Papers

History of chickenpox and steroid cards: a new warning?

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7030.542 (Published 02 March 1996) Cite this as: BMJ 1996;312:542
  1. M D Feher, lecturera,
  2. J P Simms, senior pharmacistb,
  3. A F Lant, professora
  1. a Department of Clinical Pharmacology and Therapeutics, Charing Cross and Westminster Medical School, London SW10 9NH
  2. b Pharmacy Departments, Chelsea and Westminster Hospital, London SW10 9NH and Kings College Hospital, London SW3 6LX
  1. Correspondence to: Dr Feher.
  • Accepted 11 October 1995

National steroid cards were designed to inform patients treated with corticosteroids of the dose and potential hazards of treatment. Recent reports of severe chickenpox associated with steroid treatment1 2 have highlighted a potential need to amend the current steroid card. In May 1994 the Chief Medical Officer wrote to all doctors in the United Kingdom regarding the hazards of exposure to chickenpox.3 With this background, we asked patients taking oral steroid treatment about the information they had received from their doctors.

Patients, methods, and results

Between September and November 1994 all patients who presented to the outpatient pharmacy of Chelsea and Westminster Hospital with a prescription for oral prednisolone were interviewed. Patients completed a standardised questionnaire asking their age, whether they carried a steroid card, if they had had chickenpox, and their doctors' instructions on stopping steroids and side effects. Patients were also asked about the condition for which they considered the prednisolone had been prescribed, together with the dose and duration of treatment.

A total of 105 consecutive patients presented with a prescription for steroids during the three month study. Of these, 102 (46 male and 56 female) patients (or accompanying immediate family with a child patient) fully completed the questionnaire; the median age of patients was 50 years (range 1 to 92).

About one in seven patients were unable to give details of the condition for which they had been prescribed steroids. Over a third of the patients had received their first course of oral steroids during the survey period. Of the 66 patients who had been treated previously with steroids, 45 (67%) carried a steroid card; this included 14 patients who had been treated for less than one month, 20 for one to six months, and 32 for more than six months. Previous chickenpox was acknowledged in 75 and denied in 21; six of the 102 patients surveyed were uncertain. Doctors' instructions on not stopping treatment suddenly was recalled by 60 patients, and 63 acknowledged being given advice on potential side effects of steroids. Only 24 confirmed that the doctor had specifically asked about chickenpox and only 15 had been advised about chickenpox in association with their treatment. All 27 patients who recalled no previous chickenpox (or were uncertain of it) had received no specific information from their doctor at the time of the steroid prescription about the potential hazards of chickenpox.

Comment

This survey highlights a need to update steroid cards for the benefit of both patients and prescribing doctors. Steroid cards were designed in 1961 by the Department of Health and to our knowledge have not been modified since their introduction. Distribution is through the Royal Pharmaceutical Society of Great Britain. The cards do not give specific warnings about the hazards of chickenpox with steroid treatment. Although most of the survey patients who had previously been treated with steroids carried a steroid card, only half could recall of their doctor's advice on side effects. Even though the true prevalence of immunity to varicella in patients who are uncertain of previous chickenpox infection may be high,2 there is a clear risk for those who do not have antibodies to varicella.1 2 The universal omission of advice regarding exposure to chickenpox in those patients within the present survey who had no recall of having had chickenpox reinforces the need for written instructions regarding potential severe adverse reactions with steroids.3 4

Patient information leaflets detailing drug precautions have been included by the manufacturers in only a limited number of steroid preparations but are due to be included with all steroid preparations as part of the Medicines Control Agency's patient pack initiative. As with other drug safety warnings, dated amendments should be made regularly if the steroid card is to have clinical relevance, particularly as it is reproduced in each edition of the British National Formulary. Our hospital now issues a separate written warning regarding chickenpox with all prescriptions for corticosteroids.

Footnotes

  • Funding None.

  • Conflict of interest None.

References

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