10 minute read
Emergency Steroid Cards and guidance for dermatology nurses
Polly Buchanan
Polly Buchanan is a Community Dermatology Nurse Specialist at NHS Fife, Queen’s Nurse, and Clinical Editor of Dermatological Nursing.
In the BDNG news e-Bulletin sent on 30th April 2021, there was a notification relating to Emergency Steroid Cards, with links to related papers and guidance. Having read the notification and relevant papers I thought it important to again bring this issue to the attention of our readers. This is not to be alarmist, but to support and guide readers to the relevant, up-to-date evidence and guidance, which will inform our practice and keep our patients safe.
In August 2020, NHS England, supported by the Royal College of Physicians, Royal College of General Practitioners and the Society of Endocrinology, issued a National Patient Safety Alert¹ for the dissemination of patient held Steroid Emergency Cards to support early recognition and treatment of adrenal crisis in adults. This was due to several associated deaths.
This relates to all adult individuals who are steroid dependent and at risk of adrenal insufficiency, including primary adrenal insufficiency (Addison’s disease, congenital adrenal hyperplasia, and Hypothalamo-pituitary damage) as well as those at risk of secondary adrenal insufficiency due to intake or application of exogenous steroids (oral, injection, inhaled, nasal, rectal and topical).1
Guidance has been published and can be accessed at: https://www.rcpjournals. org/content/clinmedicine/20/4/371. The guidance outlines the steps which can be taken to avoid adrenal crisis in at-risk individuals should they become seriously ill, traumatised or require surgery.
Specific actions were highlighted which were to be in place by 31st May 2021. These include:
Awareness of the issue for all healthcare professionals Complete review of policies, processes, procedures and electronic prompts relating to steroid prescriptions to ensure prescribers also issue a card if appropriate.
Patient held emergency steroid cards are available from: http://www.nhsforms. co.uk/ and at: https://secure.pcse.england. nhs.uk/_forms/pcsssignin.aspx
In response to this new guidance, David Erskine, Specialist Pharmacy Services (SPS), and Helen Simpson, on behalf of the Society for Endocrinology Steroid Emergency Card working group, published a paper which comprehensively addresses the issues surrounding exogenous steroids, adrenal insufficiency, and adrenal crisis with clear guidance on identifying those at risk and management strategies.2 This guidance has been endorsed by the British Association of Dermatologists and the Society of Endocrinology.²
I strongly recommend reading this guidance and incorporating relevant assessments, procedures and patient education into nursing practice. For us, the relevance of this paper lies mainly in the supply and administration of topical corticosteroids (TCS), which is an everyday practice in dermatology. It will be important for us to consider our prescribing practice, especially where the use of potent or very potent topical corticosteroids are utilised.
This guidance also advocates assessment and monitoring of all exogenous steroids, whether oral, articular, inhalational, nasal, rectal, or topical. The total accumulation of all steroids can, to a lesser or greater extent, put the patient at risk of adrenal insufficiency, especially if longer term use of potent or super potent steroids are applied topically (>200g potent TCS / week for four weeks or more), which may also include daily inhaled steroids or short course oral steroids.
It is important we are aware of this new guidance so that we can reassure patients and colleagues of safe and effective practice and avoid any further steroid phobia. It is likely few of our patients will require an emergency steroid card, but not impossible. It is very reassuring to know that best practice already includes individual written patient care plans which clearly define reducing regimens for potent and super potent TCS. DN
References:
1. Society for Endocrinology Clinical Committee and the Royal College of Physicians Patient Safety Committee 2020. Guidance for the prevention and emergency management of patients with adrenal Insufficiency. Available at: https://www.rcpjournals.org/ content/clinmedicine/20/4/371 [last accessed June 2021] 2. Erskine D, Simpson H. Exogenous steroids, adrenal insufficiency and adrenal crisis: Who is at risk and how should they be managed safely. Specialist Pharmacy Services (SPS), Society for Endocrinology Steroid Emergency Card Working Group 2021. Available at: https://www.endocrinology.org/media/4030/ spssfe_supporting_sec_-final_hls-19022021-2-1.pdf [last accessed June 2021].
Resources:
NHS England: https://www.england.nhs.uk/2020/08/ steroid-emergency-card-to-supportearly-recognitionand-treatment-of-adrenal-crisis-in-adults For any enquiries about this alert contact: patientsafety. enquiries@nhs.net
DAYLIGHT
Methyl aminolevulinate on your AK marks get set… done! Think PDT for treating AK; think METVIX first for proven clinical outcomes1–3
METVIX is indicated in adults (≥18 years) for the treatment of: Thin or non-hyperkeratotic and non-pigmented actinic keratoses on the face and scalp1 .
METVIX, a convenient treatment made for patients - so they can get back to what matters
PI Metvix 160 mg/g cream Abbreviated Prescribing Information (UK & IRE)
Presentation: Cream containing 160mg/g of methyl aminolevulinate (as hydrochloride). Indications: Treatment in adults over 18 years of thin or non-hyperkeratotic and non-pigmented actinic keratoses on the face and scalp. Only for treatment of superfi cial and/or nodular basal cell carcinoma unsuitable for other available therapies due to possible treatment related morbidity and poor cosmetic outcome; such as lesions on the mid-face or ears, lesions on severely sun damaged skin, large lesions, or recurrent lesions. Treatment of squamous cell carcinoma in situ (Bowen´s disease) when surgical excision is considered less appropriate. Dosage and administration: AK, BCC and Bowen’s disease using red light. For treatment of actinic keratoses (AK) one session of photodynamic therapy should be administered. For treatment of basal cell carcinoma (BCC) two sessions should be administered with an interval of one week between sessions. Before applying Metvix cream, the surface of AK and superfi cial BCC lesions should be prepared to remove scales and crusts and roughen the surface of the lesions. Nodular BCC lesions are often covered by an intact epidermal keratin layer which should be removed. Exposed tumour material should be removed gently without any attempt to excise beyond the tumour margins. Apply Metvix cream (about 1mm thick) using a spatula to the lesion and surrounding 5-10mm of normal skin. Cover the treated area with an occlusive dressing for 3 hours. Remove dressing, and clean with saline and immediately expose the lesion to red light with a continuous spectrum of 570-670nm and a total light dose of 75J/cm2. Multiple lesions may be treated during the same treatment session. Lesion response should be assessed after three months, and it is recommended to confi rm the response of BCC lesions by histological biopsy. AK and BCC lesion sites that show non- complete response may be retreated if desired. AK using daylight Daylight treatment may be used to treat mild to moderate AK lesions. One treatment should be given. Treatment lesions should be evaluated after three months and if there is incomplete response, a second treatment may be given. Daylight treatment can be used if the temperature conditions are suitable to stay comfortably outdoors for 2 hours. If the weather is rainy, or is likely to become so, daylight treatment should not be used. A sunscreen should be applied. Once sunscreen has dried, scales and crusts should be removed from the lesions and the skin surface roughened before applying a thin layer of Metvix to the treatment areas. No occlusion is necessary. Patients should go outside after Metvix application or, at the latest, 30 minutes later in order to avoid excessive protoporphyrin IX accumulation which would lead to greater pain on light exposure. In order to minimize pain and ensure maximum effi cacy the patient should then stay outdoors for 2 continuous hours in full daylight and avoid going indoors. On sunny days, should the patient feel uncomfortable in direct sunlight, shelter in the shade may be taken. Following the 2-hour exposure period, Metvix should be washed off. Please refer to summary of product characteristics before use. Contraindications: Hypersensitivity to the active or excipients, including arachis oil or peanut or soya. Morpheaform basal cell carcinoma. Porphyria. Precautions and Warnings: When using red light, should only be administered in the presence of a health care professional trained in the use of photodynamic therapy with Metvix. When using daylight treatment, a sunscreen should be applied to all areas exposed to daylight, prior to lesion preparation. Sunscreen used should offer adequate protection (SPF30 or higher) and must not include physical fi lters (e.g. titanium dioxide, zinc oxide, iron oxide). Only sunscreens with chemical fi lters should be used with daylight treatment. Not recommended during pregnancy. Only limited experience is available in relation to the treatment of actinic keratosis and/or Bowen’s disease amongst transplant patients on concomitant immunosuppressive therapy. A close monitoring of these patients ,with re-treatment if necessary is recommended in this population. There is no experience in treating Bowens disease in patients with a history of arsenic exposure. There is no experience of treating pigmented or highly infi ltrating lesions with Metvix cream. Thick (hyperkeratotic) actinic keratoses should not be treated with Metvix. Methyl aminolevulinate may cause sensitization by skin contact resulting in angioedema, application site eczema or allergic contact dermatitis. The excipient cetostearyl alcohol may cause local skin reactions (e.g. contact dermatitis), methyl- and propylparahydroxybenzoate (E218, E216) may cause allergic reactions (possibly delayed). Any UV-therapy should be discontinued before treatment. As a general precaution, sun exposure on the treated lesion sites and surrounding skin has to be avoided for a couple of days following treatment. Direct eye contact with Metvix cream should be avoided. Metvix cream should not be applied to the eyelids and mucous membranes. Pain during illumination with red light may induce increased blood pressure. Measure blood pressure in patients prior to treatment. If severe pain occurs during treatment, the blood pressure should be checked. In case of severe hypertension, the illumination with red light should be interrupted in addition to taking appropriate symptomatic measures. Pregnancy and lactation: There is no or limited data from the use of methyl aminolevulinate in pregnant women. Metvix is not recommended during pregnancy and in women of childbearing potential not using contraception. It is unknown whether methyl aminolevulinate /metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from Metvix therapy taking into account the benefi t of breast feeding for the child and the benefi t of therapy for the woman. Undesirable effects: Approximately 60% of patients experience reactions localised to the treatment site that are attributable to toxic effects of the photodynamic therapy (phototoxicity) or to preparation of the lesion. The most frequent symptoms are painful and burning skin sensation typically beginning during illumination or soon after and lasting for a few hours with resolving on the day of treatment. The symptoms are usually of mild or moderate severity and rarely require early termination of illumination. The most frequent signs of phototoxicity are erythema and scab. The majority are of mild or moderate severity and persist for 1 to 2 weeks or occasionally longer. Repeated treatment with Metvix is associated reduced frequency and severity of local phototoxic reactions. The incidence of adverse reactions in a clinical trial population of 932 patients receiving the standard treatment regimen with red light and from post marketing surveillance are shown in the table below.
Body system (MedDRA) Frequency Adverse reaction Nervous system disorders Common (≥1/100, <1/10) Paraesthesia, headache Not known Transient global amnesia (including confusional state and disorientation) Eye disorders Uncommon (≥1/1000, ≤1/100) Eye swelling, eye pain Not known Eyelid oedema Vascular disorders Uncommon (≥1/1000, ≤1/100) Wound haemorrhage Not known Hypertension Gastrointestinal disorders Uncommon (≥1/1000, ≤1/100) Nausea Skin and subcutaneous tissue disorders Very common (≥1/10) Pain of skin, skin burning sensation, scab, erythema Common (≥1/100, <1/10) Skin infection, skin ulcer, skin oedema, skin swelling, blister, skin haemorrhage, pruritus, skin exfoliation, skin warm Uncommon (≥1/1000, ≤1/100) Urticaria, rash, skin irritation, photosensitivity reaction, skin hypopigmentation, skin hyperpigmentation, heat rash, skin discomfort
Not known Angioedema, face oedema (swelling face), application site eczema, allergic contact dermatitis, rash pustular (application site pustule)
General disorders and administration site conditions Common (≥1/100, <1/10) Application site discharge, feeling hot Uncommon (≥1/1000, ≤1/100) Fatigue
Prescribers should consult the summary of product characteristics in relation to other side effects. MA Numbers: PL 10590/0048 (UK) & PA 590/20/1 (Ireland) Packaging Quantities and Cost: Tube of 2 gram, UK - £171.50 (NHS), Ireland - €227.00 Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: May 2020
Adverse events should be reported. For the UK: Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland: Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd. E-mail: Medinfo.uk@galderma.com; Tel: +44 1 923 208950
