What information is necessary for informed consent when prescribing steroids?

Informed Consent for Steroid Prescriptions

When prescribing steroids, patients must be informed about the risk of adrenal suppression requiring gradual tapering after more than 3 weeks of use, common side effects (weight gain, mood changes, infection risk, osteoporosis), serious adverse effects (diabetes, hypertension, cardiovascular disease, cataracts, glaucoma), and the need to avoid abrupt discontinuation. 1, 2

Essential Information About Treatment Duration and Tapering

• Patients must understand that steroids cannot be stopped abruptly after more than 3 weeks of treatment or doses above 7.5 mg prednisolone equivalent per day, as this can cause life-threatening adrenal insufficiency. 3, 2
• Inform patients that prolonged use causes dependence on corticosteroids, and they must advise any medical provider they encounter that they are taking steroids, especially if they develop acute illness, fever, or signs of infection. 2
• Explain that withdrawal symptoms after prolonged therapy include myalgia, arthralgia, and malaise, which are distinct from the underlying disease relapsing. 2

Pre-Treatment Risk Assessment and Comorbidities

Before initiating steroids, patients must be informed about how pre-existing conditions will be affected and monitored:

• Diabetes or glucose intolerance: Steroids increase blood glucose concentrations, requiring adjustment of antidiabetic medications. 1, 2
• Hypertension and cardiovascular disease: These conditions may worsen on steroids and require closer monitoring. 1
• Osteoporosis or recent fractures: Steroids inhibit bone formation and increase fracture risk, particularly in postmenopausal women. 1, 2
• Peptic ulcer disease: Concomitant use with NSAIDs significantly increases gastrointestinal bleeding risk. 1, 2
• Glaucoma or cataracts: Intraocular pressure may become elevated; if steroid therapy continues for more than 6 weeks, intraocular pressure should be monitored. 1, 2
• Chronic or recurrent infections: Patients on chronic steroids (≥20 mg/day prednisone for ≥2 weeks) are considered immunosuppressed. 4

Common and Expected Side Effects

Patients should be counseled that the following side effects are common and may occur even at low doses:

• Weight gain and central fat deposition: This is a side effect of particular concern to patients and occurs through increased appetite, insulin resistance, and metabolic changes. 1
• Mood and psychiatric changes: These range from euphoria, insomnia, and mood swings to severe depression and frank psychotic manifestations; existing emotional instability may be aggravated. 2
• Increased infection risk: Patients must avoid exposure to chickenpox or measles, and if exposed, should seek medical advice immediately. 2
• Skin changes: Including acne, easy bruising, and impaired wound healing. 5
• Muscle weakness: Acute myopathy can occur with high doses, particularly in patients with neuromuscular disorders. 2

Serious Adverse Effects Requiring Monitoring

• Osteoporosis prevention: For patients anticipated to receive at least 5 mg prednisone equivalent for at least 3 months, calcium and vitamin D supplementation, bisphosphonate therapy, and weight-bearing exercise should be initiated. 2
• Cardiovascular risk: Chronic glucocorticoid use, particularly at doses >15 mg/day, increases cardiovascular risk. 4
• Adrenal insufficiency: Patients must understand that their body stops producing its own cortisol during prolonged steroid use, creating dependence. 2
• Hypokalemia risk: When steroids are given with potassium-depleting agents (diuretics, amphotericin B), patients should be monitored for low potassium. 2

Critical Drug Interactions

Patients must disclose all medications, as steroids interact with:

• Warfarin: Coagulation indices require frequent monitoring. 2
• Macrolide antibiotics (erythromycin, clarithromycin): These decrease steroid clearance, increasing side effect risk. 2
• Fluoroquinolones: Concomitant use increases tendon rupture risk, especially in the elderly. 2
• NSAIDs: Combined use significantly increases gastrointestinal bleeding risk. 1, 2
• Anticholinesterase agents: In myasthenia gravis patients, severe weakness can occur; these should be withdrawn 24 hours before starting steroids if possible. 2

Emergency Considerations

• Patients should be provided with a steroid card or similar notification listing emergency-care considerations in the setting of acute medical presentation, fracture, serious infection, need for surgery, or general anesthesia. 1
• Inform patients that during acute illness or stress, they may require increased steroid doses and must contact their physician immediately. 2

Disease-Specific Counseling

For polymyalgia rheumatica patients specifically:

• Female sex is associated with higher risk of glucocorticoid side effects and higher relapse rates. 1
• High ESR (>40 mm/1st hour) and peripheral inflammatory arthritis are associated with prolonged therapy needs. 1
• Follow-up visits are suggested every 4-8 weeks in the first year, every 8-12 weeks in the second year. 1

For Duchenne muscular dystrophy patients:

• Complete the recommended national immunization schedule and establish varicella immunity before starting steroids. 1, 5
• Families should understand that the goal is preservation of ambulation and minimization of later respiratory, cardiac, and orthopedic complications. 1