allergic rhinitis and steroids

[cabinbuilder]

So I'm having a personal conundrum this week regarding patients who show up to urgent care and expect you to give in to their demands for steroids for any little thing. I never gave steroids in residency except in extreme cases and it seems that here in Texas it's the "go to drug" for just about anything.

I was double checking in uptodate today: Systemic glucocorticoids — Short courses (ie, a few days) of oral glucocorticoids usually abolish symptoms of allergic rhinitis and may be indicated for severe allergic rhinitis symptoms that are preventing the patient from sleeping or working [6]. This approach was more widely used before nasal glucocorticoids and nonsedating antihistamines became available. However, systemic glucocorticoids should not be given repeatedly or for prolonged periods of time for the management of allergic rhinitis [142]. Similarly, we do not recommend injections of long-acting glucocorticoids for this condition because of unpredictable absorption and the inability to dose adjust if side effects occur.

Now it says SEVERE. Most people don't even try anything over the counter and want the "big gun". I'm having a very hard time with this and I know the complaints are going to rack up quickly. I literally had 8 patients in a row yesterday who wanted steroids for various reasons - not one was justified. This was after I had to call the cops for being threatened by a narcotic seeker and after I was threatened by an antibiotic seeker. I feel like such a bitch these days and am just waiting for the admin axe to grind on my neck.

So, is it just Texas? I've never seen such steroid addiction. Just crazy. Thoughts? Needing to vent, so tired of the fight this week. Thanks for the support everyone.

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[Bacchus]

I don't use steroids often, either, but there has been a lot of rhus dermatitis up here in middle-of-nowhere Pennsylvania. Usually I can get by prescribing kenalog cream, but I have prescribed a few tapers over the past 3 months. I've never prescribed steroids despite recent articles suggesting it may help for AR/Sinusitis/Polyps. If it's that bad, off to ENT you need to go to get a scope. The only other time I use steroids are for the obvious cases such as asthma or COPD exacerbation. I don't use them for lumbago (acute) or sciatica (acute) as there is no evidence to support it per the AAFP.

I feel your pain, though. 2/3s of my visits on Friday were for URI symptoms.

 

[cabinbuilder]

Doesn't help either that one of the providers hands out steroids like candy. Everyone gets a shot of kenalog and a 9 day taper for sinus and head cold. What a mess.

 

[deleted87716]

Must be a regional thing. I would never prescribe systemic steroids for mild allergies. Injections...? Fuggetaboutit. I might even laugh if anyone asked. "Dude, Flonase is OTC."

That being said, I will use steroid tapers for allergic dermatitis and musculoskeletal pain, if symptoms warrant.

 

[surrender903]

sorry you had a bad few days. i hope the next few are better and more positive

 

[VA Hopeful Dr]

For allergies, not a chance. I have started using more and more PO decadron for URI symptoms - especially sore throat. I'd rather give 4-5 days of steroid than a week of augmentin.

 

[Freezeout]

I feel like it's more of a southern thing. It's very common to get the so called "sinus cocktail" shot down here. People often ask for it. I've never done it but some other residents will acquiesce.

 

[FrustratedFamDoc]

Very common to give steroids here (GA) as well. I never had allergies growing up in NC but this place is something truly special. All 3 of our local ENTs (one Harvard trained) routinely go to prednisone for treatment. I always suggest a daily nasal steroid for my allergy sufferers and will give steroids when symptoms are bad enough.

 

[HipsterLorax]

On the topic of allergic rhinitis, do any family docs do allergy testing/desensitization in office? I've heard of one doing it in a large city but am not sure how common it is, if it's a viable service to offer, or how accessible the training is.

 

[VA Hopeful Dr]

On the topic of allergic rhinitis, do any family docs do allergy testing/desensitization in office? I've heard of one doing it in a large city but am not sure how common it is, if it's a viable service to offer, or how accessible the training is.

There are several companies that will come set up and do everything for you all you do is sign off on it. Its a decent revenue source but I think its kinda shady.

 

[JustPlainBill]

As we've discussed -- and I've changed my practice somewhat --- steroids are almost like candy here in North Texas -- You can do what I used to do (and still do) which is go over potential AE/SE with the patient (psychoses (bipolar/depression/manic-depression contraindicated), arrhythmias, tendonopathies, avascular necrosis, dimpling at injection site) -- that usually gets the less committed to decline and try nasal steroids; For the hardcore, I have started doing decadron/depomedrol or PO Medrol dosepak or prednisone if indicated. After going through the risks/benefits, most will decline.

But my patients are conditioned by my practice partners that steroids are the answer for just about everything that ails you -- heck, some providers even do IV solumedrol for certain complaints. one cocktail I've seen for sinusitis/strep is rocephin 1g with 4/80.

I feel your pain, you're not going to win this fight -- I have said "No" in a few instances -- like the one who had already had their hip replaced due to avascular necrosis.....

 

[Bacchus]

You guys are so nice. I tell my URI patients they need to wait 10 days for abx. They get a cough suppressant. Unless, of course, there is obvious bacterial cause. Sinusitis? If you don't meet the IDSA severe criteria (which I quote to patients) no abx unless it's been ten days. And, if you tell me your <whomever> had a cold, no ****ing antibiotics for you.

As far as steroids go? No go.

 

[JustPlainBill]

You guys are so nice. I tell my URI patients they need to wait 10 days for abx. They get a cough suppressant. Unless, of course, there is obvious bacterial cause. Sinusitis? If you don't meet the IDSA severe criteria (which I quote to patients) no abx unless it's been ten days. And, if you tell me your <whomever> had a cold, no ****ing antibiotics for you.

As far as steroids go? No go.

Just out of curiosity --- since my Press-Ganey scores are now coming back -- along with all of my "physician measures" from the ACO --- have you had any overuse of ER or poor scores on Press Ganey from PO'd patients? Here in Dallas, it's a very fickle patient population --- if they don't get what they want or feel like they're getting something for their money they'll move on and tell everyone about it very loudly and widely --- my colleagues at the practice are very aggressive regarding therapy -- I've got a few that are very quick to pull the IV solumedrol trigger....for me, I try to stay within EBM but it's difficult seeing patients "on-call" and having the expectations of abx/steroid injections ---

 

[Bacchus]

We ditched Press-Ganey and use some other reporting/survey service. I haven't seen my numbers for myself yet, but it's something I should look into. I think I'm doing OK because there are a fair amount of calls requesting to see me. I work in a small town. Word gets around. I don't have any objective evidence yet, however. I think that's because we see it quarterly and the last meeting we had was for the quarter before I started.

Just out of curiosity --- since my Press-Ganey scores are now coming back -- along with all of my "physician measures" from the ACO --- have you had any overuse of ER or poor scores on Press Ganey from PO'd patients? Here in Dallas, it's a very fickle patient population --- if they don't get what they want or feel like they're getting something for their money they'll move on and tell everyone about it very loudly and widely --- my colleagues at the practice are very aggressive regarding therapy -- I've got a few that are very quick to pull the IV solumedrol trigger....for me, I try to stay within EBM but it's difficult seeing patients "on-call" and having the expectations of abx/steroid injections ---

 

[PlutoBoy]

I don't recall ever resorting to systemic corticosteroids for allergic rhinitis.