IV vs PO steroids

[turkeyjerky]

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So everything I've ever read or heard on the topic says that the two are essentially equivalent and to go for PO as long as the patient can tolerate it and isn't critically, immediately ill. But the practice I see is vastly different, where anyone who is even remotely ill or actively wheezing is given IV steroids. So is my understanding correct, or am I, in this like so many other subjects, just horribly misinformed. What's everyone's practice on this?

 

[WilcoWorld]

Not only are PO steroids just as effective, they don't have to be dosed as often (solumedrol is a q6 hour med for asthma/COPD). I only give IV steroids if the patient is puking, needs BiPAP or CPAP (so I don't have to take off the mask) or if there's decreased splanchnic circulation (shock or a lot of vasoconstriction).

So yeah, you're right.

 

[pratik7]

In general if patients are being admitted, i think people are more likely to give IV steroids. It helps "justify" the admission. Similar situation with antibiotics. Clinically does it matter..prob not.

 

[deleted109597]

In general if patients are being admitted, i think people are more likely to give IV steroids. It helps "justify" the admission. Similar situation with antibiotics. Clinically does it matter..prob not.

I disagree. If people are being admitted, they get IV steroids because people don't know any better.
The only reason I give IV steroids in the ED is because pharmacy doesn't see fit to put PO decadron in the pyxis. And the hospital won't let our nurses give IV decadron PO, since we have the PO formulation in the hospital. And if they don't have an IV, they get it IM. It's annoying, but there are other battles to fight.

To the OP, a lot of this comes from EMS only having solumedrol on the truck, and since the patient started with that, they keep getting it. Inertia is hard to break in medicine.

 

[Mighty Mouse]

At my first attending job -- IV solumedrol met admission criteria and PO prednisone did not. A lot of times that was the only reason I would give solumedrol -- to play the game.

 

[Cerberus]

Does anyone know the length of time to onset in PO vs IV formulation? I usually give IV to acute COPD'ers just assuming that the onset of action will be shorter than for PO (although I don't know this to actually be true).

 

[deleted109597]

At my first attending job -- IV solumedrol met admission criteria and PO prednisone did not. A lot of times that was the only reason I would give solumedrol -- to play the game.

So you're telling me that if you gave them pred, had them on an hour of nebs, couldn't get their SpO2 above 89% on room air, you couldn't admit them? Not until you gave them a dose of solumedrol?

My answer to that is the same as it is to all asinine rules I get from nursing/admin. And that's "let me see it in writing."

 

[pratik7]

My shop was the same way. They would get denied payment for an admission if PO steroids were given. If they are hypoxic they meet criteria. But if its is a old person with "I feel SOB" ,some wheezing and vitals and labs are ok, they will not meet criteria for admission. It is stupid but if I have to give IV steroids to get the patient admitted....ill do it

 

[docB]

So you're telling me that if you gave them pred, had them on an hour of nebs, couldn't get their SpO2 above 89% on room air, you couldn't admit them? Not until you gave them a dose of solumedrol?

My answer to that is the same as it is to all asinine rules I get from nursing/admin. And that's "let me see it in writing."

It doesn't really exist in writing but it is real. The whole "criteria for admission" concept is just a way for insurers (CMS and privates) to avoid paying for stuff. Most hospitals use either Interquall or Milliman as guidelines but even those are not recognized by CMS, they are just the products of their respective consulting groups best guesses as to what will be paid rather than denied on any given admission.

 

[deleted109597]

It doesn't really exist in writing but it is real. The whole "criteria for admission" concept is just a way for insurers (CMS and privates) to avoid paying for stuff. Most hospitals use either Interquall or Milliman as guidelines but even those are not recognized by CMS, they are just the products of their respective consulting groups best guesses as to what will be paid rather than denied on any given admission.

I don't disagree. I have often had to look up Milliman to convince our annoying hospitalists to admit people. And this isn't one of those things. The pulse ox criterion is one though.