GPAtlas🧭 When to suspect
Oral corticosteroids are among the most prescribed drugs in primary care – for asthma and COPD exacerbations, polymyalgia rheumatica (PMR), giant cell arteritis, inflammatory bowel disease, and a range of autoimmune conditions. The agent itself is rarely the problem; the danger lies in iatrogenic harm, in suppression of the hypothalamic–pituitary–adrenal (HPA) axis, and in unsafe withdrawal.
Three situations should prompt active review. First, the patient on long-term (> 3 weeks) or high-dose treatment presenting with adverse effects. Second, the patient who becomes acutely unwell – intercurrent infection, trauma or surgery places physiological stress on a suppressed adrenal axis and can precipitate an adrenal crisis. Third, symptoms of adrenal insufficiency emerging during or after dose reduction.
The defining safety principle: a steroid-dependent patient must never stop abruptly, and must take more steroid – not less – when physiologically stressed.
| Exposure | Significance | Key action |
|---|---|---|
| Short course < 3 weeks | HPA-axis suppression unlikely | Usually stop abruptly (caution if high-dose or frequently repeated) |
| ≥ 3 weeks, or repeated courses | HPA-axis suppression likely | Gradual withdrawal plus baseline monitoring |
| Prednisolone ≥ 5 mg/day (or equivalent), ≥ 4 weeks, any route | At risk of adrenal crisis | Issue the NHS Steroid Emergency Card and teach sick-day rules |
| High dose (e.g. > 40 mg prednisolone/day) | Greater adverse-effect and infection burden | Review indication; consider gastroprotection and bone protection |
Source: Society for Endocrinology · Royal College of Physicians
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