October 6, 2025 • 18 mins
In this episode, Sam Ashoo, MD interviews Evan Dvorin, MD about the dangers of short term steroid use.
Background & Regional Differences
- Dr. Dvorin’s clinical journey from New England to New Orleans.
- Noticing increased use of corticosteroids for common conditions in the Southeast.
- Discussion of how steroid prescribing practices vary by region and setting.
Inappropriate Steroid Use
- Common conditions where steroids are often inappropriately prescribed (sinus infections, bronchitis, sciatica, rashes, plantar fasciitis, etc.).
- Trends showing increased steroid prescribing over time.
- Similar patterns observed in emergency, urgent care, and primary care settings.
Risks and Side Effects of Short-Term Steroid Use
- Short-term steroids can cause significant side effects: infection, sepsis, bone fractures, thromboembolism, psychiatric effects, hyperglycemia.
- Dose-response relationship: higher doses and repeated use increase risks.
- Some side effects (e.g., bone loss) may persist beyond two months.
Patient Communication & Shared Decision-Making
- Importance of discussing risks with patients, tailored to individual risk factors (e.g., diabetes, psychiatric history, age).
- Strategies for educating patients and managing expectations.
- The role of patient education videos and resources.
Impact of Provider Education & Quality Metrics
- Ochsner Health’s initiatives to reduce inappropriate steroid use.
- Use of CME, quality dashboards, and feedback to clinicians.
- Evidence that education and reporting can reduce unnecessary prescriptions.
Special Populations & Scenarios
- Considerations for pediatric patients and repeated dosing.
- Challenges when specialists recommend steroids for certain conditions (e.g., sciatica, neurosurgery cases).
- The need for evidence-based practice and inter-provider communication.
Medical-Legal Considerations
- Lawsuits related to steroid side effects (e.g., fat atrophy, infection).
- Importance of documentation and informed consent.
Alternatives & Symptom Management
- Focusing on treating the patient’s most bothersome symptoms.
- Non-steroid options and the value of patient education about illness duration and expectations.
Resources
- Mention of Dr. Dvorin’s educational video on corticosteroid side effects (available on YouTube).
- Reminder of EB Medicine’s journals and resources for further learning.
Conclusion
- Key takeaway: “Do no harm” and practice evidence-based medicine.
- Encouragement for clinicians to review their prescribing habits and educate patients.
Ochsner "Side effects from corticosteroids" Video: https://www.youtube.com/watch?v=PdMJ9HYxkck
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Evan (00:00):
I've definitely seen lawsuits that came up due to fat atrophy.
(00:05):
Again, that's a permanentdimpling of the skin, which can be
rather disfiguring for patients.
Sam (00:13):
Hi everyone, and welcome to another episode of EMPlify.
I'm your host, Sam Ashoo.
Before we dive into this episode, Iwant to say thank you for joining us.
I sincerely hope that you find it tobe helpful and informative for your
clinical practice, and I want to remindyou that you can go to ebmedicine.net
where you will find our three journals,Emergency Medicine Practice, Pediatric
(00:34):
Emergency Medicine Practice, and EvidenceBased Urgent Care, and a multitude of
other resources, like the EKG course,the laceration course, interactive
clinical pathways, just tons ofinformation to support your practice
and help you in your patient care.
And now, let's jump intothis month's episode.
Evan (00:53):
My name is Evan Dvorin.
I'm a physician MD. I work atOchsner Health, Ochsner Medical
Center in New Orleans, and I'mat our main primary care clinic
. Sam: Thanks for being on the podcast.
You have a special interest in steroiduse, which is why you graciously
(01:16):
agreed to be on the podcast today.
What brought that about or how didyou fall into that special interest?
So, I trained and first worked in New England.
I went to medical school atDartmouth Medical School.
And then had my residency at Brighamand Women's Hospital in Boston.
And after that I worked nearby inBoston at Mass General Hospital.
(01:39):
While working there, I, and in myeducation prior, I really hadn't
ever heard of using corticosteroids,also known as steroids, for
sinus infections or bronchitis.
I'm well aware of the role for thingslike asthma, if someone has a flare of
asthma or chronic obstructive pulmonarydisease, but haven't heard of it for
(02:02):
these other, more run of the mill,like common cold type of situations.
And then in 2012 my family, werelocated in New Orleans where I am now.
And I've been at thesame clinic ever since.
And corticosteroids are frequentlyused for these diagnoses that
I just mentioned, like sinusinfection, a bad cold, bronchitis.
(02:26):
And so it was something that,you know the phrase if you see
something, say something, or I sawsomething and I was taken aback.
I was surprised when patients askedme for a steroid injection or a
Medrol dose pack, something I, Ijust would never have thought of.
And so that's when thisinterest came alive for me
(02:47):
.Sam: Excellent.
And now you have become sort ofthe, the steroid educator for your
practice and your system there.
Is that right?
Yes.
Yeah, we could say that.
So I've worked with a few medicalstudents, some residents over the
years and also the Ochsner Urgent Caredepartment has taken on this campaign of
(03:10):
decreasing inappropriate corticosteroids.
So, it's something that I've definitelyeducated people in my system about.
Also I've worked on some research studieson this topic, and we've created a video
and I've had an interview with the NewYork Times, so it's kind of something I,
(03:32):
I've really have taken a big interest inand wanted to spread the word that this
is something that's happening frequently.
I do wanna take a brief moment justto say that I first learned about it
here in the South and in my researchwe found that this is really common in
the Southeast in particular, but it'sactually throughout the United States.
(03:53):
I guess just in the little area Iwas practicing in, in Boston, it
wasn't common, but it's become morecommon throughout the United States.
Sam (04:01):
Great.
And now the audience who listens toour podcast is primarily emergency
medicine, but you know, EB Medicinealso has an entire collection of urgent
care journals and products and coursesand a separate podcast there as well.
So we tend to mix audiences.
If you're listening and you work inan emergency medicine environment,
or if you work in the urgent careenvironment, all of this is going
(04:24):
to sound very familiar to you.
I don't think this isunique to primary care.
Is that something you've encounteredin your research as well?
Kinda the, the similardiagnoses being treated with
steroids regardless of setting.
Evan (04:36):
Yes.
Yeah.
Yeah.
This has been the case in urgentcare settings, primary care,
and in the emergency room.
I think those three venues are themost common where inappropriate
corticosteroids are used.
And we recently started actuallylooking specifically into emergency
department use and we find ahigh rate of inappropriate use.
Sam (04:58):
Great.
And now tell me, when we talk about theuse of corticosteroids for conditions
where it may not be appropriate toprescribe them, would the data that
you've collected for the last, youknow, decade or so, shows that this
prescribing trend is increasing or hasjust been alarmingly high the entire time?
, Evan (05:19):
It has been steadily increasing actually.
We don't really have aclear explanation for that.
I mean, I have some ideas butit has been steadily increasing
throughout the country.
Sam (05:31):
And when we're looking at the conditions that they are prescribed for,
you mentioned some of them already, thingslike sinus infections and, you know,
URIs, are there other diagnoses thattend to be the high frequency diagnoses?
Evan (05:46):
Yes.
So outside of just the URI world,sciatica or acute back pain, or rash.
These are some other good exampleswhere it's inappropriately prescribed.
Shingles.
It hasn't been shown thatsteroids are very effective.
Pharyngitis, I guess that'smore in the URI type of world.
(06:09):
Oftentimes a podiatrist, not to poke atthe podiatrist, but oftentimes they'll
give steroids where it hasn't been shownthat it's effective for plantar fasciitis.
So a lot of musculoskeletal areas,it's been used inappropriately as well.
Sam (06:25):
So, in 20 years of clinical practice, I will say that I found a
similar trend in my own prescribing.
And I don't really have a goodreason to attribute to that.
I think when I was in residencytraining, we spent the bulk of our
time treating the higher risk diseases,and we had a fast track, and our
fast track was actually staffed byan attending physician and a PA.
(06:48):
And so we were rarely exposed tohigher volumes of the minor care cases.
But as soon as I graduated and westarted working in a busy urban
emergency department, all of a suddenthat was, you know, something like a
half of the cases that I was seeingwere not necessarily true emergencies,
but I think the notion for me was well.
(07:10):
You know, I've got a patient who'ssitting in front of me who is here
for a condition that they are eitherseeking maybe an antibiotic for, and I'm
gonna tell them that's not appropriate.
And that was a whole nother conversation.
But then also maybe they have somesymptoms and I'm just trying to say,
well, you know, I can't really solveyour problem, but maybe I can do
something to alleviate your symptoms.
(07:31):
And the notion kinda came up of, well thisseems like a pretty benign thing to do.
I mean, what is the harm ofa short course of steroids?
But that is not the caseaccording to your research.
Right?
Evan (07:43):
Right.
Well, yeah.
Actually not, not my research,but other people's research and
I'd like to share that with you.
So that was also in my education.
The concern was about chronicsteroids, just like you're saying.
So, people becoming a cushingoid frombeing on steroids for months or years.
The weight gain, the immunosuppression.
(08:06):
I think we can all kind of imaginewhat all that we've learned about
the side effects of chronic steroids.
And it turns out that a lot of thoseside effects, and again, this isn't my
research, but I'll just share it with you.
A lot of those similar side effects canalso be seen for short-term steroid use.
In short term steroid use your body is notreally gonna get adrenally insufficient,
(08:31):
so not that one, but short term use canincrease someone's risk for infection
for sepsis in the next one to two months.
Can increase risk for bone fractures.
Again, I'm just saying inthe next one to two months.
And thrombo embolism also an increasedrisk, again, in the short term, just
(08:53):
in the next one to two months afterreceipt of a short-term steroid use.
And the most common side effectsfrom, again, short-term steroid use.
We're talking about a steroidinjection, a Medrol dose pack.
The most common side effectsare psychiatric side effects,
loss of sleep, anxiety.
(09:15):
Some people who already havepsychiatric problems or a severe
depression, steroids can really tiptheir symptoms into a severe situation.
Sam (09:25):
And when we talk about short term use, we're talking about
things like, you know, five to sevenday courses of prescribing here.
Evan (09:32):
Exactly.
Sam (09:33):
So all of those things can still occur even in the one
week course of a prescriptionfor, you know, your typical URI.
Evan (09:41):
Right.
Yeah.
So one thing that I've looked upand seen in the published literature
is that there's a dose responsecurve too, that the higher someone's
short-term steroid use, the higherchance of those side effects.
So, that's the case.
But also it does look like after twomonths, most of these short-term side
(10:02):
effects , will attenuate and go away.
I say most except for the bones.
So repeated short-term useover somebody's lifetime will
have an impact on bone density.
Can increase the riskfor avascular necrosis.
But most of the sideeffects are gonna go away.
Sam (10:22):
Now you mentioned a timeframe of two months.
That's the typical period for howlong it takes for the side effects
of the short-term prescribingof steroids to kind of go away.
Evan (10:32):
That is what it looks like.
Yeah.
One study was published in 2016showing increased risk of infection.
In 2017, a British medical journal thatwas a study that showed increased risk for
the venous thromboembolism, fracture, andsepsis over the one to two month period
Sam (10:54):
Yeah, and that one particularly surprises me 'cause I don't really
think about severe immunosuppressionfrom a few days of steroid use.
Especially lingering for two months,so tell me more about that one.
Evan (11:06):
Yeah, I've actually seen this with several patients where, let's use the
sinusitis example, and that's where I'veseen it a few times, where someone was
given a steroid injection or a Medroldose pack and a Z-pack azithromycin
for sinusitis and in a lot of thosesituations, the patient's symptoms got
(11:29):
much worse and they may have developedactually fevers and worsened sinus
discharge, so that's something anecdotallyI've seen I'm not sure I'd use the term
immunocompromise, but there is definitelysome sort of hit to the immune system
just with a short term steroid, whichmakes sense, just about how steroids work.
(11:53):
And so you could imagine if someone hasa lingering bacterial sinusitis and if
it's not treated with azithromycin sincemost of the bacteria will be resistant
to that, and at the same time they'regiven a steroid, that definitely increases
the odds that that bacteria is gonnawin the short term battle, at least.
Sam (12:17):
And now you mentioned sepsis as well.
So when we talk about sepsis, wethink of, you know, those people who
end up in the emergency departmentand end up being hospitalized.
Was there a significant trendin the risk there for sepsis
after short term steroids?
Evan (12:32):
Yeah.
So, that study in the BritishMedical Journal, a group from
Michigan led that study and theyused a retrospective analysis,
so looking at all comers, with theOptum database of just millions
of people and prescribing.
And with that database were able tolook at people's underlying diagnoses
(12:56):
and when they'd received steroidsand not, and the researchers, they
did as good of a job as they couldto try to get rid of any confounders.
And after correcting for the same amountof patients with autoimmune disease
or, they actually excluded cancerpatients, they were able to see that
(13:17):
there was an increased risk of sepsis.
It wasn't a high number.
We're talking about out of thousandsof patients, there were maybe a, I
don't know the exact number, but, theredefinitely was a statistically significant
difference in those that developed sepsiswho were exposed to corticosteroids
versus those that were not.
Sam (13:35):
Hmm.
And was there a trend or were theyable to find a trend that correlated
with like past medical historyor other confounding illnesses?
Or is it just all comers whohad a short course of steroids?
Evan (13:48):
Yeah, I'm not an expert enough in the biostats part, but they were
able to correct for underlying healthissues, and after correcting for that,
which is not perfect in a retrospectiveanalysis, but after correcting for
that, they did have a statisticallysignificant increased risk of sepsis.
So I think of things like sepsisas if I'm going to give patient a
(14:12):
short term steroid, there's not alarge risk but you could be putting
someone to some degree in harm's way.
And so you have to kind of couplethat with what's the evidence
base for using a steroid.
You know what, if someonehas a bad asthma flare.
It's clear that steroids in a badasthma flare can really, maybe help
(14:36):
prevent an ER visit or a severeasthma flare where they're in the ICU.
So in that case, the benefits makes sense.
But in something like sinusitis orbronchitis, I'm talking about acute
bronchitis and a non asthmatic,the evidence actually shows
that steroids are not effective.
(14:56):
If you're gonna give something tosomeone where there's not evidence
to show its use and there's actuallyevidence that showing it's not
effective, then even this low risk ofsepsis, in my mind, it's not worth it.
Sam (15:11):
Yeah.
It also brings up the question of whetheror not you should be discussing that
with the patient before you prescribe it.
So in those scenarios, let's say you havesomeone who's maybe borderline for their
benefit for steroids and they're askingfor the prescription, do you intentionally
have that conversation and tell them, Hey,you know, your benefit may be marginal,
(15:32):
but you have to know that there is somerisk to this and you know, is there a
way to quantify that risk for them, or doyou just tell 'em it's low, but present.
Evan (15:40):
Yeah, well, I mean it depends on the person in front of you.
Are they already onsome immunosuppressives?
Have they already had a pneumonia onceand is there something about their
immune system that may put them at aneven higher risk for complications?
So, I think in general, yes,we should inform patients.
And that gets to one of the otherrisks a lawsuits and we could talk
(16:03):
about that in a minute, but definitelyimportant to inform patients about
the risks and also we shouldn't feelstrong armed into giving steroids.
Sam (16:12):
Hmm.
Evan (16:13):
That's important.
Really one of the key messages that I tryto convey is above all else do no harm.
Sam (16:21):
Hmm.
Evan (16:21):
The do no harm is really where we should be practicing.
Of course there's areas of uncertainty,but as much as possible, we should be in
the realm of do no harm when we're makingdecisions and talking with patients.
Sam (16:34):
Yeah, it's, I mean, I gotta say it is a little frustrating that
there are these short term sideeffects to steroids because it seems
so ubiquitous for so many things.
I can think of teenagers with severepharyngitis or you know, people with maybe
not necessarily a diagnosis of asthma, butthey've got a severe case of bronchitis.
They have a little bit of wheezing oryeah, sure they have recurrent sinusitis.
(16:57):
And maybe their own past experiencesays, Hey, I want this course of
steroids, and I came to you becauseI know I've been here a million
times and asked for the antibiotics.
And you always say no.
But now I know the steroidsmake me feel better.
This kind of brings a whole newdimension to that discussion, doesn't it?
Evan (17:15):
Yes.
Yeah, definitely.
Research on antibiotics shows thatit takes about maybe a minute at
most to educate the patient aboutreasons not to give them antibiotics.
And thankfully a lot of patientshave gotten that message.
Not all, of course, not all.
And the story of steroid stewardship,which I think we're only in the
(17:38):
infancy of this field, is very similarto antibiotic stewardship and so
hopefully over time more patientswill be educated about the risks.
In my experience, most patientsare reasonable, and most of them,
they just wanna feel better.
And if I can educate them in undera minute about that, actually this
(18:00):
hasn't been shown to help themfeel better, I could give them the
YouTube video we made, which is apatient and provider friendly video.
Most people are okay with that.
Do I occasionally have a patientwho's still dissatisfied?
Yes.
I mean, I'm not gonna lie andsay all my patients are happy
campers and happy to come back.
But I really try to upholdthe, you know, do no harm.
Sam (18:23):
I'm curious.
Sometimes in the emergency department,we will do one time dosing or
single time dosing of steroids likedexamethasone, something longer acting.
Do those adverse effects also occurwith single dosing of steroids, like a
one-time dose for a child or adolescent?
Evan (18:40):
Are you talking about like an injection
Sam (18:42):
Yeah, or oral.
I mean, sometimes we'll give Dexamethasoneoral for its bioavailability is the same.
But still, you know, somethingthat's a steroid in this scenario.
Evan (18:50):
Yeah, so the injections, they have a few other things to keep in mind.
One side effect from steroidinjections is fat atrophy.
And that does happen.
I'm not sure how frequently, but we'regiving the injection, if it's not
clearly in the intramuscular space, ifit's given a little more superficially,
(19:12):
that could lead to fat atrophy anda permanent dimpling of the skin.
So that is something that does happen.
And then the other thing with steroidinjections is a lot of patients,
when they come see us in the ER or inurgent care, they're at their peak of
symptoms, which kind of makes sense.
They're, like, I've been, you know,dealing with this at home forever,
(19:35):
and I just had enough of it.
And a lot of times people arebetter the next day or two after
they leave the urgent setting.
And so some patients , we alwayswant them to finish their antibiotic
course, but sometimes they don't 'causethey think they're feeling better.
Same with the steroid, the oral dose pack.
I was feeling better.
(19:56):
I didn't feel like I had to finishthe Medrol dose pack, and that's where
people have these leftover medicines.
So I'm not at all advocatingfor that situation.
But the thing with a steroid injectionis once you give the injection, the
patient a day or two later can't decide,you know, I'm actually doing better.
I don't have to finish this.
(20:16):
They really have a large dose.
Most steroid injections are, Ithink about the equivalence of
maybe 60 milligrams of prednisone.
And, they're different dosingobviously, but it is a large
burst of steroid in the body.
And so injections can impart this risk.
But again, repeated injections in theshort term are worse than just one
(20:39):
injection, given that dose responserelationship for short term steroids.
Sam (20:44):
Huh.
Okay, so sepsis is an increasedoccurrence in the following two
months, you said, after a short-termuse of steroids, bony fractures,
and localized reactions includingdimpling, if they're giving injections,
any other short-term side effects?
Evan (21:02):
Yeah.
Increased blood glucose especiallyin people with diabetes.
I've had several patients where theydid not have known diabetes and after
receiving steroids they probably had somesort of insulin resistance and then this
tipped them into the diabetes diagnosis.
So, definitely increased hyperglycemia.
Sam (21:24):
Good.
And then you mentioned some of the, likethe psycho behavioral issues as well.
You know, lack of sleep,increased appetite, up all night.
And then behavioral disturbances that canoccur from even short term use as well.
Evan (21:37):
Correct.
Sam (21:38):
All right.
And then touching onwhat to tell the patient.
So let's say we have come to anagreement that there might be,
I'd say not strong evidence, butmight be some evidence for using
short-term steroids in this condition.
What's the best approach fordiscussing all of those things?
Do you just run down the list reallyquickly with the patient and say, I
(21:58):
am gonna give you the steroid, but yougotta be aware you might have blood
clots, it might worsen your blood sugar.
You may not sleep, you may be hungrya lot and eat and have some weight
gain and have some swelling and you'reat higher risk for bony fractures and
infections in the next two months.
Do you just run through it likethat or do you make it more specific
to the person sitting in front ofyou, or how do you approach that?
Evan (22:16):
Yeah.
I don't think I go over allthose side effects honestly.
But I do think about who's in front of me.
Is it someone with diabetes?
And I'm definitely gonnatalk about the sugars.
Does someone have psychiatric diagnoses?
Then I'm gonna be talkingmore about those issues.
Someone elderly probably wedo wanna talk about the bones
and possible infection risk.
(22:38):
So I do somewhat tailor it and I mean,the truth is we don't have time to go over
every possible side effect for everything
Sam (22:45):
Yeah.
Evan (22:46):
So, I would say I would tailor it to who's in front of me.
Sam (22:49):
I mean, I could imagine some scenarios where you run through that list
with a patient and they say, eh, actuallyon second thought, no thanks you know,
Evan (22:57):
That has happened.
Definitely.
Yeah.
In my care of urgent care patients.
Sam (23:00):
And then so do you think with the increased education that you've been doing
and the discussions on steroid use, haveyou seen a, like a positive change in
provider behavior in your clinicians oryour nurse practitioners, your PAs, your
physicians, are they prescribing them lessknowing this, or are they just having the
conversation with their patients more?
Have you been able to tell a trend?
Evan (23:21):
Yeah, good question.
So, well, first of all, in the system I'mat, I'm at Ochsner Health in southeast
Louisiana , centered around New Orleans,but a lot of southeast Louisiana.
Our urgent care department, I'mreally thankful they've taken this on.
They've really kind of taken this onwholeheartedly as a quality metric.
(23:42):
And so the care in southeast Louisianafor when patients would come in for
acute respiratory tract infectionencounters, maybe 40% of the time patients
would receive a steroid injection,and that's been cut back significantly
to under 5% at Ochsner Urgent Care.
(24:03):
So, part of the explanationhas been education from myself.
We've developed some CME materialon this as well online, CME.
And also they include it intheir quality metric dashboard.
So, they have that in addition tochecking of a UA in patients that they're
treating for urinary tract infections.
(24:25):
Since I'm in primary care,I'm not in their department.
I don't know all the quality metrics, butthey do include that in their metrics.
And then in primary care we are in theprocess of publishing a study where
we showed that providing clinicianswith a monthly report on their
inappropriate steroid use, providingthem with a report and a one-time
(24:50):
CME continuing medical education.
That was able to effectivelydecrease steroid use.
So, we're not sure how much of this isconversations that that's being encouraged
between the patient and clinician?
Or is it that just theclinicians not offering it?
So, we're not sure.
(25:10):
But that's a good question of what'sactually leading to the decrease.
Sam (25:15):
And when you label it as inappropriate I'm assuming then
you have a list of diagnoses thatyou would say, okay, these would
meet criteria and these don't.
Evan (25:23):
Yes.
Yeah, so we've been focusingmostly on ARTI's, acute respiratory
tract infection encounters.
We exclude patients with asthma or COPD.
And so if somebody comes in withinfluenza, acute bronchitis, sinusitis,
pharyngitis, otitis media, we includeallergic rhinitis as well, which
(25:48):
systemic steroids have not beenrecommended for allergic rhinitis.
So anytime steroids are given inthose situations, and I don't mean
intranasally, but systemic steroids,either oral or intramuscular, we would
define that as inappropriate use.
Sam (26:05):
Yeah.
I always find it fascinating when wepublish data about clinicians and their
prescribing practices and share it witheveryone as a group and go, Hey, here's
where you are, here's where your group is.
I think that kind of is very revealingfor all matters of quality assurance.
You know, it could be just utilizationor imaging or labs or what have you.
I think it reveals someinteresting trends.
(26:26):
So.
It's good to hear that that is a modelthat is applicable in this scenario.
And you're using that now,not just for the IM dosing one
time, but also for prescribing.
Evan (26:39):
For oral steroids as well, yes.
Sam (26:40):
Okay.
That's great.
And does it also track thepediatric prescribing, or is
this just solely in adults?
Evan (26:47):
We've solely been working on adults.
I think pediatrics is important too.
And I mean, again, the repeatednature, especially effects on the
bones, that's even more of a reasonto not give in the pediatric setting.
But since I'm not a pediatrician,it hasn't been really something
I've delved into personally.
Sam (27:07):
Fair.
When we talk about repeated dosing aswell for short term courses, what kind
of frequency are we talking about?
Like more than once in a year,more than once in three or four
months or what defines repeated?
Evan (27:18):
Yeah.
So anecdotally, I've had severalpatients on the order of a once a year
steroid injection, say, and that's theonly thing I could figure out why they
have avascular necrosis of the hip.
So anecdotally, that'sbeen the case for me.
I mean, we definitely have researchthat shows steroids affects bone
(27:40):
density and we clearly know chronicsteroids affect bone density.
And then we know that short termuse repeated dosage, the higher
the dose response curve that'sthere for steroid fractures.
But my understanding on bones is thatrepeated use over years, even once
(28:00):
a year of a steroid injection, candecrease bone density over time..
Sam (28:04):
And then another question, what about when you, and this is probably more
common in the emergency department or inthe hospital setting, but you know, it's
frequent for us to encounter steroids asa recommendation from consultants as well.
You know, let's say, let'stake neurosurgery for example.
You've got somebody with intractablesciatica and we're trying to find
some way to alleviate the pain.
Sure there's always pain medicationbut then we're talking about other
(28:27):
ways to kind of augment that effect.
And frequently we get, okay, yeah, put'em on a Medrol pack or give them some
Decadron for the next 10 days or somethingand they can follow up in the office.
Have you noticed that that evidencealso covers those diagnoses, or is that
more gray, or how do you handle that?
Evan (28:44):
As far as acute sciatica, there's good evidence that says
that steroids are not effective.
There was a really goodrandomized controlled trial,
so that's the best study.
We have a placebo matchedrandomized controlled trial.
It was published in 2017 in JAMA, andit had patients with acute sciatica.
Some received I think it was six days ofprednisolone, very similar to prednisone.
(29:10):
And then half received placebo andthere was no long-term improvement
in acute sciatica, in pain, orwho ended up needing surgery.
So I mean I try not toargue with specialists.
I try not to get into it.
I really just wanna educatepeople and make them aware.
So, in the line of work I do, if Isend someone to a specialist in the
(29:34):
outpatient setting, the specialistwill prescribe the steroid.
But I understand what you're saying.
If inpatient or ER, if the specialistsays, okay, you do this, that does
kind of tie your hands in a bit becauseyou asked the specialist to weigh in.
But still, I think if we can educate oururgent providers, both ER and urgent care
(29:56):
and hospitalist clinicians as well, ifwe can educate them on the risks, maybe
they'll decide, oh, even though thespecialist recommended this, I don't think
that this is the best for this patient.
And really, when you're the ER doc, whenyou're the hospitalist, you know the
patient better t han the specialist,you know, all their diagnoses, and
(30:17):
you might know something about themthat does tip into the risks of
the short-term steroids are maybemore than the potential benefits.
Sam (30:25):
Yeah.
Yeah, I'm thinking about myneurosurgery colleagues, my ENT
colleagues, you know, the propensityfor prescribing steroids when we're
just kind of out of other options.
Seems like it's higher in those cases,but maybe that's just 'cause we're
not having the conversation honestly.
Evan (30:41):
Yeah, but you're right about neurosurgery.
They give a lot of steroids.
I don't wanna poke particularlyat the neurosurgeons, but they
do give a lot of steroids.
I actually had a patient who sufferedfrom a pulmonary embolism after
receiving multiple doses of steroids.
I can't say a hundred percentit's from the steroids
Sam (31:02):
Sure.
Evan (31:03):
or it's from her underlying condition.
But there are a lot of venoand thromboembolism cases
in neurosurgical patients.
So if I were in the neurosurgery world, Iwould hope that they would start thinking
about what research do we have that reallysupports the amount of steroids we use.
Sam (31:21):
Fantastic.
Evan (31:22):
I do wanna say that for some of the clinicians listening, well, first of
all, I appreciate you listening this farin, I could imagine some of you thinking,
okay, well, we can't give antibiotics.
We can't give steroids.
What can we do.
Sam (31:39):
Yeah.
Evan (31:40):
And I don't mean to say, you know, there's nothing
we can do for these things.
There are things we can do,sometimes the patient needs the
right antibiotic for sinusitis.
Sometimes people need to bepointed in the right direction
of what to get over the counter.
Sometimes patients just need educationthat on average the cough with acute
(32:04):
bronchitis lasts 10 to 20 days.
If I give you a Z-Pak 10 to 20 days, ifI gave you a steroid shot, 10 to 20 days,
so sometimes that's what patients need.
So I'm not saying, you know, don't doanything, but we don't wanna do harm.
Sam (32:19):
Yeah, I think that's great advice.
And it seems like low hanging fruitfor some education and some change.
So if you're listening and you'repart of a quality assurance project
or looking for one at your hospitalsystem, your urgent care, your ED, even
your primary care clinic, this kind ofseems like some low hanging fruit that
you could make a significant changewith just a little bit of education on.
(32:41):
I think the list of things thatwe give steroids for definitely in
the last 20 years has increased.
And as you mentioned, not evidence-based,just more out of frustration for lack
of other ways to alleviate symptoms.
But you know, sometimes havingthat conversation and just saying,
okay, what is the worst symptom?
And let's see what we can do about that.
Evan (33:01):
I use that exact same phrase with my patients.
So what's bothering you the most?
So I can target that specific symptomand I think that, you know, maybe
again we don't have scientificproof of why steroids have gone
up over the last 10 to 20 years.
But, part of it is we don'twanna give antibiotics.
We know that's not good.
We don't wanna give pain medicines.
(33:23):
We know that's not good, but sometimesif someone's in excruciating pain, that's
the best thing we could do to help them.
And to help them get throughthe next one to two weeks.
And sometimes that'sjust what patients need.
And we shouldn't be afraid togive appropriate analgesic pain
medicine, whether it's tramadolor hydrocodone or an opioid.
(33:47):
I mean, sometimes we just, that'swhat we have to give to patients.
Sam (33:49):
Yeah.
And it really does just come down to,you know, okay, what's the worst symptom?
What do we have in ourarmamentarium to treat it?
And here's the list of side effects.
Which ones do you wanna roll the dice on?
Evan (34:02):
That's a good point.
Sam (34:02):
It's kinda you know, we have pain medicines.
Those come with a bunch of risks.
We have steroids.
Those come with risks forshort and long-term use.
We could do nothing.
And that comes with itsown short-term risk, right?
You know, maybe 10 to 20 days.
I guess it's a good conversation to have.
And it seems like that's ripe for someeducational material for patients.
Earlier, you did mention somemedical legal concerns with
(34:25):
steroids that I forgot to ask about.
So tell me have you seen any examplesof medical legal outcomes from
short term steroid prescribing?
Evan (34:34):
Yes.
I've definitely seen lawsuitsthat came up due to fat atrophy.
Again, that's a permanentdimpling of the skin, which can be
rather disfiguring for patients.
There's actually a publishedstudy that looked at lawsuits that
came from steroid prescribing.
It was in one of the ENT journals.
(34:56):
And some of the side effects that cameup, a lot of them related to infection
risk, so that gets to the sepsis.
So there definitely is a whole literatureout there on the medical-legal side
Sam (35:09):
Gotcha.
So not always at the forefrontof our mind for why we do the
things we do with patients.
We definitely want to do noharm, like you mentioned, and be
evidence-based in our practice.
But just one more layer to the equationthat yes, there are some real bad
outcomes, and yes, it can be a medicallegal concern for our clinicians as well.
Evan (35:28):
Yes.
Yeah, that is the reality.
Sam (35:30):
Perfect.
All right.
Now, you mentioned a video.
You've made a video that's now thisis a video that's for clinicians
or a video for patients or both?
Evan (35:37):
I'd say it's for both.
It's three minutes.
And in the way that I think it'sfor clinicians is how a lot of us
and me, before I started thinking alot about this topic, thought that
short-term steroids didn't have anyof the same side effects as long-term.
So the video definitely talks about that.
And then for patients, it usespatient friendly material.
(35:59):
It's three minutes.
So I think it can be used for both.
Sam (36:02):
And that's publicly available.
Evan (36:04):
Yes.
Yeah.
On YouTube, if you just search Ochsner,that's OCHSNER, corticosteroids
that'll show up or I think ifyou search corticosteroid side
effects, it'll be like number one,two, or three if you search that.
Sam (36:21):
Awesome.
All right, well, I'll do that searchand put that link in the show notes.
And if you're listening and you're youknow, a fond prescriber of steroids, this
may be some food for thought just to kindof take a look at that practice, maybe go
back to the evidence base and see if theremight be room to adjust your frequency
of prescription for a certain diagnosis.
(36:42):
Well thank you very much foragreeing to be on the podcast.
I found this really quite informative.
I was looking through some of theeducational materials you've developed
and like I said, a little bit dismayedthat something I've been doing for so
long actually does have some significantshort-term harm and, you know, something
I'm definitely gonna have to bringup with patients from now on each
time that we're talking about steroidprescribing as just another cause of
(37:06):
potential short term side effects.
Evan (37:08):
Well, you're welcome.
Thank you for being open tothis and for the listeners.
Thank you for listening.
My point is not to make anybody feelbad about not doing the right thing.
It's just to educate and think twice.
Sam (37:20):
And that's a wrap.
Thanks for joining us forthis episode of EMPlify.
I hope you found it informative, and Iwant to remind you that ebmedicine.net
is your one stop shop for all of yourCME needs, whether that be for emergency
medicine or urgent care medicine.
There are three journals, there'stons of CME, there's lots of
courses, there's so many clinicalpathways, all this information at
(37:43):
your fingertips at ebmedicine.net.
Until next time, everyone,I'm your host, Sam Ashoo.
Be safe.
I've definitely seen lawsuits that came up due to fat atrophy.
(00:05):
Again, that's a permanentdimpling of the skin, which can be
rather disfiguring for patients.
Sam (00:13):
Hi everyone, and welcome to another episode of EMPlify.
I'm your host, Sam Ashoo.
Before we dive into this episode, Iwant to say thank you for joining us.
I sincerely hope that you find it tobe helpful and informative for your
clinical practice, and I want to remindyou that you can go to ebmedicine.net
where you will find our three journals,Emergency Medicine Practice, Pediatric
(00:34):
Emergency Medicine Practice, and EvidenceBased Urgent Care, and a multitude of
other resources, like the EKG course,the laceration course, interactive
clinical pathways, just tons ofinformation to support your practice
and help you in your patient care.
And now, let's jump intothis month's episode.
Evan (00:53):
My name is Evan Dvorin.
I'm a physician MD. I work atOchsner Health, Ochsner Medical
Center in New Orleans, and I'mat our main primary care clinic
. Sam: Thanks for being on the podcast.
You have a special interest in steroiduse, which is why you graciously
(01:16):
agreed to be on the podcast today.
What brought that about or how didyou fall into that special interest?
So, I trained and first worked in New England.
I went to medical school atDartmouth Medical School.
And then had my residency at Brighamand Women's Hospital in Boston.
And after that I worked nearby inBoston at Mass General Hospital.
(01:39):
While working there, I, and in myeducation prior, I really hadn't
ever heard of using corticosteroids,also known as steroids, for
sinus infections or bronchitis.
I'm well aware of the role for thingslike asthma, if someone has a flare of
asthma or chronic obstructive pulmonarydisease, but haven't heard of it for
(02:02):
these other, more run of the mill,like common cold type of situations.
And then in 2012 my family, werelocated in New Orleans where I am now.
And I've been at thesame clinic ever since.
And corticosteroids are frequentlyused for these diagnoses that
I just mentioned, like sinusinfection, a bad cold, bronchitis.
(02:26):
And so it was something that,you know the phrase if you see
something, say something, or I sawsomething and I was taken aback.
I was surprised when patients askedme for a steroid injection or a
Medrol dose pack, something I, Ijust would never have thought of.
And so that's when thisinterest came alive for me
(02:47):
.Sam: Excellent.
And now you have become sort ofthe, the steroid educator for your
practice and your system there.
Is that right?
Yes.
Yeah, we could say that.
So I've worked with a few medicalstudents, some residents over the
years and also the Ochsner Urgent Caredepartment has taken on this campaign of
(03:10):
decreasing inappropriate corticosteroids.
So, it's something that I've definitelyeducated people in my system about.
Also I've worked on some research studieson this topic, and we've created a video
and I've had an interview with the NewYork Times, so it's kind of something I,
(03:32):
I've really have taken a big interest inand wanted to spread the word that this
is something that's happening frequently.
I do wanna take a brief moment justto say that I first learned about it
here in the South and in my researchwe found that this is really common in
the Southeast in particular, but it'sactually throughout the United States.
(03:53):
I guess just in the little area Iwas practicing in, in Boston, it
wasn't common, but it's become morecommon throughout the United States.
Sam (04:01):
Great.
And now the audience who listens toour podcast is primarily emergency
medicine, but you know, EB Medicinealso has an entire collection of urgent
care journals and products and coursesand a separate podcast there as well.
So we tend to mix audiences.
If you're listening and you work inan emergency medicine environment,
or if you work in the urgent careenvironment, all of this is going
(04:24):
to sound very familiar to you.
I don't think this isunique to primary care.
Is that something you've encounteredin your research as well?
Kinda the, the similardiagnoses being treated with
steroids regardless of setting.
Evan (04:36):
Yes.
Yeah.
Yeah.
This has been the case in urgentcare settings, primary care,
and in the emergency room.
I think those three venues are themost common where inappropriate
corticosteroids are used.
And we recently started actuallylooking specifically into emergency
department use and we find ahigh rate of inappropriate use.
Sam (04:58):
Great.
And now tell me, when we talk about theuse of corticosteroids for conditions
where it may not be appropriate toprescribe them, would the data that
you've collected for the last, youknow, decade or so, shows that this
prescribing trend is increasing or hasjust been alarmingly high the entire time?
, Evan (05:19):
It has been steadily increasing actually.
We don't really have aclear explanation for that.
I mean, I have some ideas butit has been steadily increasing
throughout the country.
Sam (05:31):
And when we're looking at the conditions that they are prescribed for,
you mentioned some of them already, thingslike sinus infections and, you know,
URIs, are there other diagnoses thattend to be the high frequency diagnoses?
Evan (05:46):
Yes.
So outside of just the URI world,sciatica or acute back pain, or rash.
These are some other good exampleswhere it's inappropriately prescribed.
Shingles.
It hasn't been shown thatsteroids are very effective.
Pharyngitis, I guess that'smore in the URI type of world.
(06:09):
Oftentimes a podiatrist, not to poke atthe podiatrist, but oftentimes they'll
give steroids where it hasn't been shownthat it's effective for plantar fasciitis.
So a lot of musculoskeletal areas,it's been used inappropriately as well.
Sam (06:25):
So, in 20 years of clinical practice, I will say that I found a
similar trend in my own prescribing.
And I don't really have a goodreason to attribute to that.
I think when I was in residencytraining, we spent the bulk of our
time treating the higher risk diseases,and we had a fast track, and our
fast track was actually staffed byan attending physician and a PA.
(06:48):
And so we were rarely exposed tohigher volumes of the minor care cases.
But as soon as I graduated and westarted working in a busy urban
emergency department, all of a suddenthat was, you know, something like a
half of the cases that I was seeingwere not necessarily true emergencies,
but I think the notion for me was well.
(07:10):
You know, I've got a patient who'ssitting in front of me who is here
for a condition that they are eitherseeking maybe an antibiotic for, and I'm
gonna tell them that's not appropriate.
And that was a whole nother conversation.
But then also maybe they have somesymptoms and I'm just trying to say,
well, you know, I can't really solveyour problem, but maybe I can do
something to alleviate your symptoms.
(07:31):
And the notion kinda came up of, well thisseems like a pretty benign thing to do.
I mean, what is the harm ofa short course of steroids?
But that is not the caseaccording to your research.
Right?
Evan (07:43):
Right.
Well, yeah.
Actually not, not my research,but other people's research and
I'd like to share that with you.
So that was also in my education.
The concern was about chronicsteroids, just like you're saying.
So, people becoming a cushingoid frombeing on steroids for months or years.
The weight gain, the immunosuppression.
(08:06):
I think we can all kind of imaginewhat all that we've learned about
the side effects of chronic steroids.
And it turns out that a lot of thoseside effects, and again, this isn't my
research, but I'll just share it with you.
A lot of those similar side effects canalso be seen for short-term steroid use.
In short term steroid use your body is notreally gonna get adrenally insufficient,
(08:31):
so not that one, but short term use canincrease someone's risk for infection
for sepsis in the next one to two months.
Can increase risk for bone fractures.
Again, I'm just saying inthe next one to two months.
And thrombo embolism also an increasedrisk, again, in the short term, just
(08:53):
in the next one to two months afterreceipt of a short-term steroid use.
And the most common side effectsfrom, again, short-term steroid use.
We're talking about a steroidinjection, a Medrol dose pack.
The most common side effectsare psychiatric side effects,
loss of sleep, anxiety.
(09:15):
Some people who already havepsychiatric problems or a severe
depression, steroids can really tiptheir symptoms into a severe situation.
Sam (09:25):
And when we talk about short term use, we're talking about
things like, you know, five to sevenday courses of prescribing here.
Evan (09:32):
Exactly.
Sam (09:33):
So all of those things can still occur even in the one
week course of a prescriptionfor, you know, your typical URI.
Evan (09:41):
Right.
Yeah.
So one thing that I've looked upand seen in the published literature
is that there's a dose responsecurve too, that the higher someone's
short-term steroid use, the higherchance of those side effects.
So, that's the case.
But also it does look like after twomonths, most of these short-term side
(10:02):
effects , will attenuate and go away.
I say most except for the bones.
So repeated short-term useover somebody's lifetime will
have an impact on bone density.
Can increase the riskfor avascular necrosis.
But most of the sideeffects are gonna go away.
Sam (10:22):
Now you mentioned a timeframe of two months.
That's the typical period for howlong it takes for the side effects
of the short-term prescribingof steroids to kind of go away.
Evan (10:32):
That is what it looks like.
Yeah.
One study was published in 2016showing increased risk of infection.
In 2017, a British medical journal thatwas a study that showed increased risk for
the venous thromboembolism, fracture, andsepsis over the one to two month period
Sam (10:54):
Yeah, and that one particularly surprises me 'cause I don't really
think about severe immunosuppressionfrom a few days of steroid use.
Especially lingering for two months,so tell me more about that one.
Evan (11:06):
Yeah, I've actually seen this with several patients where, let's use the
sinusitis example, and that's where I'veseen it a few times, where someone was
given a steroid injection or a Medroldose pack and a Z-pack azithromycin
for sinusitis and in a lot of thosesituations, the patient's symptoms got
(11:29):
much worse and they may have developedactually fevers and worsened sinus
discharge, so that's something anecdotallyI've seen I'm not sure I'd use the term
immunocompromise, but there is definitelysome sort of hit to the immune system
just with a short term steroid, whichmakes sense, just about how steroids work.
(11:53):
And so you could imagine if someone hasa lingering bacterial sinusitis and if
it's not treated with azithromycin sincemost of the bacteria will be resistant
to that, and at the same time they'regiven a steroid, that definitely increases
the odds that that bacteria is gonnawin the short term battle, at least.
Sam (12:17):
And now you mentioned sepsis as well.
So when we talk about sepsis, wethink of, you know, those people who
end up in the emergency departmentand end up being hospitalized.
Was there a significant trendin the risk there for sepsis
after short term steroids?
Evan (12:32):
Yeah.
So, that study in the BritishMedical Journal, a group from
Michigan led that study and theyused a retrospective analysis,
so looking at all comers, with theOptum database of just millions
of people and prescribing.
And with that database were able tolook at people's underlying diagnoses
(12:56):
and when they'd received steroidsand not, and the researchers, they
did as good of a job as they couldto try to get rid of any confounders.
And after correcting for the same amountof patients with autoimmune disease
or, they actually excluded cancerpatients, they were able to see that
(13:17):
there was an increased risk of sepsis.
It wasn't a high number.
We're talking about out of thousandsof patients, there were maybe a, I
don't know the exact number, but, theredefinitely was a statistically significant
difference in those that developed sepsiswho were exposed to corticosteroids
versus those that were not.
Sam (13:35):
Hmm.
And was there a trend or were theyable to find a trend that correlated
with like past medical historyor other confounding illnesses?
Or is it just all comers whohad a short course of steroids?
Evan (13:48):
Yeah, I'm not an expert enough in the biostats part, but they were
able to correct for underlying healthissues, and after correcting for that,
which is not perfect in a retrospectiveanalysis, but after correcting for
that, they did have a statisticallysignificant increased risk of sepsis.
So I think of things like sepsisas if I'm going to give patient a
(14:12):
short term steroid, there's not alarge risk but you could be putting
someone to some degree in harm's way.
And so you have to kind of couplethat with what's the evidence
base for using a steroid.
You know what, if someonehas a bad asthma flare.
It's clear that steroids in a badasthma flare can really, maybe help
(14:36):
prevent an ER visit or a severeasthma flare where they're in the ICU.
So in that case, the benefits makes sense.
But in something like sinusitis orbronchitis, I'm talking about acute
bronchitis and a non asthmatic,the evidence actually shows
that steroids are not effective.
(14:56):
If you're gonna give something tosomeone where there's not evidence
to show its use and there's actuallyevidence that showing it's not
effective, then even this low risk ofsepsis, in my mind, it's not worth it.
Sam (15:11):
Yeah.
It also brings up the question of whetheror not you should be discussing that
with the patient before you prescribe it.
So in those scenarios, let's say you havesomeone who's maybe borderline for their
benefit for steroids and they're askingfor the prescription, do you intentionally
have that conversation and tell them, Hey,you know, your benefit may be marginal,
(15:32):
but you have to know that there is somerisk to this and you know, is there a
way to quantify that risk for them, or doyou just tell 'em it's low, but present.
Evan (15:40):
Yeah, well, I mean it depends on the person in front of you.
Are they already onsome immunosuppressives?
Have they already had a pneumonia onceand is there something about their
immune system that may put them at aneven higher risk for complications?
So, I think in general, yes,we should inform patients.
And that gets to one of the otherrisks a lawsuits and we could talk
(16:03):
about that in a minute, but definitelyimportant to inform patients about
the risks and also we shouldn't feelstrong armed into giving steroids.
Sam (16:12):
Hmm.
Evan (16:13):
That's important.
Really one of the key messages that I tryto convey is above all else do no harm.
Sam (16:21):
Hmm.
Evan (16:21):
The do no harm is really where we should be practicing.
Of course there's areas of uncertainty,but as much as possible, we should be in
the realm of do no harm when we're makingdecisions and talking with patients.
Sam (16:34):
Yeah, it's, I mean, I gotta say it is a little frustrating that
there are these short term sideeffects to steroids because it seems
so ubiquitous for so many things.
I can think of teenagers with severepharyngitis or you know, people with maybe
not necessarily a diagnosis of asthma, butthey've got a severe case of bronchitis.
They have a little bit of wheezing oryeah, sure they have recurrent sinusitis.
(16:57):
And maybe their own past experiencesays, Hey, I want this course of
steroids, and I came to you becauseI know I've been here a million
times and asked for the antibiotics.
And you always say no.
But now I know the steroidsmake me feel better.
This kind of brings a whole newdimension to that discussion, doesn't it?
Evan (17:15):
Yes.
Yeah, definitely.
Research on antibiotics shows thatit takes about maybe a minute at
most to educate the patient aboutreasons not to give them antibiotics.
And thankfully a lot of patientshave gotten that message.
Not all, of course, not all.
And the story of steroid stewardship,which I think we're only in the
(17:38):
infancy of this field, is very similarto antibiotic stewardship and so
hopefully over time more patientswill be educated about the risks.
In my experience, most patientsare reasonable, and most of them,
they just wanna feel better.
And if I can educate them in undera minute about that, actually this
(18:00):
hasn't been shown to help themfeel better, I could give them the
YouTube video we made, which is apatient and provider friendly video.
Most people are okay with that.
Do I occasionally have a patientwho's still dissatisfied?
Yes.
I mean, I'm not gonna lie andsay all my patients are happy
campers and happy to come back.
But I really try to upholdthe, you know, do no harm.
Sam (18:23):
I'm curious.
Sometimes in the emergency department,we will do one time dosing or
single time dosing of steroids likedexamethasone, something longer acting.
Do those adverse effects also occurwith single dosing of steroids, like a
one-time dose for a child or adolescent?
Evan (18:40):
Are you talking about like an injection
Sam (18:42):
Yeah, or oral.
I mean, sometimes we'll give Dexamethasoneoral for its bioavailability is the same.
But still, you know, somethingthat's a steroid in this scenario.
Evan (18:50):
Yeah, so the injections, they have a few other things to keep in mind.
One side effect from steroidinjections is fat atrophy.
And that does happen.
I'm not sure how frequently, but we'regiving the injection, if it's not
clearly in the intramuscular space, ifit's given a little more superficially,
(19:12):
that could lead to fat atrophy anda permanent dimpling of the skin.
So that is something that does happen.
And then the other thing with steroidinjections is a lot of patients,
when they come see us in the ER or inurgent care, they're at their peak of
symptoms, which kind of makes sense.
They're, like, I've been, you know,dealing with this at home forever,
(19:35):
and I just had enough of it.
And a lot of times people arebetter the next day or two after
they leave the urgent setting.
And so some patients , we alwayswant them to finish their antibiotic
course, but sometimes they don't 'causethey think they're feeling better.
Same with the steroid, the oral dose pack.
I was feeling better.
(19:56):
I didn't feel like I had to finishthe Medrol dose pack, and that's where
people have these leftover medicines.
So I'm not at all advocatingfor that situation.
But the thing with a steroid injectionis once you give the injection, the
patient a day or two later can't decide,you know, I'm actually doing better.
I don't have to finish this.
(20:16):
They really have a large dose.
Most steroid injections are, Ithink about the equivalence of
maybe 60 milligrams of prednisone.
And, they're different dosingobviously, but it is a large
burst of steroid in the body.
And so injections can impart this risk.
But again, repeated injections in theshort term are worse than just one
(20:39):
injection, given that dose responserelationship for short term steroids.
Sam (20:44):
Huh.
Okay, so sepsis is an increasedoccurrence in the following two
months, you said, after a short-termuse of steroids, bony fractures,
and localized reactions includingdimpling, if they're giving injections,
any other short-term side effects?
Evan (21:02):
Yeah.
Increased blood glucose especiallyin people with diabetes.
I've had several patients where theydid not have known diabetes and after
receiving steroids they probably had somesort of insulin resistance and then this
tipped them into the diabetes diagnosis.
So, definitely increased hyperglycemia.
Sam (21:24):
Good.
And then you mentioned some of the, likethe psycho behavioral issues as well.
You know, lack of sleep,increased appetite, up all night.
And then behavioral disturbances that canoccur from even short term use as well.
Evan (21:37):
Correct.
Sam (21:38):
All right.
And then touching onwhat to tell the patient.
So let's say we have come to anagreement that there might be,
I'd say not strong evidence, butmight be some evidence for using
short-term steroids in this condition.
What's the best approach fordiscussing all of those things?
Do you just run down the list reallyquickly with the patient and say, I
(21:58):
am gonna give you the steroid, but yougotta be aware you might have blood
clots, it might worsen your blood sugar.
You may not sleep, you may be hungrya lot and eat and have some weight
gain and have some swelling and you'reat higher risk for bony fractures and
infections in the next two months.
Do you just run through it likethat or do you make it more specific
to the person sitting in front ofyou, or how do you approach that?
Evan (22:16):
Yeah.
I don't think I go over allthose side effects honestly.
But I do think about who's in front of me.
Is it someone with diabetes?
And I'm definitely gonnatalk about the sugars.
Does someone have psychiatric diagnoses?
Then I'm gonna be talkingmore about those issues.
Someone elderly probably wedo wanna talk about the bones
and possible infection risk.
(22:38):
So I do somewhat tailor it and I mean,the truth is we don't have time to go over
every possible side effect for everything
Sam (22:45):
Yeah.
Evan (22:46):
So, I would say I would tailor it to who's in front of me.
Sam (22:49):
I mean, I could imagine some scenarios where you run through that list
with a patient and they say, eh, actuallyon second thought, no thanks you know,
Evan (22:57):
That has happened.
Definitely.
Yeah.
In my care of urgent care patients.
Sam (23:00):
And then so do you think with the increased education that you've been doing
and the discussions on steroid use, haveyou seen a, like a positive change in
provider behavior in your clinicians oryour nurse practitioners, your PAs, your
physicians, are they prescribing them lessknowing this, or are they just having the
conversation with their patients more?
Have you been able to tell a trend?
Evan (23:21):
Yeah, good question.
So, well, first of all, in the system I'mat, I'm at Ochsner Health in southeast
Louisiana , centered around New Orleans,but a lot of southeast Louisiana.
Our urgent care department, I'mreally thankful they've taken this on.
They've really kind of taken this onwholeheartedly as a quality metric.
(23:42):
And so the care in southeast Louisianafor when patients would come in for
acute respiratory tract infectionencounters, maybe 40% of the time patients
would receive a steroid injection,and that's been cut back significantly
to under 5% at Ochsner Urgent Care.
(24:03):
So, part of the explanationhas been education from myself.
We've developed some CME materialon this as well online, CME.
And also they include it intheir quality metric dashboard.
So, they have that in addition tochecking of a UA in patients that they're
treating for urinary tract infections.
(24:25):
Since I'm in primary care,I'm not in their department.
I don't know all the quality metrics, butthey do include that in their metrics.
And then in primary care we are in theprocess of publishing a study where
we showed that providing clinicianswith a monthly report on their
inappropriate steroid use, providingthem with a report and a one-time
(24:50):
CME continuing medical education.
That was able to effectivelydecrease steroid use.
So, we're not sure how much of this isconversations that that's being encouraged
between the patient and clinician?
Or is it that just theclinicians not offering it?
So, we're not sure.
(25:10):
But that's a good question of what'sactually leading to the decrease.
Sam (25:15):
And when you label it as inappropriate I'm assuming then
you have a list of diagnoses thatyou would say, okay, these would
meet criteria and these don't.
Evan (25:23):
Yes.
Yeah, so we've been focusingmostly on ARTI's, acute respiratory
tract infection encounters.
We exclude patients with asthma or COPD.
And so if somebody comes in withinfluenza, acute bronchitis, sinusitis,
pharyngitis, otitis media, we includeallergic rhinitis as well, which
(25:48):
systemic steroids have not beenrecommended for allergic rhinitis.
So anytime steroids are given inthose situations, and I don't mean
intranasally, but systemic steroids,either oral or intramuscular, we would
define that as inappropriate use.
Sam (26:05):
Yeah.
I always find it fascinating when wepublish data about clinicians and their
prescribing practices and share it witheveryone as a group and go, Hey, here's
where you are, here's where your group is.
I think that kind of is very revealingfor all matters of quality assurance.
You know, it could be just utilizationor imaging or labs or what have you.
I think it reveals someinteresting trends.
(26:26):
So.
It's good to hear that that is a modelthat is applicable in this scenario.
And you're using that now,not just for the IM dosing one
time, but also for prescribing.
Evan (26:39):
For oral steroids as well, yes.
Sam (26:40):
Okay.
That's great.
And does it also track thepediatric prescribing, or is
this just solely in adults?
Evan (26:47):
We've solely been working on adults.
I think pediatrics is important too.
And I mean, again, the repeatednature, especially effects on the
bones, that's even more of a reasonto not give in the pediatric setting.
But since I'm not a pediatrician,it hasn't been really something
I've delved into personally.
Sam (27:07):
Fair.
When we talk about repeated dosing aswell for short term courses, what kind
of frequency are we talking about?
Like more than once in a year,more than once in three or four
months or what defines repeated?
Evan (27:18):
Yeah.
So anecdotally, I've had severalpatients on the order of a once a year
steroid injection, say, and that's theonly thing I could figure out why they
have avascular necrosis of the hip.
So anecdotally, that'sbeen the case for me.
I mean, we definitely have researchthat shows steroids affects bone
(27:40):
density and we clearly know chronicsteroids affect bone density.
And then we know that short termuse repeated dosage, the higher
the dose response curve that'sthere for steroid fractures.
But my understanding on bones is thatrepeated use over years, even once
(28:00):
a year of a steroid injection, candecrease bone density over time..
Sam (28:04):
And then another question, what about when you, and this is probably more
common in the emergency department or inthe hospital setting, but you know, it's
frequent for us to encounter steroids asa recommendation from consultants as well.
You know, let's say, let'stake neurosurgery for example.
You've got somebody with intractablesciatica and we're trying to find
some way to alleviate the pain.
Sure there's always pain medicationbut then we're talking about other
(28:27):
ways to kind of augment that effect.
And frequently we get, okay, yeah, put'em on a Medrol pack or give them some
Decadron for the next 10 days or somethingand they can follow up in the office.
Have you noticed that that evidencealso covers those diagnoses, or is that
more gray, or how do you handle that?
Evan (28:44):
As far as acute sciatica, there's good evidence that says
that steroids are not effective.
There was a really goodrandomized controlled trial,
so that's the best study.
We have a placebo matchedrandomized controlled trial.
It was published in 2017 in JAMA, andit had patients with acute sciatica.
Some received I think it was six days ofprednisolone, very similar to prednisone.
(29:10):
And then half received placebo andthere was no long-term improvement
in acute sciatica, in pain, orwho ended up needing surgery.
So I mean I try not toargue with specialists.
I try not to get into it.
I really just wanna educatepeople and make them aware.
So, in the line of work I do, if Isend someone to a specialist in the
(29:34):
outpatient setting, the specialistwill prescribe the steroid.
But I understand what you're saying.
If inpatient or ER, if the specialistsays, okay, you do this, that does
kind of tie your hands in a bit becauseyou asked the specialist to weigh in.
But still, I think if we can educate oururgent providers, both ER and urgent care
(29:56):
and hospitalist clinicians as well, ifwe can educate them on the risks, maybe
they'll decide, oh, even though thespecialist recommended this, I don't think
that this is the best for this patient.
And really, when you're the ER doc, whenyou're the hospitalist, you know the
patient better t han the specialist,you know, all their diagnoses, and
(30:17):
you might know something about themthat does tip into the risks of
the short-term steroids are maybemore than the potential benefits.
Sam (30:25):
Yeah.
Yeah, I'm thinking about myneurosurgery colleagues, my ENT
colleagues, you know, the propensityfor prescribing steroids when we're
just kind of out of other options.
Seems like it's higher in those cases,but maybe that's just 'cause we're
not having the conversation honestly.
Evan (30:41):
Yeah, but you're right about neurosurgery.
They give a lot of steroids.
I don't wanna poke particularlyat the neurosurgeons, but they
do give a lot of steroids.
I actually had a patient who sufferedfrom a pulmonary embolism after
receiving multiple doses of steroids.
I can't say a hundred percentit's from the steroids
Sam (31:02):
Sure.
Evan (31:03):
or it's from her underlying condition.
But there are a lot of venoand thromboembolism cases
in neurosurgical patients.
So if I were in the neurosurgery world, Iwould hope that they would start thinking
about what research do we have that reallysupports the amount of steroids we use.
Sam (31:21):
Fantastic.
Evan (31:22):
I do wanna say that for some of the clinicians listening, well, first of
all, I appreciate you listening this farin, I could imagine some of you thinking,
okay, well, we can't give antibiotics.
We can't give steroids.
What can we do.
Sam (31:39):
Yeah.
Evan (31:40):
And I don't mean to say, you know, there's nothing
we can do for these things.
There are things we can do,sometimes the patient needs the
right antibiotic for sinusitis.
Sometimes people need to bepointed in the right direction
of what to get over the counter.
Sometimes patients just need educationthat on average the cough with acute
(32:04):
bronchitis lasts 10 to 20 days.
If I give you a Z-Pak 10 to 20 days, ifI gave you a steroid shot, 10 to 20 days,
so sometimes that's what patients need.
So I'm not saying, you know, don't doanything, but we don't wanna do harm.
Sam (32:19):
Yeah, I think that's great advice.
And it seems like low hanging fruitfor some education and some change.
So if you're listening and you'repart of a quality assurance project
or looking for one at your hospitalsystem, your urgent care, your ED, even
your primary care clinic, this kind ofseems like some low hanging fruit that
you could make a significant changewith just a little bit of education on.
(32:41):
I think the list of things thatwe give steroids for definitely in
the last 20 years has increased.
And as you mentioned, not evidence-based,just more out of frustration for lack
of other ways to alleviate symptoms.
But you know, sometimes havingthat conversation and just saying,
okay, what is the worst symptom?
And let's see what we can do about that.
Evan (33:01):
I use that exact same phrase with my patients.
So what's bothering you the most?
So I can target that specific symptomand I think that, you know, maybe
again we don't have scientificproof of why steroids have gone
up over the last 10 to 20 years.
But, part of it is we don'twanna give antibiotics.
We know that's not good.
We don't wanna give pain medicines.
(33:23):
We know that's not good, but sometimesif someone's in excruciating pain, that's
the best thing we could do to help them.
And to help them get throughthe next one to two weeks.
And sometimes that'sjust what patients need.
And we shouldn't be afraid togive appropriate analgesic pain
medicine, whether it's tramadolor hydrocodone or an opioid.
(33:47):
I mean, sometimes we just, that'swhat we have to give to patients.
Sam (33:49):
Yeah.
And it really does just come down to,you know, okay, what's the worst symptom?
What do we have in ourarmamentarium to treat it?
And here's the list of side effects.
Which ones do you wanna roll the dice on?
Evan (34:02):
That's a good point.
Sam (34:02):
It's kinda you know, we have pain medicines.
Those come with a bunch of risks.
We have steroids.
Those come with risks forshort and long-term use.
We could do nothing.
And that comes with itsown short-term risk, right?
You know, maybe 10 to 20 days.
I guess it's a good conversation to have.
And it seems like that's ripe for someeducational material for patients.
Earlier, you did mention somemedical legal concerns with
(34:25):
steroids that I forgot to ask about.
So tell me have you seen any examplesof medical legal outcomes from
short term steroid prescribing?
Evan (34:34):
Yes.
I've definitely seen lawsuitsthat came up due to fat atrophy.
Again, that's a permanentdimpling of the skin, which can be
rather disfiguring for patients.
There's actually a publishedstudy that looked at lawsuits that
came from steroid prescribing.
It was in one of the ENT journals.
(34:56):
And some of the side effects that cameup, a lot of them related to infection
risk, so that gets to the sepsis.
So there definitely is a whole literatureout there on the medical-legal side
Sam (35:09):
Gotcha.
So not always at the forefrontof our mind for why we do the
things we do with patients.
We definitely want to do noharm, like you mentioned, and be
evidence-based in our practice.
But just one more layer to the equationthat yes, there are some real bad
outcomes, and yes, it can be a medicallegal concern for our clinicians as well.
Evan (35:28):
Yes.
Yeah, that is the reality.
Sam (35:30):
Perfect.
All right.
Now, you mentioned a video.
You've made a video that's now thisis a video that's for clinicians
or a video for patients or both?
Evan (35:37):
I'd say it's for both.
It's three minutes.
And in the way that I think it'sfor clinicians is how a lot of us
and me, before I started thinking alot about this topic, thought that
short-term steroids didn't have anyof the same side effects as long-term.
So the video definitely talks about that.
And then for patients, it usespatient friendly material.
(35:59):
It's three minutes.
So I think it can be used for both.
Sam (36:02):
And that's publicly available.
Evan (36:04):
Yes.
Yeah.
On YouTube, if you just search Ochsner,that's OCHSNER, corticosteroids
that'll show up or I think ifyou search corticosteroid side
effects, it'll be like number one,two, or three if you search that.
Sam (36:21):
Awesome.
All right, well, I'll do that searchand put that link in the show notes.
And if you're listening and you're youknow, a fond prescriber of steroids, this
may be some food for thought just to kindof take a look at that practice, maybe go
back to the evidence base and see if theremight be room to adjust your frequency
of prescription for a certain diagnosis.
(36:42):
Well thank you very much foragreeing to be on the podcast.
I found this really quite informative.
I was looking through some of theeducational materials you've developed
and like I said, a little bit dismayedthat something I've been doing for so
long actually does have some significantshort-term harm and, you know, something
I'm definitely gonna have to bringup with patients from now on each
time that we're talking about steroidprescribing as just another cause of
(37:06):
potential short term side effects.
Evan (37:08):
Well, you're welcome.
Thank you for being open tothis and for the listeners.
Thank you for listening.
My point is not to make anybody feelbad about not doing the right thing.
It's just to educate and think twice.
Sam (37:20):
And that's a wrap.
Thanks for joining us forthis episode of EMPlify.
I hope you found it informative, and Iwant to remind you that ebmedicine.net
is your one stop shop for all of yourCME needs, whether that be for emergency
medicine or urgent care medicine.
There are three journals, there'stons of CME, there's lots of
courses, there's so many clinicalpathways, all this information at
(37:43):
your fingertips at ebmedicine.net.
Until next time, everyone,I'm your host, Sam Ashoo.
Be safe.
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