Recommendations for prescribing:
• Do not administer corticosteroids unless absolutely indicated or more conservative measures have failed.
• Keep dosage and duration of administration to the minimum required for adequate treatment.
• Screen for tuberculosis with a purified protein derivative (PPD) test or chest radiograph before commencing long-term corticosteroid therapy.
• Screen for pregnancy in reproductive age women; recommend contraceptive measures.
• Screen for diabetes mellitus before treatment and at each clinician visit.
• Teach patient about the symptoms of hyperglycemia.
• Screen for hypertension before treatment and at each clinician visit.
• Screen for glaucoma and cataracts before treatment, 3 months after treatment inception, and then at least yearly.
• Monitor plasma potassium for hypokalemia and treat as indicated.
• Obtain bone densitometry before treatment and then periodically. Treat osteoporosis.
• Weigh daily. Use dietary measures to avoid obesity and optimize nutrition.
• Measure height frequently to document the degree of axial spine demineralization and compression.
• Watch for fungal or yeast infections of skin, nails, mouth, vagina, and rectum, and treat appropriately.
• With dosage reduction, watch for signs of adrenal insufficiency or corticosteroid withdrawal syndrome.
• Prepare the patient and family for possible adverse effects on mood, memory, and cognitive function.
• Inform the patient about other possible side effects, particularly weight gain, osteoporosis, and aseptic necrosis of bone.
• Counsel to avoid smoking and excessive ethanol consumption.
• Institute a vigorous physical exercise and isometric regimen tailored to each patient's abilities or disabilities.
• Administer calcium (1 g elemental calcium) and vitamin D 3 , 400-800 units orally daily.
-Check spot morning urines for calcium; alter dosage to keep urine calcium concentration < 30 mg/dl (< 7.5 mmoi/L).
-If the patient is receiving thiazide diuretics, check for hypercalcemia, and administer only 500 mg elemental calcium daily.
• If the patient has pre-existent osteoporosis or has been receiving glucocorticoids for ;, 3 months, consider prophylaxis:
- Bisphosphonate such as alendronate (70 mg every week orally), zoledronate (5 mg every year intravenously) for up to 3-5 years;
- Denosumab (60 mg every 6 months subcutaneously) for up to 3-5 years.
• Avoid prolonged bed rest that will accelerate muscle weakness and bone mineral loss. Ambulate early after fractures.
• Avoid elective surgery, if possible. Vitamin A in a daily dose of 20,000 units orally for 1 week may improve wound healing, but it is not prescribed in pregnancy.
• Fall prevention strategies: walking assistance (cane, walker, wheelchair, handrails) when required due to weakness or balance problems; avoid activities that could cause falls or other trauma.
• For ulcer prophylaxis, if administering corticosteroids with nonsteroidals, prescribe a proton pump inhibitor (not required for corticosteroids alone). Avoid large doses of antacids containing aluminum hydroxide (many popular brands) because aluminum hydroxide binds phosphate and may cause a hypophosphatemic osteomalacia that can compound corticosteroid osteoporosis.
• Treat hypogonadism.
• Treat infections aggressively. Consider unusual pathogens.
• Treat edema as indicated.
- CURRENT Medical Diagnosis & Treatment FIFTY-SIXTH EDITION (CMDT) - 2017: 1209