Practice Makes Perfect!

I had the privilege this week of watching my favorite sport….10 players dribbling an inflated ball up & down a court, trying to throw it through a steel hoop more times than the opposing team.  Yeah, it’s my passion.  The Thunder vs Bobcats and Oral Roberts University vs the Sooners of Oklahoma.  (little in state rivalry) What impressed me about the current state of basketball is how fast any human 6 ft 8 inches tall can get up and down the court!  As a devout Kansas Jayhawk fan growing up, we (of course I’m part of the team!) had some good exhibits, but never with the agility, speed, and shooting accuracy seen today.  Regardless of better nutrition, year round practice schedules, and the 3-point shot, we all practice to get better. I didn’t realize that despite many alternatives to oral steroids, our use of a “quick fix” is increasing.  Is that why we call this the “practice of medicine?”

I report here a study published barely one month ago on the use of steroids for treating many medical conditions.  Our approach to steroids (by mouth) is to use them when necessary, but substitute with inhaled steroids or other alternatives whenever possible.  Why?  Side effects.  In fact, did you know that based on systemic absorption, a 5 day “burst” of oral steroids is equal to 20 years of the inhaled route?  Based on this poster presentation, it would seem that we need more practice in reducing the use of steroids, especially in children!  My recommendations:

  1. As noted below, emergency rooms and urgent care clinics often don’t know how many times in one year a patient has been on steroids.  Patients often don’t go to the same clinic, and the doctor in that case has no way of monitoring overall steroid use and exposure.  The fix: communicate to ANY provider how many times you have used oral steroids.  You’ll be pleasantly surprised at the results!
  2. Inhaled steroids, allergy shots, avoidance of pets are all designed to reduce your need for bursts of oral steroids.  I agree, avoiding dust and animal dander can be a hassle, but you’ll have better control of asthma if you do and less of a need for oral steroids.  The fix:  take preventive medications as prescribed, avoid all known triggers of asthma (perfume included), and measure your peak flow reading at the first sign of coughing or wheezing. 
  3. Who gets tired of repeating the same list of medications every time you go to the doctor?  Oh, yes, I get tired of writing them down!  There is a reason for the madness….your arthritis doctor, allergist, and ER doctor all prescribe prednisone for different conditions, and unless each prescription is written down and recorded, it’s easy to get an overdose.   The fix: try to remember “in-between” medicine that you have received from one doctor visit to the next.  This is especially important to review with your “primary care doctor”. 

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract P313. Presented November 11, 2012.

English: Ball-and-stick model of the immunosup...
English: Ball-and-stick model of the immunosuppressant drug prednisone (Photo credit: Wikipedia)

The number of prescriptions for prednisone has been increasing steadily since 2000 in the United States, and not all prescriptions are appropriate, researchers reported in a poster session here at the American College of Allergy, Asthma & Immunology 2012 Annual Scientific Meeting.

“I have been in residency for the past 3 and a half years, and was surprised at the amount of steroids being prescribed and the diseases they were being prescribed for,” Tricia Lee, MD, 2012 chief resident in internal medicine and pediatrics at the University of Louisville in Kentucky, told Medscape Medical News.

“This impressed me because we are taught in medical school about all of the significant side effects of systemic steroids, which include weight gain, thinning of skin, psychiatric changes, and adrenal suppression. I wanted to see if we, as physicians, were truly prescribing more prednisone now than we were a few years ago,” Dr. Lee explained.

She and her group examined data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey databases, which were collected by the Centers for Disease Control and Prevention, from 2000 to 2009.

During that time, 11 billion visits were recorded in the 2 databases. Prednisone was prescribed in 178,655,280 visits for any diagnosis — an increase of 17% for all ages.

For adults, prednisone was prescribed 13% more frequently in 2009 than it was in 2000; for children, it was prescribed 38% more frequently, Dr. Lee said.

Diagnoses Associated With Prednisone Prescription

More than 1000 different primary diagnoses were associated with a prescription for prednisone. Asthma, allergy, bronchitis, rheumatoid arthritis, urticaria, contact dermatitis, acute upper respiratory infections, and pneumonia accounted for the majority of prescriptions.

For allergic rhinitis, prednisone prescriptions increased from 1.9% in 2000 to 2.2% in 2009, Dr. Lee noted.

“The worry is that a patient will go to one doctor to get a prescription for prednisone for his rheumatoid arthritis, go to another to get prednisone for a pain in his shoulder, go to another to get a prescription for his asthma, and so on, until he is taking a dangerous amount of prednisone, without all of his doctors being aware,” Dr. Lee said.

“The danger to the patient is that, in the span of a few months, they may be exposed to steroids for a chronic period,” she said.

Emergency Department Implicated

John Oppenheimer, MD, clinical professor of medicine at the New Jersey Medical School in Newark, was asked by Medscape Medical News to comment on the study. “This abstract highlights a significant rise in the use of prednisone, specifically in the emergency department setting,” he said.

He added that “in the case of allergic respiratory illness, this is overall the most effective therapy; however, as pointed out by Dr. Lee and her colleagues, it is not without side effects.”

Dr. Oppenheimer called this increase in the use of prednisone “alarming.”

“The authors postulate that this is the result of a lack of appreciation of potential side effects. However, one may also argue that this is the sequel to the undertreatment in a proactive approach of the underlying illness.”

 
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