Diabetes, hypertension, and weight gain (all poor prognostic factors for COVID-19) are widely recognised adverse events associated with long-term corticosteroid use; however, the high prevalence of glucocorticoid-induced adrenal suppression (eg, in 20 [48%] of 42 patients with rheumatoid arthritis receiving prednisolone at ≥5 mg/day for at least 6 months
) is less well known.
Prompt supplementary corticosteroids are required in the context of significant intercurrent infection, including COVID-19, major trauma, or surgery; and intravenous corticosteroids are needed if vomiting.
Despite the importance for patient safety, guidelines regarding corticosteroid sick day rules for rheumatology patients are unclear and, consequently, there is variation in practice. Most clinicians double the corticosteroid dose, but this crude rule-of-thumb can lead to undertreatment or overtreatment. Clear information for patients is particularly important during the current COVID-19 pandemic due to restricted or modified access to usual levels of health care—eg, delayed or virtual conversion of clinic appointments and difficulty accessing helplines. In September, 2020, WHO recommended corticosteroids to reduce mortality in critically ill COVID-19 patients.
However, worse outcomes were suggested in patients with COVID-19 not requiring supplemental oxygen. Significantly poorer outcomes were reported in patients receiving at least 10 mg/day prednisolone (n=64)
for rheumatic disease, but to the best of our knowledge, there has been no evidence of adverse outcomes attributed to supplemental stress doses of corticosteroids in COVID-19.
The shielding guidance identified categories of patients as clinically vulnerable, who were advised to take extra precautions during the first peak of the pandemic in England. Some clinicians and patients elected to delay starting or increasing corticosteroids for inflammatory flares, due to perceived safety concerns and to avoid needing to shield. Anecdotally, we became aware of safety incidents (adrenal crises) after discontinuation of long-term corticosteroids or inadequate dose increments with concomitant COVID-19 (unpublished). In April, 2020, the BSR updated their advice to reflect endocrinology consensus guidelines on prevention of adrenal crisis for COVID-19.
These guidelines stated that hospitalised patients on long-term corticosteroids with COVID-19 should receive intravenous corticosteroids; in the community, patients taking 5 mg to 20 mg prednisolone daily should take 10 mg prednisolone twice daily and patients taking more than 20 mg should continue their usual dose, but in divided doses.
The twice-daily prednisolone dose (to mimic the stress response
), is an unfamiliar frequency of administration in rheumatology practice. We conducted an online survey, via the BSR (electronic newsletter and social media), between May 16, and July 16, 2020, to assess corticosteroid sick day rule counselling and to improve visibility of the COVID-19-specific corticosteroid guidelines.
We aimed for a sample size of 100 respondents, which was selected as a reasonable compromise between generalisability of the results and feasibility. Although the survey was done during the peak of the first wave of the COVID-19 pandemic, there was rapid engagement, with the target of 100 responses achieved within a short period of time. Respondent characteristics reflected the BSR professional body, as the majority of respondents were consultants.
71% changed their management and 16% stated that they had not read the guidance.
however, approximately half might have adrenal insufficiency and are at risk of adrenal crisis with significant intercurrent infection, as highlighted by the UK National Patient Safety Alert.
Patients with primary adrenal insufficiency on replacement corticosteroids exhibit greater knowledge of sick day rules than patients receiving corticosteroids for non-endocrine immunosuppressive indications, and therefore rheumatology patients might be at higher risk of adrenal crisis.
and patient information leaflets.
Consideration should be given to the type and severity of stressors (eg, infection, surgery, and trauma). Guidelines published in May, 2020,
recommend perioperative stress-dosing, despite limited evidence. Supplemental steroid dosing during times of physiological stress is considered the safest approach. Guidance is also needed for the evaluation of adrenal insufficiency in patients taking long-term prednisolone.
CC, HLS, and SLM contributed equally. PM is a Medical Research Council (MRC)-GlaxoSmithKline (GSK) EMINENT clinical training fellow with project funding outside the submitted work. PM receives co-funding by the National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre. PM has served on an advisory board for SOBI, outside the submitted work. VR reports grants from Roche (Basel) outside the submitted work and funding support from MRC. SM reports non-financial support from Roche (co-investigator on a grant), Sanofi (advisory board and consultancy), GSK (local investigator on GSK-sponsored study), and travel expenses for conference attendance from Roche, outside the submitted work; and Patron of the UK charity, PMRGCAuk. This report presents independent research supported by the NIHR Leeds Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. All other authors declare no competing interests. We thank all respondents of the survey and the British Society for Rheumatology for disseminating the survey.
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Published: December 03, 2020
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© 2020 Elsevier Ltd. All rights reserved.
