Clinical audit suggestions: corticosteroids

Corticosteroids and immunosuppression

Standards

Patients on long-term corticosteroid treatment are considered immunosuppressed and should be offered a seasonal influenza vaccine and pneumococcal vaccine. See the British National Formulary (BNF) section 14.4 Vaccines and antisera. (Log-in required).

Audit criteria

• All adult patients on 20mg or more a day or children on 1mg/kg/day or more for longer than one month should be offered pneumococcal and seasonal influenza vaccination.

Search strategy

• Search for patients on systemic corticosteroids (BNF section 10.1.2) on repeat/automatic prescriptions.
• Refine search to adults on 20mg or more a day or children on 1mg/kg/day or more for longer than 1 month.
• Refine your search for influenza (65E) and pneumococcal (6572) vaccinations.
• Those patients who have not been vaccinated should be offered pneumonia and seasonal influenza vaccination.

Corticosteroids and osteoporosis risk

Standards

BNF section 6.6 – corticosteroid-induced osteoporosis

Glucocorticoid-induced osteoporosis: a concise guide to prevention and treatment (PDF, 183 kb). This was published in 2002 by The Bone and Tooth Society, National Osteoporosis Society and Royal College of Physicians.   

Audit criteria

All patients taking (or who are likely to take) >5mg a day of prednisolone (or equivalent) for over three months

• should be assessed for their risk of fragility fracture
• should have the following documented in their notes:
  • dietary advice (especially adequate calcium and vitamin D)
  • advice regarding regular weight-bearing exercise
  • advice regarding maintenance of body weight
  • smoking status and appropriate intervention
  • alcohol use and appropriate intervention
  • assessment of falls risk and advice if appropriate.

Search strategy

• Search for patients on systemic corticosteroids (BNF section 10.1.2) on repeat/automatic prescriptions.
• Follow algorithm to aid decisions on whether to investigate and/or treat these patients (see section BNF section 6.6.2) for their fragility fracture risk.

Corticosteroids and adrenal suppression

During prolonged therapy with corticosteroids adrenal atrophy develops and can persist for years after stopping. This places patients at high risk of adverse sequelae including acute adrenal insufficiency, hypotension or death.

Standards

BNF 6.3.2 Glucocorticoid therapy: cautions and contra-indications of corticosteroids

Audit criteria

All patients taking (or who are likely to take) >5mg a day of prednisolone (or equivalent) for over three months should be issued with a Steroid Treatment Card which gives guidance on minimising risk and provides details of prescriber, drug, dosage and duration of treatment