Subject:Â Corticosteroid (CS) Stewardship Best Practices
Patient:Â Population Adults and children
Rationale:Â Â 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:Â Â 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:Â 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:
• Healthcare organizations should develop their own CS stewardship statement and/or policies and procedures
• Each organization and clinician should strive to use the lowest effective dose for the shortest effective duration to manage the acute medical problem.
• To support the CS statement, organizations should develop a system to monitor CS utilization among clinicians and then to provide coaching as necessary to comply with the CS stewardship statement and evidence-based medicine
• Clinicians should be encouraged to provide information to patients on the risks and benefits of steroid use and to document that discussion in the medical record
• Some healthcare organizations may even consider requiring clinicians to have patients sign an informed consent, as is customary with steroid epidural or joint injections
• Clinicians are asked to consider CS sparing treatment options when CS use is not supported by guidelines
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.Â
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/s3fspublic/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-helpfultreating-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-legalconsiderations-and-legal-adventures
Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature
https://pubmed.ncbi.nlm.nih.gov/34151596/
