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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Glucocorticoids and steroid risk reduction

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Adrenal crisis or steroid-associated infection

Hypotension, collapse, vomiting, severe weakness, hypoglycaemia, hyponatraemia, fever or confusion in a steroid-exposed patient may represent adrenal crisis, severe infection or both; glucocorticoids can suppress typical inflammatory signs.

Action: Treat suspected adrenal crisis immediately with hydrocortisone 100 mg intravenously or intramuscularly, rapid isotonic saline and endocrine guidance, while obtaining cultures and treating sepsis without waiting for a cortisol result; never stop chronic glucocorticoid abruptly during acute illness.

Synopsis

Use systemic and local glucocorticoids only for a defined inflammatory indication, prescribe a time-limited regimen with an exit strategy, and prevent adrenal, infectious, metabolic, skeletal and psychiatric harm.

  • Glucocorticoids are a bridge or rescue treatment, not a substitute for diagnosis and disease-modifying therapy; record the indication, dose, duration, taper and review date at initiation.
  • In rheumatoid arthritis, NICE permits short-term glucocorticoid bridging when starting a new conventional DMARD and short-term treatment for flares; continuing longer requires discussion of long-term complications and alternatives.
  • Use the lowest effective dose for the shortest period. A disease-specific regimen takes precedence over an improvised standard dose, particularly in giant-cell arteritis, vasculitis and organ-threatening connective-tissue disease.
  • Prednisolone 5 mg daily or more for four weeks or longer can suppress the hypothalamic-pituitary-adrenal axis; provide a steroid emergency card and sick-day guidance when risk criteria are met.
  • Never stop a prolonged systemic course abruptly. Tapering is faster above physiological range and slower near prednisolone 3–5 mg daily, with endocrine assessment if withdrawal symptoms, adrenal features or uncertain recovery develops.
  • Before and during treatment assess infection, vaccination, blood pressure, weight, glucose, mood, sleep, eyes and bone risk; prophylaxis is determined by dose, duration and comorbidity.
  • Glucocorticoid-induced fracture risk starts early and is partly independent of bone-mineral density; begin fracture assessment promptly when long-term exposure is expected, not after the first fracture.
  • Intra-articular injection requires secure anatomy, asepsis, consent, infection exclusion and a rehabilitation plan; it can still cause hyperglycaemia and transient adrenal suppression.
  • A normal temperature or CRP does not reliably exclude infection during higher-dose steroid treatment. Investigate the patient, not the inflammatory marker.
  • During vomiting, severe illness, surgery or trauma, patients at adrenal risk need stress-dose instructions and must carry enough information for emergency teams to act.

Key red flags

Collapse, hypotension, vomiting, abdominal pain, hyponatraemia or hypoglycaemia during illness or after steroid interruption requires immediate adrenal-crisis treatment.

Fever, rigors, focal pain, breathlessness, confusion or zoster during systemic glucocorticoid treatment may indicate serious infection even when CRP or fever is blunted.

New severe agitation, insomnia, mania, psychosis, depression or suicidal thinking after a dose increase needs urgent mental-health and prescribing review.

Acute visual loss, severe eye pain or halos may indicate ocular hypertension, glaucoma or another ophthalmic emergency.

New back pain, height loss, hip pain after minor trauma or sudden limb pain can represent fragility fracture or osteonecrosis.

A hot swollen joint should be aspirated for infection when feasible before intra-articular steroid; a recent injection does not make subsequent sepsis benign.

Adrenal insufficiency

Fatigue, anorexia, nausea, abdominal pain, postural dizziness, hypotension, hyponatraemia or hypoglycaemia during taper or illness suggests inadequate endogenous cortisol.

Masked infection

New functional decline, delirium, focal pain, breathlessness, dysuria or shingles may be the main infection signal because fever and inflammatory markers can be attenuated.

Psychiatric toxicity

Insomnia and activation may precede mood lability, mania, psychosis, depression or suicidality, often after initiation or dose escalation.

Investigation priorities

01
First-line baseline risk inventoryFirst stepFirst line

Define infection, metabolic, skeletal, psychiatric, ocular and adrenal vulnerability before a planned systemic course.

Management branches

First prescribing stepDefine bridge, rescue and exit

Active inflammatory disease requires rapid control and glucocorticoid benefit is judged to outweigh immediate risk.

  1. Name the diagnosis and target, exclude important infection, reconcile all steroid routes and document a baseline toxicity profile.
  2. Select the disease-specific preparation, dose, route and duration, and start or optimise the steroid-sparing treatment that will maintain control.
  3. Issue written taper or stop instructions, review date, sick-day advice and a steroid emergency card when adrenal-risk criteria are met.

Key medicines

PrednisoloneFor a selected inflammatory-arthritis bridge, a common specialist regimen is 5–10 mg orally once each morning for the shortest feasible period with an explicit taper; organ-threatening diseases use diagnosis-specific higher regimens and must not be inferred from this example.Screen infection and monitor glucose, blood pressure, mood, eyes and bone. Courses causing adrenal suppression require taper, emergency card and sick-day cover; avoid abrupt withdrawal.
Methylprednisolone intravenous pulseFor selected organ-threatening autoimmune disease, specialist protocols use 250–1000 mg intravenously once daily for one to three days, followed by a diagnosis-specific oral and steroid-sparing plan.Exclude or treat infection, monitor rhythm, pressure, glucose, electrolytes, psychiatric effects and fluid status; the regimen is specialist-directed and not routine musculoskeletal flare treatment.
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG100 rheumatoid arthritis recommendationsShort-term bridging, flare treatment and caution around long-term glucocorticoids.
  • NICE NG243 adrenal insufficiency recommendationsAdrenal-risk thresholds, emergency cards, crisis treatment and taper assessment.
  • NOGG glucocorticoid-induced osteoporosis guidancePrompt fracture assessment and bone-protective treatment.
  • Prednisolone 5 mg UK product informationDose principles, contraindications, infection, psychiatric, metabolic and withdrawal safety.
  • Hydrocortisone sodium succinate UK product informationParenteral hydrocortisone use and acute safety.
  • Kenalog intra-articular UK product informationJoint-specific triamcinolone doses and injection contraindications.
  • Alendronic acid 70 mg UK product informationOnce-weekly regimen, administration and renal or oesophageal cautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

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Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom