Oral steroids risky

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lobelsteve

lobelsteve

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Do not Rx oral steroids for back pain.
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Its easier to make the case of an oral steroid taper for radiculopathy while waiting for MRI/procedure approval if in severe pain even though it doesn't work really. Its far harder to justify oral steroid taper for an axial back pain.
 
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pmrmd said:
Its easier to make the case of an oral steroid taper for radiculopathy while waiting for MRI/procedure approval if in severe pain even though it doesn't work really. Its far harder to justify oral steroid taper for an axial back pain.
Click to expand...

EVEN THOUGH IT DOESN’T WORK
 
We have a PA who keeps giving Medrol PO for axial LBP and it drives me crazy bc I follow the "cortisone" closely. I document all the shots they've taken, whether it is me or someone else in our group giving them. No one else does that, bc NO ONE ELSE reads anyone's notes (I do).

If I have a radic that is on fire I'd appreciate some prednisone yall. It may not work, but it often does for a few days and I'd appreciate that.
 
Support:
.
(600mg total prednisone- improved function but not pain) From the author: Dr. Goldberg said he was surprised that oral prednisone did not significant improve pain levels over placebo. “It was my clinical impression that steroids were helpful in these patients, which is why we conducted the trial,” he said. “This demonstrates the value of well-conducted trials. Patients were getting better, just no different from those that received placebo,” Dr. Goldberg said.

Does not support:

The article above.

and

pubmed.ncbi.nlm.nih.gov

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians - PubMed

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Low-quality evidence showed no difference in pain or function between a single intramuscular injection of methylprednisolone or a 5-day course of prednisolone compared with placebo in patients with acute low back pain (24, 25).
 
That's fine, but I've seen ppl with HNP transiently improve with oral steroids, and so have you.
 
You've never given a Medrol dose pack for an acute radic? I don’t do it often but an acute radic and I'm trying to get them in for a shot i have given 3-5 days of PO steroid. I won't for gross PMH pts.
 
Toradol is now harmless?
 
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Eek. I use medrol for acute radics. I’m so booked in asc that from order to shot it’s typically 3-4 weeks and I hate waiting that long w patient in ton of pain.
 
paindoc007 said:
Eek. I use medrol for acute radics. I’m so booked in asc that from order to shot it’s typically 3-4 weeks and I hate waiting that long w patient in ton of pain.
Click to expand...

I do it maybe once a month at most. There's no issue with it if the pt has a somewhat normal PMH, and it works occasionally.

If my leg is on fire I know I want it.

I fail to see anything worthwhile in 15mg of Toradol on a hot radiculitis. I use that too - 30mg though (our vials are 60mg so I use half) and it occasionally works for me.
 
SommeRiver said:
I do it maybe once a month at most. There's no issue with it if the pt has a somewhat normal PMH, and it works occasionally.

If my leg is on fire I know I want it.

I fail to see anything worthwhile in 15mg of Toradol on a hot radiculitis. I use that too - 30mg though (our vials are 60mg so I use half) and it occasionally works for me.
Click to expand...

never given an in office IM injection before. Is that something you bill for? Or just a normal office visit like 99213 or whatever
 
I bill an IM Toradol shot as TPI x 1, then bill for the Toradol or whatever, but make no mistake - I really don't see a ton of benefit from IM Toradol 30mg.

In my 3 yrs of private practice (a lot less than many of you, but I'm busy AF and I think I've done enough to discuss this) I have seen more benefit from Medrol PO or prednisone for the acute radic.

Toradol simply doesn't treat neurogenic pain in my experience. If you're having coinciding muscle spasm, which many do of course, maybe it would help that perhaps?

Maybe you're just misdiagnosing a lumbar strain bc the pt has leg pain too...I don't know.
 
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I’m on the only one here that would just give the patient a shot when they come in with their leg on fire. Waiting 3 to 4 weeks to get into the ASC, would love for my competition to be like that. We’d take their business every day of the week. I never give oral steroids, like Steve said, and all the studies… It doesn’t work. Give them a shot and move on. We do 3 to 4 a week for free, or very cheap, for this exact reason. Don’t make them wait on insurance auth, tell them $150 cash and get them feeling better. They’ll pay you back with all the referrals they send because you truly helped them.
 
gdub25 said:
I’m on the only one here that would just give the patient a shot when they come in with their leg on fire. Waiting 3 to 4 weeks to get into the ASC, would love for my competition to be like that. We’d take their business every day of the week. I never give oral steroids, like Steve said, and all the studies… It doesn’t work. Give them a shot and move on. We do 3 to 4 a week for free, or very cheap, for this exact reason. Don’t make them wait on insurance auth, tell them $150 cash and get them feeling better. They’ll pay you back with all the referrals they send because you truly helped them.
Click to expand...

I am not set up for this.
 
gdub25 said:
Haha, from the guy roasting me for being the million dollar baller...here you are outsmarting me in business by billing the IM toradol as a TPI.

Smart idea.
Click to expand...

Never once did I say or hint at anything like that.

I said REPEATEDLY I am looking to learn how my care differs from someone like yourself.

Tell me how you bill the Toradol injxn? Seriously...For the one I do per month, how do I bill it and make some SIGNIFICANTLY bigger sum of money?
 
gdub25 said:
I’m on the only one here that would just give the patient a shot when they come in with their leg on fire. Waiting 3 to 4 weeks to get into the ASC, would love for my competition to be like that. We’d take their business every day of the week. I never give oral steroids, like Steve said, and all the studies… It doesn’t work. Give them a shot and move on. We do 3 to 4 a week for free, or very cheap, for this exact reason. Don’t make them wait on insurance auth, tell them $150 cash and get them feeling better. They’ll pay you back with all the referrals they send because you truly helped them.
Click to expand...

No real competition where I am. It’s my way or the high way.. I’d aware I’d def have to adjust Living in a different area
 
paindoc007 said:
No real competition where I am. It’s my way or the high way.. I’d aware I’d def have to adjust Living in a different area
Click to expand...

Me too...

BTW - My wait for an ASC or clinic procedure in a hot radic is less than a week. So Medrol DP for a few days takes the edge off, which is all it is supposed to do...
 
My wait time for asc is dependent on NIA/evil-core “auth.” Followed by “peer”to peer where we wait for an hour, talk to a nurse who approves it then we get the denial.
 
SommeRiver said:
Me too...

BTW - My wait for an ASC or clinic procedure in a hot radic is less than a week. So Medrol DP for a few days takes the edge off, which is all it is supposed to do...
Click to expand...

But often people are complaining, and I don’t even have an mri. Some PP folks may be ok with epidural without mri but I get anxious medical-legally. So I’ll give po medrol, order mri, f/u in 2-3 weeks with mri followup review, and if po steroids don’t touch it, then we can inject.
 
Posts like this are very useful to all of us. Especially those in the first few years after fellowship. I have definitely changed my practice, my stupid billing or stupid practice habits based off of posts like these over the years.

Now let’s find a way to turn this into a pissing contest or start inserting our ridiculous politic opinions.
 
SommeRiver said:
Never once did I say or hint at anything like that.

I said REPEATEDLY I am looking to learn how my care differs from someone like yourself.

Tell me how you bill the Toradol injxn? Seriously...For the one I do per month, how do I bill it and make some SIGNIFICANTLY bigger sum of money?
Click to expand...

I think the context of what I said was lost due to this being an online text rather than in person conversation. What I was saying is I do toradol injections very rarely, maybe a few a month, and don’t get paid on most since insurance rarely reimburses very much if anything. Billing for a TPI is a smart idea although could be criticized as not the absolute correct use of the TPI code and could open you up to scrutiny.
 
gdub25 said:
I think the context of what I said was lost due to this being an online text rather than in person conversation. What I was saying is I do toradol injections very rarely, maybe a few a month, and don’t get paid on most since insurance rarely reimburses very much if anything. Billing for a TPI is a smart idea although could be criticized as not the absolute correct use of the TPI code and could open you up to scrutiny.
Click to expand...

Cool...

I do maybe one a month, truthfully probably 2 per Q, and when I do it I generally mix something like ropi 0.5% 1cc. Go into the paraspinals once, buttock once.

Speaking of Toradol - We had a pt a few weeks ago come in from Florida. Her ortho surgeon retired. He was giving her 60mg Toradol into the knee. I've never heard of that.

In fellowship, every stellate or lumbar sympathetic contained Toradol 15mg.

So weird.
 
Yo GabbaPentin said:
My wait time for asc is dependent on NIA/evil-core “auth.” Followed by “peer”to peer where we wait for an hour, talk to a nurse who approves it then we get the denial.
Click to expand...

Evicore failed to contact me twice last week.
 
I do TPI with toradol or dexa when appropriate. Learned that on here several years ago. There is some data that shows it to be more beneficial than saline or lido alone but there is also data that says the opposite.

I give 30mg toradol/80mg Depo/50mg lidocaine divided between the paraspinals in the “my back is out” patient if it is really severe. Works well.

I prescribed a medrol dose pack to a lady with lateral epicondylitis and patellar tendinitis yesterday. I injected with lidocaine the visit before which worked well until she did a ropes course ‍
🤔
 
So this thread echoes what many of us practice. Anecdotal medicine...

speaking of that. I gave a 35 yo healthy patient 15mg of toradol for a d and c once. Developed ARF requiring dialysis. ...
 
Ronin1 said:
So this thread echoes what many of us practice. Anecdotal medicine...

speaking of that. I gave a 35 yo healthy patient 15mg of toradol for a d and c once. Developed ARF requiring dialysis. ...
Click to expand...

Thank God you didn't give her 4 days of PO corticosteroid.
 
Ronin1 said:
So this thread echoes what many of us practice. Anecdotal medicine...

speaking of that. I gave a 35 yo healthy patient 15mg of toradol for a d and c once. Developed ARF requiring dialysis. ...
Click to expand...


pubmed.ncbi.nlm.nih.gov

Ketorolac-induced acute renal failure and hyperkalemia: report of three cases - PubMed

Ketorolac tromethamine (Toradol, Syntex Laboratories Inc, Palo Alto, CA) is a new nonsteroidal anti-inflammatory drug widely used in emergency departments and during the postoperative period because of its potent analgesic effects and lack of central nervous system activities. We present three...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


I bet anaphylaxis is more likely.

I posted to draw people out and say what they do. Nothing wrong with po steroids. They just do not have good support in literature.

My nurses do the IM shots. No rvu
 
lobelsteve said:
pubmed.ncbi.nlm.nih.gov

Ketorolac-induced acute renal failure and hyperkalemia: report of three cases - PubMed

Ketorolac tromethamine (Toradol, Syntex Laboratories Inc, Palo Alto, CA) is a new nonsteroidal anti-inflammatory drug widely used in emergency departments and during the postoperative period because of its potent analgesic effects and lack of central nervous system activities. We present three...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


I bet anaphylaxis is more likely.

I posted to draw people out and say what they do. Nothing wrong with po steroids. They just do not have good support in literature.

My nurses do the IM shots. No rvu
Click to expand...
Not anaphylaxis. Normal OR and PACU Course. Didn’t give another dose for years. Yet another example of anecdotal practice
 
Truly mean this...I do not think that pain is a field that traditional research will support given the fact pain is an emotional experience and at any point in time there are 50 things that can hurt once we're 60 and lit up with "ahth-ur-i-tis."

Obviously, there isn't another way to do it, but research in pain will never approach insulin performance, antimicrobials, etc...

It really is sort of laughable to say a pain doctor isn't practicing evidence based care...There really isn't much evidence for anything we do, and we all frequently do things based off anecdotes...

Look at SCS device selection FFS. Give me a break.

Dogma presides of the practice of pain.
 
I only give po steroids when i cant get them for a shot quickly for one reason or another. Never for axial pain. This happens maybe once every other month, if that
 
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Giving a single shot of 15mg of toradol and developing ARF has got to be extremely rare, likely other contributors
 
paindoc007 said:
never given an in office IM injection before. Is that something you bill for? Or just a normal office visit like 99213 or whatever
Click to expand...
SommeRiver said:
I bill an IM Toradol shot as TPI x 1, then bill for the Toradol or whatever, but make no mistake - I really don't see a ton of benefit from IM Toradol 30mg.
Click to expand...
Pretty sure that's not appropriate and is considered upcoding.
The correct way to bill a toradol injection would be 96372 and J1885(for every 15mg)
99213 is for an office visit, not an injection. If you do the injection same day as a visit, use the 25 modifier on your 99213/4.

SommeRiver said:
Cool...

I do maybe one a month, truthfully probably 2 per Q, and when I do it I generally mix something like ropi 0.5% 1cc. Go into the paraspinals once, buttock once.

Speaking of Toradol - We had a pt a few weeks ago come in from Florida. Her ortho surgeon retired. He was giving her 60mg Toradol into the knee. I've never heard of that.

In fellowship, every stellate or lumbar sympathetic contained Toradol 15mg.

So weird.
Click to expand...
Ortho often gives toradol (and a bunch of other random stuff) in knees. Local doc near me gives a little local and steroid with every visco shot. In the OR after knee surgery, I know of a surgeon who injects a magic mixture of Sufentanil, toradol, bupivicaine, and steroid. :shrug:
 
lobelsteve said:
Do not Rx oral steroids for back pain.
Click to expand...

Agreed. Unfortunately, I am on low dose chronic steroids for an entirely different medical problem myself. However, one periodically sees patients placed on steroids for back/neck pain from PCPs. I still use a burst and taper if one has a severe neuritis after an rf, but that is about it.

I think that roids do have a place in cancer pain management, albeit a small one. With the advent of the biologics, we see far fewer patients with rheumatological conditions on roids.
 
I have a medical issue with my spine disk for a long time, need surgery but maybe later, now trying to improve my state with rehabilitation fitness and some health supplements plus better nutrition with more protein, also I am about to start epidural steroid injections therapy so I am interested about steroids influence, I still think what is better to choose as a therapy because I`ve heard all good about using USA peptides (a short course of injections) like it is good for whole the body recover especially for the articular cartilages because there like small protein bits in it
 
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I've been told stem cells are helpful.
 
gdub25 said:
Haha, from the guy roasting me for being the million dollar baller...here you are outsmarting me in business by billing the IM toradol as a TPI.

Smart idea.
Click to expand...
Just split the dose in the bilateral deltoids and call it a 20553 while we’re at it
 
I’ll offer a pulse of oral steroids for acute radiculopathy, definitely doesn’t cure anything but people for sure get some relief, very modest, pain will often come right back after stopping.

Somtimes I’ll see patient that have done two courses of oral roids before seeing the pain clinic. It’s unfortunate, but sometimes hard to get into a pain clinic around my area.
 
You guys that are arguing for giving oral steroids because you think it works should prove it.
Because as posted above, there was a guy that thought it worked (just like all of you), and he tried to prove it, and found out it did ABSOLUTELY NOTHING. Is he wrong? Maybe. To those who think he is wrong, prove it.
 
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