Table 2.

Suggested measures to reduce the side effects of glucocorticoids

Variable	Details
Type of drugs	For chronic treatment short-acting glucocorticoids should be preferred.
Time of administration	The daily dose of glucocorticoid should be given in a single morning administration between 7 and 9 am to mimic the circadian cycle of cortisol.
Concomitant drugs	Glucocorticoids are metabolized by cytochrome P450 enzymes. Simultaneous use of drugs that inhibit the activity of cytochrome P450 enzymes increase the blood and tissue levels of glucocorticoids (ketoconazole, itraconazole, clarithromycin). On the other hand, drugs that activate cytochrome P450 (phenobarbital, phenytoin, and rifampin) reduce the blood levels of glucocorticoids. The prolonged use of proton pump inhibitors may cause interstitial nephritis, magnesuria, and osteoporosis.
Hygienic measures	Good personal hygiene, low-calorie diet, limited salt intake, physical activity, smoking cessation, mild alcohol intake, and strict control of BP are recommended.
Monitoring	Patients should be instructed to promptly report side effects and physicians should not disregard apparently trivial adverse events.
Gradual discontinuation	To avoid acute hypoadrenalism episodes glucocorticoids should be withdrawn gradually, tapering the doses over weeks or months to allow the atrophied cortex to regain functional status.
Selection of patients	Glucocorticoids should be used with caution in patients with chronic infection, severe hypertension, diabetes, obesity, psychiatric disease, and in those with eGFR<30 ml/min per 1.73 m2.