Steroids, less is better

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There seems to be more and scientific evidence these days that less is better when it comes to our favorite poison…ie, corticosteroids, such as prednisone or IV methylprednisone. And that applies not only to day to day maintenance doses, but also to the treatment of severe exacerbations that require emergency hospital care.

When I say less is better, Im referring to some recent data that suggests there is little to no added benefit for steroid doses exceeding 2mg/kg of body weight/day (or roughly 60-100 mg per day) for treating asthma. While it true that taking corticosteroids reduces the risk of hospitalization during asthma exacerbation in adults, for those who are already taking these drugs everyday, or have extremely severe disease, the question really becomes, how much is enough!

While I’m not your typical asthmatic, a few weeks ago while I was in the ER for during a bad flare, the ER physician asked me how big of a loading dose of IV steroids I usually get during one these flares? I told him they usually give me a 120mg bolus. He said Ok, but this time lets try you on 60mg instead of 120. He told about a study they had done there regarding steroids. Now, I hate steroids as much as the next person, but to be honest I was little nervous about the whole thing because Id never received such a low dose during a bad attack. heck, I took 60mg that morning at home. But to my surprise, a after few hours later I didn’t feel any worse. I didn’t feel any better either, but that’s not unusual for me during the first 24-48 hours of a really bad flare. Between the barrage of continuous neb treatments, Bipap and other things going on, it’s really hard to which, if any of the drugs they’re are helping. But here’s the kicker, though I eventually did require intubation for respiratory failure, which a higher dose of steroid would have not prevented, when I came off the ventilator I had none of the delirium that I usually suffer from. But even more striking, is that I was able to wean to down to an oral prednisone dose of 40mg on just my 5th day in the hospital and was discharged home on only 20 mg. Just a fluke? I doubt it because this exaceration was trigger by a cold, and those are always the worse ones.

So, why do I find this one episode in my life so astonishing and worthy of blogging about? In the past, well actually for as long as I can remember, the customary loading dose for IV steroids (Solumedrol or equiv) for an asthmatic in severe distress ( ie,status asthmaticus) was always 120 mg followed by dosages of 60-80-120 mg every 6-8 hours for the first few days before even considering cutting the dose down….and that’s being conservative. We’re talking a whopping 300-400 mg per day right from the git go. I can even remember hospital stays in the not so distant past where I was receiving close to 500 mg per day for an entire week before they gradually reduced the dose. And if you react to steroids the way I do, you know what kind of psychological impact that can have on a person, not to mention all the physical side effects. If you’ve read some of my earlier posts on the subject you know what exactly Im talking about. But it’s not only that, the longer you’re on high dose steroids, the longer your recovery will take. And longer it takes to recover the great your chances of falling down that slippery slope.

Don’t get me wrong, steroids save lives. I wouldn’t be here without if it weren’t for them. But do we really need as much as previously thought? Apparently not, and that’s good news. As a person who has lived with this disease since day one and as a respiratory therapist who has the witnessed the horrors of steroid side effect on others, Ive always suspected(and have been quite vocal about it at times), that steroids often do as much harm in the long run as they do good. Having said that, I think its important to note are not always to blame for this. To a large extent, steroid doses are actually patient driven. It’s how the person “feels” that often dictates the dose. The doctor just orders a recommended range. That’s why it’s so important to document your symptoms and use objective measurement tools like peak flows, especially when you’re on steroids to make sure you’re weaning at the proper pace. As Ive experienced over and over again during my own exacerbations and recoveries, not all shortness of breath is the same. There are times when you can feel absolutely awful during the weaning process, yet have pretty much normal PFT values, and visa versa.

To sum up, Im very encouraged that the medical community is finally starting to recognize the pros and cons of these potent drugs. I hope this new found awareness continues to spread and with help from new biologic medications and other steroid-sparing drugs in the pipeline, that one day steroids will be the drug of last resort for asthma, instead of the first, like its been for the past 50 years.

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