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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.
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).
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
Date: August 18, 2022
Subject: Corticosteroid Stewardship Best Practices
Patient Population: Adults and Children
Rationale
Steroid stewardship is needed in all clinical settings, including urgent care. It is acknowledged that corticosteroids can be a critical tool in the management of both acute and chronic conditions. The focus of this stewardship statement is to create awareness amongst clinicians regarding CS usage, encourage a stewardship approach, and to educate patients on the risks and benefits of their use and overuse.
Introduction
Steroid stewardship is the systematic effort to administer or prescribe glucocorticoids in a rational, evidence-based manner, balancing any benefits and the potential risks. There is evidence that even a short course of CS increases the risk of fracture, blood clots, GI bleeding, mood changes, sleep disturbances, heart failure, and sepsis. Long term or repeated use of CS can result in adrenal insufficiency and/or adrenal crisis. These risks may be present with a lifetime cumulative dose of steroids with a lower threshold than might be expected.
Significant drug interactions exist that impact how steroids and medications are metabolized, either increasing or decreasing the effect of CS and/or medications. CS are frequently involved in malpractice claims which can lead to costly payments and may result in a report to the National Practitioners Data Bank (NPDB).
Discussion
There is evidence that patients benefit from the proper utilization of CS and that they can potentially suffer serious consequences for using CS even when indicated.
Corticosteroid stewardship recognizes physicians’ and advanced practice providers’ responsibility to practice evidence-based medicine. Clinicians must assess the need for systemic CS in each individual patient, balancing benefit versus risk of harm. Clinicians have the responsibility to educate patients on the risk and benefits of CS based on the patient’s condition and individual health status including adverse drug reactions and drug interactions.
Major drivers for the inappropriate use of CS include clinicians’ lack of understanding of the risks of even short-course steroids, the appropriate and inappropriate indications for systemic CS, and patient expectations.
Strategies to assist clinicians with steroid stewardship:
Summary
Just as antibiotic stewardship is a clinician’s responsibility, so is CS stewardship. A change in CS prescribing practices will require ongoing education and involve extra effort and time spent with patients. Clinicians are encouraged to stay current on the appropriate use of CS and the potential risks of overuse and misuse. Medical providers should have a conversation with each patient to explain the decision to recommend CS for a specific diagnosis. Clinicians should include documentation in the medical record of the discussion with the patient on the risks and benefits of corticosteroids.
References
Corticosteroid Stewardship – Background
Provider Perceptions on Steroid Dosing in AECOPD; Laying the Groundwork for Steroid Stewardship Cole, J. L., & Smith, S. (2020). Provider perceptions on steroid dosing in AECOPD: Laying the groundwork for steroid stewardship. The clinical respiratory journal, 14(11), 1105–1108. https://doi.org/10.1111/crj.13247
Increased Risk of Venous Thromboembolic Events with Corticosteroid vs Biologic Therapy for Inflammatory Bowel Disease https://www.cghjournal.org/article/S1542-3565(14)01045-3/fulltext Short-term Corticosteroids and Avascular Necrosis: Medical and Legal Realities https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/080040343.pdf
Early Use of Corticosteroid May Prolong SARS-CoV-2 Shedding in Non-Intensive Care Unit Patients with COVID-19 Pneumonia: A Multicenter, Single-Blind, Randomized Control Trial ps://www.karger.com/Article/FullText/512063
Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort stud Waljee, A. K., Rogers, M. A., Lin, P., Singal, A. G., Stein, J. D., Marks, R. M., Ayanian, J. Z., & Nallamothu, B. K. (2017). Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort study. BMJ (Clinical research ed.), 357, j1415. https://doi.org/10.1136/bmj.j1415
Association Between Oral Corticosteroid Bursts and Severe Adverse Events Yao, T. C., Huang, Y. W., Chang, S. M., Tsai, S. Y., Wu, A. C., & Tsai, H. J. (2020). Association Between Oral Corticosteroid Bursts and Severe Adverse Events: A Nationwide Population-Based Cohort Study. Annals of internal medicine, 173(5), 325–330. https://doi.org/10.7326/M20-0432
Association of Oral Corticosteroid Bursts with Severe Adverse Events in Children Yao, T. C., Wang, J. Y., Chang, S. M., Chang, Y. C., Tsai, Y. F., Wu, A. C., Huang, J. L., & Tsai, H. J. (2021). Association of Oral Corticosteroid Bursts with Severe Adverse Events in Children. JAMA pediatrics, 175(7), 723–729.
Corticosteroid Stewardship – Specific Medical Conditions
Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care https://www.aafp.org/pubs/afp/issues/2020/0115/p89.html
Exogenous steroids treatment in adults. Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely https://www.endocrinology.org/media/4091/spssfe_supporting_sec_-final_10032021-1.pdf
4 Common Side Effects of Inhaled Steroids https://www.verywellhealth.com/side-effects-of-inhaled-steroids-83086
Is Dexamethasone Helpful for Treating Pharyngitis https://www.acepnow.com/article/dexamethasone-helpful-treating-pharyngitis/?singlepage=1&theme=print-friendly AND Corticosteroids as standalone or add-on treatment for sore throat https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008268.pub3/full
Steroid Statements
Joint Oral Corticosteroid Stewardship Statement https://www.aafa.org/media/2244/oral-corticosteroid-stewardship-statement-november-2018.pdf
Breathe California: Oral Corticosteroid Stewardship Statement https://www.lungsrus.org/oral-corticosteroid-stewardship-statement/
Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand https://onlinelibrary.wiley.com/doi/full/10.1111/resp.14147
Medicolegal Considerations
Informed consent and its documentation: Implications for medical malpractice liability https://bcmj.org/articles/informed-consent-and-its-documentation-implications-medical-malpractice-liability
Corticosteroids: Side Effects, Legal Considerations and Legal Adventures https://www.hmpgloballearningnetwork.com/site/thederm/site/cathlab/event/corticosteroids-side-effects-legal-considerations-and-legal-adventures
Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature https://pubmed.ncbi.nlm.nih.gov/34151596/
UNDER CONSTRUCTION – hyperlinks coming soon
Corticosteroid Stewardship – Background
Provider Perceptions on Steroid Dosing in AECOPD; Laying the Groundwork for Steroid Stewardship Cole, J. L., & Smith, S. (2020). Provider perceptions on steroid dosing in AECOPD: Laying the groundwork for steroid stewardship. The clinical respiratory journal, 14(11), 1105–1108. https://doi.org/10.1111/crj.13247
Increased Risk of Venous Thromboembolic Events with Corticosteroid vs Biologic Therapy for Inflammatory Bowel Disease https://www.cghjournal.org/article/S1542-3565(14)01045-3/fulltext Short-term Corticosteroids and Avascular Necrosis: Medical and Legal Realities https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/080040343.pdf
Early Use of Corticosteroid May Prolong SARS-CoV-2 Shedding in Non-Intensive Care Unit Patients with COVID-19 Pneumonia: A Multicenter, Single-Blind, Randomized Control Trial ps://www.karger.com/Article/FullText/512063
Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort stud Waljee, A. K., Rogers, M. A., Lin, P., Singal, A. G., Stein, J. D., Marks, R. M., Ayanian, J. Z., & Nallamothu, B. K. (2017). Short term use of oral corticosteroids and related harms among adults in the United States: population-based cohort study. BMJ (Clinical research ed.), 357, j1415. https://doi.org/10.1136/bmj.j1415
Association Between Oral Corticosteroid Bursts and Severe Adverse Events Yao, T. C., Huang, Y. W., Chang, S. M., Tsai, S. Y., Wu, A. C., & Tsai, H. J. (2020). Association Between Oral Corticosteroid Bursts and Severe Adverse Events: A Nationwide Population-Based Cohort Study. Annals of internal medicine, 173(5), 325–330. https://doi.org/10.7326/M20-0432
Association of Oral Corticosteroid Bursts with Severe Adverse Events in Children Yao, T. C., Wang, J. Y., Chang, S. M., Chang, Y. C., Tsai, Y. F., Wu, A. C., Huang, J. L., & Tsai, H. J. (2021). Association of Oral Corticosteroid Bursts with Severe Adverse Events in Children. JAMA pediatrics, 175(7), 723–729.
Corticosteroid Stewardship – Specific Medical Conditions
Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care https://www.aafp.org/pubs/afp/issues/2020/0115/p89.html
Exogenous steroids treatment in adults. Adrenal insufficiency and adrenal crisis-who is at risk and how should they be managed safely https://www.endocrinology.org/media/4091/spssfe_supporting_sec_-final_10032021-1.pdf
4 Common Side Effects of Inhaled Steroids https://www.verywellhealth.com/side-effects-of-inhaled-steroids-83086
Is Dexamethasone Helpful for Treating Pharyngitis https://www.acepnow.com/article/dexamethasone-helpful-treating-pharyngitis/?singlepage=1&theme=print-friendly AND Corticosteroids as standalone or add-on treatment for sore throat https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008268.pub3/full
Steroid Statements
Joint Oral Corticosteroid Stewardship Statement https://www.aafa.org/media/2244/oral-corticosteroid-stewardship-statement-november-2018.pdf
Breathe California: Oral Corticosteroid Stewardship Statement https://www.lungsrus.org/oral-corticosteroid-stewardship-statement/
Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand https://onlinelibrary.wiley.com/doi/full/10.1111/resp.14147
Medicolegal Considerations
Informed consent and its documentation: Implications for medical malpractice liability https://bcmj.org/articles/informed-consent-and-its-documentation-implications-medical-malpractice-liability
Corticosteroids: Side Effects, Legal Considerations and Legal Adventures https://www.hmpgloballearningnetwork.com/site/thederm/site/cathlab/event/corticosteroids-side-effects-legal-considerations-and-legal-adventures
Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature https://pubmed.ncbi.nlm.nih.gov/34151596/
