Corticosteroid Stewardship

Systemic corticosteroids (S-CS) have a significant role in Urgent Care medicine, primarily in use of significant infectious and immune-mediated conditions. It is imperative to establish appropriate S-CS prescribing practices amongst clinician’s while simultaneously being supported by organizational guidelines and algorithms. Though ultimately, responsible use of S-CS is a clinician’s responsibility, prescribers are urged to review risks of use, as well as the potential for misuse and overuse, with patients at each visit where appropriate and should be documented in the medical record. (It is noted, that expansive use of inhaled and topical corticosteroids can lead to systemic effects, these notes will primarily address parenteral and oral uses. These recommendations are also geared toward immunocompetent adult patients).

In particular asthma presents specific challenges to both patients and Urgent Care providers alike. Recommendations for S-CS stewardship in asthmatic conditions are being encouraged by the major asthma and allergy foundations. This particular subset of patients are at a higher risk of exposure to S-CS and remaining up to date on treatment guidelines is a must. More information can be found here: Asthma & Allergy Foundation of America.

Oral Corticosteroids

Risk of OCS use, all patients

Patients at an increased risk of the above effects include extremes of age (pediatric and geriatric populations), those with conditions already noted in the indirect risk column, like diabetes and osteoporosis, and any patient with metabolic conditions that can increase the bioavailability of the steroid (CKD, CLD, endocrine disorders).

There is no one algorithm for appropriate use of S-CS. Each condition in which S-CS are considered require individualized review of evidence based best practices and patient risks. The bottom line, before prescribing a S-CS for a patient, consider if there are other more appropriate options.

Time for Stewardship?

CUCM Position Statement

References to CUCM position

Resources

Time for Stewardship?

by Joe Toscano, MD – August 11, 2023

The side-effects of the long-term use of corticosteroids have been known to clinicians and even many patients for some time, but since the publication of a paper1 by Waljee at al in 2017, there has been growing interest in understanding the side effects of short-term steroid use. Their study was observational and retrospective, but what they found surprised many in acute care. In an insured population of over 1.5 million people 18 to 64 years old, 1 in 5 patients received a prescription for short-term corticosteroid treatment in the 2-year study period. The median duration of prescriptions was 6 days, in doses typically prescribed in Urgent Care. Compared to those not receiving corticosteroids, within 30 days of the prescription the rate of sepsis in those who received short-term steroids was over 5 times higher and venous thromboembolism over 3 times higher, and the risk of fracture almost doubled. Risks of these side effects decreased with time after the steroid prescription, but were still significantly increased 31-90 days after prescription, and increased risk was demonstrated even for daily doses lower than 20 mg prednisone equivalent per day. Over half of the prescriptions were for upper respiratory tract infections, spinal conditions, allergies, bronchitis, and other lower respiratory tract disorders. From this same data set, Rogers et al2 found that risk was even higher in diabetic than nondiabetic patients.

Published in 2020, another study3 by Yao et al examined an insurance database from Taiwan including over 15 million patients age 20-64 years old. The risk of GI bleeding was increased by a factor of 1.8, sepsis by 1.99 and heart failure by 2.37 within 5 to 30 days after a short-term (< 14 days) course of steroids. Over 16% of patients received a steroid prescription over the 2-year study period. The most common indications were dermatological conditions and respiratory tract infections.

And if the risk to patients from steroid use, even appropriate steroid use, is not enough to convince us to examine our practice, risk to the clinician exists as well. Corticosteroids have been reported to be the third most common medication involved in malpractice claims4. The most common complications in those cases have been avascular necrosis, changes in mood, and vision changes, which have been the side effects more traditionally associated with steroid use. Whether the new evidence of a wider range of complications resulting from short-term use results in more cases for broader types of “injury” remains to be seen.

Corticosteroids in treating disease

Pharmaceutical corticosteroids were developed to mirror the actions of the adrenal glands’ natural corticosteroid hormones5. Hydrocortisone was initially developed for the treatment of Addison’s disease, a true hormone deficiency state. Subsequently, the use of supraphysiologic amounts of corticosteroids started, to treat rheumatoid arthritis and other connective tissue diseases showed promise. The use of systemic steroids has subsequently become far more generalized with, at best, poor quality evidence to support use for many indications. Even inhaled and topical steroids have the potential for local and systemic side effects that need to be balanced with benefit when making treatment decisions.

Unnecessary prescribing

Due to their many effects, patients do feel different, even “better”, when taking corticosteroids, but if there is little or no evidence of these medications helping a patient’s underlying disease process, the only thing that can potentially happen is side-effects. There is no high-quality evidence that corticosteroids improve meaningful clinical outcomes in undifferentiated respiratory tract infections or musculoskeletal complaints, and there is evidence of high rates of over-prescription in urgent care settings6. Even for such “tried and true” and potentially life-threatening indications as anaphylaxis and other allergic reactions, steroids do no improve relapses or repeat visits7. And with the risks that have been demonstrated, using them in these situations could be just asking for problems – for the patient and the clinician. As well, cumulative exposure to steroids increases risks of complications.

Where do we go from here?

Kalra et al summarized a reasonable stewardship plan in their 2022 publication8. Borrowing from Antibiotic Stewardship principles, the mantra boils down to a similar “right patient, right diagnosis, right drug, right dose, right duration”. Steroid Stewardship statements and position papers have been published by many organizations9,10,11,12,13, including the College of Urgent Care Medicine14. In addition to outlining the issue and the need for stewardship, the College of Urgent Care Medicine (CUCM) statement summarizes practice guidelines for appropriate corticosteroid use (Table 1), similar to what has been outlined for the primary care setting15, providing useful clinical guidance to urgent care clinicians. Informing patients of the risk of steroids and documenting this discussion is also strongly recommended.

Summary

Evidence suggests that even appropriate, short-term corticosteroid use can result in increased risk of sepsis, fractures, venous thromboembolism, gastrointestinal bleeding, and heart failure. Inappropriate use exposes patients to the same potential complications with no expectable clinical benefit. Anecdotal and study evidence suggests that high rates of corticosteroid use exist in urgent care. In the effort to prescribe appropriately, every clinician should:

· Be aware of the inappropriate indications for corticosteroid use and avoid prescribing in these cases

· Screen patients for recent and lifetime steroid use when making treatment decisions, as well as for diabetes, all of which increase risk even higher than baseline

· Get educated about the appropriate indications for corticosteroid use and prescribe the best dosing and duration of therapy

· Advise patients of the risks of steroid use with each prescription and document informed consent regarding the discussion

· Educate patients and colleagues, in general, about the issue; this may represent a paradigm shift for many, in terms of their customary expectations, training, and practice

· Look for more education on the steroid use and stewardship from UCA and CUCM!

References