Rheumatology COVID guidelines

How do I manage patients on long-term steroids at risk of adrenal suppression?

The Society for Endocrinology has produced guidance for management of patients with adrenal insufficiency who have COVID-19. This guidance applies to any patient who has been taking 5mg prednisolone or more for four weeks or longer, as this may cause adrenal insufficiency.

As noted in the British National Formulary, adrenal insufficiency due to steroid therapy can persist even after a patient has tapered their prednisolone dose below 5mg, so many rheumatology patients currently taking <5mg prednisolone are also at risk of adrenal insufficiency (see paper published in European Journal of Endocrinology).

Patients with adrenal insufficiency need to temporarily increase their steroid dose if they have any significant intercurrent infection. Patients with COVID-19 may have high fever or other systemic symptoms for many hours of the day. In COVID-19, therefore, the standard advice to double the prednisolone dose in the event of significant intercurrent illness may not be sufficient. This can be applied to rheumatology patients as follows:

• Patients on 5-15 mg prednisolone daily should take 10 mg prednisolone every 12 hours

• Patients on oral prednisolone >15 mg should continue their usual dose but take it split into two equal doses of at least 10 mg every 12 hours

• Patients with COVID-19 may have large insensible water losses, and should be advised to drink plenty of fluids especially if they may have adrenal insufficiency

• Patients can be issued with the new NHS emergency steroid card which signposts healthcare providers to the latest guidance on management of adrenal crisis