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Optimum management of glucocorticoid-treated patients

Nature Clinical Practice Endocrinology & Metabolism volume 4, pages 262–271 (2008)Cite this article

Abstract

Glucocorticoids are taken by approximately 2% of the US adult population at any given time. The powerful anti-inflammatory and immunosuppressive benefits of these drugs must, however, be weighed against their multisystem adverse effects. Clinicians should always prescribe the lowest possible dose for the shortest possible time. Patients should be informed of the short-term and long-term adverse effects to expect, particularly if the dose of glucocorticoids is expected to exceed the equivalent of approximately 7.5 mg prednisone daily for 2 months or more. At the commencement of glucocorticoid therapy, a patient's blood pressure, lipid profile, 25-hydroxyvitamin D3 level and fasting glucose level should be measured and baseline bone densitometry performed. Bisphosphonate therapy should be initiated for postmenopausal women and men with a bone density T-score below −1 or for those with a history of fracture. Regular ophthalmic screening for cataracts and glaucoma is warranted, and patients at high-risk of gastric ulceration (especially patients simultaneously taking nonsteroidal anti-inflammatory drugs) should receive proton-pump inhibitors. Prophylaxis against opportunistic infections is appropriate for high-risk populations, such as organ-transplant recipients. Trimethoprim plus sulfamethoxazole can be given to high-risk populations, such as organ transplant recipients. The duration of weaning from glucocorticoid treatment should be proportionate to treatment duration. Appropriate preventive therapy can mitigate many of the adverse effects associated with glucocorticoid therapy.

Key Points

  • Glucocorticoids should be prescribed at the lowest possible dose for the shortest possible time

  • Appropriate baseline tests for patients initiating chronic glucocorticoid therapy include lipid profile, vitamin D3 level, fasting glucose level, and bone densitometry

  • Bisphosphonate therapy is appropriate for glucocorticoid-treated men or postmenopausal women who have a bone density T-score of less than −1

  • Prophylaxis against opportunistic infections is appropriate for high-risk patients

  • The duration of weaning from glucocorticoids should correlate with the duration of treatment

  • Proton-pump inhibitors are appropriate for patients receiving concurrent nonsteroidal anti-inflammatory drugs

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Authors and Affiliations

  1. S Trikudanathan is a Member of the Faculty in the Department of Medicine at the Tufts University School of Medicine, and practices clinical medicine at the St Elizabeth's Medical Center, Boston.,

    Subbulaxmi Trikudanathan

  2. GT McMahon is a Member of the Faculty in the Division of Endocrinology at the Brigham and Women's Hospital, and an Assistant Professor of Medicine at Harvard Medical School, Boston, MA, USA.,

    Graham T McMahon

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Correspondence to Graham T McMahon.

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Trikudanathan, S., McMahon, G. Optimum management of glucocorticoid-treated patients. Nat Rev Endocrinol 4, 262–271 (2008). https://doi.org/10.1038/ncpendmet0791

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