The Pharmaceutical Journal
Vol 279 No 7473 p406
13 October 2007

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Taking extra care with corticosteroids

Beth Hird discusses safety issues associated with corticosteroids and how pharmacists can promote the safer use of these medicines

The 54th edition of the British National Formulary (September 2007) draws attention to the psychiatric reactions associated with systemic corticosteroids (p377). It is stated that these drugs, particularly at high doses and in tablet form, can alter mood and behaviour early in treatment and rarely during withdrawal of treatment.

Systemic corticosteroids should be prescribed with care to patients who are predisposed to psychiatric reactions, including patients who have previously suffered corticosteroid-induced psychosis or who have a personal or family history of psychiatric disorders.

This advice is based on information received from the Medicines and Healthcare products Regulatory Agency (MHRA), which can be found in its “Drug safety update, volume 1, issue 2”.¹ This states that the risk of early psychiatric side effects is one of several important safety issues for health care professionals to discuss with patients and carers. Patients or carers should seek urgent medical advice in the event of any worrying symptoms.

Psychiatric reactions may occur in up to 5–6 per cent of patients and have been reported to include affective disorders, psychotic reactions, behavioural disturbances, irritability, anxiety, sleep disturbances and cognitive dysfunction.¹ The onset of such reactions, which may occur in both adults and children, tends to emerge a few days or weeks after treatment starts.

Patients with a history or close family history of affective disorders should be treated with a corticosteroid with care. Most patients recover from these reactions with a reduction in dose or withdrawal, although specific treatment may be necessary.¹ Psychiatric side effects have also been reported on withdrawal of treatment.¹

The BNF 54 also reminds us that a patient information leaflet should be supplied to every patient when a systemic steroid is prescribed. The minimum information supplied should be that which accompanies the medicine. Additional patient information leaflets are available (see Resources).

The BNF 54 also states that patients should be informed of specific side effects, including the psychiatric effects of corticosteroids, and they should be provided with information about the withdrawal of corticosteroids.

What role can pharmacists play?

What does this mean for pharmacists? What advice should pharmacists be giving to patients — whether we are writing the prescription or dispensing the medicine?

Explain the reason for the medicine As the prescriber we should make sure that we explain what the medicine is for and how effective it is (sometimes it is life saving). A concordant approach should be taken, where appropriate, within the consultation and all risks and benefits explained to ensure agreement on the way forward for the patient’s treatment.

Pharmacists should ensure that we discuss the key safety issues with patients and their carers in language that they can understand to ensure that they are fully informed.

As the pharmacist dispensing the medicine we should make sure that we know why the medicine has been prescribed and explain this to the patient, emphasising the consequences of not taking it. The use of a patient information leaflet may be helpful to support any further information provided to the patient.

Reassure about side effects We should reassure patients that most people do not experience serious side effects. However, patients may wish to be aware of the following signs and symptoms. If they experience these signs and symptoms they should continue to take their tablets and seek further medical advice (the side effects listed below relate mainly to steroids taken as tablets or by regular injection). Signs to look out for include²:

• Mood changes, depression, suicidal thoughts or feeling high, difficulty sleeping, confusion and agitation

• Skin rashes or other signs of infection

• Stomach problems, eg, nausea, diarrhoea and pain

• Worsening of diabetes (ie, higher blood sugar levels)

• Worsening of epilepsy (ie, more frequent fits)

• Headaches

• Changes to menstruation

• Poor vision (usually a long-term side effect)

Steroids may reduce the body’s ability to fight infection, so the person may be more likely than usual to catch infection, or be more unwell when this happens. Chicken pox is a particular concern, therefore if the person has not had chicken pox, he or she should avoid close contact with anyone who has chicken pox or shingles.

Explain potential long-term effects Pharmacists may want to cover some of the other potential side effects that could occur. Again, pharmacists should remember to reassure that most patients do not get serious side effects. Other side effects include²:

• Muscle weakness

• Thinning of the bones and an increased risk of fractures

• Reduced growth in children

• High blood pressure

• Change in the appearance of skin: bruising and stretch marks

Demonstrate use of the medicine It is important to remember that pharmacists, whether prescribing or dispensing the medicine, can play a key role in counselling patients to ensure that the patients know how and when to take their medicines. We may want to demonstrate inhaler technique should the steroid be in inhaled form.

Warn not to stop medicines suddenly Unless on a short course, patients should be reminded not to stop taking their steroid medicine suddenly, but to ask a health care professional who will advise if, when and how they should stop taking it. Abrupt withdrawal may cause an acute flare-up of the disease, or could cause adrenal suppression if the corticosteroid has been taken for longer than three weeks.

Adrenal suppression may last for up to a year or more after taking cortico-steroids and the patient must remember to tell health care professionals about the course when receiving treatment for any illness or injury.

Remind patients to speak up Patients should always remember to tell health care professionals that they are taking or have been taking a corticosteroid — they should be given a blue card if they are taking tablets for more than three weeks or are on a high dose of steroid inhaler.² Patients can use the blue card as a reminder for themselves and other health care professionals.

A list of questions and answers for patients on the safety of corticosteroids is available on the Medicines and Healthcare products Regulatory Agency’s website (see reference 2).

References

1. Medicines and Healthcare products Regulatory Agency.
Drug safety update, volume 1, issue 2

2. Medicines and Healthcare products Regulatory Agency.
Steroids: 10 questions and answers for patients