Steroids get a shot of doubt
Evidence of benefit in often prescribed respiratory infection treatment is lacking
“Steroid Shots and the Culture of Instant Gratification,” an editorial published Oct. 8 in JAMA Otolaryngology-Head & Neck Surgery online, highlights a chronic ailment in American medical care: a frequent failure to practice evidence-based medicine. Maybe I’ve been living under a rock, but I was surprised to learn that doctors often prescribe oral or injected corticosteroids for acute respiratory tract infections such as sore throat, sinusitis, bronchitis and the common cold even though evidence of benefit is sorely lacking and risks of the drugs are widely known.
Yet a recent analysis of nearly 10 million outpatient medical visits in the U.S. showed that nearly 12% of patients with acute respiratory infections were prescribed oral or injected steroids, and this dubious practice is on the rise. The analysis found that prescriptions for steroids such as prednisone to treat acute respiratory ailments nearly doubled from 2007 to 2016.
Although steroids can be invaluable — even lifesaving — medications often vital to treating asthma, autoimmune conditions and chronic pulmonary disease, as well as preventing transplant rejection, their misuse can result in a treatment that is worse than the disease.
The editorial writer,
Dr. Edward McCoul, otolaryngologist at the Ochsner Clinic Foundation, described a scenario that is apparently replicated hundreds of thousands of times a year in the U.S. among patients given steroid injections for acute respiratory infections: “Within moments of receiving the intramuscular injection your congestion wanes, the headache vanishes, and your energy level skyrockets.”
Sure, Dr. McCoul told me, you feel better, at least temporarily — steroids, after all, counter inflammation and have a euphoric, energizing effect. But at what price?
The answer to that question is addressed in another commentary published in the Annals of Internal Medicine. Dr. Beth Wallace at Michigan Medicine and Dr. Akbar Waljee of the V.A. Ann Arbor Healthcare System listed serious risks that can follow in as few as three days of treatment with corticosteroids taken orally even by relatively young, otherwise healthy patients: gastrointestinal bleeding, sepsis and heart failure.
Dr. Evan Dvorin, internist at the Ochsner Health System and Dr. Mark Ebell of the University of Georgia, writing in the journal American Family Physician, added several other frightening side effects linked to the brief use of steroids: low blood sugar, elevated blood pressure, mood and sleep disturbances, fracture, and blood clots.
Wallace, a rheumatologist whose patients often depend on long-term steroid therapy, said with regard to short bursts of steroids for respiratory infections, “A very large number of young, otherwise healthy patients are receiving a treatment that we know can be harmful for a condition where steroids just aren’t indicated.”
In an interview, Dvorin said that although steroids may make people euphoric, they can also “make some people feel pretty bad by causing anxiety, jitteriness and manic-like behavior.”
Dvorin and Ebell wrote, “Physicians might assume that short-term steroids are harmless and free from the widely known longterm effects of steroids. However, even short courses of systemic corticosteroids are associated with many possible adverse effects.” (“Systemic” refers to both oral and injected steroids, as opposed to topical uses on the skin.)
Furthermore, there is no credible evidence to justify such risks when treating a condition such as a cold or sinus infection, the Michigan doctors noted. When any treatment is prescribed, it’s the practitioner’s job to first weigh its expected benefits against possible risks. However, Wallace and Waljee reported that “corticosteroid bursts are frequently prescribed for self-limited conditions, where evidence of benefit is lacking.” Leading the list of such inappropriate uses of steroids are acute respiratory tract infections that usually resolve without specific treatment within a week or two.
As with antibiotics and opiates, short-term use of injected or oral steroids have “well-defined indications but can cause net harm when used — as they frequently are — when evidence of benefit is low,” they concluded.
In Louisiana, where McCoul practices, steroid shots for upper respiratory infections are shockingly common, he said. “Patients may go to urgent care five or six times a year to get a steroid shot.” Although the drugs themselves are not addictive, getting these shots “is like a behavioral addiction,” he said.
However, when patients do go to the doctor, they expect something to happen, and doctors are often happy to oblige. They are reimbursed by insurance if they administer an injection but not if they hand patients a prescription for oral steroids.
Asked how to avoid inappropriate use of steroids, Dvorin suggested that patients look providers in the eye and ask, “Is this evidence-based? Is it something that’s really going to help me? What are the possible side effects? Are steroids really needed? What else can I do or take to relieve my symptoms?”
Less hazardous options abound, Wallace said. They include over-the-counter drugs such as ibuprofen, acetaminophen and a nighttime cough syrup.
McCoul suggested using an over-the-counter decongestant to reduce mucus production and relieve pressure in the head. Alternatively, try a saline nasal spray, which he said is “one of the best things a person can do for any acute or chronic upper respiratory condition in which inflammation plays a role.”
You can purchase a salt mixture or make your own to use in a nasal irrigation device such as a neti pot. Mix 3 teaspoons of noniodized salt with 1 teaspoon of baking soda. Add 1 teaspoon of the mixture to 8 ounces of distilled (or boiled and cooled) water in the device. Tilt your head over the sink at a 45-degree angle, place the spout in one nostril and gently pour in the salt solution. Repeat in the other nostril.