Introduction
Hypoadrenalism (primary and secondary) affects 4/10,000 individuals.1 But the commonest cause of hypothalamo-pituitary-adrenal axis suppression is exogenous steroid use, and about 1% of the UK population are on such therapy.2 These steroid-treated subjects have a higher incidence of adrenal crises (15.2/100 patient years) compared with patients with Addison's and pituitary disease. Mortality is increased in hypoadrenalism and 25% die of an adrenal crisis.2 These crises should be preventable with education of patients and healthcare professionals (HCPs). However, studies show significantly poor knowledge in both groups,3,4 leading to failure to increase steroids during ‘stress’ and potentially an adrenal crisis. Knowledge is poor about ‘sick day’ rules, the importance of ‘steroid cards’ and the utility of parenteral steroids.5 We studied knowledge of these safety aspects of long-term steroid therapy in patients and HCPs, in a university health board hospital.
Methods and results
Patients
97 consecutive patients (median age 63.2 years) on steroids for 6 weeks to 20 years were recruited. A questionnaire was completed relating to (a) ownership of a ‘steroid card’ or bracelet; (b) dose adjustment during strenuous exercise, vomiting once or more, a ‘bad cold’, high fever, broken bone, infections requiring antibiotics, illness requiring hospital admission, minor surgery without anaesthesia and major surgery under anaesthesia; (c) HCP advice about ‘sick day’ rules; (d) availability of parenteral steroids at home (Table 1).
Knowledge about the safety aspects of long-term steroid use among patients and healthcare professionals
The most common steroid used was prednisolone (69%), with hydrocortisone and dexamethasone next. Common indications were rheumatological (33%), chest (30%) and others (10–14%).
Healthcare professionals
84 HCP were recruited: internal medicine and endocrine physicians (56%); nurses in acute medicine (34%) and pharmacists and medical students (10%). The questionnaire assessed knowledge about (a) issuing ‘steroid cards’; (b) advice to patients during the scenarios detailed above; (c) prescribing steroid emergency packs; (d) advice to patients about ‘sick day rules’; (e) sources of advice about long-term steroid therapy (Table 1).
As a service improvement/audit project, this study was exempt from ethics approval was not required. Verbal consent was obtained from all participants.
Discussion
There are significant gaps in knowledge about safety aspects of long-term steroid therapy among patients and HCPs in this locality. This is of great concern as HCPs are the main source of information for patients about steroid therapy.5 This study confirms findings of previous studies from community and hospital settings.5 Of significant concern is the poor use of steroid cards and bracelets, poor knowledge of the need to increase steroids during ‘stress’ and the lack of emergency packs at home. HCPs had poor knowledge of when to issue ‘steroid cards’, did not give advice about ‘sick day’ rules and over a tenth failed to recommend increasing steroids at times of stress.
A recent study from Germany showed that although physicians identified situations requiring increased steroids, only 9.6% identified all of them.3 Furthermore, patients had difficulty in persuading HCPs to increase steroids at times of acute stress.5 Therefore, HCP education is vital in preventing adrenal crises. However, patient education alone does not guarantee success, as patients on steroids failed to adjust dose.
We recommend formal patient education (patient registers, information leaflets, group teaching etc) when long-term steroids are prescribed. Education of HCPs is equally important and should be part of their continuing professional development. These aspects of care appear to be seriously deficient in our practice.
Conflicts of interest
The authors have no conflicts of interest to declare.
Author contributions
IK, MA, LP – conceived study; KG, IN – data collection; MA, LP – writing of manuscript; KG, IK, MA, LP – contribute to final draft.
- © Royal College of Physicians 2017. All rights reserved.
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