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Steroid stewardship: An urgent need of the hour

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#Diabetes and Endocrinology  #Multispeciality 

Dr Sanjay Kalra, DM (AIIMS); President-elect, SAFES, Bharti Hospital, Karnal, India; and Dr Suneet Kumar Verma, Department of Internal Medicine, Alchemist Hospital, Panchkula, and Sparsh Clinic, Panchkula    29 April 2022

Steroids are a very frequently prescribed drug for a wide variety of indications including asthma, COPD, rheumatoid arthritis, SLE, allergies, eczema, anaphylaxis, urticaria, shock, IBD, MS, prevention of graft rejection. They have been used in almost all specialties of clinical medicine. However, their use has come into sharp focus with the advent of the Covid pandemic. Steroids have transformed the management of Covid-19 following the publication of the groundbreaking RECOVERY trial, which showed that low dose dexamethasone reduced mortality in hospitalized patients on mechanical ventilation or those receiving oxygen without invasive mechanical ventilation. Steroids came as a beacon of light amidst the crisis and uncertainty and soon became a standard of care for hospitalized Covid patients and along with anticoagulants have averted thousands of deaths.

Nonetheless, steroids are a double-edged sword. The beneficial and adverse effects often occur hand in hand. Both short-term and long-term risks are associated with steroids, which affect almost every organ.

Short-term risks include fracture, sepsis, VTE, mood changes, dyspepsia, insomnia. The long-term adverse effects include depression, anxiety, insulin resistance/diabetes, weight gain, osteoporosis, infections (secondary or opportunistic), hypertension, to name a few. Steroids are the most common cause, aside from pituitary disorders, of secondary adrenal insufficiency leading to adrenal crisis, a potentially fatal condition. Besides uncontrolled diabetes, the overuse and indiscriminate use of steroids in Covid patients was a major factor for the “epidemic” of rhino-orbital-cerebral mucormycosis (ROCM), popularly known as the “Black fungus”.

Given the numerous health risks associated with steroids, which may at times be irreversible, there is an urgent need for steroid stewardship along the same lines as antibiotic stewardship to curb their indiscriminate use and at the same time promote their rational use. The need becomes even more relevant in the context of the current Covid-19 pandemic.

The Merriam-Webster dictionary describes stewardship as “the conducting, supervising, or managing of something especially: the careful and responsible management of something entrusted to ones care”. We have defined steroid stewardship as “the systematic effort to prescribe and monitor glucocorticoids in a rational manner, while balancing benefit and potential risk, in patients who require this therapy”.1 Stewardship is not just limited to oral/parenteral steroid formulations. Given the expansive indications, all topical preparations including ointments, creams, gels, eye/ear drops, lotions, sprays also come under the ambit of stewardship.

Steroid stewardship begins before steroids are prescribed and continues during their administration.1

Pre‑prescription stewardship includes the awareness of the right indication for use, patient counselling and education and screening for metabolic and endocrine conditions such as dysglycemia, sarcopenia, obesity, uncontrolled diabetes, which may be unmasked or worsened by steroid use. Three mnemonics can come to the aid of the physician in this regard. “The mnemonic BLACK provides a checklist for steroid counseling: Benefits, Limitations, possible Adverse events, Cost, and Knowledge/skills required to use steroid. The mnemonic 4C: contraindications, concerns, caveats, and checkpoints remind the treating physician to rule out contraindications, remember the caveats related to steroid use and observe the checkpoints (or monitoring rules) during steroid use. The 5D rubric – dosage for initiation delivery, duration of treatment, dose titration/holiday, sick day management, and documentation is another tool which helps appropriate patient counseling and care”.1

During administration, patients should be duly instructed about the duration of therapy, the tapering schedule and the dangers of abruptly stopping. Sick day rules must be clearly explained. 1

Notably, steroid stewardship does not end with cessation of therapy. It continues even after treatment is stopped. Post-steroid stewardship involves monitoring patients for any adverse events (such as hypertension, osteoporosis, dysglycemia, infections, dyslipidemia) and acting in time to minimize their impact on the patient.1

The rampant use of antibiotics has led to the escalating public health crisis of antibiotic resistance, which is threatening to take us back to the “pre-antibiotic era” and could well be the next pandemic. The current pandemic has fast-tracked this threat due to the widespread use of antibiotics in Covid patients to prevent secondary infections. Antibiotic Stewardship Programs are in place to optimize rational use of antibiotics and mitigate antibiotic resistance. India has a National Action Plan on Antimicrobial Resistance. The Ministry of Health & Family Welfare has identified AMR as one of the top 10 priorities for its collaborative work with WHO.

There is a similar need to introduce steroid stewardship programs at institutional levels to improve the risk-benefits of these life‑saving drugs. “Each healthcare team should have a written steroid stewardship document, relevant for its clinical environment. This must contain a prescription checklist, preferred names, doses and route of administration of steroids, protocols for dose titration and tapering, and instructions for post‑prescription follow‑up”.

We should be mindful of the “five rights” for safe medication practices: the right patient, the right drug, the right time, the right dose, and the right routes”. 2 The law of “therapeutic parsimony” also requires a mention here. When applied to steroid use, it states “long‑term complications of steroid use can be mitigated by using the minimum required dose of steroids, for the shortest duration necessary”. 3

References

  1. Kalra S, Kumar A, Sahay R. Steroid stewardship. Indian J Endocr Metab 2022;26:13-6
  2. Grissinger M. The Five Rights. P T. 2010 Oct; 35(10):542.
  3. Kalra S, Gupta Y, Sahay R. The law of therapeutic parsimony. Indian J Endocrinol Metab. 2016;20(3):283-4.

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