Best practice for patients taking oral glucocorticoids

Introduction

Glucocorticoids (GC) are steroid hormones that have a significant role in regulating various physiological processes, including in metabolism and the body’s response to stress^​1​. The potent anti-inflammatory effects of GC make this class of medication crucial in the management of various chronic inflammatory diseases^​2​.

Synthetic GC have been used for decades in the treatment of chronic inflammatory conditions, with their use first documented in 1948 for the treatment of rheumatoid arthritis^​3​. When used for long-term disease control, prednisolone is the most prescribed oral GC in the UK^​4​. Asthma and chronic obstructive pulmonary disease (COPD) are the conditions most frequently treated with oral GC^​5​.

While GC are highly effective at treating chronic inflammatory conditions, their use has significant short- and long-term risks^​5​. In the short term, GC can increase the risk of infection and gastrointestinal ulceration, while long-term exposure is associated with complications, including osteoporosis, type 2 diabetes mellitus and cataracts. The likelihood of complications increases with both higher dosages and prolonged cumulative exposure. Furthermore, the risks of abrupt withdrawal of GC after prolonged exposure — even at low doses — can put patients at significant risk of adrenal insufficiency and adrenal crisis^​6​.

As experts on medicines, pharmacists are well placed in both community and hospital settings, to provide counselling on the risks of oral GC to patients. This article will cover appropriate counselling for patients starting oral GC. It is most relevant to patients on long-term, high-dose oral GC but may apply to other patient groups, including those at increased risk of complications such as patients with diabetes. 

Interactions

As with all newly started medications, a review of the patient’s current medications and clinical history should be completed prior to starting oral GCs. See Figure 1 for an overview of some drug interactions with GCs, but this list is not exhaustive^​7–14​.

Figure 1: Drug interactions with oral GC including examples and management 

Overview of side effects

GC do not often cause side effects if they are taken for a short period of time or at a low dose. For detail on what is considered high-dose or long-term GC, see Table 1^​4,7​. Prednisolone is used as an example of a widely used oral GC^​7​. Side effects are dependent on the type, strength and treatment duration, and usually cease when treatment is complete^​15​.

Table 1: Examples of high-dose, long-term oral prednisolone treatments

Excessive dosage or prolonged use of GC may potentiate their normal physiological effects, resulting in mineralocorticoid and glucocorticoid-related side effects (see Table 2)^​15,16​. Mineralocorticoids manage fluid and electrolyte balance, while glucocorticoids regulate metabolism and stress response.  

Patients should be advised to consult with their medical team if any of these side effects are experienced. Patients are at increased risk of developing infection while taking GC. It is important to rule out underlying infection prior to initiating therapies, patients should seek medical attention if they develop signs of infection. Hygiene practices should be encouraged including food and hand hygiene. See Table 2 for further information^{​15–19​}.

Table 2: Common side effects associated with oral GC

General principles for managing side effects can be seen in Box 1^​16,18​.

Proton pump inhibitors as an adjunct to oral GC

Proton pump inhibitors (PPIs) can be prescribed alongside oral GC to reduce the risk of gastrointestinal ulcers^​7,8​. Risk factors include patients with a history of gastrointestinal bleeding, perforation or ulceration or those taking medications that increase GI bleeding risk (e.g. non-steroidal anti-inflammatory drugs (NSAIDs)). PPIs should be considered in patients who are of older age, heavy smokers, who have excessive alcohol intake or have serious comorbidities such as advanced cancer^​7​.

Serious side effects

Although rare, serious side effects can occur. There is a risk of risk of central serous chorioretinopathy (i.e. fluid leaking under the macula, causing vision disturbances), patients should be advised to report any vision problems or disturbances, especially affecting one eye rather than both. If a patient presents with vision problems, refer to an ophthalmologist for evaluation of possible causes or alternatively, advise the patient to attend their nearest eye casualty.

If a patient presents with symptoms of adrenal crisis (e.g. severe hypotension, dizziness, severe nausea/vomiting), they should be advised to attend an emergency department urgently. Adrenal crises can occur in patients on long-term GC owing to trauma, illness, surgery and severe emotional stress. It is an emergency requiring treatment with intravenous steroids and fluids, as well as possible intensive care admission^​23​. When starting high-dose or long-term oral GC, patients should be counselled on the risks of adrenal insufficiency and adrenal crisis^​7​. Patients and healthcare professionals should be aware of symptoms of adrenal crisis (e.g. nausea, vomiting, fatigue, fever, weight loss, anorexia, abdominal pain, hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia) and what to do if these occur^​24​.

Vaccinations

In some situations, live vaccines can cause severe or fatal infections in immunosuppressed individuals owing to extensive replication of the vaccine strain^​23​. Live vaccines should not be given to patients (i.e. adults and children) receiving or who have in the past three months received:

• High-dose GC (i.e. >40mg prednisolone per day or 2mg/kg per day in children under 20kg) for more than one week;
• Lower-dose GC (i.e. >20mg prednisolone per day or 1mg/kg per day in children under 20kg) for more than two weeks.

Live vaccines may be given to immunosuppressed individuals if deemed appropriate according to Green Book guidance and their specialist (see Box 2)^​23​.

As live vaccines replicate after administration, ideally individuals who have received a live vaccine should wait until their immune response has been established to receive immunosuppressive therapy^​7,23​. For most viral live vaccines, a period of up to four weeks should be sufficient. However, as viruses in vaccines are generally attenuated, immunosuppressive treatment should not be delayed if this would result in the worsening of the underlying condition^​7,23​. Patients and pharmacists should engage with the clinical team when live vaccination is considered for individuals undergoing immunosuppressive therapy. 

Inactivated vaccines cannot be replicated and, therefore, may be administered to immunosuppressed individuals; although they may elicit a lower immune response^​7,23​. Where possible, inactivated vaccines should be given at least two weeks before treatment; however, they may be given during treatment, if deemed necessary. 

Considerations for bone health 

GC are associated with an increased risk of bone loss, which is more pronounced in the first few months of use, as well as bone fracture, which can occur with prednisolone or its equivalent at doses as low as 2.5 to 7.5mg daily^​25,26​.

Pharmacists should encourage patients to adopt lifestyle measures to reduce risk of GC-induced osteoporosis (see Box 3)^​7​. Patients should be reminded not to stop treatments of oral GC suddenly, even if they are worried about their osteoporosis risk and should be encouraged to consult with their GP or specialist for further advice^{​25–27​}.

Where possible, localised GC should be used (i.e. inhalers, topical, enemas, joint injections), to mitigate risk of systemic absorption. Bisphosphonate medications (e.g. risedronate, alendronic acid) may be considered in patients with higher risk of fracture (e.g., individuals of increasing age, women, menopause, smoking, alcohol, previous fractures, parenteral history of hip fracture, body mass index of <18.5kg/m²)^​7,28​.

What ‘sick day rules’ information do patients need?

Sick day rules provide information to patients on what to do if they have an acute illness or are due to undergo a surgical procedure. National Institute for Health and Care Excellence guidance, published in 2025, refers to information from the Society of Endocrinology; however, specific trust guidance should be checked first^​7,29​. There are various situations in which an increase in GC is required owing to illness and the advice is based upon the patient’s current GC dose^​29​. Patients may be advised to double their current dose or otherwise to split their dose to take half in the morning and half in the afternoon. Advice is also included for patients who are having planned surgery, where the clinical team must be informed beforehand of the patient’s GC use so that they can provide appropriate treatment throughout hospital admission. 

As part of sick day rules guidance, it is essential to highlight to patients the importance of not stopping GC abruptly, other than in specific circumstances, such as with very short courses^​29​. Patients should ensure they always have additional supply of GC in case they need to follow sick day guidance. 

Patients at risk of adrenal insufficiency should receive a steroid emergency card (red), while blue steroid treatment cards are given only in specific circumstances (see Figure 2^​30,31​).

For more with details concerning steroid emergency and steroid treatment cards, see Figure 3^​7​.

Figure 2: Steroid emergency and steroid treatment cards

Figure 3: Summary of when patients require steroid emergency, sick day rules and/or treatment cards

Considerations for stopping and tapering steroids

Tapering oral GC should be individualised to the patient, with the rate and extent of dose reduction guided by clinical context. Important considerations include the underlying condition being treated, the duration of therapy and patient-specific factors, such as the risk of relapse and reported side effects.

Gradual withdrawal of systemic GC should be considered in the majority of patients whose disease is unlikely to relapse, which includes:

• Adults who have received more than 40mg prednisolone — or equivalent — daily for more than one week;
• Children and paediatrics who have received more than 40mg prednisolone daily for more than one week or 2mg/kg daily for one week or 1mg/kg daily for one month^​32,33​.

Gradual withdrawal of GC should also be considered in the following patient scenarios:

• If the patient has been given repeat doses in the evening;
• If the patient received more than three weeks’ treatment;
• If the patient recently received repeated courses (particularly if taken for longer than three weeks); 
• If the patient has taken a short course within one year of stopping long-term therapy;
• Other possible causes of adrenal suppression^​32,33​.

In patients whose condition is unlikely to relapse and who have received treatment for three weeks or less and who are not included in the patient groups above, systemic GC may be stopped abruptly.

During GC withdrawal, the dose may be reduced rapidly down to physiological doses, which is equivalent to prednisolone 7.5mg daily in adults or prednisolone 2.0–2.5mg/m² daily in children, and then reduced more slowly. Ongoing clinical assessment during tapering is essential to monitor for potential disease recurrence.