Saudi Journal of Clinical Pharmacy

SHORT COMMUNICATION
Year : 2022  |  Volume : 1  |  Issue : 4  |  Page : 107--111

The necessity of implementing steroid stewardship: Are we lagging behind antimicrobials and opioids?

Shabeer Ali Thorakkattil1, Gopika Krishnan2, Savera Ikram Arain1, Mohammed Salim Karattuthodi3, Mamdouh Mohammed Ahmed Ageeli1, Sarath Chandran4, Suhaj Abdulsalim5,  
1 Pharmacy Services Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
2 Department of Pharmacy Practice, The Erode College of Pharmacy, Erode, Tamil Nadu, India
3 Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Department of Pharmacy, College of Pharmaceutical Sciences, Government Medical College Kannur, Kannur, Kerala, India
5 Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Buraydah, Saudi Arabia

Correspondence Address:
Savera Ikram Arain
Pharmacy Services Department, Johns Hopkins Aramco Healthcare, Dhahran
Saudi Arabia

Abstract

Stewardship programs aiming at optimizing medication use are a core element of healthcare organizations. It allows for strategic interventions to improve both financial and therapeutic outcomes. The antibiotic and opioid stewardship programs have already been successfully established in several healthcare organizations. In addition to the financial aspect, they have also improved clinical outcomes and minimized harm by reducing antibiotic resistance, opioid use disorders, morbidity, and mortality. Steroids, also known as corticosteroids, are anti-inflammatory medications used to treat a range of conditions. If used inappropriately, they can result in serious and undesirable adverse effects. Steroid stewardship is a rather novel concept that aims to reduce inappropriate prescribing and improve clinical outcomes by creating a careful balance between therapeutic doses vs. doses that may cause adverse effects. The article’s objective is to highlight the need for a comprehensive approach to implement steroid stewardship programs as a multicomponent program involving multidisciplinary teams to identify potential treatment gaps and establish cognitive and practical approaches to overcome them.


How to cite this article:
Thorakkattil SA, Krishnan G, Arain SI, Karattuthodi MS, Ageeli MM, Chandran S, Abdulsalim S. The necessity of implementing steroid stewardship: Are we lagging behind antimicrobials and opioids?.Saudi J Clin Pharm 2022;1:107-111


How to cite this URL:
Thorakkattil SA, Krishnan G, Arain SI, Karattuthodi MS, Ageeli MM, Chandran S, Abdulsalim S. The necessity of implementing steroid stewardship: Are we lagging behind antimicrobials and opioids?. Saudi J Clin Pharm [serial online] 2022 [cited 2023 Apr 1 ];1:107-111
Available from: http://www.sjcp.org/text.asp?2022/1/4/107/366501


Full Text



 Introduction



The term stewardship refers to the planning and management of resources positively impacting the environment, economics, property, and cultural resources.[1] Stewardship programs such as antimicrobial stewardship (AMS) programs to aid the proper use of antimicrobials are already well known to healthcare professionals.[2]

The first corticosteroid therapy was used in 1949 for rheumatoid arthritis. A wide range of conditions have been treated since then, spanning a variety of specialties and organ systems.[3] The use of glucocorticosteroids in non-endocrine disorders is commonly based on their ability to suppress inflammation in therapeutic doses. The doses of corticosteroids given in endocrine disorders are often close to physiologic dosages (rather than therapeutic doses). However, using these agents for long periods (oral or parenteral) has been associated with numerous adverse events such as hyperglycemia, osteoporosis, dermatological and digestive disorders, adrenal suppression, cardiovascular disease, dyslipidemia, immune suppression, and psychiatric disturbances.[4] A study from the United States by Dorin et al.[5] reported that there is no benefit of treating acute respiratory infection with steroids; even short courses of steroid therapy can lead to harmful adverse effects. Corticosteroids have also been reported to cause various neuropsychiatric adverse effects, invasive pulmonary mucormycosis, and glaucoma.[6],[7],[8] Solely approximately 1% of asthmatic patients are responsive to regular oral corticosteroids, whereas 10% of asthmatics require maximum inhaled corticosteroids (ICS) dose, which creates a concern for steroid resistance.[9] Therefore, there is a need to implement a steroid stewardship program to steer healthcare professionals to ensure appropriate doses, indications, and durations of treatment. Appropriate dosing regimens, managing potential adverse events and drug-drug interactions, increasing awareness about adrenal insufficiency and crises, and monitoring parameters, including blood glucose, constitute a successful steroid stewardship program.

AMS is a tool utilized by healthcare organizations to ensure the appropriate utilization of antibiotics. The goal is to reduce costs, optimize therapeutic outcomes, and reduce antimicrobial resistance (AMR). The AMR arises from misuse of over-the-counter antibiotics, improper empiric use, lack of knowledge on AMS, inadequate use of diagnostics, cross-infections, prescribing preferences overshadowed by pharmaceutical companies, and lack of new antimicrobial development.[10] AMS has delivered positive clinical outcomes with a significant reduction in overall antibiotic use, a decline in Clostridium difficile infection and multidrug-resistant organisms.[4] While Australia used AMS) to streamline fluoroquinolones use, Sweden used a strategic program to become the lowest antibiotic-utilizing nation in Europe.[11],[12]

The opioid stewardship program (OSP) is a relatively novel concept defined as “coordinated interventions designed to improve, monitor, and evaluate the use of opioids to support and protect human health”.[13]The crucial dilemma with opioid prescribing is that it may result in opioid-use disorder (OUD) even when prescribed at low doses for a short duration. It has been estimated that approximately 2 million Americans have an OUD and reported more than 42,000 deaths due to opioid overuse.[14],[15] The mission of opioid stewardship is to provide safe and effective pain management while promoting responsible opioid prescribing and facilitating harm reduction by minimizing its use. The concept of OSP lies in moving from opioid-centric to opioid-sparing approaches. A scoping review by Gondora et al. and many more studies summarizes the various successful opioid stewardship interventions done to mitigate the opioid crisis.[16],[17],[18]

 Steroid Indications and Inappropriate Use Overview



It is essential that all medications are used with a clear goal of achieving the therapeutic objective and expected outcomes. Here are some examples of inappropriate use patterns for steroids. Even though ocular inflammations are most responsive to topical steroids, various guidelines recommend reserving steroid use for severe conjunctivitis.[19] Lam et al.[8] reported five cases of devastating complications related to long-term topical steroid use in children for vernal keratoconjunctivitis. The inappropriate use of fluorometholone, dexamethasone, and prednisolone in these patients has, unfortunately, caused steroid-induced glaucoma. Additionally, increased intraocular pressure is evident within hours to weeks of topical corticosteroid use.[20]

Both inhaled and oral corticosteroids are widely prescribed in the management of asthma and chronic obstructive pulmonary disease (COPD), which urges the need for a risk-benefit assessment of steroid use in both long-term and acute exacerbation management.[21] Despite the consensus guidelines from experts, poor compliance, unwanted side effects, steroid overuse, and the high overall cost of medical care from inappropriate steroid use requires immediate attention and resolution. Cole et al. in their report on “Provider perceptions on steroid dosing in Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)” showed that there was no considerable improvement in re-exacerbation with higher steroid doses but a marked longer relapse duration in the low dose group. The report also showed prolonged hospital and ICU stay, ventilator requirement, higher incidence of fungal infections, increased need for insulin use, and increased hospital cost in patients on higher steroid doses.[22] Another common inappropriate use is for treating acne and as an ingredient of commercially available fairness products.[23] A prevalence study confined to topical steroids demonstrated that 28.5% of people use topical steroids on the face without any elements of dermatosis.[24]

 Potential Adverse Effects and Drug Interactions



Regardless of their remarkable clinical uses in various specialties, steroids are associated with a wide variety of side effects listed in [Table 1].[25],[26],[27] Hence, steroid pharmacotherapy is often referred to as a double-edged sword. If used in optimum dosage and duration, lower adverse effects are observed. Inadequate dose, duration, and abrupt withdrawal after prolonged use can result in severely undesirable consequences. The toxicity from the long-term use of corticosteroids most commonly accounts for iatrogenic complications in patients on chronic therapy. There are no specific reversal agents available to counteract corticosteroid toxicity. Their effect in excess is managed by gradual taper and addressing the particular complication (e.g., hyperglycemia, infection, and hypertension).[28] Curtis et al.[27] demonstrated that regular therapy with prednisolone, a commonly used steroid, at a dose of 5 mg daily for a period of 1 year resulted in side effects, including mood problems(40%], sleep problems (45%), skin bruising (40%), weight gain (60%), cataracts (10%), hyperglycemia (5%), and bone fractures (10%). The occurrence of diabetes in patients on steroids without any past history of hyperglycemia varies from 34.3% to 56%.[29]{Table 1}

Corticosteroids are also widely used in chemotherapy patients to manage chemotherapy-induced nausea and vomiting (CINV), prevent hypersensitivity reactions, and reduce inflammation and tumor size. Given the widespread use, it is vital to encourage judicious use to prevent adverse events such as endocrine imbalances, musculoskeletal problems, and immunosuppression, and neuropsychiatric adverse effects.[6] In response to dexamethasone administration, Kimmel and Combs reported agitation, cognitive impairment, depression, and insomnia. The patients demonstrated the onset of symptoms within 30 days of its initiation requiring discontinuation of the steroid and the addition of an antipsychotic to manage side effects.[30] The withdrawal of steroids was necessary to resolve side effects as it could lead to many other complications, such as adrenal insufficiency and withdrawal symptoms.[31] Hoang et al.[7] reported a case of invasive pulmonary mucormycosis in a well-controlled diabetes patient as a complication of short-term steroid use. The administration of intravenous and oral steroids for only two weeks worsened the patient’s cough and fever, resulting in mucormycosis. Similarly, Veisi et al.[32] reported two similar complications in COVID-19 patients on steroids. One of the cases was of rhino-orbit cerebral mucormycosis, and the other was of rhino-orbital mucormycosis, and both patients had received dexamethasone (8 mg/day). According to NICE (The National Institute for Health and Care Excellence), regular monitoring may help overcome these adverse effects through early identification and management. NICE recommends regular blood pressure, glucose levels, weight, triglycerides, urea and electrolyte monitoring for patients on steroid therapy. In addition, yearly vision assessment for cataracts and bone mineral density for osteoporosis is considered beneficial.[33]

Steroids can also have moderate to severe drug-drug interactions that may necessitate use with precaution, monitoring during therapy, or discontinuation. Some of the moderate to severe drug interactions are listed in [Table 2].[34] Managing steroid drug-drug interactions is another crucial element warranting the establishment of formal steroid stewardship programs.{Table 2}

 Importance of Implementing a Steroid Stewardship Program



There is also an urgent need to design and implement steroid stewardship programs (SSP) as their widespread use is similar to over-prescribing of antibiotics irrespective of confirmed infections causing AMR. Implementation of AMS principles represents a prominent initiative that reduces irrational antibiotic use. An analogous strategy must be implemented for steroids like the one for asthma in adults and adolescents by the Thoracic Society of Australia and New Zealand for better outcomes from steroid use.[1]

Steroid stewardship programs should include constituting an appropriate dosing regimen, keeping pharmacodynamics and pharmacokinetics in mind, titration and tapering dose charts, preventing and minimizing adverse events, and vital patient monitoring such as weight gain and blood glucose etc. Abrupt discontinuation of steroids is sometimes associated with steroid withdrawal which resembles true adrenal insufficiency and includes fever, loss of appetite, arthralgia, weight loss, malaise, and lethargy. Appropriate tapering regimens developed as part of steroid stewardship can help overcome this problem.[35],[36],[37]

Some important recommendations to be included in the steroid stewardship program for an organization should include:

  1. Strategic planning and development of a multidisciplinary steroid stewardship committee. This should be tailored to the individual requirement of that organization to address the need for steroid stewardship based on its prescribing patterns.


  2. Appropriate prescribing to prevent adverse effects. To prevent or reduce the adverse effects, it is highly recommended to individualize the dosage of corticosteroids. Other factors influencing the dosage of corticosteroids include the pharmacokinetics of different preparations, intended use for the disease being treated, patient response to steroid therapy, and managing drug-drug interactions.[4]


  3. Appropriate monitoring. The following parameters should be monitored at baseline and then routinely: blood pressure, weight change, fracture risk score, glycemic control, bone mineral density, and vision exams to prevent cataracts and glaucoma.[38]


  4. Appropriate tapering and stopping to avoid withdrawal symptoms. Steroids can present a significant challenge to managing the withdrawal of long-term glucocorticoids and oral corticosteroids. Withdrawal of steroid medication therapy requires careful tapering to prevent symptoms, including body aches, nausea, and loss of appetite. Blakey et al.[1] described using the “back titration” method to wean OCS in patients with asthma using symptoms and exacerbation history while monitoring for disease control. The tapering must include the appropriate interval for dose reduction and careful monitoring of disease relapse.


  5. Establish appropriate intervention strategies to improve patient compliance. This includes collaborative efforts to educate both staff and patients to achieve therapeutic outcomes and better quality of life for patients. Also, reducing the complexity of the regimen and ensuring proper patient follow-up will improve medication compliance. It is important to educate patients on the potential adverse effects of steroids in advance and explain how to prevent them or seek medical support if necessary.


  6. Design measurable elements. This can be used to determine the total number of steroid prescriptions to monitor excessive use, inappropriate duration, therapeutic duplications, and early refills.


 Identifying Pharmacist Role in Steroid Stewardship Programs



The pharmacist can play a vital role in patient assessment and education and make interventions and recommendations on appropriate steroid medication use. Ahmad et al.[39] measured the impact of the clinical pharmacist intervention on patients’ fear of, compliance and understanding towards their corticosteroid therapeutic regimens. A positive impact was noted with a shifted patients’ compliance from low to high and reduced patients’ fear of corticosteroids from medium to low. The steroid stewardship program requires concerted efforts from prescribers, pharmacists, nurses, and organizational leadership. It is important to note that even after the patient has stopped treatment with the steroid, it is often necessary to continue monitoring. Therefore active pharmacovigilance reporting by the pharmacist, especially for any unusual side effect or complication can prompt urgent management in a timely and effective manner.[40]

 Conclusion



The benefits of steroids are well known; however, several risks are also associated with their use. The burden of the steroid side effects affecting patients’ lives must be recognized and intervened upon in a timely manner as part of person-centered care. Similar to the antimicrobial and OSPs, the implementation of steroid stewardship programs can help ensure appropriate treatment patterns (the right steroid, for the right duration), manage overall disease state, provide cost savings, improve patient adherence, prevent misuse, and lower the risk of adverse events.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

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