Corticosteroid Prescribing — UKMLA Guide 2026

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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

Short courses (≤3 weeks): can usually stop abruptly without taper
Prolonged courses (>3 weeks at ≥7.5 mg prednisolone equivalent/day): taper gradually to avoid adrenal crisis
Adrenal suppression risk: >3 weeks of ≥7.5 mg prednisolone/day, repeated courses, evening dosing, or ≥40 mg prednisolone for >1 week
Steroid side effects: Cushing syndrome, osteoporosis, diabetes, infections, peptic ulcers, cataracts, glaucoma, avascular necrosis, mood disturbance
All patients on long-term steroids need: steroid card, bone protection (calcium + vitamin D ± bisphosphonate), and sick day rules education

Overview

Corticosteroids (glucocorticoids) are among the most widely prescribed drugs in medicine, used for their anti-inflammatory and immunosuppressive effects. Prednisolone is the most commonly used oral corticosteroid. Hydrocortisone is used for replacement in adrenal insufficiency. Dexamethasone is used for its high potency in cerebral oedema, croup, and specific oncological indications. Prolonged corticosteroid use suppresses the hypothalamic-pituitary-adrenal (HPA) axis, leading to secondary adrenal insufficiency. If corticosteroids are withdrawn abruptly after the HPA axis has been suppressed, the patient cannot mount an adequate cortisol response to physiological stress (illness, surgery, trauma), potentially resulting in adrenal crisis — a life-threatening medical emergency.

Epidemiology

Approximately 1–2% of the UK adult population is on long-term oral corticosteroids at any time. Common indications include asthma/COPD exacerbations, autoimmune diseases (rheumatoid arthritis, SLE, IBD, vasculitis), transplant immunosuppression, and malignancy. The risk of adrenal suppression increases with dose, duration, and potency. Even inhaled corticosteroids at high doses can cause measurable HPA axis suppression.

Clinical Features

Symptoms

Cushingoid features with chronic use: weight gain (central obesity, moon face, buffalo hump), striae, thin skin, easy bruising

Steroid withdrawal symptoms: fatigue, myalgia, arthralgia, fever, malaise, anorexia

Adrenal crisis (if abrupt withdrawal): severe hypotension, shock, confusion, abdominal pain, hyponatraemia, hyperkalaemia, hypoglycaemia

Signs

Cushingoid habitus (moon face, central obesity, proximal myopathy, bruising, striae)

Hypertension and hyperglycaemia

Signs of adrenal crisis: postural hypotension, tachycardia, confusion, collapse

Investigations

First-line

Blood glucose/HbA1cMonitor for steroid-induced diabetes — particularly in patients with risk factors

Blood pressureRegular monitoring — steroids cause sodium and water retention

Second-line

DEXA scanIf on steroids for ≥3 months — assess for steroid-induced osteoporosis

Short Synacthen testIf adrenal suppression suspected — assesses adrenal reserve before stopping steroids

Management

BNF Corticosteroid guidance + NICE CKS

When to taper (not stop abruptly)

Treatment >3 weeks duration
Dose ≥40 mg prednisolone daily for >1 week
Repeated courses (especially within 1 year)
Received treatment in the evening (suppresses morning cortisol peak)
Any dose if other causes of adrenal suppression (pituitary disease)
Typical taper: reduce by 5 mg prednisolone every 1–2 weeks until 5 mg/day, then 1 mg decrements

Steroid card and emergency ID

ALL patients on long-term steroids should carry a steroid card
Consider a medical alert bracelet/necklace
Patient information: do NOT stop steroids suddenly, sick day rules, inform all healthcare providers

Sick day rules

Minor illness (cold, mild infection): DOUBLE the steroid dose until recovery
Significant illness (vomiting, unable to take oral): IM/IV hydrocortisone 100 mg and seek medical help urgently
Surgery/major procedure: IV hydrocortisone cover as per anaesthetic protocol

Bone protection

ALL patients on ≥7.5 mg prednisolone for ≥3 months: calcium + vitamin D
Consider bisphosphonate (alendronate 70 mg weekly) if additional fracture risk factors or DEXA shows osteoporosis
FRAX score adjusted for steroid use

Other monitoring

Blood glucose (steroid-induced diabetes)
Blood pressure
Weight, mood, sleep disturbance
Ophthalmology: screen for cataracts and glaucoma with long-term use
Gastroprotection: PPI if also on NSAIDs or anticoagulants

Complications

Adrenal crisis: Life-threatening — from abrupt withdrawal or inadequate stress dose during illness/surgery
Steroid-induced osteoporosis: Most common cause of secondary osteoporosis
Steroid-induced diabetes
Immunosuppression: Increased infection risk including opportunistic infections (PCP, TB reactivation)
Avascular necrosis: Particularly of the femoral head
Proximal myopathy
Mood disturbance: Euphoria, insomnia, psychosis (steroid psychosis)

UKMLA Exam Tips

1≤3 weeks course: can usually stop abruptly. >3 weeks: MUST taper
2Sick day rules: double dose for minor illness, IM hydrocortisone if vomiting/unable to take oral
3Steroid equivalence: prednisolone 5 mg = hydrocortisone 20 mg = dexamethasone 0.75 mg
4Steroid-induced osteoporosis is the MOST COMMON cause of secondary osteoporosis
5Always co-prescribe calcium + vitamin D for patients on steroids ≥3 months
6Steroid-induced diabetes: typically causes postprandial hyperglycaemia — may need insulin
7Adrenal crisis: hypotension + hyponatraemia + hyperkalaemia + hypoglycaemia — treat with IV hydrocortisone 100 mg STAT + IV fluids

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