Use of new steroid emergency cards in palliative care

In August 2020, in response to four deaths and more than 300 reported incidents with steroid replacement therapy involving patients with adrenal insufficiency, a National Patient Safety Alert was published by NHS England and NHS Improvement announcing the introduction of a new patient-held steroid EMERGENCY card. All patients with primary adrenal insufficiency are steroid dependent by default and some patients who take oral, inhaled or topical steroids for other medical conditions may develop secondary adrenal insufficiency and become steroid dependent(1).

The omission of steroids in patients who have endocrine disorders such as Addison’s disease or who become steroid dependent can lead to adrenal crisis and death if not identified and treated.

The NPSA alert was not fully clear about who should be issued with these cards, who should provide them and how they differed from the existing blue steroid card. We are now able to offer some clarity, but it seems their distribution still involves an element of discretion by the prescriber, who should assess their risk if for one reason or another their steroid was to be abruptly withdrawn.

When either card is given, their purpose should be explained to the patient, which is to make them aware of the importance of not abruptly stopping their steroid and to make it clear how essential it is for everyone concerned to be aware of their prescription if they become unwell and need to be seen by healthcare professionals who do not know all their medical history. One of the most hazardous scenarios for patients dependent on steroids is when they become acutely unwell and are possibly unable to give their full medical history – perhaps when admitted to hospital in an emergency and especially at the moment when they are more likely to be transferred alone so unable to be represented by a family member to help with a history.

The new steroid EMERGENCY card

• Is intended for patients with a diagnosis of primary adrenal insufficiency and those who are or who may become ‘steroid dependent’ – on long-term oral steroids.
• Should be given to any patient using injectable steroids, e.g. hydrocortisone, for adrenal insufficiency or Addison’s disease.
• holders should be encouraged to register as steroid-dependent with their local ambulance service
• Should be considered for patients taking steroids at a higher dose across all routes of administration (oral, topical, inhaled or intranasal)
  – higher dose is stated to be 5mg prednisolone for four weeks or longer (dexamethasone equivalent 750 micrograms)
  – inhaled beclomethasone above 1000 micrograms per day or fluticasone above 500 micrograms per day(2).

The blue steroid TREATMENT card

• Has been in circulation for many years and although guidance suggests that prescribers should issue one at the time the prescription for steroids is written, the cards are more often given to patients by the pharmacy when the steroids are dispensed
• Should be given to anyone who is prescribed oral steroids for more than three weeks
• Should be issued at the discretion of the prescriber or pharmacist for people who are taking oral steroids for less than three weeks or who have more than four short courses per year, e.g. people who required them for acute exacerbations of asthma
• Should be given for those on long-term high-dose steroid inhalers or steroid nasal drops (because absorption is higher than when inhaled)
• Should be carried by patients and presented when they are seeking advice or treatment from another healthcare professional.

Both cards can be obtained from NHS forms, NHS Business Services and they can also be supplied by Ashtons.

The cards may be given to patients by the prescriber at the time of consultation or given by the pharmacy dispensing the steroid preparation. Hospices may decide to keep a stock of both to give to patients when they are discharged home or to another setting.

Considering the information above, hospice patients need to be given a steroid card and many may be justifiably given the EMERGENCY card, especially as the steroid doses we use would fall into the higher-dose category. Injectable steroids do not automatically mean an EMERGENCY card is appropriate but a patient on subcutaneous steroids would need one if being given over 750 micrograms of dexamethasone for three or four weeks. However, as mentioned, prescribers should use their discretion and provide or request an EMERGENCY card for people who they feel are at risk.

We also need to consider patients who are admitted under the care of the hospice, either as an inpatient or at home, who has adrenal insufficiency as a co-morbidity. It would likely require a discussion with their endocrinologist to agree on the clinical management of their steroid requirements as they approach the end of life.