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Drugs and devices

Corticosteroids - oral

Last revised in July 2025

Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.

Corticosteroids - oral: Summary

  • Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.
  • They exhibit glucocorticoid and/or mineralocorticoid properties, and the ratio of these properties influences their efficacy and therapeutic use.
    • Prednisolone, prednisone, betamethasone, deflazacort, dexamethasone, and methylprednisolone primarily exhibit glucocorticoid activity.
    • Fludrocortisone primarily exhibits mineralocorticoid activity.
    • Hydrocortisone has equal glucocorticoid and mineralocorticoid activity.
  • Oral corticosteroids are contraindicated in people with acute infections uncontrolled by appropriate antibiotics, as they may mask the symptoms of infection.
    • They should be used with caution in people with hepatic impairment, psychiatric disorders, wounds, and other conditions that may be exacerbated by the treatment, such as heart failure, diabetes mellitus, recent myocardial infarction, or hypertension.
    • Use during pregnancy and breastfeeding may be considered if the benefits to the mother and child outweigh the risks.
  • Adverse effects are more likely with higher doses, prolonged use (more than four weeks), or frequent courses (three or more per year), but can also occur with lower doses or shorter durations. They include immunosuppression, adrenal suppression, diabetes, psychiatric disturbance, osteoporosis, gastrointestinal (GI) complications, visual changes, and growth retardation in children and adolescents.
  • When long-term oral corticosteroids are initiated:
    • Baseline measurements should be taken, including HbA1c, blood pressure, body mass index, triglycerides, potassium, height (children and adolescents), and eye health (screening for glaucoma and cataract). Assessment of osteoporosis risk, falls risk, and adrenal suppression may also be needed.
    • Monitoring should be done at appropriate intervals during treatment, guided by clinical judgement. 
    • A steroid alert card should be provided if appropriate. 
  • To reduce the risk of corticosteroid adverse effects:
    • The lowest effective dose should be prescribed for the shortest possible duration.
    • Proton pump inhibitors should be considered for people at risk of GI bleeding or dyspepsia.
    • Gradual tapering should be carried out when withdrawing long-term treatment (to reduce the risk of adrenal insufficiency or relapse of the underlying condition).
    • Appropriate information and advice should be given to the person, including not stopping corticosteroids suddenly, recognizing infection risk, identifying signs of adrenal suppression, carrying a steroid alert card (if needed), following sick day rules (where relevant), maintaining bone health through diet and exercise, and attending review appointments.
  • Drug interactions of corticosteroids include:
    • Enzyme inducers (for example, rifampicin and carbamazepine) — reduced corticosteroid effectiveness.
    • Enzyme inhibitors (for example, ritonavir and ketoconazole) — increased corticosteroid levels and toxicity.
    • Nonsteroidal anti-inflammatory drugs (such as naproxen and ibuprofen) — increased risk of GI bleeding.
    • Diuretics (such as furosemide) — enhanced risk of hypokalaemia.
    • Antihypertensives and antidiabetics — reduced effectiveness of these medicines. 
    • Live vaccines — impaired immune response and increased risk of severe infection. Should be postponed for at least 3 months after high-dose corticosteroids are stopped. 

Have I got the right topic?

From birth onwards.

This CKS topic covers the management of people receiving oral corticosteroids in primary care, particularly glucocorticoids. 

This CKS topic does not cover the management of the specific condition for which the oral corticosteroid is prescribed. It also does not include information on treatment dosages.

There are separate CKS topics on Corticosteroids - inhaled and Corticosteroids - topical (skin), nose, and eyes.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2025 — minor update. The sections on Contraindications and cautions, Initiation, and Steroid alert cards have been revised. A typographical error has also been corrected.

Previous changes

June 2025 — reviewed. A literature search was conducted in May 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last version of this topic. No major changes to recommendations have been made.

February 2025 — minor update. Based on the National Institute for Health and Care Excellence (NICE) guideline Adrenal insufficiency: identification and management, the physiological dose equivalent of prednisolone has been revised and the recommended tapering period for oral steroids has been extended from three to four weeks.

January 2024 — minor update. Information on the risk of coadministration of oral steroids with fluoroquinolones has been added. 

December 2023 — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.

June 2020 — minor update. The section on the use of corticosteroids in pregnancy has been updated to clarify that available data do not suggest an increased risk of congenital malformations after first-trimester exposure to oral corticosteroids.

May 2020 — reviewed. A literature search was conducted in April 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic.

April 2020 — minor update. Advice on using oral corticosteroids during the COVID-19 pandemic has been added in line with the NICE rapid guidelines COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD) [NICE, 2020], COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response [NICE, 2020], and COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders [NICE, 2020]. 

November 2017 — minor update. Systemic sclerosis has been included as a caution for oral corticosteroids, in line with updates to manufacturers’ Summaries of Product Characteristics (SPCs). 

September 2017 — minor update. The section on Adverse effects has been updated to include information on the ophthalmic adverse effects of corticosteroids, in line with updates to manufacturers’ SPCs.

December 2016 — minor update. CKS now recommends seeking immediate medical attention if symptoms of adrenal insufficiency occur, in line with the SPC for Plenadren 5 mg and 20 mg modified-release tablets [ABPI, 2016]

November 2016 — minor update. The section on Contraindications and cautions has been updated to advise that administration of live or live-attenuated vaccines is contraindicated in people receiving immunosuppressive doses of corticosteroids, in line with the SPC for Medrone 100mg tablets [ABPI, 2016].

June to August 2015 — reviewed. A literature search was conducted in June 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last version of this topic. There have been no major changes to the recommendations.

February 2014 — minor update. The text regarding how to minimize the risk of osteoporosis has been deleted and replaced with a link to the CKS topic Osteoporosis - prevention of fragility fractures.

April to August 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new guidelines since 1 May 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 May 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 May 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 May 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 May 2025.

New policies

No new national policies or guidelines since 1 May 2025.

New safety alerts

No new safety alerts since 1 May 2025.

Changes in product availability

No changes in product availability since 1 May 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Ensure that people receiving oral corticosteroids in primary care are properly managed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What are corticosteroids?

  • Corticosteroids are synthetic analogues of hormones produced by the adrenal cortex.
    • They are used to treat a wide range of conditions, including:
      • Autoimmune diseases, such as rheumatoid arthritis and inflammatory bowel disease.
      • Endocrine disorders, such as Addison’s disease.
      • Respiratory diseases, such as asthma and chronic obstructive pulmonary disease.
      • Skin disorders, such as eczema and dermatitis.
      • Nasal conditions, such as allergic rhinitis and nasal polyps.
      • Eye conditions, such as uveitis and post-operative inflammation.

[Ritter, 2020]

How do corticosteroids work?

  • Corticosteroids mimic the effects of hormones naturally produced by the adrenal cortex, exhibiting glucocorticoid and/or mineralocorticoid effects. The ratio of glucocorticoid to mineralocorticoid activity varies between corticosteroids and influences their efficacy and therapeutic use.
  • Glucocorticoid effects include:
    • Metabolic actions:
      • Decreased glucose uptake and utilization, with increased gluconeogenesis.
      • Decreased protein synthesis and increased protein breakdown.
      • Permissive effect on lipolytic hormones, leading to fat redistribution (as seen in Cushing's syndrome).
      • Decreased calcium stores.
    • Regulatory actions:
      • Hypothalamus and anterior pituitary gland: negative feedback action resulting in reduced release of adrenocorticotropic hormone and, therefore, endogenous glucocorticoids.
      • Cardiovascular system: reduced vasodilation and decreased fluid exudation. 
      • Musculoskeletal system: decreased osteoblast (bone-forming) activity and increased osteoclast (bone-resorbing) activity.
    • Anti-inflammatory effects:
      • In acute inflammation: decreased influx and activity of leucocytes. 
      • In chronic inflammation: reduced activity of mononuclear cells, decreased angiogenesis, and less fibrosis.
      • Reduced generation of eicosanoids (such as prostaglandins and leukotrienes).
      • Decreased production and action of proinflammatory cytokines, including interleukins, tumour necrosis factor-α, and granulocyte-macrophage colony-stimulating factor.
      • Increased release of anti-inflammatory factors (such as interleukin-10 and annexin-1).
    • Immunosuppressive effects:
      • In lymphoid tissue: decreased clonal expansion of T and B cells and reduced action of cytokine-secreting T cells.
      • Switch from T-helper 1 (Th1) response, which supports cell-mediated immunity, to T-helper 2 (Th2) response, which promotes antibody production.
      • Decreased production of immunoglobulin G (IgG) antibodies.
      • Reduced levels of complement components in the blood.
    • Anti-proliferative effects:
      • Inhibition of fibroblast proliferation and keratinocyte growth, contributing to skin thinning with prolonged use.
    • Vasoconstrictive effects:
      • Direct vasoconstriction of small blood vessels, contributing to reduced erythema and oedema in inflamed tissues.
  • Mineralocorticoid effects include: 
    • Increased sodium and water retention.
    • Increased potassium and hydrogen ion loss. 

[Atack, 2018; Brown, 2018; Ritter, 2020]

Which oral corticosteroids are available in the UK?

  • The oral corticosteroids available in the UK are:
    • Prednisolone.
    • Prednisone.
    • Betamethasone.
    • Deflazacort.
    • Dexamethasone.
    • Methylprednisolone.
    • Fludrocortisone.
    • Hydrocortisone.
  • The ratio of glucocorticoid to mineralocorticoid activity varies between corticosteroids and determines their efficacy and therapeutic use [BNF, 2025]:
    • Prednisolone, prednisone, betamethasone, deflazacort, dexamethasone, and methylprednisolone primarily exhibit glucocorticoid activity.
    • Fludrocortisone primarily exhibits mineralocorticoid activity.
    • Hydrocortisone has equal glucocorticoid and mineralocorticoid activity.
    • See Table 1 for information on the properties and therapeutic indications of oral corticosteroids relative to hydrocortisone.
  • Oral corticosteroids are available in various formulations, including plain, enteric-coated, and soluble tablets and oral solutions.

Table 1. Properties and therapeutic indications of oral corticosteroids relative to hydrocortisone.

DrugApproximate relative potency in clinical useDuration of action after oral dose*General therapeutic indication
Anti-inflammatorySodium retaining
Hydrocortisone 11Short 

The relatively high mineralocorticoid activity and the resulting fluid retention make it unsuitable for long-term disease suppression. However, it can be used for adrenal replacement therapy.

The relatively moderate anti-inflammatory potency also makes it a useful topical corticosteroid for managing inflammatory skin conditions because adverse effects (topical and systemic) are less marked.

 

Prednisolone 40.8IntermediateDrug of choice for anti-inflammatory and immunosuppressive effects.
Methylprednisolone5MinimalIntermediateAnti-inflammatory and immunosuppressive.
Deflazacort3MinimalShort

Converted by plasma esterases into active metabolite.

Derived from prednisolone.

Dexamethasone 27Minimal Long

Anti-inflammatory and immunosuppressive.

Used especially where water retention is undesirable, for example, cerebral oedema.

Long duration of action and lack of mineralocorticoid action make it particularly suitable for conditions that require suppression of corticotropin (corticotrophin) secretion (for example, congenital adrenal hyperplasia).

Betamethasone 27NegligibleLong

Anti-inflammatory and immunosuppressive.

Used especially where water retention is undesirable.

Long duration of action and lack of mineralocorticoid action make it particularly suitable for conditions that require suppression of corticotropin (corticotrophin) secretion (for example, congenital adrenal hyperplasia).

Some esters of betamethasone and beclometasone dipropionate (beclomethasone) exert a considerably more marked topical effect (for example, on the skin or the lungs) than when given by mouth; this is used to obtain topical effects whilst minimising systemic adverse effects (for example, for skin applications and asthma inhalations).

Fludrocortisone15150ShortDrug of choice for mineralocorticoid effects (for example, in orthostatic hypotension).
*Short: half-life 8–12 hours; intermediate: half-life 12–36 hours; long: half-life 36–72 hours.
Data from: [Brayfield, 2020; Ritter, 2020; BNF, 2025]

 

Management

Scenario: Corticosteroids

From birth onwards.

What are the contraindications and cautions of oral corticosteroids?

  • Do not prescribe oral corticosteroids to:
    • People with acute infections uncontrolled by appropriate antibiotics — corticosteroids can mask symptoms of infection.
  • Ensure vaccinations are up to date before starting long-term or high-dose corticosteroid treatment.
    • Inactivated vaccines should ideally be given at least 2 weeks before treatment, but they can be given during treatment if necessary.
    • Live vaccines should not be given to people on high-dose immunosuppressant treatment, due to impaired immune response. If needed, they should be given at least 4 weeks before starting treatment or delayed until at least 3 months after stopping treatment.
  • Prescribe oral corticosteroids with caution to:
    • Children and older adults — increased risk of adverse effects.
    • Pregnant and breastfeeding women — treatment may be considered if the benefits to the mother and child outweigh the risks. For more information, see the section on Pregnancy and breastfeeding.
    • People with the following conditions, which may be exacerbated by the treatment (frequent monitoring is necessary):
      • Congestive heart failure.
      • Diabetes mellitus, or a family history of diabetes mellitus.
      • Diverticulitis.
      • Diverticular disease — increased risk of diverticular perforation.
      • Epilepsy.
      • Glaucoma, or a family history or increased susceptibility.
      • Hepatic impairment — risk of increased exposure.
      • History of steroid myopathy.
      • History of tuberculosis or X-ray changes characteristic of tuberculosis, where frequent monitoring is required.
      • Hypertension.
      • Hypothyroidism.
      • Infection (particularly untreated).
      • Myasthenia gravis.
      • Ocular herpes simplex — risk of corneal perforation.
      • Osteoporosis.
      • Personal or family history of psychiatric disorders, including psychoses, severe affective disorders, particularly if there is a history of steroid-induced psychosis.
      • Peptic ulcer.
      • Recent intestinal anastomoses.
      • Recent myocardial infarction — rupture reported.
      • Renal impairment.
      • Systemic sclerosis — increased risk of potentially fatal scleroderma renal crisis with hypertension and decreased urinary output has been observed with daily prednisolone doses of 15 mg or more. 
      • Thromboembolic disorders — may, rarely, increase blood coagulability and precipitate intravascular thrombosis, thromboembolism, and thrombophlebitis.
      • Ulcerative colitis.

Basis for recommendation

These recommendations are largely based on the British National Formulary (BNF) [BNF, 2025] and the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021].

Vaccination
  • These recommendations are also based on expert opinion in a review article [Caplan, 2017] and the British Association of Dermatology (BAD) leaflet Immunisation advice for people on immune-suppressing medicines [BAD, 2022].
    • People who are not up-to-date on vaccinations should, where possible, receive them before corticosteroids are initiated to allow for an adequate protective immune response [Caplan, 2017].
    • According to BAD [BAD, 2022]:
      • Inactivated vaccines should ideally be given at least 2 weeks before immunosuppressant treatment but can be administered during treatment.
      • Live vaccines, if needed, should be given at least 4 weeks before starting immunosuppressant treatment.
      • Live vaccines should not be given to people taking high-dose immunosuppressant treatment.
      • Live vaccines should not be given within 3 months of stopping prednisolone or other immunosuppressants.
  • The BNF advises that live virus vaccines should be avoided in people receiving immunosuppressive doses of corticosteroid, due to diminished serum antibody response [BNF, 2025].
  • Similarly, the SPC states that live vaccines should not be given to people on high doses of corticosteroids because of impaired immune response; vaccination should be postponed until at least 3 months after stopping corticosteroid treatment [EMC, 2021].

What should I consider when initiating oral corticosteroids?

  • When initiating oral corticosteroids:

Steroid alert cards

There are two types of steroid alert cards: the Steroid Treatment Card (Blue) and the Steroid Emergency Card (Red). 

  • The Steroid Treatment Card (Blue) provides treatment details (prescriber, dosage, and duration) and guidance on reducing steroid risks.
    • It should be given to people prescribed [NHS Dorset, 2021; NHS Hertfordshire and West Essex, 2023]:
      • Oral corticosteroids for periods of more than 3 weeks.
      • More than four short courses of oral corticosteroid per year (if considered necessary by the prescriber or pharmacist).
      • Oral corticosteroids in combination with other glucocorticoid preparations (such as inhaled or topical).
      • Oral corticosteroids in combination with a cytochrome P450 3A4 (CYP3A4) inhibitor, such as ritonavir, itraconazole, and ketoconazole.
    • The Steroid Treatment Card can be ordered from Primary Care Support England (PCSE) online.
  • The Steroid Emergency Card (Red) helps healthcare staff identify adults with adrenal insufficiency and provides guidance on emergency treatment during acute illness, trauma, surgery, or other significant stress.
    • It should be given to adults with adrenal insufficiency and steroid dependence for whom missed doses, illness, or surgery puts them at risk of adrenal crisis, such as those with Addison’s disease, congenital adrenal hyperplasia, and hypothalamo-pituitary damage from tumours or surgery.
    • People on prolonged and/or high-dose corticosteroid treatment for other conditions may also develop adrenal insufficiency due to suppression of the hypothalamic–pituitary–adrenal (HPA) axis and become steroid dependent.
    • A joint guideline by the Society for Endocrinology (SfE) Steroid Emergency Card working group and Specialist Pharmacy Services (SPS) recommends issuing a Steroid Emergency Card to adults prescribed:
      • Three or more short courses of high-dose oral glucocorticoids within the last 12 months, and for 12 months after stopping.
      • Oral corticosteroids in combination with specified doses of inhaled corticosteroids (ICS) — see the guideline for ICS dose details.
    • The  SfE/SPS guideline also recommends providing both a Steroid Emergency Card and sick day rules advice to:
      • People taking oral prednisolone 5 mg or more (or equivalent oral glucocorticoid dose) for more than 4 weeks, and for 12 months after stopping.
      • People with respiratory disease (such as asthma) who are on high-dose ICS and have received repeated courses of oral corticosteroids (three or more in the past 6 months).
      • People receiving intra-articular or intramuscular glucocorticoid injections in combination with other glucocorticoid preparations.
      • People taking CYP3A4 enzyme inhibitors (such as ritonavir, itraconazole, and ketoconazole) in combination with glucocorticoids (via any route, except small amounts of mild or moderate topical glucocorticoids, which should be assessed on a case-by-case basis).
    • The Steroid Emergency Card can be ordered from PCSE online. A printable version is available on the SfE website (www.endocrinology.org).
  • For children with adrenal insufficiency and steroid dependence, the British Society for Paediatric Endocrinology and Diabetes (BSPED) has developed an Adrenal Insufficiency Card, which includes a management summary for the emergency treatment of adrenal crisis and sick day dosing. 

Basis for recommendation

These recommendations are largely based on the British National Formulary (BNF) [BNF, 2025], the textbook Rang and Dale's Pharmacology [Ritter, 2020], and what CKS considers good clinical practice. 

Can I prescribe oral corticosteroids to a woman who is pregnant or breastfeeding?

  • Pregnancy
    • Oral corticosteroids may be used in pregnancy if the benefits to the mother and child outweigh the risks.
    • Monitor pregnant women with fluid retention closely. 
  • Breastfeeding
    • Oral corticosteroids may be used during breastfeeding if the benefits to the mother and child outweigh the risks.
    • Where possible, avoid prolonged high-dose treatment (over 40 mg daily), as adrenal suppression and other adverse effects may occur in the infant, although no adverse effects have been reported. 
    • If high doses of prednisolone are repeatedly required, monitor the infant for signs of adrenal insufficiency. 

Basis for recommendation

These recommendations are largely based on the UK Teratology Information Service (UKTIS) [UKTIS, 2023], Drugs and Lactation Database (LactMed®) [LactMed, 2024], the British National Formulary (BNF) [BNF, 2025], and the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021].

Pregnancy
  • The UKTIS advises that if systemic corticosteroids are clinically indicated for the mother or fetus, treatment should not be withheld because of pregnancy. A review of the available evidence found that [UKTIS, 2023]:
    • Most human data do not show an increased risk of orofacial clefts, although a few studies suggest a possible association; therefore, further research is needed.
    • No association has been found with cardiac defects; data on other malformations are too limited to draw conclusions.
    • Evidence on low birth weight, intrauterine growth restriction, and small for gestational age is inconclusive and limited. 
    • Some studies suggest an association between in utero exposure and preterm delivery, but this may reflect confounding from maternal illness rather than the corticosteroids. Therefore, further research is needed.
    • Data are insufficient to assess the risk of miscarriage or intrauterine death; however, uncontrolled inflammation may increase the risk of fetal loss.
    • Neurodevelopmental outcomes are difficult to interpret due to confounding from premature membrane rupture and/or preterm or very preterm delivery.
    • Most studies reporting pregnancy outcomes following gestational exposure to systemic corticosteroids are limited by a lack of stratification to account for differing doses, treatment duration, and steroid potencies, so the risks of high-dose or long-term use cannot be excluded.
  • The Summary of Product Characteristics (SPC) for prednisolone tablets states that corticosteroids should only be prescribed when the benefits to the mother and child outweigh the risks. When treatment is clinically essential, women with normal pregnancies may be managed as though they were in the non-gravid state. Women with pre-eclampsia or fluid retention require close monitoring [EMC, 2021].
  • The British National Formulary (BNF) states that the benefit of treatment with systemic corticosteroids during pregnancy outweighs the risk [BNF, 2025].
Breastfeeding
  • Expert opinion in the LactMed® database is that [LactMed, 2024]:
    • No adverse effects have been reported in breastfed infants with maternal use of any corticosteroid during breastfeeding.
    • Although it is often recommended to avoid breastfeeding for 4 hours after a dose, this is unnecessary because prednisolone milk levels are very low.
    • Medium to large doses of corticosteroids given systemically or injected into joints or the breast have been reported to cause temporary reduction of lactation.
  • The SPC for prednisolone tablets states that [EMC, 2021]:
    • Corticosteroids are excreted in small amounts in breast milk, and corticosteroids distributed into breast milk may suppress growth and interfere with endogenous glucocorticoid production in nursing infants.
    • Since adequate reproductive studies have not been performed in humans, glucocorticoids should be administered to nursing mothers only if the benefits of therapy are judged to outweigh the potential risks to the infant.
    • There are no reports found regarding neonatal toxicity following exposure to corticosteroids during lactation; however, if the maternal daily dose is greater than 40 mg of prednisolone, the infant should be monitored for adrenal suppression. 
  • The BNF states that the benefit of treatment with systemic corticosteroids during breastfeeding outweighs the risk [BNF, 2025].

What are the adverse effects of oral corticosteroids?

  • The adverse effects of oral corticosteroids are dose-related and can often be predicted based on their mineralocorticoid and glucocorticoid properties.
  • People receiving long-term oral corticosteroids (more than four weeks duration) and those needing frequent courses (three or four per year) are at risk of systemic adverse effects, including:
    • Infections and Infestations:
      • Increases susceptibility to, and severity of, infections (with suppression of clinical symptoms and signs).
      • Opportunistic infections.
      • Activation of latent infection.
      • Oesophageal candidiasis.
    • Endocrine disorders:
      • Adrenal suppression.
      • Cushing's syndrome (this is usually reversible on withdrawal of treatment).
      • Diabetes mellitus (new onset or worsening of blood glucose control in existing diabetes).
      • Impaired carbohydrate tolerance with increased requirement for antidiabetic treatment.
    • Metabolism and nutrition disorders:
      • Sodium and water retention, hypokalaemic alkalosis, potassium loss, negative nitrogen and calcium balance, glucose intolerance, and protein catabolism.
      • Increase in both high and low-density lipoprotein cholesterol concentration in the blood.
      • Increased appetite (which may result in weight gain).
      • Weight gain, obesity, hyperglycaemia, and dyslipidaemia.
      • Very rarely, calciphylaxis.
    • Psychiatric disorders:
      • Mood and behavioural, including anxiety, depressed and labile mood, irritability, euphoria, mood swings, sleep disturbances, and suicidal thoughts.
      • Psychotic reactions, including mania, delusions, hallucinations, and aggravation of schizophrenia.
      • Cognitive dysfunction, including confusion, restlessness, nervousness, and amnesia.
      • Psychological dependence.
    • Nervous system disorders:
      • Insomnia, dizziness, headache, and vertigo.
      • Raised intracranial pressure with papilloedema (pseudotumor cerebri).
      • Aggravation of epilepsy.
      • Epidural lipomatosis.
      • Vertebrobasilar stroke.
    • Eye disorders:
      • Glaucoma, cataract, central serous chorioretinopathy (CSC), blurred vision, and other visual disturbances.
      • Exophthalmos, corneal or scleral thinning, exacerbation of ophthalmic viral or fungal disease.
      • Severe exacerbation of bullous exudative retinal detachment.
      • Lasting visual loss in some people with idiopathic CSC. 
    • Cardiac disorders:
      • Hypertension.
      • Congestive heart failure in susceptible people.
      • Increased risk of heart failure.
      • Increased risk of cardiovascular disease, including myocardial infarction (with high-dose treatment).
      • Bradycardia (following high doses).
    • Gastrointestinal disorders (especially in high-risk people):
      • Dyspepsia.
      • Nausea and diarrhoea.
      • Peptic ulceration with perforation and haemorrhage.
      • Abdominal distension or pain.
      • Oesophageal ulceration.
      • Acute pancreatitis.
    • Skin and subcutaneous tissue disorders:
      • Hirsutism.
      • Skin atrophy.
      • Bruising, striae, and telangiectasia.
      • Acne.
      • Increased sweating.
      • Pruritus and rash.
      • Urticaria.
    • Musculoskeletal and connective tissue disorders:
      • Proximal myopathy.
      • Myalgia.
      • Osteoporosis.
      • Vertebral and long bone fractures.
      • Avascular osteonecrosis.
      • Tendon rupture.
      • Tendinopathies (particularly of the Achilles and patellar tendons).
      • Growth suppression in infancy, childhood, and adolescence.
    • Renal and urinary disorders:
      • Scleroderma renal crisis — may occur in people with systemic sclerosis and is more likely with a daily dose of 15 mg or more of prednisolone.
    • Others:
      • Fatigue, malaise, and impaired healing.
      • Vertigo.
      • Leucocytosis.
      • Thromboembolism.
      • Menstrual irregularity and amenorrhoea.
      • Hypersensitivity, including anaphylaxis.
      • Suppressed reactions to skin tests.
      • Increased intraocular pressure.

Adrenal insufficiency

  • Adrenal insufficiency describes a range of conditions caused by dysfunction within the hypothalamic-pituitary-adrenal (HPA) axis, leading to a deficiency of one or more adrenal hormones, primarily cortisol. It can be classified as primary, secondary, or tertiary, depending on the underlying cause [NICE, 2024]:
    • Primary adrenal insufficiency occurs when the adrenal glands are damaged or dysfunctional, leading to reduced production of cortisol and other adrenal hormones. The most common causes are Addison’s disease (in adults) and congenital adrenal hyperplasia (in children).
    • Secondary adrenal insufficiency occurs when adrenocorticotropic hormone (ACTH) production by the pituitary gland is reduced, leading to decreased cortisol production. This can result from pituitary disorders or their treatment, including surgery or radiotherapy.
    • Tertiary adrenal insufficiency occurs when corticotropin-releasing hormone (CRH) production by the hypothalamus is reduced, leading to lower ACTH and cortisol levels. This can result from hypothalamic disease or treatment affecting nearby structures. More commonly, tertiary adrenal insufficiency is caused by prolonged use of glucocorticoids, which suppress the HPA axis through negative feedback.
  • The risk, extent, and duration of adrenal suppression from corticosteroid use depend on several factors, particularly duration, dose, frequency, and timing of treatment [EMC, 2021; BNF, 2025].
    • Longer treatment durations (typically longer than four weeks), higher doses, and more frequent dosing increase the risk and severity of adrenal suppression.
    • Morning dosing (rather than evening or night dosing) causes less suppression of the HPA axis by aligning better with the body’s natural cortisol rhythm.
    • Other factors, such as age, comorbidities, and concurrent medications, can also influence the degree of adrenal suppression.
  • Adrenal insufficiency should be suspected in people with unexplained hyperpigmentation or when there is no other clinical explanation for the presence of one or more of the following persistent symptoms, signs, or features [NICE, 2024]:
    • Weight loss.
    • Nausea, vomiting, or diarrhoea.
    • Lack of appetite or unable to eat a full meal.
    • Dizziness or light-headedness on standing.
    • Electrolyte abnormalities (hyponatraemia, hyperkalaemia), salt craving, orthostatic hypotension.
    • Lethargy.
    • Early puberty.
    • Feeling of muscle weakness.
    • Hypoglycaemia (particularly in children).
    • Hypotensive crisis (particularly in children)
    • Faltering growth (in children).
    • Prolonged neonatal jaundice.
  • Adrenal crisis is the most serious complication of adrenal insufficiency and can be life-threatening [EMC, 2021; Huecker, 2023; BNF, 2025].
    • It occurs when a person with adrenal insufficiency experiences significant stress and their adrenal glands cannot produce enough cortisol to meet the body's increased needs.
    • During prolonged corticosteroid treatment, especially with systemic use, adrenal atrophy develops and may persist for years after treatment cessation. Consequently, abrupt withdrawal following prolonged use can lead to adrenal crisis, hypotension, or even death. 
    • Any significant intercurrent illness, trauma, or surgical procedure requires a temporary increase in corticosteroid dose to compensate for a diminished adrenocortical response caused by prolonged corticosteroid treatment. If corticosteroids have already been stopped, temporary reintroduction may be necessary.
    • Symptoms of adrenal crisis include hypotension, dehydration, weakness, and confusion.
    • Life-threatening circulatory complications, ranging from severe hypotension to hypovolaemic shock, may occur if treatment is delayed [ACAP, 2020].
    • The NHS Steroid Emergency Card (Red) supports early recognition and treatment of adrenal crisis in adults.
    • For children with adrenal insufficiency and steroid dependence, the British Society for Paediatric Endocrinology and Diabetes (BSPED) has developed an Adrenal Insufficiency Card, which includes a management summary for the emergency treatment of adrenal crisis and sick day dosing.

Basis for recommendation

This information is largely based on the manufacturer's Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021], the British National Formulary (BNF) [BNF, 2025], and the drug reference compendium Martindale: the complete drug reference [Brayfield, 2020].

Psychiatric adverse effects
  • This information is also based on the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update Corticosteroids: early psychiatric side-effects [MHRA, 2014]:
    • A wide range of psychiatric reactions have been reported with corticosteroids, including affective disorders, psychotic reactions, behavioural disturbances, irritability, anxiety, sleep disturbances, and cognitive dysfunction.
    • Reactions are common and may occur in both adults and children. 
    • Symptoms typically emerge within a few days or weeks of starting the treatment.
    • Risks may be higher with high doses/systemic exposure, although dose levels do not allow prediction of the onset, type, severity, or duration of reactions.
    • Most reactions recover after dose reduction or withdrawal, although specific treatment may be necessary.
    • Psychological effects have also been reported on the withdrawal of corticosteroids; the frequency is unknown.
Serous chorioretinopathy (CSCR)
  • This information is also based on the MHRA drug safety update Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration [MHRA, 2017]:
    • CSCR is a retinal disorder associated with both systemic and local corticosteroid use.
    • It is characterized by subretinal fluid accumulation at the posterior pole, which can lead to retinal detachment.
    • Blurred vision is a key symptom of CSCR, but may also indicate other corticosteroid-related ocular complications, such as cataracts or glaucoma.

How should I reduce the risks of adverse effects in people taking oral corticosteroids?

  • To reduce the risk of adverse effects of oral corticosteroids:
    • Prescribe the lowest effective dose for the shortest possible duration.
    • When appropriate, prescribe the dose as a single morning administration or on alternate days (or at longer intervals) to reduce adrenal suppression.
    • Consider prescribing a proton pump inhibitor (PPI) for people with risk factors for gastrointestinal (GI) bleeding or dyspepsia.
      • Risk factors include concurrent use of medicines known to increase the risk of GI bleeding, such as nonsteroidal anti-inflammatory drugs; excessive alcohol consumption; heavy smoking; history of gastroduodenal ulcer, GI bleeding, or gastroduodenal perforation; older age; and serious comorbidity, such as advanced cancer. 
      • Note that enteric-coated corticosteroid formulations are not recommended for reducing the risk of GI bleeding or dyspepsia.
    • Monitor the person regularly during prolonged corticosteroid treatment.
    • When stopping treatment, taper gradually to maintain disease control and reduce the risk of adrenal crisis.
    • Provide clear information and advice to ensure safe use and reduce the risk of adverse effects.

Basis for recommendation

These recommendations are largely based on the British National Formulary (BNF) [BNF, 2025], the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021], expert opinion in review articles [Liu et al, 2013; Caplan, 2017], and what CKS considers good clinical practice.

Gastrointestinal adverse effects and proton pump inhibitors (PPIs)
  • The risk of peptic ulcer disease due to corticosteroids alone is low, but it increases significantly when corticosteroids are used in combination with non-steroidal anti-inflammatory drugs (NSAIDs) [Liu et al, 2013].
  • Routine use of a PPI is not recommended for those taking glucocorticoids alone; however, a PPI should be [Caplan, 2017]:
    • Prescribed for people on concurrent treatment with a glucocorticoid and an NSAID.
    • Considered in people with other risk factors for peptic ulcer disease.
  • There is no strong evidence that enteric-coated prednisolone reduces the risk of peptic ulcers compared with plain prednisolone.
    • A study presented at the 2017 British Endocrine Societies (BES) meeting highlighted the absence of evidence supporting any gastroprotective benefit of enteric-coated prednisolone. Moreover, these formulations exhibit considerable intra-individual variability in absorption. The delayed and unpredictable absorption can result in less consistent pharmacokinetics, which should be carefully considered when switching between formulations [Zhang, 2017]. 
    • NHS Trust formularies and regional medicines optimisation groups consistently state that enteric-coated formulations do not offer a significant advantage in reducing gastrointestinal adverse effects. For example, the Greater Manchester Medicines Management Group (GMMMG) states that the enteric coating does not reduce the risk of peptic ulceration, since this is a systemic effect. Additionally, enteric-coated formulations appear to be associated with less predictable absorption of prednisolone, and there are case reports of loss of disease control in people with inflammatory bowel disease [GMMMG, 2024].

How should I monitor a person on long-term oral corticosteroids?

  • Before starting long-term corticosteroid treatment (and at regular intervals during treatment, frequency depending on clinical judgement), check: 
    • HbA1c. 
    • Blood pressure.
    • Body weight and body mass index (BMI).
    • Triglycerides. 
    • Potassium.
    • Eye examination (for glaucoma and cataract).
  • Monitor the following during treatment, depending on clinical judgement:
  • Additionally:
    • Monitor pregnant women for fluid retention and hypertension, as corticosteroids can exacerbate both and increase the risk of complications such as pre-eclampsia.
    • Monitor breastfeeding infants for adrenal suppression if the mother is taking high-dose corticosteroids (for example, more than 40 mg prednisolone). See the section on Pregnancy and breastfeeding for more information.
    • Monitor blood pressure and renal function (serum creatinine) in people with systemic sclerosis who take prednisolone, as this can increase the risk of scleroderma renal crisis.
  • In children and adolescents receiving prolonged or frequent oral corticosteroid treatment:
    • Record baseline height using an appropriate growth chart before starting treatment.
    • Monitor height accurately and regularly (at least annually) using a growth chart, as growth velocity may decrease during treatment.
    • If a reduction in growth rate is observed, consider lowering the corticosteroid dose if clinically appropriate. Refer to a paediatrician if needed.

Basis for recommendation

These recommendations are based on the British National Formulary [BNF, 2025] and the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021].

How should I withdraw oral corticosteroid treatment?

  • Tailor the dose and rate of corticosteroid tapering on a case-by–case basis, considering factors such as the underlying condition, treatment duration and dosage, and the risk of relapse. 
    • Consider gradual withdrawal in people whose disease is unlikely to relapse and who meet the following criteria: 
      • Received more than 40 mg of prednisolone (or equivalent) daily for more than 1 week, or 2 mg/kg daily for 1 week, or 1 mg/kg daily for 1 month.
      • Have been taking repeated evening doses of corticosteroids, which increases the risk of developing adrenal suppression.
      • Received corticosteroid treatment for more than 4 weeks if aged 16 and over (or more than 3 weeks if under 16 years).
      • Recently received repeated courses of corticosteroids (especially if they have been taken for longer than 3 weeks), for example, prescribed for the treatment of acute exacerbations of asthma.
      • Taken a short course of corticosteroids within 1 year of stopping long-term treatment.
      • Other possible causes of adrenal suppression, such as excessive alcohol consumption or stress (for example, due to infection, trauma, or surgery).
    • Systemic corticosteroids may be stopped abruptly in people whose disease is unlikely to relapse, who have received treatment for 3 weeks or less, and who do not meet the criteria described above.
  • During corticosteroid withdrawal:
    • Reduce the dose rapidly to the daily physiological dose, which is the glucocorticoid dose equivalent to the amount that a healthy adrenal gland would typically produce.
      • For people aged 16 years and over, this is a total daily dose of hydrocortisone 15 mg to 25 mg, prednisolone 3 mg to 5 mg, or dexamethasone 0.5 mg.
      • For babies, children, and young people under 16 years, this is a total daily dose of hydrocortisone 8 mg/m2.
    • Once on a physiological dose, taper more gradually, for example, by using that dose every other day for 2 weeks, then twice a week for 2 weeks, and then stopping.
    • Assess for disease relapse during tapering. 
      • If withdrawal symptoms occur, resume a higher dose and continue the withdrawal at a slower rate.
    • Advise the person:
      • To expect temporary symptoms, including fatigue, reduction in appetite, and low mood.
      • To be alert for the signs and symptoms of adrenal suppression, such as fatigue, weight loss, abdominal pain, headache, nausea, and vomiting. 

Equivalent anti-inflammatory doses

Table 2. Equivalent anti-inflammatory doses of oral corticosteroids.

Oral corticosteroidDose equivalent to 5 mg of prednisolone
Betamethasone750 micrograms
Deflazacort6 mg
Dexamethasone750 micrograms
Hydrocortisone20 mg
Methylprednisolone4 mg
Prednisone5 mg
Triamcinolone4 mg
This table does not consider mineralocorticoid effects or variations in duration of action of the corticosteroids.
Data from: [BNF, 2025]

Basis for recommendation

These recommendations are based on National Institute for Health and Care Excellence (NICE) guidance Adrenal insufficiency: identification and management [NICE, 2024], the British National Formulary (BNF) [BNF, 2025],  expert opinion in a review article [Ahmet, 2019], and the manufacturer's Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021].

  • Abrupt withdrawal of corticosteroids after a prolonged period can lead to acute adrenal insufficiency, hypotension, or death [EMC, 2021; BNF, 2025].
    • A distinct withdrawal syndrome may also occur, unrelated to adrenal insufficiency, and is thought to result from sudden changes in glucocorticoid concentration (rather than low corticosteroid levels). Symptoms include anorexia, nausea, vomiting, lethargy, headache, fever, joint and muscle pain, skin rashes or nodules, weight loss, rhinitis, conjunctivitis, and hypotension. 
    • Psychological effects have also been reported on withdrawal of corticosteroids.
  • The recommendations on when to consider dose tapering are based on the BNF [BNF, 2025], SPC [EMC, 2021], and NICE guideline [NICE, 2024].
    • How dose reduction should be carried out depends largely on whether the disease is likely to relapse as the dose of systemic corticosteroids is reduced [EMC, 2021].
    • Clinical assessment of disease activity may be needed during withdrawal [EMC, 2021].
    • If the disease is unlikely to relapse on withdrawal of systemic corticosteroids but there is uncertainty about hypothalamic-pituitary-adrenal (HPA) suppression, the dose of corticosteroid may be reduced rapidly to physiological doses and then reduced more slowly to allow the HPA-axis to recover [EMC, 2021], for example, by using that dose every other day for 2 weeks, then twice a week for 2 weeks, then stopping [NICE, 2024].
  • The suggested tapering regimen is based on NICE guideline [NICE, 2024]. 
    • The physiological equivalent dose is the glucocorticoid dose equivalent to the amount that a healthy adrenal gland would normally produce.
    • The BNF and SPC list the physiological replacement dose of prednisolone as 7.5 mg/day. However, NICE recommends a physiological replacement dose of prednisolone at 3–5 mg/day, based on evidence indicating that 4 mg/day of prednisolone achieves physiological serum cortisol levels, and that doses exceeding 7.5 mg/day are associated with adverse effects, such as obesity, hypertension, osteoporosis, and reduced fertility, particularly in people with congenital adrenal hyperplasia. Therefore, to balance the risk of adverse effects at higher doses against inadequate cortisol replacement at lower doses, the guideline suggests a starting dose of 3–5 mg/day for physiological replacement.
    • The NICE committee highlighted that if there are any symptoms of adrenal insufficiency or any uncertainty, glucocorticoid should be reverted to a physiological equivalent dose and consideration given to contacting an endocrine specialist. 

What are the key drug interactions with oral corticosteroids?

  • Drug interactions of corticosteroids include:
    • Antacids — large doses of some antacids, such as magnesium trisilicate or aluminium hydroxide, may reduce the absorption of prednisolone.
      • No action is usually needed.
      • If an interaction is suspected, consider separating the doses by 2–3 hours.
    • Anticoagulants — response to anticoagulants may be reduced or, less often, enhanced by corticosteroids. 
      • Monitor the international normalized ratio (INR) closely to avoid spontaneous bleeding.  
    • Antidiabetic drugs — the blood glucose-lowering effects of antidiabetics are opposed by corticosteroids, and clinically important hyperglycaemia has been seen with systemic corticosteroids.
      • Monitor blood glucose concentrations more closely and adjust the dose of the antidiabetic treatment accordingly.
    • Carbimazole — prednisolone clearance is increased by the concurrent use of carbimazole.
      • Monitor the outcome of concurrent use, and adjust the corticosteroid dose as necessary.
    • Ciclosporin — reduces corticosteroid clearance; signs of corticosteroid toxicity have been reported.
      • Concurrent use is common and advantageous; however, be alert for increased corticosteroid adverse effects.
    • Combined hormonal contraceptives — the levels of prednisone, prednisolone, hydrocortisone, methylprednisolone, and possibly other corticosteroids are increased by oral combined hormonal contraceptives. Therapeutic and adverse effects would be expected to be increased, but there appear to be no clinical reports of adverse reactions.
      • Until more is known, bear this interaction in mind should any unexpected increase in corticosteroid adverse effects occur on concurrent use.
    • Enzyme inducers — cytochrome P450 3A4 (CYP3A4) inducers (such as phenobarbital, phenytoin, rifampicin, rifabutin, carbamazepine, and primidone) may reduce the therapeutic efficacy of corticosteroids by increasing the rate of metabolism. 
      • Monitor the effects of concurrent use to ensure corticosteroid efficacy and adjust the corticosteroid dose accordingly.
    • Enzyme inhibitors — CYP3A4 inhibitors (such as ketoconazole, ritonavir, clarithromycin, and fluoxetine) may increase plasma concentrations of corticosteroids by slowing their metabolism.
      • Monitor for corticosteroid adverse effects, and adjust the dose as needed to maintain safety and effectiveness.
    • Fluoroquinolones — concurrent use of corticosteroids and fluoroquinolones (such as ciprofloxacin) may increase the risk of tendinitis and tendon rupture. This combination can also exacerbate hypokalaemia, increasing the risk of Torsades de Pointes.
      • Avoid concurrent use.
      • If concurrent use is unavoidable, monitor for symptoms of tendinitis (painful swelling, inflammation) and stop treatment if this occurs. Monitor potassium concentrations closely.
    • Isoniazid — prednisolone can reduce isoniazid levels by up to 40%.
      • Be aware of the possibility of a reduced response during concurrent use, and increase the isoniazid dose if necessary. 
    • Live vaccines — people immunized with live vaccines while taking immunosuppressive doses of corticosteroids (equivalent to 40 mg of prednisolone daily for more than 7 days) may develop generalized (and possibly life-threatening) infections.
      • Postpone live vaccines for at least 3 months after high-dose corticosteroids are stopped. 
    • Macrolides — macrolides (such as clarithromycin and erythromycin) may increase prednisolone levels and exacerbate hypokalaemia, raising the risk of torsades de pointes.
      • Monitor potassium and for steroid-related adverse effects, and reduce the corticosteroid dose if necessary.
    • Methotrexate — increased risk of haematological toxicity with methotrexate.
      • If concurrent use is necessary, closely monitor full blood count and liver function tests. 
    • Medicines that cause hypokalaemia — corticosteroids can cause hypokalaemia that may be additive with the effects of other medicines, including: 
      • Amitriptyline, bicalutamide, chloroquine, clozapine, lithium — monitor potassium levels closely. 
      • Bronchodilators (for example, salbutamol, salmeterol, and terbutaline) — consider monitoring potassium levels based on the severity of the person's condition and the number of potassium-depleting drugs used. 
      • Digoxin — monitor concurrent use for digoxin adverse effects (for example, bradycardia), and consider monitoring potassium levels. 
      • Diuretics (for example, furosemide and hydrochlorothiazide) — monitor potassium levels during concurrent use.
    • Mifepristone — the effects of corticosteroids may be reduced for 3–4 days after mifepristone.
      • Monitor the effects of concurrent use to ensure corticosteroid efficacy, and adjust the corticosteroid dose accordingly.
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) — NSAIDs may increase the risk of gastrointestinal (GI) bleeding and ulceration when they are given with corticosteroids.
      • Consider the use of a proton pump inhibitor if the person is at high risk for GI bleeding or dyspepsia.
      • Risk factors include concurrent use of medicines known to increase the risk of GI bleeding, such as nonsteroidal anti-inflammatory drugs; excessive alcohol consumption; heavy smoking; history of gastroduodenal ulcer, GI bleeding, or gastroduodenal perforation; older age; and serious comorbidity, such as advanced cancer. 
      • Enteric-coated corticosteroid formulations are not recommended for reducing the risk of GI bleeding or dyspepsia.

Basis for recommendation

These recommendations are largely based on Stockley's drug interactions [Preston, 2025], the British National Formulary (BNF) [BNF, 2025], and the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021]. The information on fluoroquinolones is also based on the Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update Fluoroquinolone antibiotics: reminder of the risk of disabling and potentially long-lasting or irreversible side effects [MHRA, 2023].

What information and advice should I give to a person receiving oral corticosteroids?

  • Discuss the possible adverse effects of corticosteroids.
    • Advise the person to:
      • Take their treatment as directed. They must not stop abruptly unless advised by a healthcare professional.
      • Be alert for the symptoms of adrenal suppression (such as dizziness, nausea, lethargy, and hypotension) and seek urgent medical attention if these occur.
      • Seek medical advice if they experience other adverse effects, such as visual disturbances, mood or behavioural changes, easy bruising, or signs of infection.
      • Attend all review appointments with the primary care team and, if applicable, their specialist to ensure safe monitoring and effective management of their condition.
    • Encourage the person to adopt lifestyle measures to help reduce the risk of corticosteroid-related adverse effects. They should:
      • Eat a healthy, balanced diet with adequate calcium — to help reduce the risk of steroid-induced bone loss and osteoporosis. 
      • Maintain a healthy body weight — to minimize the risk of weight gain, diabetes, and cardiovascular complications associated with corticosteroids. 
      • Stop smoking and limit alcohol intake — to reduce the risk of cardiovascular disease. 
      • Stay physically active (within the limits of their underlying condition) — to support bone health, weight management, and cardiovascular health.
      • For more information, see the CKS topics on Osteoporosis - prevention of fragility fractures, Obesity, Smoking cessation, Alcohol - problem drinking, and CVD risk assessment and management).
  • Advise people on long-term, high-dose, or frequent oral corticosteroid treatment to:
    • Carry a Steroid Treatment Card (Blue) and/or a Steroid Emergency Card (Red), as as appropriate.
    • Follow sick day rules advice during illness or physical stress, if applicable.
    • Seek prompt medical advice if they become unwell or are exposed to an infectious disease, such as measles.
    • Avoid close contact with anyone who has chickenpox or shingles if they have never had chickenpox, and seek medical advice if exposed.

Basis for recommendation

These recommendations are largely based on the British National Formulary (BNF) [BNF, 2025], the Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021], expert opinion in review articles [Liu et al, 2013; Caplan, 2017], and what CKS considers good clinical practice.

Measles and chickenpox
  • These recommendations are extrapolated from information in the BNF [BNF, 2025] and the Steroid Treatment Card (Blue). 
    • The BNF advises that prolonged use of corticosteroids can increase the risk and severity of infections, and clinical presentation of infections may also be atypical. Therefore [BNF, 2025]:
      • People taking corticosteroids should take particular care to avoid exposure to measles and seek immediate medical advice if exposure occurs.
      • People receiving systemic (oral or parenteral) corticosteroids for purposes other than replacement should be considered at risk of severe chickenpox unless they have previously had the infection. Confirmed chickenpox warrants specialist care and urgent treatment.
    • The Steroid Treatment Card (Blue) advises that people should promptly consult their doctor if they become ill or come into contact with anyone who has an infectious disease. Those who have never had chickenpox should avoid close contact with people who have chickenpox or shingles, and seek urgent medical advice if exposed.

Supporting evidence

The recommendations in this CKS topic are largely based on expert opinion in the textbook Rang and Dale's Pharmacology [Ritter, 2020], a drug reference compendium Martindale: the complete drug reference [Brayfield, 2020], the British National Formulary (BNF) [BNF, 2025], and the manufacturer's Summary of Product Characteristics (SPC) for prednisolone tablets [EMC, 2021]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on the use of oral corticosteroids in primary care.

Search dates

April 2020 - May 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 27th April 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S32    S28 AND S31 
S31    S29 OR S30 
S30    AB ( oral* or systemic* ) OR TI ( oral or systemic*) 
S29    (MH "Administration, Oral+") 
S28    S8 AND S27 
S27    S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 
S26    TI drug monitoring 
S25    (MH "Drug Monitoring") 
S24    (MH "Contraindications, Drug") 
S23    TI contraindication* 
S22    TI drug interaction* 
S21    (MH "Drug Interactions+") 
S20    TI drug withdrawal 
S19    TI teratol* 
S18    (MH "Fetus+") 
S17    (MH "Breast Feeding+") 
S16    (MH "Lactation+") 
S15    (MH "Pregnancy Complications+") 
S14    TI pregnan* 
S13    (MH "Pregnancy+") 
S12    MW ae 
S11    TI side effect* 
S10    TI adverse* 
S9    (MH "Drug-Related Side Effects and Adverse Reactions+") 
S8    S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 
S7    TI corticosteroid* or glucocorticoid* or steroid* or betamethasone or deflazacort or dexamethasone or hydrocortisone or methylprednisolone or prednisolone or fludrocortisone 
S6    (MH "Prednisolone+") 
S5    (MH "Methylprednisolone+") 
S4    (MH "Hydrocortisone+") 
S3    (MH "Dexamethasone+") 
S2    (MH "Betamethasone+") 
S1    (MH "Glucocorticoids") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
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  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
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Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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