Following concern about severe chickenpox associated with systemic corticosteroids, every patient prescribed a systemic corticosteroid should receive the patient information leaflet supplied by the manufacturer. Steroid treatment cards should also be issued where appropriate.

Patients receiving long-term oral corticosteroids should be assessed for risk of long-term side effects e.g. osteoporosis (Please refer to: Algorithm for Management of glucocorticoid osteoporosis / Prevention of Glucocorticoid – Induced Osteoporosis) or steroid cataract.

Patients with primary or secondary adrenocortical insufficiency need monitoring and should be under the care of an endocrinologist.

Equivalent doses of glucocorticoid activity:

5mg Prednisolone =

• Betamethasone 750 micrograms, or
• Dexamethasone 750 micrograms, or
• Hydrocortisone 20mg, or
• Methylprednisolone 4mg

Withdrawal of corticosteroids

The magnitude and speed of dose reduction in corticosteroid withdrawal should be determined on a case-by-case basis, taking into consideration the underlying condition that is being treated, and individual patient factors such as the likelihood of relapse and the duration of corticosteroid treatment. Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:

• received more than 40mg prednisolone (or equivalent) daily for more than 1 week
• been given repeat doses in the evening
• received more than 3 weeks' treatment
• recently received repeated courses (particularly if taken for longer than 3 weeks)
• taken a short course within 1 year of stopping long-term therapy
• other possible causes of adrenal suppression

Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above.

During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5mg daily) and then reduced more slowly. Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.

Prednisolone

• Tablets (non-enteric coated) 1mg, 5mg (£1.60 = 10mg daily)
• Soluble tablets 5mg (£89.60 = 10mg daily)
• Oral solution sugar free 10mg/ml (£55.50 = 30ml)
• Tablets 25mg

Indications

• Suppression of inflammatory and allergic disorders
• Prednisolone is the corticosteroid most commonly used by mouth for long-term disease suppression
• Acute gout

Notes

1. Oral solution 10mg/ml 30ml container. For patients unable to use standard tablets and when total treatment course exceeds 150mg (equivalent to more than 30 soluble 5mg tablets).
2. Prednisolone is the standard glucocorticoid steroid. The link with peptic ulceration and standard formulation of prednisolone is weak and therefore E/C tablets offer no additional benefit. Enteric coated preparations of prednisolone are not included in the formulary.
3. Prednisolone 25mg tablets are more expensive and are intended only for use in chemotherapy regimens that use very high dose steroids.
4. Soluble tablets are included for the treatment of acute asthma in children, and should be changed when the child is able to swallow tablets.

Hydrocortisone

• Injection (as sodium succinate) 100mg (£1.16 = vial)
• Injection (as sodium phosphate) 100mg in 1ml (£2.12 = 1ml ampoule)
• Tablets 10mg, 20mg (£1.86 = 30 x 10mg)
• 100mg (using injection) in 50 - 100ml normal saline for rectal administration
• Liquid 2.5mg/ml (unlicensed preparation)

Indications

• Adrenocortical insufficiency; hypersensitivity reactions

Notes

1. Hydrocortisone is included as a first line drug for adrenocortical insufficiency and hypersensitivity reactions only. If adrenocortical insufficiency is diagnosed the usual maintenance dose is 10mg in the morning, 5mg at midday and 5mg in the early evening. A daily profile of cortisol levels should be performed to check the adequacy of replacement
2. COVID-19 – treatment with corticosteroids (CAS alert, 03 September 2020): includes criteria for treatment of patients with severe or critical COVID-19 with corticosteroids, and dose schedules

Betamethasone

• Soluble tablets sugar free (as sodium phosphate) 500microgram (£19.75 = 100 tablets)
• Solution for injection 4mg in 1ml

Indications

• Suppression of inflammatory and allergic disorders
• Congenital adrenal hyperplasia

Dose

• Oral, usual range 0.5–5mg daily

Dexamethasone

• Tablets 500microgram, 2mg (£3.19 = 2mg x 50)
• Injection (as sodium phosphate) 3.3mg/ml, 3.8mg/ml (£2.00 = 3.8mg x 1ml ampoule)
• Oral solution sugar free 2mg/5ml (£42.30 = 150ml)
• Capsule 100 microgram (unlicensed preparation)

Indications

• Suppression of inflammatory and allergic disorders
• Diagnosis of Cushing's disease, congenital adrenal hyperplasia
• Cerebral oedema associated with malignancy
• Croup
• Nausea and vomiting with chemotherapy

Dose

• Oral, usual range 0.5–10mg daily

Notes

1. Dexamethasone has very high glucocorticoid activity and low mineralocorticoid activity therefore is suited to treat those conditions where additional fluid retention or oedema may be a problem e.g. cerebral oedema.
2. Different preparations of dexamethasone contain different salts. Therefore, care is needed to ensure that patients receive equivalent doses when transferring from tablets to injections. The equivalent doses are:
   1. 1mg dexamethasone (tablets)
   2. 1.3mg dexamethasone sodium phosphate (injections and oral solutions)
3. Dexamethasone (given by mouth) or budesonide (by nebuliser) may be used in the treatment of croup.
4. COVID-19 – treatment with corticosteroids (CAS alert, 03 September 2020): includes criteria for treatment of patients with severe or criticalCOVID-19 with corticosteroids, and dose schedules

Methylprednisolone

• Tablets 100mg
• Injection (as sodium succinate) 40mg, 125mg, 500mg, 1g
• Injection (as acetate) 40mg in 1ml, 80mg in 2ml

Notes

1. Methylprednisolone is used intravenously for specific conditions requiring high dose, short-term treatment
2. MHRA Drug Safety Update (October 2017): Do not use injectable methylprednisolone medicines that contain lactose in patients with known or suspected allergy to cows' milk