) for self-administration or family member administration during vomiting, severe illness, or inability to take oral medications 1, 2
• Train a family member or companion to administer the emergency injection 1
• Instruct patients to seek immediate medical attention if they develop nausea, vomiting, severe weakness, confusion, or orthostatic hypotension—these may signal impending adrenal crisis 1, 3
• During physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal production 3, 2

Medical Alert Identification

Every patient must carry a steroid emergency card and wear a medical alert bracelet or necklace. 1, 2 This is critical for emergency situations where the patient cannot communicate their steroid dependence.

• The alert should specify the diagnosis, current steroid dose, and need for stress-dose steroids during acute illness or trauma 1
• Healthcare providers encountering these patients must recognize that "listening to a well-informed adrenal patient who says that he or she needs additional steroids, and taking urgent action, will avoid unnecessary deaths" 1

Infection Precautions and Heightened Risk

Patients on ≥20 mg/day prednisone (or equivalent) for ≥2 weeks are considered immunosuppressed by CDC criteria. 1 This threshold defines clinically significant immunosuppression requiring specific precautions.

• Infection risk increases significantly at doses >15 mg/day of prednisone or equivalent 1
• Maintain heightened awareness for sepsis risk, particularly the combination of steroid therapy and neutropenia, which carries substantial mortality risk 1
• Fever (single temperature ≥38.3°C or ≥38.0°C over 1 hour) requires immediate evaluation and intravenous antibiotics with inpatient admission 1
• Consider prophylactic antibiotics during periods of neutropenia: fluoroquinolones for antibacterial coverage, acyclovir/valacyclovir for HSV prophylaxis, and trimethoprim-sulfamethoxazole for Pneumocystis pneumonia prevention 1
• Consider antifungal prophylaxis with fluconazole or amphotericin B agents for patients on intensive chemotherapy regimens 1

Vaccination Guidance: Critical Timing Considerations

Avoid all live vaccines while on supraphysiologic steroid doses due to risk of vaccine-associated disease. 1 The CDC considers doses ≥20 mg/day prednisone for ≥2 weeks as the threshold for contraindication to live vaccines.

Live Vaccines to Avoid:

• Measles-Mumps-Rubella (MMR)
• Varicella (chickenpox)
• Zoster (shingles) live vaccine
• Yellow fever
• Oral polio
• Intranasal influenza
• Oral typhoid 1

Inactivated Vaccines to Prioritize:

• Annual inactivated influenza vaccine
• Pneumococcal vaccines (PCV13 followed by PPSV23)
• COVID-19 vaccines
• Hepatitis B
• Recombinant zoster vaccine (Shingrix) - this is NOT live and is safe 1

Wait at least 3 days to 2 weeks after discontinuing oral/intramuscular/intravenous steroids before administering live vaccines, depending on dose and duration. 1 Inhaled and topical corticosteroids do not contraindicate live vaccines. 1

Skin and Wound Care Considerations

Glucocorticoids impair wound healing and increase infection risk through multiple mechanisms. 1 This requires proactive wound management strategies.

• Inspect skin daily for breakdown, particularly over pressure points and areas of trauma 1
• Any wound requires meticulous care with heightened infection surveillance 1
• Avoid elective surgery when possible; if surgery is necessary, optimize steroid dosing to <20 mg/day prednisone equivalent preoperatively when feasible 1
• Persistent pyrexia may indicate either infection or adrenal insufficiency—never reduce or withdraw steroid supplementation while the patient is febrile 1
• Steroid-induced skin fragility increases risk of tears and bruising; counsel on protective measures and gentle skin handling 4

Bone Health Management: Aggressive Prevention Required

Initiate calcium and vitamin D supplementation immediately upon starting supraphysiologic steroids to prevent glucocorticoid-induced osteoporosis. 1 This is preventive, not reactive.

Specific Supplementation:

• Calcium: 1200-1500 mg daily in divided doses 1
• Vitamin D: Check baseline 25-OH vitamin D level and replete to >30 ng/mL; typical supplementation 1000-2000 IU daily, adjusted based on levels 1
• Consider bisphosphonate therapy for patients on long-term steroids, particularly postmenopausal women and men >50 years 1

Osteonecrosis/Avascular Necrosis Surveillance:

• Maintain high clinical suspicion for osteonecrosis, particularly of the femoral head, in patients on prolonged high-dose steroids 1
• New hip, knee, or shoulder pain warrants radiographic evaluation with plain films or MRI 1
• Weight-bearing exercise as tolerated helps maintain bone density 1

Gastrointestinal Protection

Use a histamine-2 receptor antagonist or proton pump inhibitor during steroid therapy to prevent peptic ulceration. 1 This is standard prophylaxis, not optional.

• The combination of steroids and NSAIDs dramatically increases GI bleeding risk; avoid NSAIDs when possible 1
• Consider starting a bowel regimen (docusate sodium daily) to prevent constipation, which is common with steroid therapy 1

Metabolic Monitoring: Steroid-Induced Diabetes

Implement tight glucose control using sliding-scale insulin to decrease infection complications in patients who develop steroid-induced hyperglycemia. 1 Hyperglycemia is expected and must be aggressively managed.

• Monitor blood glucose regularly, particularly during dose escalations 1
• Steroid-induced diabetes typically improves with dose reduction but may require ongoing management 1, 4
• Hyperglycemia occurs in >90% of critically ill patients receiving stress-dose steroids 5

Critical Pitfalls to Avoid

Never start thyroid hormone, testosterone, or estrogen replacement before ensuring adequate corticosteroid replacement—these hormones accelerate cortisol clearance and can precipitate adrenal crisis. 3, 2, 5 This is a potentially fatal error.

• Do not assume patients have been adequately educated on sick-day rules; systems failures occur, and patients may have been discharged without proper counseling 1
• Adrenal crisis can occur even when plasma cortisol levels appear normal or elevated (relative adrenal insufficiency), so treat based on clinical suspicion, not laboratory values 3, 2
• Sodium and water retention from mineralocorticoid effects may require fluid balance monitoring, particularly in patients with heart failure or renal disease 1
• Patients with comorbidities such as asthma and diabetes are more vulnerable to adrenal crisis 3