Can someone ELI5 different steroids?

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witzelsucht

witzelsucht

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Intern here. Attendings be like "think he needs some steroids?" and I say yeah i guess then I have to pretend to pimp the med student til he tells me what I should order. I know decadron 10mg for croup, and 125 of solumedrol for ...respiratory? Is that right? Then we discharge asthmatics on prednisone, ok, got that. What else do I need to know?
 
pretty simple. dex has a long half life. rule of thumb works for 72hrs. can give to asthmatics and redose x1 in 3 days for 6 days of total coverage. there have been a few studys in peds looking at dex vs prednisolone and data shows a slight trend towards better compliance and less repeat visits/hospitalizations.

with that said , in adults, i still give prednisone as an outpatient and solumedrol as an inpatient. purely as a habit.

decadron usually given for severe pharyngitis.
decadron for croup as day 1-2 are usually the worst.
decadron for cerebral edema

solumedrol for anaphalaxis.

dont know why for the last few besides thats how i was trained.

as for po vs iv. if they can swallow and are not in severe respiratory distress, i usually go PO. time of response, efficacy are very similar and IV dex given fast will cause burning of the crotch.

Sent from my XT1635-01 using Tapatalk
 
Apart from duration of action as wrote above....

A lot of the dosing and specifics benefits of steroids are unclear. If you look through the past 50 years of medical science many conditions have been treated, then not treated, then treated again, etc. with steroids.
 
Apollyon said:
What is "eli5"? And, "attendings be like"? What is happening here?
Click to expand...
"Attendings be like" I got. It's stupid, but I understood it.

ELI5 is a total mystery.

Short answer to the OP:
If you think they need steroids, pick one and give it.

10 of dex. 60 of prednisone. 125 of solu-whatever.

Dosing is basically by whatever's in the Pyxis.

Long answer:
Iiiifff yyoooouuu tttthhhiiiinnnnkkk ttthhheeeyyy nnnneeeeddd ssstttteeerrrrooooiiidddsss, pppiiiccckk ooonnneee aaannnddd gggiiivvveee iiittt....
 
ELI5 steroids:

"This is a pointy kiss to help you breath better.

If you want to be a doctor when you grow up you'll need to study things like English and pharmacology."
 
Head over to reddit, there's a whole sub-forum devoted to ELI5 topics, and they frequently make the top page.


Sent from my iPhone using SDN mobile
 
The short answer is that this is a complicated topic and the data to support type and dose of steroids is poor.

The long answer is that as a resident it is your job to dive into the deep answers and educate yourself.
Don't just do stuff because an attending tells you.
This is how out of date medicine keeps being practiced for 40 years.
Learn from your attendings, but make sure you educate yourself as well.
 
When attendings tell me something I usually just think of it as them pointing me in the direction to learn a topic I would have never thought to research more so than taking the facts directly from them and incorporating into practice.


Sent from my iPhone using SDN mobile app
 
Don't see it mentioned but for peds 2mg/kg/day of prednisolone. 0.6 mg/kg of decadraon for croup.

As above if IV 125mg solumedrol. 60 mg prednisone for home or 10 mg PO decadron. I usually use prednisone for COPD/Asthma/Bronchitis although lots of studies may show equal efficacy with decadron cause its what I do. I change that for the person with limited insurance (or the one that bounces back d/t no money and won't fill scripts) to decadron that I cannot admit to try and keep them out longer/help with money.
 
EMDOC17 said:
Don't see it mentioned but for peds 2mg/kg/day of prednisolone. 0.6 mg/kg of decadraon for croup.

As above if IV 125mg solumedrol. 60 mg prednisone for home or 10 mg PO decadron. I usually use prednisone for COPD/Asthma/Bronchitis although lots of studies may show equal efficacy with decadron cause its what I do. I change that for the person with limited insurance (or the one that bounces back d/t no money and won't fill scripts) to decadron that I cannot admit to try and keep them out longer/help with money.
Click to expand...

what frequency do you use for home decadron for respiratory?
 
Rarely. From my personal opinion the best research for decadron is in peds asthma and still don't know that I can conclude it is as good or better than prednisone. Granted I haven't looked at it for a while. Not sure of any convincing evidence in COPD. The times I have chosen decadron specifically for COPD is the homeless COPD patient that cannot and won't fill a prednisone script and will be back in 2 days because of it. I will give them decadron as theoretically I think it will keep them out of the ED longer.
 
Steroids are voodoo. And like any therapy that is poorly supported by evidence there is both significant variability in practice and a paradoxical belief that your magic recipe works better than anyone else's potion. Safest thing to do is ask first time you work with attending and see an asthmatic, ask what dose and type of steroid the attending prefers.
 
Arcan57 said:
Steroids are voodoo. And like any therapy that is poorly supported by evidence there is both significant variability in practice and a paradoxical belief that your magic recipe works better than anyone else's potion. Safest thing to do is ask first time you work with attending and see an asthmatic, ask what dose and type of steroid the attending prefers.
Click to expand...

Steroids in asthma are voodoo? I must admit I've never looked into the evidence on this, because it's always seemed so obviously true. If you have any evidence casting doubt on it I'd be eager to be enlightened.
 
What do you guys usually give for poison ivy dermatitis? Oral prednisone taper? If yes, what does your taper look like (dose, duration)? If you use kenalog, what dose do you use (40mg, 60mg or 80mg IM)?
 
WilcoWorld said:
Steroids in asthma are voodoo? I must admit I've never looked into the evidence on this, because it's always seemed so obviously true. If you have any evidence casting doubt on it I'd be eager to be enlightened.
Click to expand...
So steroids in asthma aren't voodoo but there's never been a high quality study that shows a difference in primary outcome attributable to type of steroid, dose, or route which is kinda odd. It may be that 10mg of prednisone a day works as well as 40mg or 60mg for acute exacerbation.
 
Also, depending on the clinical situation, you may need more glucocorticoid vs. mineralocorticoid effect. See the attached tables.
 

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BJJVP said:
What do you guys usually give for poison ivy dermatitis? Oral prednisone taper? If yes, what does your taper look like (dose, duration)? If you use kenalog, what dose do you use (40mg, 60mg or 80mg IM)?
Click to expand...

I usually give 60 mg x5 days, 40 x5 days, 20 x 5 days then 10 x 5 days.
 
BJJVP said:
What do you guys usually give for poison ivy dermatitis? Oral prednisone taper? If yes, what does your taper look like (dose, duration)? If you use kenalog, what dose do you use (40mg, 60mg or 80mg IM)?
Click to expand...
Most poison ivy you can prescribe steroid creams for. When you get facial involvement or a huge body surface area where creams would be ridiculous, that's when you need oral. Prescription should be greater than 14 days taper to avoid rebound. Usually 2-3 weeks is fine.
 
Thats like asking a surgeon what he gives for appendicitis. Invanz, unasyn, zosyn, levaquin.... etc....

Just give something.
 
WilcoWorld said:
Steroids in asthma are voodoo? I must admit I've never looked into the evidence on this, because it's always seemed so obviously true. If you have any evidence casting doubt on it I'd be eager to be enlightened.
Click to expand...

Systemic steroids for COPD are voodoo. Standard use to be 8 weeks of treatment with them, then that was shortened to 2 weeks, then they showed recently 5 days was equivalent to 2 weeks:

http://jamanetwork.com/journals/jama/article-abstract/1688035

No difference in mortality, no difference in lung function, no difference in need for mechanical ventilation, but it shortened hosp LOC by 1 day.

This study showed no difference on intubated pts with COPD exacerbations (steroid vs placebo): https://www.ncbi.nlm.nih.gov/pubmed/23794465



My personal belief? COPD, like sepsis, has multiple phenotypes that are expressed. There is probably a subset of patients who benefit from steroids but probably a large amount that don't. We don't have a great way of identifying them. I wouldn't withhold systemic steroids from my COPD exacerbations at this time, but I'm a lot less gung-ho about the mega doses we throw at them "ZOMG 125MG SOLUMEDROL Q1H STAT" and don't believe in anything longer than 5 day courses for outpatient treatment.





As an aside I had a patient come to the ED last night for her COPD who was pissed off because the ED doctor she saw three days prior gave her the wrong steroids. Apparently he wrote her for 5 days of once-per-day prednisone, but the only thing that works for her are the packs which have 5 pills, then 4, then 3 etc...

Everyone knows medrol dose packs are way more expensive than daily prednisone right? (4$ generic list for prednisone)
 
engineeredout said:
Systemic steroids for COPD are voodoo. Standard use to be 8 weeks of treatment with them, then that was shortened to 2 weeks, then they showed recently 5 days was equivalent to 2 weeks:

http://jamanetwork.com/journals/jama/article-abstract/1688035

No difference in mortality, no difference in lung function, no difference in need for mechanical ventilation, but it shortened hosp LOC by 1 day.

This study showed no difference on intubated pts with COPD exacerbations (steroid vs placebo): https://www.ncbi.nlm.nih.gov/pubmed/23794465



My personal belief? COPD, like sepsis, has multiple phenotypes that are expressed. There is probably a subset of patients who benefit from steroids but probably a large amount that don't. We don't have a great way of identifying them. I wouldn't withhold systemic steroids from my COPD exacerbations at this time, but I'm a lot less gung-ho about the mega doses we throw at them "ZOMG 125MG SOLUMEDROL Q1H STAT" and don't believe in anything longer than 5 day courses for outpatient treatment.





As an aside I had a patient come to the ED last night for her COPD who was pissed off because the ED doctor she saw three days prior gave her the wrong steroids. Apparently he wrote her for 5 days of once-per-day prednisone, but the only thing that works for her are the packs which have 5 pills, then 4, then 3 etc...

Everyone knows medrol dose packs are way more expensive than daily prednisone right? (4$ generic list for prednisone)
Click to expand...


We get dinged for NOT giving roids in COPD exacerbation. It's now a "fall-out" according to CMS and is below standard of care.
 
shoal007 said:
pretty simple. dex has a long half life. rule of thumb works for 72hrs. can give to asthmatics and redose x1 in 3 days for 6 days of total coverage. there have been a few studys in peds looking at dex vs prednisolone and data shows a slight trend towards better compliance and less repeat visits/hospitalizations.

with that said , in adults, i still give prednisone as an outpatient and solumedrol as an inpatient. purely as a habit.

decadron usually given for severe pharyngitis.
decadron for croup as day 1-2 are usually the worst.
decadron for cerebral edema

solumedrol for anaphalaxis.

dont know why for the last few besides thats how i was trained.

as for po vs iv. if they can swallow and are not in severe respiratory distress, i usually go PO. time of response, efficacy are very similar and IV dex given fast will cause burning of the crotch.

Sent from my XT1635-01 using Tapatalk
Click to expand...

Great post. The only part I practice differently is with regard to PO vs IV. I only give PO if I am immediately discharging the patient. Otherwise, I give IV because if the patient vomits it up, then I don't know how much went in or didn't. Also, after breathing treatments patients will often become tachycardic, so I end up writing IV fluids. Although now that I think of it, I don't know if the IV fluids actually helps any in this case, but I think it does if there is any element of dehydration from increased RR. Dunno.
 
gutonc said:
"Attendings be like" I got. It's stupid, but I understood it.

ELI5 is a total mystery.

Short answer to the OP:
If you think they need steroids, pick one and give it.

10 of dex. 60 of prednisone. 125 of solu-whatever.

Dosing is basically by whatever's in the Pyxis.

Long answer:
Iiiifff yyoooouuu tttthhhiiiinnnnkkk ttthhheeeyyy nnnneeeeddd ssstttteeerrrrooooiiidddsss, pppiiiccckk ooonnneee aaannnddd gggiiivvveee iiittt....
Click to expand...
It seems now Prednisone is the new Percocet😱
 
Angry Birds said:
Great post. The only part I practice differently is with regard to PO vs IV. I only give PO if I am immediately discharging the patient. Otherwise, I give IV because if the patient vomits it up, then I don't know how much went in or didn't. Also, after breathing treatments patients will often become tachycardic, so I end up writing IV fluids. Although now that I think of it, I don't know if the IV fluids actually helps any in this case, but I think it does if there is any element of dehydration from increased RR. Dunno.
Click to expand...

Why give iv fluids? Use your noggin and write an MDM that explains why they would be this way.


Sent from my iPhone using Tapatalk
 
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