Steroids, less is always better

Ive always had a hunch, but now there seems to be more and more scientific evidence that less is better when it comes to our favorite poison…corticosteroids! ( ie, prednisone pills and IV steroids.) And that applies not only to daily 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 severe asthma flares. And while it’s true that taking corticosteroids reduces the risk of hospitalization during asthma exacerbations in adults, for those who are already taking these drugs everyday or have extremely severe disease, the question really becomes, how much is too much?

Even though I’m a frequent flyer at a local ER with a well documented history of steroid psychosis, a few weeks ago during a bad flare, the ER doc on duty asked me how big of a loading dose of IV steroids do 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. Knowing Im sort of a geek when it comes to asthma statistics, he told me about a study they had done there regarding steroids. To be honest though I was little nervous, because Id never received such a small dose during a bad attack. Heck, I’d taken 60mg by pill that morning at home. But to my surprise, several 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 full 24-48 hours of a really bad flare.

For those who dont know, steroids are not fast acting drugs. Even when given directly through a vein they can take several hours to kick in. Between the barrage of continuous neb treatments, other meds like Mag sulfate, epi, etc, and the use of Bipap and everything else going on while you’re in the throws of a bad flare, it’s really hard to tell which, if any, of the drugs you’re getting are helping. But here’s the kicker, though I eventually did require intubation for respiratory failure, for which a higher dose of steroids would not have prevented, when I came off the ventilator I had none of the delirium that I usually experience. But even more striking, is how fast I recovered. They were able to switch me over to an oral prednisone dose of just 40mg on my 5th day in the hospital and I was discharged home on only 20 mg. For me that’s nothing short of amazing. Just a fluke? I doubt it, because this exaceration was triggered by a cold, and those are always the worse ones, which is probably why I ended up on a vent.

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 maladies you develop. 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 today without 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 witnessed the horrors of steroid side effects 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 in the short term. Having said that, Physicians are not always to blame for this. To a large extent, steroid doses are actually patient driven. It’s how the patient “feels” or the clinical course of their hospital stay that often dictates the dose they take. The doctor just orders a recommended range with a guessitmate of how long they think you should stay on them. As Ive experienced over and over again during my own exacerbations and recoveries, not all shortness of breath is the same. Whether it be air trapping or residual inflammation or mucus or whatever, there are times during the steroids weaning process when you can feel absolutely awful, yet have pretty much normal PF values. Every asthmatic handles steroids differently, that’s why it’s so important to not only monitor your symptoms , but also to use objective measurements like peak flows to guide your weaning pace. Going by subjective symptoms alone can sometimes trick you into bumping up your steroids unnecessarily, thereby extending your recovery period.

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.