11/13/24, 8\:16 PM Guide | Corticosteroid counselling

Corticosteroid counselling

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Clarify the purpose of the consultation\:
“ I’ v e c o m e t o d i s c u s s a t y p e o f m e d i c a t i o n k n o w n a s s t e r o i d s , w o u l d t h a t b e o k a y ?”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t - o r i f s o m e t h i n g i s n o t c l e a r - p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of counselling involves exploring a patient's ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives
their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use
the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
Ideas
“ H a v e y o u h e a r d o f s t e r o i d s ?”
“ W h a t d o y o u k n o w a b o u t s t e r o i d s ?”
“ D o y o u k n o w w h a t s t e r o i d s a r e u s e d f o r ?"
Concerns
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u a b o u t t a k i n g s t e r o i d s ?”
Expectations
“ W h a t w e r e y o u h o p i n g t o g e t f r o m o u r d i s c u s s i o n t o d a y ?”
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , y o u w o u l d l i k e m e t o d i s c u s s o r f o c u s o n t o d a y ?”
Tip\: Establishing the patient’s ideas, concerns and expectations early in the consultation will enable you to focus on the factors
that matter most to the patient. This will increase the quality of the consultation and further build rapport between you and the
patient.

Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the
consultation.
This should include an exploration of the patient’s symptoms and management of their condition, including trials of previous
medications, their impact, compliance and adverse e
and cautions, other medications the patient is taking, smoking and pregnancy.
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Systemic corticosteroids treat a wide range of conditions and come in various formulations with di
Identifying the condition and the indication for starting corticosteroids in each patient is important.
Conditions treated with systemic corticosteroids
Rheumatological conditions\:
Rheumatoid arthritis
Systemic lupus erythematosus
Polymyalgia rheumatica
Temporal (giant cell) arteritis
Sarcoidosis
Gastrointestinal\:
Crohn's disease
Ulcerative colitis
Respiratory
Asthma
COPD
Other
Organ transplants
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their situation.

Allergies

Ask the patient if they have any known allergies. If the patient has had a drug reaction previously, ask about the features and
severity of the reaction.
An individual’s drug allergy status should be documented in their medical records, and this information should be kept distinct
from the details of any adverse drug reactions.
1
“ A r e y o u a l l e r g i c t o a n y m e d i c a t i o n s ?”
“ H a v e y o u r e a c t e d t o a n y m e d i c a t i o n s i n t h e p a s t ?”

Contraindications and cautions for steroids

Before prescribing corticosteroids, it is important to screen for any contraindications. Patients with acute systemic infections
should not receive corticosteroids, as they can weaken the immune system.
2
There are several cautions to consider when prescribing systemic corticosteroids. These include\:
3,4
Hepatic impairment
Unhealed wounds
Stomach ulcers
Pre-existing conditions such as heart failure, hypertension, diabetes mellitus or epilepsy
History of mental health problems\: corticosteroids can exacerbate emotional instability or psychotic tendencies
“ D o y o u k n o w o f a n y r e a s o n s w h y y o u m a y n o t b e a b l e t o t a k e s t e r o i d s ?”
“ B e f o r e s t a r t i n g c o r t i c o s t e r o i d t r e a t m e n t , w e m u s t k n o w i f y o u h a v e a n y m e d i c a l c o n d i t i o n s . T h i s i n c l u d e s c o n d i t i o n s l i k e
d i a b e t e s , e p i l e p s y , h i g h b l o o d p r e s s u r e , o r p r o b l e m s w i t h y o u r l i v e r , h e a r t , k i d n e y s o r s t o m a c h u l c e r s . D o y o u h a v e a n y o f t h e s e
c o n d i t i o n s ?”

Pregnancy and breastfeeding

If appropriate, ask the patient if there is any chance they are pregnant or are currently breastfeeding. Corticosteroids may be
prescribed during pregnancy if the bene
mother's medical needs and potential risk to the foetus.
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However, prolonged or repeated courses of steroids during pregnancies may have adverse e
In breastfeeding women, prednisolone is usually recommended as it has a lower transfer rate to breast milk and is considered
safe for the infant. Infants should be monitored for signs of adrenal insu
2,5
“ I s t h e r e a n y c h a n c e y o u a r e p r e g n a n t , o r a r e y o u c u r r e n t l y b r e a s t f e e d i n g?”
Drug history2
An accurate drug history is essential to identify potential drug interactions.
Patients should avoid taking steroids with NSAIDs (e.g. ibuprofen) as this increases the risk of stomach or duodenal ulceration
and bleeding. However, if a patient needs to take both medications, a proton pump inhibitor (PPI) can be prescribed to reduce
this risk.
For patients on immunosuppressive doses of corticosteroids, live vaccines (e.g. polio, MMR and BCG) should be avoided.
These vaccines should be postponed for at least 3 months after the patient stops taking high-dose steroids, as they may
develop a life-threatening infection.
6
Other medications which may interact with systemic corticosteroids include\:
2
Anticoagulants
Anticonvulsants
Diabetes medication
HIV medication and protease inhibitors
Corticosteroids can increase the chance of hypokalemia when prescribed with other potassium-lowering medications.
Medications which reduce potassium levels include diuretics, laxatives, bronchodilators, insulin and digoxin.
8
“ A r e y o u c u r r e n t l y t a k i n g a n y r e g u l a r m e d i c a t i o n s o r o v e r-t h e-c o u n t e r m e d i c i n e s ?”

What are corticosteroids?

Corticosteroids, or steroids, are medications used to reduce in
conditions.
5
Corticosteroids are produced naturally in the cortex of the adrenal gland, regulated by the hypothalamic-pituitary-adrenal
(HPA) axis. They are involved in many physiological processes, including stress and immune response, in
electrolyte levels.
Systemic corticosteroids are administered orally or by injection and a
corticosteroids are applied topically, as drops, inhaled, or through intra-articular injection, targeting a speci
Common systemic corticosteroids include dexamethasone, hydrocortisone,
Systemic corticosteroids can be used in the treatment of autoimmune disease (e.g. in
arthritis, autoimmune hepatitis or systemic lupus erythematosus), allergic in
eczema), corticosteroid replacement therapy (e.g. adrenal insu
6,8
Make it clear to the patient that corticosteroids di
3
mass.
“ C o r t i c o s t e r o i d s , c o m m o n l y j u s t c a l l e d s t e r o i d s , a r e m e d i c a t i o n s u s e d t o r e d u c e i n
s y s t e m . T h e y a r e c o m m o n l y u s e d t o t r e a t a r a n ge o f c o n d i t i o n s s u c h a s a s t h m a , r h e u m a t o i d a r t h r i t i s , a n d s k i n c o n d i t i o n s l i k e
”
e c z e m a .
How do systemic corticosteroids work?8,9,10
There are two classi
Glucocorticoids\: potent inhibitors of in
Mineralocorticoids\: in
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Corticosteroids have several di
expression of cells. This reduces the in
in
They can also have mineralocorticoid activity, stimulating sodium resorption and water retention with selective potassium
excretion by the kidneys.
Synthetic corticosteroid drugs have di
example, dexamethasone has almost purely glucocorticoid ecroup). In contrast,

hypotension.
“ C o r t i c o s t e r o i d s w o r k b y r e d u c i n g i n
b e h a v e . T h i s r e d u c e s s w e l l i n g , r e d n e s s a n d p a i n f r o m i n
”

How to take steroids

Systemic steroids are available in various forms, including tablets, liquids, powders, and injectables, but they are most
commonly prescribed as a tablet.
Steroids should be taken at the same time(s) each day, usually in the morning. This is because steroids can cause insomnia,
and taking them in the morning mimics the body’s normal circadian rhythm.
2,5
Oral steroids should be taken with or soon after a meal, typically breakfast, as they can irritate the stomach. Patients should
take all their prescribed tablets in a single administration. Sometimes, this is a signi
patient is prescribed a daily dose of 40mg of prednisone, they would need to take eight 5mg tablets.
7

Duration of treatment

The duration of treatment varies depending on the condition. Some patients may require long-term corticosteroids (months to
years).
The doses of steroid can be adjusted based on the patient’s response to the therapy and the severity of the condition.
Patient factors (e.g. age, medical history, weight, and overall health) are considered when determining the appropriate dose and
duration of treatment. The goal is to use the lowest e
minimise side e
7, 10
“ T h e d u r a t i o n o f s t e r o i d t r e a t m e n t a n d t h e d o s e p r e s c r i b e d w i l l d e p e n d o n h o w w e l l y o u r b o d y r e s p o n d s t o t h e t r e a t m e n t , a s
w e l l a s t h e n a t u r e a n d s e v e r i t y o f t h e c o n d i t i o n b e i n g t r e a t e d . A l t h o u gh s t e r o i d s a r e v e r y e
s h o r t e s t p o s s i b l e t i m e a n d a t t h e l o w e s t d o s e . T h i s r e d u c e s t h e r i s k o f a n y s i d e e
”

Missed doses

Patients who forget a dose should take it as soon as they remember. However, if it is the next day or time for their next dose,
they should not take two doses to compensate for the forgotten dose.
3
“ I f y o u f o r g e t t o t a k e y o u r s t e r o i d a t t h e p r e s c r i b e d t i m e , t a k e i t a s s o o n a s y o u r e m e m b e r . H o w e v e r , i f i t’ s a l m o s t t i m e f o r y o u r
n e x t d o s e , s k i p t h e m i s s e d d o s e a n d r e s u m e y o u r r e gu l a r d o s i n g s c h e d u l e . D o n o t t a k e a n e x t r a d o s e t o m a k e u p f o r a m i s s e d
d o s e .
”

Steroid monitoring

Before patients start long-term systemic corticosteroid treatment, baseline tests should be performed\:
2,10
Blood pressure, body weight, and BMI measurements
Eye examination to assess for cataracts or glaucoma
Blood tests\: HbA1c, triglycerides, and potassium levels
Patients should be screened for adverse e
2
Regular blood pressure and body weight checks
An eye examination every 6-12 months to monitor for cataracts and glaucoma
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Triglycerides and potassium levels one month after initiation and then every 6-12 months
HbA1c 1 month after initiation after treatment, then every 3 months
“ B e f o r e s t a r t i n g s t e r o i d s , y o u w i l l n e e d s o m e b a s e l i n e t e s t s l i k e y o u r b l o o d p r e s s u r e , w e i gh t a n d a n e y e e x a m i n a t i o n . Y o u w i l l
a l s o n e e d a b l o o d t e s t t o c h e c k y o u r b l o o d s u g a r a n d e l e c t r o l y t e l e v e l s .
”
“ W h e n y o u a r e t a k i n g s t e r o i d s , w e w i l l r e v i e w y o u r e gu l a r l y . w e i g h t .
”
I t i s i m p o r t a n t t o m o n i t o r y o u r b l o o d p r e s s u r e , b l o o d s u ga r a n d

What are the side e

Like all medications, there are side e
patients about the signs associated with serious side e
Patients are more likely to experience side e
repeated short courses.
Common short-term side e
3,7,10,11
Sleep disturbance and insomnia
Weight gain\: this can be due to increased appetite and water retention
Mood changes

Long-term side e

Prolonged use of corticosteroids can have serious long-term side e
3,7,10,11
Cushing's syndrome
Osteoporosis\: increased risk of fractures
Proximal muscle weakness
Hypertension
Hyperglycaemia and diabetes
Increased risk of infection
Adrenal insu
Peptic ulceration
Cataracts
Mental health problems\: depression, psychosis, delirium or suicidal thoughts
Cushing's syndrome
Cushing’s syndrome occurs because of prolonged exposure to excess glucocorticoids.
Typical clinical features of Cushing’s syndrome include\:
Truncal obesity
Bu
Supraclavicular fat pads
Moon facies
Proximal muscle wasting
Bruising
Peripheral oedema
Acne
For more information, see the Geeky Medics guide to performing a Cushing's syndrome examination.
“ S t e r o i d s c a n h a v e b o t h s h o r t-t e r m a n d l o n g-t e r m s i d e e
a n d m o o d c h a n g e s m a k i n g y o u f e e l i r r i t a b l e o r s h o r t-t e m p e r e d .
”
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“ I f y o u t a k e s t e r o i d s f o r a l o n g t i m e , y o u m a y b e a t r i s k o f m o r e s e r i o u s s i d e e
”
s t o m a c h
“ C o r t i c o s t e r o i d s c a n a l s o i n c r e a s e y o u r r i s k o f d e v e l o p i n g d i a b e t e s , h y p e r t e n s i o n , a n d c a t a r a c t s . I f y o u h a v e a n y c o n c e r n s o r
n o t i c e n e w s y m p t o m s w h i l e t a k i n g s t e r o i d s , i t’ s i m p o r t a n t t o s e e k a d v i c e . W e w i l l b e r e v i e w i n g y o u r e gu l a r l y w h i l s t y o u a r e o n
t r e a t m e n t , a n d w e w i l l m o n i t o r f o r a n y s i d e e
”
“ M o s t s h o r t-t e r m s i d e e
”
Steroid withdrawal & adrenal insu2,3,7
When patients take steroids for more than 3 weeks, it can cause adrenal insu
steroids can precipitate an adrenal crisis, which can be life-threatening.
Patients should be informed of the signs of adrenal insu
Feeling extremely tired and weak
Nausea and vomiting
Abdominal pain
Diarrhoea
Dizziness
Loss of appetite and weight loss
If patients are to stop steroids, the dose should be reduced gradually, as this allows the body to resume the natural production
of steroids.
“ I t’ s i m p o r t a n t t o t a l k t o y o u r d o c t o r b e f o r e s t o p p i n g s t e r o i d s . N e v e r s t o p t h e m s u d d e n l y . I f y o u h a v e b e e n t a k i n g s t e r o i d s f o r a
l o n g t i m e , s t o p p i n g t h e m a b r u p t l y c a n c a u s e a l i f e-t h r e a t e n i n g c o n d i t i o n c a l l e d a n a d r e n a l c r i s i s . T h i s o c c u r s b e c a u s e y o u r
b o d y’ s n a t u r a l p r o d u c t i o n o f s t e r o i d s h a s b e e n s w i t c h e d o
”
“ A n a d r e n a l c r i s i s c a n c a u s e s y m p t o m s s u c h a s t u m m y p a i n , f e e l i n g s i c k , d i z z i n e s s , f e v e r , h e a d a c h e , w e i gh t l o s s o r f e e l i n g
e x t r e m e l y t i r e d a n d w e a k . I f y o u e x p e r i e n c e a n y o f t h e s e s y m p t o m s , e s p e c i a l l y i f t h e y o c c u r s u d d e n l y o r s e v e r e l y , s e e k u r ge n t
m e d i c a l h e l p .
”
“ W h e n s t o p p i n g s t e r o i d s , y o u r d o c t o r w i l l v e r y g r a d u a l l y r e d u c e y o u r d o s e , a g a i n .
”
a l l o w i n g y o u r b o d y t o s t a r t m a k i n g i t s o w n s t e r o i d s
Steroid emergency card12,13,14
Patients with adrenal insusteroid emergency
card or medical alert bracelet. This should include patient details, information about the steroid medication and dosage, and
emergency contact information.
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The NHS steroid emergency card for adults from the Society of Endocrinology. [14]
Steroid emergency cards should be issued to patients taking the following doses of cortiosteroids\:
15
Prednisolone 5mg per day (or an equivalent steroid) for four weeks or longer (all routes of administration - oral, topical,
inhaled or intranasal)
Inhaled beclomethasone >1000 mcg per day or
Patients should be educated on the importance of carrying the card, as this ensures steroids are never omitted or discontinued,
as missed doses or illness can trigger an adrenal crisis.
“ A s t e r o i d e m e r g e n c y c a r d i s a s m a l l c a r d y o u s h o u l d a l w a y s c a r r y i f y o u t a k e r e gu l a r s t e r o i d s . T h i s c a r d i s i m p o r t a n t i f y o u
b e c o m e a c u t e l y u n w e l l , t h e h e a l t h c a r e t e a m n e e d t o k n o w t h a t y o u t a k e s t e r o i d s a s s t o p p i n g o r m i s s i n g a d o s e c o u l d b e l i f e-
t h r e a t e n i n g . A l w a y s k e e p i t w i t h y o u a t a l l t i m e s a n d s h o w i t t o a n y h e a l t h c a r e p r o f e s s i o n a l y o u s e e .
”
Steroid sick day rules2,12,16
Patients with adrenal suppression cannot produce enough natural steroids to cope with acute stress (e.g. illness, trauma or
surgery). Therefore, they must increase their steroid dose to prevent an adrenal crisis. These are called 'sick day rules'
.
Usually, the daily dose is doubled during an acute illness. The increased dose should be continued until the patient recovers,
and then the dose is reduced back to the usual maintenance dose.
“ W h e n y o u g e t s i c k , y o u r b o d y n a t u r a l l y p r o d u c e s m o r e s t e r o i d s t o h e l p y o u c o p e w i t h t h e s t r e s s o f t h e i l l n e s s . H o w e v e r , i f y o u
h a v e b e e n t a k i n g s t e r o i d s f o r a l o n g t i m e , y o u r b o d y’ s n a t u r a l p r o d u c t i o n o f s t e r o i d s m a y h a v e b e e n s w i t c h e d o
l e a d t o a l i f e-t h r e a t e n i n g a d r e n a l c r i s i s .
”
“ T o a v o i d t h i s , i t i s i m p o r t a n t t o f o l l o w s i c k d a y r u l e s . I f y o u b e c o m e s u d d e n l y u n w e l l , w e m a y n e e d t o i n c r e a s e y o u r s t e r o i d
d o s e . P l e a s e c o n t a c t u s i f y o u b e c o m e u n w e l l w h i l s t t a k i n g s t e r o i d s .
”
.

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Ask the patient if they have any questions or concerns that have not been addressed.
Finally, thank the patient for their time and o
Dispose of PPE appropriately and wash your hands.
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Reviewer

Holly Elwell
Highly Specialist Pharmacist for Medical Education
Honorary Lecturer in Pharmacology and Prescribing Practice

References

1. Medscape UK. D r u g a l l e r g y \: d i a g n o s i s a n d m a n a g e m e n t . 2014. Available from\: [LINK]
2. NICE CKS. S c e n a r i o \: C o r t i c o s t e r o i d s . 2020. Available from\: [LINK]
3. NHS. S t e r o i d t a b l e t s . 2020. Available from\: [LINK]
4 NHS S t e r o i di n j e c t i o n s 2023 Available from\: [LINK]
Source\: geekymedics.com
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