1. Guidelines on Indications of Use of Steroids
Annie Kung
Specialist in Endocrinology, Diabetes & Metabolism

2. Types of Steroids Replacement Therapy glucocorticoid (hydrocortisone)
mineralocorticoid (fludrocortisone)
Anti-inflammatory Therapy
Short acting: hydrocortisone
Intermediate acting: prednisolone; methylprednisolone; triamcinolone
Long acting: dexamethasone

3. Chinese Translation for Steroid
From Google; English-Chinese Dictionary
Steroid 類固醇
Corticosteroid類固醇;皮質類固醇;
糖皮質激素;皮質激素
Hydrocortisone副腎荷爾蒙;腎上腺荷爾蒙

4. Routes of Administration
Systemic : oral, transrectal, IV, IM
Local: topical, intranasal, intraocular, intraarticular

5. Availability of International Guidelines on Use of Steroid
No one-for-all guideline
Glucocorticoid Replacement Therapy : Guidelines published by Royal College of Physicians of London, UK ; not available from Endocrine Society, USA.
Systemic Use of Glucocorticoid: Guidelines available for EULAR (European League for Rheumatology)
Local Use of Steroid: guidelines on individual disease, general guidelines not available

6. Royal College of Physicians of London Guidelines on Glucocorticoid Replacement Therapy
Recommended Daily Dose for Glucocorticoid
Hydrocortisone (cortisol) 15-30mg
Cortisone acetate mg
Prednisolone 5-7.5mg
Dexamethasone 0.5mg
Recommended Daily Dose of Mineralocorticoid
Fludrocortisone mcg

7. Monitoring hydrocortisone replacement
Hypoadrenalism is a rare condition and should be managed by a specialist
Biochemical monitoring enables detection of minor degrees of under- or over-replacement
Symptoms of hypo- or over-replacement are vague
24 h urine free cortisol measurement should be in the normal range; mid-day and evening plasma cortisol should be >50nmol/l

8. Long-term Follow Up Regular review
Steroid card/bracelet/medallion indicating the diagnosis and replacement therapy
Advice for concurrent illness management and augmentation of replacement dose; IV therapy for surgery/hospitalisation
College of Physicians London, UK recommend patients on glucocorticoid replacement long-term FU by endocrinologist

9. EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases J N Hoes et al, Ann Rheum Dis 2007;66:1560–1567

10. EULAR Expert Recommendation
Top Number 1 Recommendation
1 a The ADVERSE effects of glucocorticoid therapy should be considered and discussed with the patient before glucocorticoid therapy is started
1 b This advice should be reinforced by giving information regarding glucocorticoid management
1 c If glucocorticoids are to be used for a more prolonged period of time, a ‘‘glucocorticoid card’’ is to be issued to every patient, with the date of commencement of treatment, the initial dosage and the subsequent reductions and maintenance regimens
Hoes et al Ann Rheum Dis 2007

11. EULAR Recommendation on Systemic Steroid
Initial steroid dose/dosage reduction/long-term dosing depends on underlying rheumatic disease, disease activity, patient response
Comorbidity should be evaluated: hypertension, DM, peptic ulcer, fractures and osteoporosis, cataract/glaucoma, infection, dyslipidaemia, NSAID
Monitoring: body weight, BP, oedema, lipid, glucose, ocular pressure, cardiac insufficiency
Prevention of bone loss with anti-resorptives+calcium+Vitamin D (assess of steroid dose/duration/BMD)
Children should be monitored for growth
IV Steroid during surgery if systemic steroid is used for >1 month
Gastric protection if concomittent use of NSAID

12. Intra-articular Steroid Injection
First use dated back to 1951 by Hollander et al for arthritic joints; evidence for effectiveness was based on anecdotal studies rather than placebo-controlled trials
Few facts but mostly opinions about diagnosis, which lesions to treat, optimal steroid choice, dosage, injection techniques, intervals, frequency
Triamcinolone; methylprednisolone; dexamathesone.
Insoluble/long-acting steroid remained in the joint, contact with inflamed synovial surface, taken up by synovial cells and absorbed into blood stream
Similar side-effects as systemic steroids although the percentage of patients having side-effects is less
Recommendation: injection by trained personnel, e.g. rheumatologist, orthopaedic surgeon, orthopaedic physiotherapists practitioners in certain countries

13. Common Indications for Local Steroid Injection
Trigger finger
Carpel tunnel syndrome
De Quervain’s tenosynovitis
Joint Arthritis
Chronic spinal pain/facet joint pain
Sacroiliac joint arthritis
Osteoarthritis
Rheumatoid arthritis

14. Side-effects of Steroid Injection Therapy
Systemic Side-effects
Facial Flushing
Menstrual Irregularity
Hyperglycaemia
Suppress pituitary-adrenal axis
Emotional upset
Anaphylaxis
Local Side-effects
Post-injection flare of pain
Skin depigmentation
Subcutaneous atrophy
Bleeding
Infection
Steroid Arthropathy
Tendon rupture/atrophy
Soft tissue calcification

15. Frequency of Intra-articular Steroid Injection
Prolonged steroid injection is associated with osteonecrosis
Injection frequency into major joints in lower limbs at no less than 3-4 month intervals. This is based on consensus rather than evidence
Joint sepsis is a known complication but rare (1 in 17,000-77,000)
Injection should be given by trained personnel

16. Use of Topical Corticosteroids according to British National Formulary
Indications: inflammatory condition of the skin other than infection.
Common indications: eczema, contact dermatitis, insect sting, eczema of scabies
Contraindications: infection (bacteria/viral/fungal), rosacea
Use of systemic and potent steroid in psoriasis should be avoided or given only under specialist supervision
BNF Formulary Guide: potency grouped as Mild/Moderate/Potent/Very Potent
Potent topical steroid should generally be avoided on the face and skin flexures except under special circumstances by specialist supervision
Intralesional steroid injection should be reserved by severe cases/localised lesions, eg keloid scars, hypertrophic lichen planus, alopecia areata

17. Side-effects with topical Steroid
Spread/worsening of untreated infection
Thinning of skin
Irreversible striae and telangiectasia
Contact dermatitis
Perioral dermatitis
Acne, worsening of acne rosacea
Depigmentation
hypertichosis

18. Caution with Topical Steroid
No more frequently than twice daily, apply thinly to the affected area only
Use the least potent formulation which is fully effective
Avoid prolonged use on the face and keep away from eyes
Caution in children and during pregnancy
Suppression of pituitary adrenal axis and even cause Cushing’s syndrome with prolonged use in large area