Introduction: Long term treatment with corticosteroids has been widely used, due to the well documented immunosuppressive and anti-inflammatory activity. Corticosteroids are among the most widely prescribed drugs in oncology and post-transplant patients. However, long-term treatment with a dose of corticosteroids, which equals prednisolone 5mg/day for at least 4 weeks, is very likely to result in suppressed function of the hypothalamic pituitary adrenal (HPA) axis, a condition known as tertiary adrenal insufficiency. Patients on long-term corticosteroids should be well educated on steroid sick day rules, including the risk of adrenal crisis. We aimed to assess the practice of healthcare professionals (HCP) involved in the care of transplant and oncology patients requiring treatment with corticosteroids long-term.
Method: This prospective qualitative study aimed to evaluate the educational practice of corticosteroid sick day rules among the HCP (clinician and nurses). For this purpose, we selected HCPs primarily looking after Transplant (Liver and Kidney) and Oncology patients at Royal Free Hospital NHS Trust, requiring prolonged course of corticosteroids. A survey including a set of questions was circulated among the relevant staff.
Results: Of the 30 respondents (27 physicians and 3 specialist nurses), 66% mentioned being aware of adrenal suppressive doses of corticosteroids and 70% mentioned being aware of the corticosteroid sick day rules. However, regarding corticosteroid sick day rules counselling, only 40% confirmed counselling the patients at the time of initiation of long-term corticosteroids and 27% counselled on subsequent contact after initiating treatment. Variability was observed in the content of education where 50% of HCP counselled on illness with fever, 7% counselled on treatment around major/minor surgery and Covid-19, while 27% mentioned that they do not offer specific advice on sick day rules. Regarding testing of HPA-function, majority (60%) of respondents considered testing for suspected adrenal insufficiency and would refer the patients to Endocrine Services. However, variability was observed in the timing of testing.
Discussion and Conclusion: This is the first evaluation of the education practice on corticosteroid sick day rules in oncology and transplant services of a tertiary hospital. Our results highlight the need for standardised education on sick day rule counselling along with issuing the steroid emergency card to these patients. Specific guidance and clinician training to standardise sick day rule counselling across non-endocrine specialties should be undertaken to improve the level of care of patients on long-term corticosteroids and to reduce hospital admissions with adrenal crises.
13 May 2023 - 16 May 2023