Maximum Steroid Dosage

[Aether2000]

I have searched far and wide for a reference as to the pain clinic urban legend of 3mg/kg/year or some number for lifetime injection dosage of depomedrol/kenalog and can find no scientific source. The earliest allusion to this number appears to be a singular author that in 2002 quoted the 3mg/kg/year number without including a reference or any scientific/medical data to support such an assertion. The number appears to have materialized as an effort to define a standard or guideline without quoting any support for this number. Is there any truth to this number or is it simply a fabrication of wishful thinking that incorporated one author's self quoted opinion that has morphed into an urban legend?

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[lobelsteve]

Urban legend.

SLE patient on 10mg prednisone qd c 5 + yrs.
Ditto for RA in the past. Sometimes copd
1000mg day x 5 days for MS.


We are not close even if we gave 80mg dep every month.

 

[emd123]

3mg/kg/yr of methylprednisolone?

Urban legend

Methylprednisolone for acute spinal cord injury: 30mg/kg IV bolus in the first hour alone, then 5.4mg/kg/hr for 23 hr. That's 154 mg/kg in one day. Controversial, but a dose given for many years in acute SCI



Yes, that's 11,000+ mg of Medrol (solu-medrol, not depo- but same drug) IV over 24 hours in spinal cord injury for your 75 kg male patient. More for a "real" patient.

 

[Ducttape]

I have searched far and wide for a reference as to the pain clinic urban legend of 3mg/kg/year or some number for lifetime injection dosage of depomedrol/kenalog and can find no scientific source. The earliest allusion to this number appears to be a singular author that in 2002 quoted the 3mg/kg/year number without including a reference or any scientific/medical data to support such an assertion. The number appears to have materialized as an effort to define a standard or guideline without quoting any support for this number. Is there any truth to this number or is it simply a fabrication of wishful thinking that incorporated one author's self quoted opinion that has morphed into an urban legend?

i have heard 3 mg/kg/6 month period of time.

the reason to limit the dose of steroids has nothing to do with that stevelobel and emd have commented on - obviously it is to reduce the side effect profile of long term steroid use.


it may be in part due to the 1980 study by Knight and Burnell that showed that some patients who recieved a cumulative dose of 6-10 ml (over 200 mg) of methylprednisolone developed Cushings syndrome.

Right at the end of the article, right before Acknowledgements, is the statement "The dose of methylprednisolone is now limited to a maximum of 3 mg/kg of body weight".


oops link Knight and Burnell 1980

 

[knoxdoc]

View attachment Knight-Anaesthesia 1980 (Steroid Dose Limit).pdf

Sorry ducttape - just realized you had the link up. Thanks for the reference.

 

[Tenesma]

there is a needle jockey in my state who has no problem doing an injection every week to two weeks for about 5-6 months straight, then discharging the patient if no improvement... I have seen in excess of 40 injections over 4 months w/ him, with dosages (based on reading the reports) >2000mg of depomedrol over that time span.

I do adrenal tests on all of those patients - and to my shock, none of them are adrenally insufficient...

 

[clubdeac]

there is a needle jockey in my state who has no problem doing an injection every week to two weeks for about 5-6 months straight, then discharging the patient if no improvement... I have seen in excess of 40 injections over 4 months w/ him, with dosages (based on reading the reports) >2000mg of depomedrol over that time span.

I do adrenal tests on all of those patients - and to my shock, none of them are adrenally insufficient...

What adrenal test do you do? Just am cortisol level?

 

[Tenesma]

cosyntropin stim test

 

[Aether2000]

Thanks for the delicious reference! The 3mg/kg is a limit self imposed by that practice based on the side effects of giving up to 280mg methylprednisolone epidurally over 3 days- a dose that would probably be considered high by most of us. The 3mg/kg was not specified as to the time frame in the article- that was imputed by later authors. Also this was all based on anecdotal evidence from a total of 4 patients.

What ASIPP says about this:
From ASIPP 2009 Evidence Based Guidelines for Spinal Interventional Techniques page 766:
"Some have preached 3 injections in a series irrespective of a patient’s progress or lack thereof, whereas others suggest 3 injections followed by a repeat course of 3 injections after 3-, 6-, or 12-month intervals. There are also proponents who propose that an unlimited number of injections with no established goals or parameters should be available. A limitation of 3 mg per kilogram of body weight of steroid or 210 mg per year in an average person and a lifetime dose of 420 mg of steroid also has been advocated; however, with no scientific basis. The comprehensive review of the literature in preparation of these guidelines and review of all the systematic reviews has not shown any basis for the above reported assumptions and limitations. The administration must be based solely on patients’ response, safety profile of the drug, experience of the patient, and pharmacological and chemical properties such as duration of action and suppression of adrenals."

I think ASIPP got it right.

 

[drusso]

View attachment 22196

Sorry ducttape - just realized you had the link up. Thanks for the reference.

Good Job, Knox! I've been trying to find that reference for YEARS. The issue came up once when I was being deposed as an expert witness on a MVC claim.

 

[knoxdoc]

Yeah, I remember hearing that in residency but could never find it either. The last line of the article is hilarious - he just drops the dosing "new dosing" bomb out of the blue.

 

[dc2md]

Thanks guys. We just had an interventional anesthesia guy in town just criticize our practice to a mutual patient, saying we gave her more steroid in 6 months than he would give in a year, and that that was the reason why she got pneumonia recently (and the patient is in her 80s and it's flu season). She's now speaking to our CEO about this and my partner will now have some evidence to show him.

 

[drusso]

Yeah, I remember hearing that in residency but could never find it either. The last line of the article is hilarious - he just drops the dosing "new dosing" bomb out of the blue.

Knox, thanks so much! Can you also find the reference for q weekly impedance plethysmography for routine surveillance of DVT in hospitalized patients??

 

[deleted185747]

There is a pain physician in my area who may be losing his license due to multiple complaints.
They counted each steroid injection above "6" in a 12 month period as 'repeated negligent acts'.

See medical board accusation and recommendation to revoke his license
http://www2.mbc.ca.gov/BreezePDL/do....DID&licenseType=G&licenseNumber=75296#page=1

page 6; line 3 spells out the steroid injections.

I'm never doing more than 6 per year although I'm not sure a little steroid after RFA counts or not...

 

[pmrmd]

^ The injections weren't in the same place. He initially did ESIs then lumbar facets and then ostensibly the complaint changed because he did thoracic intervention. The patient must have improved from what he did. The complaint does not mention the dose he used or if there were adverse effects from it. He is more at fault with his records and SCS practice patterns. And ESI sans fluoro, of course.

 

[emd123]

^ The injections weren't in the same place. He initially did ESIs then lumbar facets and then ostensibly the complaint changed because he did thoracic intervention. The patient must have improved from what he did. The complaint does not mention the dose he used or if there were adverse effects from it. He is more at fault with his records and SCS practice patterns. And ESI sans fluoro, of course.

Right. Documenting no history or exam routinely. Doing multiple injections including a stim without ever getting imaging. Doing a stim with no diagnosis other than "Low back pain". Multiple esi's without fluoro. There's way more here than the amount of steroids.

 

[lobelsteve]

Right. Documenting no history or exam routinely. Doing multiple injections including a stim without ever getting imaging. Doing a stim with no diagnosis other than "Low back pain". Multiple esi's without fluoro. There's way more here than the amount of steroids.

Needs to lose license. Or death by pitchfork with torches and such.

 

[ampaphb]

there is a needle jockey in my state who has no problem doing an injection every week to two weeks for about 5-6 months straight, then discharging the patient if no improvement... I have seen in excess of 40 injections over 4 months w/ him, with dosages (based on reading the reports) >2000mg of depomedrol over that time span.

I do adrenal tests on all of those patients - and to my shock, none of them are adrenally insufficient...

What reimbursement source is willing to cover in excess of 40 injections over 4 months?

 

[Papa Lou]

This happened in 2008. Fluoro wasn't bundled back then…as long as he didn't bill for fluoro it would have been totally fine to do an ESI without fluoro. It's not good practice but it's not an indication to revoke license. Neither is questioning of his steroid injections, which aren't even quantified in the paper (I'm not a lawyer but this should render it useless).
The SCS indication was not specific and it should have been. Perhaps his biggest problem is poor record keeping, and overall poor doctoring by not reviewing imaging, taking a good history, performing physical exams. That is a decent enough reason to consider license revocation I think.
The other thing is who does facet injections each month x 3 like that. When taken all together it leaves me with a distaste for this person's character. But all we have is this document and no further context to draw from, so it's a little unfair to judge I guess. Especially when his biggest issue may just be language based. For example, if he has a very big accent and poor writing skills some of the documentation issues can be understood in context a little better.
Poor guy (if he's noble).

 

[lobelsteve]

This happened in 2008. Fluoro wasn't bundled back then…as long as he didn't bill for fluoro it would have been totally fine to do an ESI without fluoro. It's not good practice but it's not an indication to revoke license. Neither is questioning of his steroid injections, which aren't even quantified in the paper (I'm not a lawyer but this should render it useless).
The SCS indication was not specific and it should have been. Perhaps his biggest problem is poor record keeping, and overall poor doctoring by not reviewing imaging, taking a good history, performing physical exams. That is a decent enough reason to consider license revocation I think.
The other thing is who does facet injections each month x 3 like that. When taken all together it leaves me with a distaste for this person's character. But all we have is this document and no further context to draw from, so it's a little unfair to judge I guess. Especially when his biggest issue may just be language based. For example, if he has a very big accent and poor writing skills some of the documentation issues can be understood in context a little better.
Poor guy (if he's noble).

You sound like someone who has no idea what is happening in the world of private practice and the rampant fraud that is perpetuated daily.

Here is a snippet from a case I am reviewing tonight:



The doc had him on 4 Norco per day. Patient took 20 and had MI/ARF. Started back on 4 per day 1 month later. SCS didn't get done until 5 months post overdose.

 

[pmrmd]

I would think that fluoroscopic guidance was standard of care, even in 2008. The fact it got bundled is because CMS noted they were paying the fluoro fee with 62310 all the time.

 

[emd123]

You sound like someone who has no idea what is happening in the world of private practice and the rampant fraud that is perpetuated daily.

Here is a snippet from a case I am reviewing tonight:



The doc had him on 4 Norco per day. Patient took 20 and had MI/ARF. Started back on 4 per day 1 month later. SCS didn't get done until 5 months post overdose.

I'm not endorsing any potential severe judgement lapse in continued prescribing acutely post overdose, but show me any documentation of link between norco overdose and MI or renal failure. Liver failure (Tylenol) and respiratory depression (hydrocodone), sure. But not MI or renal failure. I've taken care of hundreds of opiate ODs and nary a one had acute renal failure or STEMI. It's not even in the toxindrome.

 

[Papa Lou]

I think the MI/ARF was related to hypoxemia from respiratory depression in a guy with severe CAD.

Needs to lose license. Or death by pitchfork with torches and such.

I'm aware of the rampant fraud. I just think more information is warranted before we get out the pitchforks and torches. I'm also asian, and I feel for my brethren.

 

[lobelsteve]

I'm not endorsing any potential severe judgement lapse in continued prescribing acutely post overdose, but show me any documentation of link between norco overdose and MI or renal failure. Liver failure (Tylenol) and respiratory depression (hydrocodone), sure. But not MI or renal failure. I've taken care of hundreds of opiate ODs and nary a one had acute renal failure or STEMI. It's not even in the toxindrome.

http://www.ncbi.nlm.nih.gov/pubmed/18338302


1 to 2%.. got to the Psych notes. 40 Norco 10mg and 40 Ativan 1mg. Agonal breathing at rate of 4, intubated by EMT. Found by wife with black emesis all over him. Though not mentioned in any notes the utox in ED also positive for amphetamines not prescribed.

 

[Ducttape]

you know that ED Utox can be incorrect for amphetamines.

first, venlafaxine/effexor and lamotrigine can cause false positive urine tox for amphetamines. second, samples that are stagnant for an extended period of time can generate breakdown products in the urine that may cause a false positive amphetamine.

third, the article describes cases of nephrotoxicity but it does not distinguish it as a sole problem without concurrent hepatotoxicity. you did not mention any hepatotoxicity or use of NAC for tylenol OD. did the patient also have acute elevations of liver enzymes in conjunction with this overdose?

if the liver enzymes were not elevated, i daresay this might be a case report. in fact, reviewing the literature on pubmed, i could find really only 1 mention of a patient that had AKI without elevated LFTs.

fourth, i know, going off topic. sorry.