Short-term oral corticosteroid use common, but may pose risks

Researchers conducted a retrospective cohort study and self-controlled case series to determine the frequency of prescriptions for less than 30 days of oral corticosteroids and any association with adverse events.

One in five American adults were given prescriptions for short-term use of oral corticosteroids during a three-year period, and they had increased risk of sepsis, venous thromboembolism, and fracture, a study found.

To determine the frequency of prescriptions for less than 30 days of oral corticosteroids, and any association with adverse events, researchers conducted a retrospective cohort study and self-controlled case series among a nationwide dataset of private insurance claims of adults ages 18 to 64 years who were continuously enrolled from 2012 to 2014.

Results were published by BMJ on April 12.

Of 1,548,945 adults, 327,452 (21.1%) received at least one outpatient prescription for short-term oral corticosteroids during the three-year period. The most common indications for short-term oral corticosteroid use were upper respiratory tract infections, spinal conditions, intervertebral disc disorders, allergies, and bronchitis and nonbronchitic lower respiratory tract disorders. These five conditions were associated with about half of all prescriptions. Prescriptions were provided by a diverse range of specialties, although family medicine and internal medicine specialists accounted for most prescriptions.

The median number of days of use was 6 (interquartile range, 6 to 12 days), with 47.4% of patients receiving treatment for seven or more days. Overall, the median prednisone equivalent daily dose was 20 mg/d (interquartile range, 17.5 to 36.8 mg/d) with 23.4% receiving ≥40 mg/d. The most common prescription written for oral corticosteroids was a six-day methylprednisolone “dosepak,” which accounted for 46.9% of prescriptions. Among corticosteroid users, 70.5% received one course of treatment, 20.7% received two courses, and 8.8% received three or more courses. For those patients with two or more prescriptions, the average prescription count was 2.4 (SD, 0.7).

Within 30 days of starting the drug, there was an increase in rates of sepsis (incidence rate ratio [RR], 5.30; 95% CI, 3.80 to 7.41), venous thromboembolism (RR, 3.33; 95% CI, 2.78 to 3.99), and fracture (RR, 1.87; 95% CI, 1.69 to 2.07), which diminished during the 31 to 90 days after the prescription. The increased risk persisted at prednisone equivalent doses of less than 20 mg/d (sepsis RR, 4.02; venous thromboembolism RR, 3.61; fracture RR, 1.83; all P<0.001).

The authors wrote that clinical guidelines typically recommend using the lowest dose of steroids for the shortest period to prevent adverse events but that only 6.3% of the prescriptions were for a prednisone equivalent dose of less than 17.5 mg/d, and 1.0% of prescriptions were for less than 7.5 mg/d. They noted that a major reason for the higher than expected doses was the widespread use of fixed-dose methylprednisolone dosepaks that are tapered over a short period. While they offer ease of use, they do not permit the individualization of drug dosing to minimize exposure.

“A substantial challenge to improving use of oral corticosteroids will be the diverse set of conditions and types of providers who administer these drugs in brief courses,” the authors wrote. “This raises the need for early general medical education of clinicians about the potential risks of oral corticosteroids and the evidence basis for their use, given that use may not be specific to a particular disease or specialty.”