1 00:00:00,000 --> 00:00:05,010 Evan: I've definitely seen lawsuits that came up due to fat atrophy. 2 00:00:05,190 --> 00:00:08,760 Again, that's a permanent dimpling of the skin, which can be 3 00:00:09,180 --> 00:00:11,250 rather disfiguring for patients. 4 00:00:13,503 --> 00:00:16,273 Sam: Hi everyone, and welcome to another episode of EMPlify. 5 00:00:16,273 --> 00:00:17,793 I'm your host, Sam Ashoo. 6 00:00:18,053 --> 00:00:21,793 Before we dive into this episode, I want to say thank you for joining us. 7 00:00:21,843 --> 00:00:25,383 I sincerely hope that you find it to be helpful and informative for your 8 00:00:25,383 --> 00:00:29,813 clinical practice, and I want to remind you that you can go to ebmedicine.net 9 00:00:29,883 --> 00:00:34,033 where you will find our three journals, Emergency Medicine Practice, Pediatric 10 00:00:34,043 --> 00:00:39,193 Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of 11 00:00:39,213 --> 00:00:43,563 other resources, like the EKG course, the laceration course, interactive 12 00:00:43,563 --> 00:00:48,003 clinical pathways, just tons of information to support your practice 13 00:00:48,143 --> 00:00:49,753 and help you in your patient care. 14 00:00:50,023 --> 00:00:52,213 And now, let's jump into this month's episode. 15 00:00:53,186 --> 00:00:54,606 Evan: My name is Evan Dvorin. 16 00:00:54,626 --> 00:01:00,876 I'm a physician MD. I work at Ochsner Health, Ochsner Medical 17 00:01:00,876 --> 00:01:07,340 Center in New Orleans, and I'm at our main primary care clinic 18 00:01:07,985 --> 00:01:09,575 . Sam: Thanks for being on the podcast. 19 00:01:09,575 --> 00:01:16,565 You have a special interest in steroid use, which is why you graciously 20 00:01:16,565 --> 00:01:18,155 agreed to be on the podcast today. 21 00:01:18,155 --> 00:01:21,275 What brought that about or how did you fall into that special interest? 22 00:01:22,210 --> 00:01:25,995 Evan: So, I trained and first worked in New England. 23 00:01:26,058 --> 00:01:28,518 I went to medical school at Dartmouth Medical School. 24 00:01:29,218 --> 00:01:34,278 And then had my residency at Brigham and Women's Hospital in Boston. 25 00:01:34,758 --> 00:01:39,378 And after that I worked nearby in Boston at Mass General Hospital. 26 00:01:39,728 --> 00:01:45,718 While working there, I, and in my education prior, I really hadn't 27 00:01:45,718 --> 00:01:50,668 ever heard of using corticosteroids, also known as steroids, for 28 00:01:50,728 --> 00:01:53,608 sinus infections or bronchitis. 29 00:01:53,658 --> 00:01:58,068 I'm well aware of the role for things like asthma, if someone has a flare of 30 00:01:58,068 --> 00:02:02,828 asthma or chronic obstructive pulmonary disease, but haven't heard of it for 31 00:02:02,828 --> 00:02:07,758 these other, more run of the mill, like common cold type of situations. 32 00:02:08,208 --> 00:02:13,858 And then in 2012 my family, we relocated in New Orleans where I am now. 33 00:02:14,098 --> 00:02:16,348 And I've been at the same clinic ever since. 34 00:02:16,738 --> 00:02:21,168 And corticosteroids are frequently used for these diagnoses that 35 00:02:21,168 --> 00:02:25,648 I just mentioned, like sinus infection, a bad cold, bronchitis. 36 00:02:26,053 --> 00:02:29,863 And so it was something that, you know the phrase if you see 37 00:02:29,863 --> 00:02:33,770 something, say something, or I saw something and I was taken aback. 38 00:02:33,770 --> 00:02:39,280 I was surprised when patients asked me for a steroid injection or a 39 00:02:39,280 --> 00:02:42,910 Medrol dose pack, something I, I just would never have thought of. 40 00:02:43,610 --> 00:02:46,664 And so that's when this interest came alive for me 41 00:02:47,541 --> 00:02:48,141 . Sam: Excellent. 42 00:02:48,231 --> 00:02:53,161 And now you have become sort of the, the steroid educator for your 43 00:02:53,161 --> 00:02:54,721 practice and your system there. 44 00:02:54,721 --> 00:02:54,856 Is that right? 45 00:02:55,556 --> 00:02:55,916 Evan: Yes. 46 00:02:55,916 --> 00:02:57,176 Yeah, we could say that. 47 00:02:57,206 --> 00:03:01,796 So I've worked with a few medical students, some residents over the 48 00:03:01,796 --> 00:03:10,116 years and also the Ochsner Urgent Care department has taken on this campaign of 49 00:03:10,116 --> 00:03:12,876 decreasing inappropriate corticosteroids. 50 00:03:12,876 --> 00:03:18,566 So, it's something that I've definitely educated people in my system about. 51 00:03:18,876 --> 00:03:27,481 Also I've worked on some research studies on this topic, and we've created a video 52 00:03:27,751 --> 00:03:32,234 and I've had an interview with the New York Times, so it's kind of something I, 53 00:03:32,234 --> 00:03:37,225 I've really have taken a big interest in and wanted to spread the word that this 54 00:03:37,225 --> 00:03:39,085 is something that's happening frequently. 55 00:03:39,435 --> 00:03:44,002 I do wanna take a brief moment just to say that I first learned about it 56 00:03:44,062 --> 00:03:49,202 here in the South and in my research we found that this is really common in 57 00:03:49,202 --> 00:03:53,582 the Southeast in particular, but it's actually throughout the United States. 58 00:03:53,582 --> 00:03:58,162 I guess just in the little area I was practicing in, in Boston, it 59 00:03:58,162 --> 00:04:01,073 wasn't common, but it's become more common throughout the United States. 60 00:04:01,773 --> 00:04:02,213 Sam: Great. 61 00:04:02,283 --> 00:04:06,500 And now the audience who listens to our podcast is primarily emergency 62 00:04:06,500 --> 00:04:11,270 medicine, but you know, EB Medicine also has an entire collection of urgent 63 00:04:11,275 --> 00:04:15,640 care journals and products and courses and a separate podcast there as well. 64 00:04:15,640 --> 00:04:17,600 So we tend to mix audiences. 65 00:04:17,600 --> 00:04:21,570 If you're listening and you work in an emergency medicine environment, 66 00:04:21,570 --> 00:04:24,930 or if you work in the urgent care environment, all of this is going 67 00:04:24,930 --> 00:04:26,190 to sound very familiar to you. 68 00:04:26,190 --> 00:04:28,560 I don't think this is unique to primary care. 69 00:04:28,840 --> 00:04:31,150 Is that something you've encountered in your research as well? 70 00:04:31,150 --> 00:04:33,880 Kinda the, the similar diagnoses being treated with 71 00:04:33,880 --> 00:04:35,440 steroids regardless of setting. 72 00:04:36,140 --> 00:04:36,630 Evan: Yes. 73 00:04:36,660 --> 00:04:37,080 Yeah. 74 00:04:37,140 --> 00:04:37,410 Yeah. 75 00:04:37,410 --> 00:04:41,040 This has been the case in urgent care settings, primary care, 76 00:04:41,040 --> 00:04:42,544 and in the emergency room. 77 00:04:43,074 --> 00:04:47,112 I think those three venues are the most common where inappropriate 78 00:04:47,112 --> 00:04:48,885 corticosteroids are used. 79 00:04:48,885 --> 00:04:54,235 And we recently started actually looking specifically into emergency 80 00:04:54,285 --> 00:04:58,025 department use and we find a high rate of inappropriate use. 81 00:04:58,210 --> 00:04:58,434 Sam: Great. 82 00:04:58,434 --> 00:05:03,715 And now tell me, when we talk about the use of corticosteroids for conditions 83 00:05:03,715 --> 00:05:07,825 where it may not be appropriate to prescribe them, would the data that 84 00:05:07,825 --> 00:05:13,158 you've collected for the last, you know, decade or so, shows that this 85 00:05:13,158 --> 00:05:18,678 prescribing trend is increasing or has just been alarmingly high the entire time? 86 00:05:19,428 --> 00:05:22,248 , Evan: It has been steadily increasing actually. 87 00:05:22,548 --> 00:05:26,028 We don't really have a clear explanation for that. 88 00:05:26,108 --> 00:05:29,848 I mean, I have some ideas but it has been steadily increasing 89 00:05:29,848 --> 00:05:30,778 throughout the country. 90 00:05:31,038 --> 00:05:35,988 Sam: And when we're looking at the conditions that they are prescribed for, 91 00:05:35,988 --> 00:05:39,918 you mentioned some of them already, things like sinus infections and, you know, 92 00:05:39,918 --> 00:05:45,528 URIs, are there other diagnoses that tend to be the high frequency diagnoses? 93 00:05:46,228 --> 00:05:46,948 Evan: Yes. 94 00:05:47,028 --> 00:05:56,328 So outside of just the URI world, sciatica or acute back pain, or rash. 95 00:05:56,373 --> 00:06:00,333 These are some other good examples where it's inappropriately prescribed. 96 00:06:00,593 --> 00:06:01,433 Shingles. 97 00:06:01,433 --> 00:06:04,973 It hasn't been shown that steroids are very effective. 98 00:06:05,643 --> 00:06:08,906 Pharyngitis, I guess that's more in the URI type of world. 99 00:06:09,520 --> 00:06:14,840 Oftentimes a podiatrist, not to poke at the podiatrist, but oftentimes they'll 100 00:06:14,900 --> 00:06:19,700 give steroids where it hasn't been shown that it's effective for plantar fasciitis. 101 00:06:19,920 --> 00:06:24,535 So a lot of musculoskeletal areas, it's been used inappropriately as well. 102 00:06:25,235 --> 00:06:29,135 Sam: So, in 20 years of clinical practice, I will say that I found a 103 00:06:29,135 --> 00:06:31,235 similar trend in my own prescribing. 104 00:06:31,425 --> 00:06:34,595 And I don't really have a good reason to attribute to that. 105 00:06:34,595 --> 00:06:37,595 I think when I was in residency training, we spent the bulk of our 106 00:06:37,595 --> 00:06:44,020 time treating the higher risk diseases, and we had a fast track, and our 107 00:06:44,020 --> 00:06:48,010 fast track was actually staffed by an attending physician and a PA. 108 00:06:48,200 --> 00:06:53,920 And so we were rarely exposed to higher volumes of the minor care cases. 109 00:06:54,170 --> 00:06:58,030 But as soon as I graduated and we started working in a busy urban 110 00:06:58,060 --> 00:07:01,500 emergency department, all of a sudden that was, you know, something like a 111 00:07:01,500 --> 00:07:05,660 half of the cases that I was seeing were not necessarily true emergencies, 112 00:07:05,870 --> 00:07:09,350 but I think the notion for me was well. 113 00:07:10,050 --> 00:07:13,410 You know, I've got a patient who's sitting in front of me who is here 114 00:07:13,410 --> 00:07:18,970 for a condition that they are either seeking maybe an antibiotic for, and I'm 115 00:07:18,970 --> 00:07:20,440 gonna tell them that's not appropriate. 116 00:07:20,800 --> 00:07:22,390 And that was a whole nother conversation. 117 00:07:22,530 --> 00:07:25,470 But then also maybe they have some symptoms and I'm just trying to say, 118 00:07:25,470 --> 00:07:29,310 well, you know, I can't really solve your problem, but maybe I can do 119 00:07:29,310 --> 00:07:31,290 something to alleviate your symptoms. 120 00:07:31,480 --> 00:07:35,495 And the notion kinda came up of, well this seems like a pretty benign thing to do. 121 00:07:35,495 --> 00:07:39,005 I mean, what is the harm of a short course of steroids? 122 00:07:39,065 --> 00:07:42,220 But that is not the case according to your research. 123 00:07:42,220 --> 00:07:42,500 Right? 124 00:07:43,200 --> 00:07:43,650 Evan: Right. 125 00:07:43,650 --> 00:07:44,340 Well, yeah. 126 00:07:44,340 --> 00:07:47,660 Actually not, not my research, but other people's research and 127 00:07:47,710 --> 00:07:49,150 I'd like to share that with you. 128 00:07:49,200 --> 00:07:52,120 So that was also in my education. 129 00:07:52,820 --> 00:07:56,250 The concern was about chronic steroids, just like you're saying. 130 00:07:56,250 --> 00:08:02,900 So, people becoming a cushingoid from being on steroids for months or years. 131 00:08:02,900 --> 00:08:06,140 The weight gain, the immunosuppression. 132 00:08:06,430 --> 00:08:10,420 I think we can all kind of imagine what all that we've learned about 133 00:08:10,420 --> 00:08:12,940 the side effects of chronic steroids. 134 00:08:13,360 --> 00:08:17,890 And it turns out that a lot of those side effects, and again, this isn't my 135 00:08:17,890 --> 00:08:19,630 research, but I'll just share it with you. 136 00:08:20,330 --> 00:08:26,000 A lot of those similar side effects can also be seen for short-term steroid use. 137 00:08:26,361 --> 00:08:31,461 In short term steroid use your body is not really gonna get adrenally insufficient, 138 00:08:31,461 --> 00:08:38,871 so not that one, but short term use can increase someone's risk for infection 139 00:08:38,871 --> 00:08:41,481 for sepsis in the next one to two months. 140 00:08:41,931 --> 00:08:44,811 Can increase risk for bone fractures. 141 00:08:44,811 --> 00:08:47,096 Again, I'm just saying in the next one to two months. 142 00:08:47,796 --> 00:08:53,536 And thrombo embolism also an increased risk, again, in the short term, just 143 00:08:53,536 --> 00:08:57,916 in the next one to two months after receipt of a short-term steroid use. 144 00:08:58,486 --> 00:09:03,216 And the most common side effects from, again, short-term steroid use. 145 00:09:03,216 --> 00:09:07,806 We're talking about a steroid injection, a Medrol dose pack. 146 00:09:08,106 --> 00:09:11,841 The most common side effects are psychiatric side effects, 147 00:09:11,941 --> 00:09:14,861 loss of sleep, anxiety. 148 00:09:15,231 --> 00:09:19,721 Some people who already have psychiatric problems or a severe 149 00:09:19,721 --> 00:09:25,395 depression, steroids can really tip their symptoms into a severe situation. 150 00:09:25,995 --> 00:09:28,905 Sam: And when we talk about short term use, we're talking about 151 00:09:28,905 --> 00:09:32,145 things like, you know, five to seven day courses of prescribing here. 152 00:09:32,845 --> 00:09:33,505 Evan: Exactly. 153 00:09:33,555 --> 00:09:37,185 Sam: So all of those things can still occur even in the one 154 00:09:37,185 --> 00:09:40,470 week course of a prescription for, you know, your typical URI. 155 00:09:41,170 --> 00:09:41,590 Evan: Right. 156 00:09:41,590 --> 00:09:42,070 Yeah. 157 00:09:42,070 --> 00:09:46,010 So one thing that I've looked up and seen in the published literature 158 00:09:46,340 --> 00:09:51,500 is that there's a dose response curve too, that the higher someone's 159 00:09:51,500 --> 00:09:56,120 short-term steroid use, the higher chance of those side effects. 160 00:09:56,445 --> 00:09:57,615 So, that's the case. 161 00:09:57,705 --> 00:10:02,575 But also it does look like after two months, most of these short-term side 162 00:10:02,575 --> 00:10:04,675 effects , will attenuate and go away. 163 00:10:04,945 --> 00:10:07,965 I say most except for the bones. 164 00:10:08,005 --> 00:10:13,465 So repeated short-term use over somebody's lifetime will 165 00:10:13,465 --> 00:10:15,685 have an impact on bone density. 166 00:10:15,925 --> 00:10:20,081 Can increase the risk for avascular necrosis. 167 00:10:20,511 --> 00:10:22,651 But most of the side effects are gonna go away. 168 00:10:22,966 --> 00:10:25,186 Sam: Now you mentioned a timeframe of two months. 169 00:10:25,186 --> 00:10:29,796 That's the typical period for how long it takes for the side effects 170 00:10:29,826 --> 00:10:32,381 of the short-term prescribing of steroids to kind of go away. 171 00:10:32,761 --> 00:10:33,781 Evan: That is what it looks like. 172 00:10:33,781 --> 00:10:34,021 Yeah. 173 00:10:34,265 --> 00:10:41,235 One study was published in 2016 showing increased risk of infection. 174 00:10:41,455 --> 00:10:47,885 In 2017, a British medical journal that was a study that showed increased risk for 175 00:10:47,885 --> 00:10:54,188 the venous thromboembolism, fracture, and sepsis over the one to two month period 176 00:10:54,263 --> 00:10:56,893 Sam: Yeah, and that one particularly surprises me 'cause I don't really 177 00:10:56,893 --> 00:11:02,478 think about severe immunosuppression from a few days of steroid use. 178 00:11:02,608 --> 00:11:06,025 Especially lingering for two months, so tell me more about that one. 179 00:11:06,725 --> 00:11:11,708 Evan: Yeah, I've actually seen this with several patients where, let's use the 180 00:11:11,708 --> 00:11:17,263 sinusitis example, and that's where I've seen it a few times, where someone was 181 00:11:17,263 --> 00:11:23,400 given a steroid injection or a Medrol dose pack and a Z-pack azithromycin 182 00:11:23,740 --> 00:11:29,440 for sinusitis and in a lot of those situations, the patient's symptoms got 183 00:11:29,440 --> 00:11:36,093 much worse and they may have developed actually fevers and worsened sinus 184 00:11:36,093 --> 00:11:41,976 discharge, so that's something anecdotally I've seen I'm not sure I'd use the term 185 00:11:41,976 --> 00:11:48,763 immunocompromise, but there is definitely some sort of hit to the immune system 186 00:11:48,763 --> 00:11:53,313 just with a short term steroid, which makes sense, just about how steroids work. 187 00:11:53,363 --> 00:12:00,638 And so you could imagine if someone has a lingering bacterial sinusitis and if 188 00:12:00,638 --> 00:12:06,845 it's not treated with azithromycin since most of the bacteria will be resistant 189 00:12:06,845 --> 00:12:12,815 to that, and at the same time they're given a steroid, that definitely increases 190 00:12:12,815 --> 00:12:16,918 the odds that that bacteria is gonna win the short term battle, at least. 191 00:12:17,128 --> 00:12:19,768 Sam: And now you mentioned sepsis as well. 192 00:12:19,798 --> 00:12:22,678 So when we talk about sepsis, we think of, you know, those people who 193 00:12:22,678 --> 00:12:25,348 end up in the emergency department and end up being hospitalized. 194 00:12:25,448 --> 00:12:29,968 Was there a significant trend in the risk there for sepsis 195 00:12:30,148 --> 00:12:31,468 after short term steroids? 196 00:12:32,168 --> 00:12:32,498 Evan: Yeah. 197 00:12:32,498 --> 00:12:36,398 So, that study in the British Medical Journal, a group from 198 00:12:36,398 --> 00:12:39,685 Michigan led that study and they used a retrospective analysis, 199 00:12:41,778 --> 00:12:48,168 so looking at all comers, with the Optum database of just millions 200 00:12:48,168 --> 00:12:50,358 of people and prescribing. 201 00:12:50,588 --> 00:12:56,028 And with that database were able to look at people's underlying diagnoses 202 00:12:56,028 --> 00:13:00,335 and when they'd received steroids and not, and the researchers, they 203 00:13:00,335 --> 00:13:05,975 did as good of a job as they could to try to get rid of any confounders. 204 00:13:06,275 --> 00:13:12,955 And after correcting for the same amount of patients with autoimmune disease 205 00:13:12,955 --> 00:13:17,265 or, they actually excluded cancer patients, they were able to see that 206 00:13:17,265 --> 00:13:19,125 there was an increased risk of sepsis. 207 00:13:19,155 --> 00:13:21,059 It wasn't a high number. 208 00:13:21,259 --> 00:13:25,079 We're talking about out of thousands of patients, there were maybe a, I 209 00:13:25,079 --> 00:13:29,794 don't know the exact number, but, there definitely was a statistically significant 210 00:13:29,794 --> 00:13:34,504 difference in those that developed sepsis who were exposed to corticosteroids 211 00:13:34,504 --> 00:13:35,479 versus those that were not. 212 00:13:35,634 --> 00:13:35,814 Sam: Hmm. 213 00:13:36,324 --> 00:13:40,684 And was there a trend or were they able to find a trend that correlated 214 00:13:40,684 --> 00:13:45,104 with like past medical history or other confounding illnesses? 215 00:13:45,104 --> 00:13:47,954 Or is it just all comers who had a short course of steroids? 216 00:13:48,354 --> 00:13:52,034 Evan: Yeah, I'm not an expert enough in the biostats part, but they were 217 00:13:52,034 --> 00:13:57,404 able to correct for underlying health issues, and after correcting for that, 218 00:13:57,614 --> 00:14:02,294 which is not perfect in a retrospective analysis, but after correcting for 219 00:14:02,294 --> 00:14:06,634 that, they did have a statistically significant increased risk of sepsis. 220 00:14:06,634 --> 00:14:12,074 So I think of things like sepsis as if I'm going to give patient a 221 00:14:12,074 --> 00:14:17,780 short term steroid, there's not a large risk but you could be putting 222 00:14:17,780 --> 00:14:21,410 someone to some degree in harm's way. 223 00:14:21,967 --> 00:14:25,547 And so you have to kind of couple that with what's the evidence 224 00:14:25,547 --> 00:14:27,557 base for using a steroid. 225 00:14:27,957 --> 00:14:31,137 You know what, if someone has a bad asthma flare. 226 00:14:31,462 --> 00:14:36,112 It's clear that steroids in a bad asthma flare can really, maybe help 227 00:14:36,112 --> 00:14:41,332 prevent an ER visit or a severe asthma flare where they're in the ICU. 228 00:14:41,772 --> 00:14:44,322 So in that case, the benefits makes sense. 229 00:14:44,542 --> 00:14:48,965 But in something like sinusitis or bronchitis, I'm talking about acute 230 00:14:48,965 --> 00:14:53,475 bronchitis and a non asthmatic, the evidence actually shows 231 00:14:53,475 --> 00:14:55,875 that steroids are not effective. 232 00:14:56,409 --> 00:15:01,269 If you're gonna give something to someone where there's not evidence 233 00:15:01,295 --> 00:15:04,625 to show its use and there's actually evidence that showing it's not 234 00:15:04,625 --> 00:15:11,115 effective, then even this low risk of sepsis, in my mind, it's not worth it. 235 00:15:11,485 --> 00:15:11,785 Sam: Yeah. 236 00:15:12,485 --> 00:15:16,115 It also brings up the question of whether or not you should be discussing that 237 00:15:16,115 --> 00:15:18,335 with the patient before you prescribe it. 238 00:15:18,335 --> 00:15:22,975 So in those scenarios, let's say you have someone who's maybe borderline for their 239 00:15:23,255 --> 00:15:28,365 benefit for steroids and they're asking for the prescription, do you intentionally 240 00:15:28,365 --> 00:15:32,495 have that conversation and tell them, Hey, you know, your benefit may be marginal, 241 00:15:32,495 --> 00:15:36,635 but you have to know that there is some risk to this and you know, is there a 242 00:15:36,635 --> 00:15:40,245 way to quantify that risk for them, or do you just tell 'em it's low, but present. 243 00:15:40,945 --> 00:15:43,665 Evan: Yeah, well, I mean it depends on the person in front of you. 244 00:15:43,665 --> 00:15:46,665 Are they already on some immunosuppressives? 245 00:15:46,665 --> 00:15:50,799 Have they already had a pneumonia once and is there something about their 246 00:15:50,799 --> 00:15:55,219 immune system that may put them at an even higher risk for complications? 247 00:15:55,219 --> 00:15:59,919 So, I think in general, yes, we should inform patients. 248 00:15:59,919 --> 00:16:03,662 And that gets to one of the other risks a lawsuits and we could talk 249 00:16:03,662 --> 00:16:07,225 about that in a minute, but definitely important to inform patients about 250 00:16:07,225 --> 00:16:12,439 the risks and also we shouldn't feel strong armed into giving steroids. 251 00:16:12,504 --> 00:16:12,624 Sam: Hmm. 252 00:16:13,059 --> 00:16:14,059 Evan: That's important. 253 00:16:14,129 --> 00:16:21,169 Really one of the key messages that I try to convey is above all else do no harm. 254 00:16:21,239 --> 00:16:21,569 Sam: Hmm. 255 00:16:21,635 --> 00:16:25,305 Evan: The do no harm is really where we should be practicing. 256 00:16:25,355 --> 00:16:29,945 Of course there's areas of uncertainty, but as much as possible, we should be in 257 00:16:29,945 --> 00:16:33,630 the realm of do no harm when we're making decisions and talking with patients. 258 00:16:34,330 --> 00:16:39,070 Sam: Yeah, it's, I mean, I gotta say it is a little frustrating that 259 00:16:39,070 --> 00:16:43,360 there are these short term side effects to steroids because it seems 260 00:16:43,360 --> 00:16:45,250 so ubiquitous for so many things. 261 00:16:45,500 --> 00:16:50,574 I can think of teenagers with severe pharyngitis or you know, people with maybe 262 00:16:50,784 --> 00:16:54,324 not necessarily a diagnosis of asthma, but they've got a severe case of bronchitis. 263 00:16:54,324 --> 00:16:57,594 They have a little bit of wheezing or yeah, sure they have recurrent sinusitis. 264 00:16:57,714 --> 00:17:02,514 And maybe their own past experience says, Hey, I want this course of 265 00:17:02,514 --> 00:17:06,264 steroids, and I came to you because I know I've been here a million 266 00:17:06,264 --> 00:17:07,644 times and asked for the antibiotics. 267 00:17:07,644 --> 00:17:08,694 And you always say no. 268 00:17:08,904 --> 00:17:11,484 But now I know the steroids make me feel better. 269 00:17:11,727 --> 00:17:14,667 This kind of brings a whole new dimension to that discussion, doesn't it? 270 00:17:15,367 --> 00:17:15,837 Evan: Yes. 271 00:17:15,867 --> 00:17:16,737 Yeah, definitely. 272 00:17:16,967 --> 00:17:22,557 Research on antibiotics shows that it takes about maybe a minute at 273 00:17:22,557 --> 00:17:27,657 most to educate the patient about reasons not to give them antibiotics. 274 00:17:27,857 --> 00:17:31,187 And thankfully a lot of patients have gotten that message. 275 00:17:31,217 --> 00:17:32,987 Not all, of course, not all. 276 00:17:33,347 --> 00:17:38,220 And the story of steroid stewardship, which I think we're only in the 277 00:17:38,220 --> 00:17:43,884 infancy of this field, is very similar to antibiotic stewardship and so 278 00:17:43,884 --> 00:17:47,514 hopefully over time more patients will be educated about the risks. 279 00:17:47,864 --> 00:17:53,984 In my experience, most patients are reasonable, and most of them, 280 00:17:53,984 --> 00:17:55,439 they just wanna feel better. 281 00:17:56,139 --> 00:18:00,969 And if I can educate them in under a minute about that, actually this 282 00:18:00,969 --> 00:18:04,569 hasn't been shown to help them feel better, I could give them the 283 00:18:04,569 --> 00:18:08,969 YouTube video we made, which is a patient and provider friendly video. 284 00:18:09,254 --> 00:18:10,894 Most people are okay with that. 285 00:18:10,934 --> 00:18:14,294 Do I occasionally have a patient who's still dissatisfied? 286 00:18:14,324 --> 00:18:14,804 Yes. 287 00:18:14,894 --> 00:18:18,225 I mean, I'm not gonna lie and say all my patients are happy 288 00:18:18,225 --> 00:18:19,958 campers and happy to come back. 289 00:18:20,148 --> 00:18:22,906 But I really try to uphold the, you know, do no harm. 290 00:18:23,256 --> 00:18:24,096 Sam: I'm curious. 291 00:18:24,276 --> 00:18:27,366 Sometimes in the emergency department, we will do one time dosing or 292 00:18:27,366 --> 00:18:31,262 single time dosing of steroids like dexamethasone, something longer acting. 293 00:18:31,502 --> 00:18:38,402 Do those adverse effects also occur with single dosing of steroids, like a 294 00:18:38,402 --> 00:18:40,472 one-time dose for a child or adolescent? 295 00:18:40,549 --> 00:18:42,469 Evan: Are you talking about like an injection 296 00:18:42,754 --> 00:18:43,564 Sam: Yeah, or oral. 297 00:18:43,564 --> 00:18:47,304 I mean, sometimes we'll give Dexamethasone oral for its bioavailability is the same. 298 00:18:47,474 --> 00:18:50,234 But still, you know, something that's a steroid in this scenario. 299 00:18:50,934 --> 00:18:56,484 Evan: Yeah, so the injections, they have a few other things to keep in mind. 300 00:18:56,834 --> 00:19:01,184 One side effect from steroid injections is fat atrophy. 301 00:19:01,484 --> 00:19:02,844 And that does happen. 302 00:19:03,274 --> 00:19:07,264 I'm not sure how frequently, but we're giving the injection, if it's not 303 00:19:07,354 --> 00:19:12,424 clearly in the intramuscular space, if it's given a little more superficially, 304 00:19:12,424 --> 00:19:16,444 that could lead to fat atrophy and a permanent dimpling of the skin. 305 00:19:16,934 --> 00:19:19,367 So that is something that does happen. 306 00:19:19,787 --> 00:19:25,167 And then the other thing with steroid injections is a lot of patients, 307 00:19:25,437 --> 00:19:30,687 when they come see us in the ER or in urgent care, they're at their peak of 308 00:19:30,687 --> 00:19:32,397 symptoms, which kind of makes sense. 309 00:19:32,397 --> 00:19:35,957 They're, like, I've been, you know, dealing with this at home forever, 310 00:19:35,957 --> 00:19:37,487 and I just had enough of it. 311 00:19:37,537 --> 00:19:42,307 And a lot of times people are better the next day or two after 312 00:19:42,307 --> 00:19:44,017 they leave the urgent setting. 313 00:19:44,674 --> 00:19:48,334 And so some patients , we always want them to finish their antibiotic 314 00:19:48,334 --> 00:19:51,484 course, but sometimes they don't 'cause they think they're feeling better. 315 00:19:51,664 --> 00:19:54,664 Same with the steroid, the oral dose pack. 316 00:19:54,934 --> 00:19:56,014 I was feeling better. 317 00:19:56,014 --> 00:19:59,904 I didn't feel like I had to finish the Medrol dose pack, and that's where 318 00:19:59,994 --> 00:20:01,764 people have these leftover medicines. 319 00:20:01,764 --> 00:20:05,004 So I'm not at all advocating for that situation. 320 00:20:05,634 --> 00:20:10,197 But the thing with a steroid injection is once you give the injection, the 321 00:20:10,197 --> 00:20:14,727 patient a day or two later can't decide, you know, I'm actually doing better. 322 00:20:14,727 --> 00:20:16,107 I don't have to finish this. 323 00:20:16,157 --> 00:20:19,257 They really have a large dose. 324 00:20:19,287 --> 00:20:23,402 Most steroid injections are, I think about the equivalence of 325 00:20:23,402 --> 00:20:26,012 maybe 60 milligrams of prednisone. 326 00:20:26,112 --> 00:20:29,312 And, they're different dosing obviously, but it is a large 327 00:20:29,312 --> 00:20:31,052 burst of steroid in the body. 328 00:20:31,112 --> 00:20:34,632 And so injections can impart this risk. 329 00:20:34,912 --> 00:20:39,512 But again, repeated injections in the short term are worse than just one 330 00:20:39,782 --> 00:20:44,429 injection, given that dose response relationship for short term steroids. 331 00:20:44,564 --> 00:20:44,774 Sam: Huh. 332 00:20:45,434 --> 00:20:50,128 Okay, so sepsis is an increased occurrence in the following two 333 00:20:50,183 --> 00:20:54,183 months, you said, after a short-term use of steroids, bony fractures, 334 00:20:54,583 --> 00:20:59,373 and localized reactions including dimpling, if they're giving injections, 335 00:20:59,613 --> 00:21:01,873 any other short-term side effects? 336 00:21:02,573 --> 00:21:02,903 Evan: Yeah. 337 00:21:02,963 --> 00:21:07,043 Increased blood glucose especially in people with diabetes. 338 00:21:07,573 --> 00:21:13,304 I've had several patients where they did not have known diabetes and after 339 00:21:13,304 --> 00:21:18,714 receiving steroids they probably had some sort of insulin resistance and then this 340 00:21:18,714 --> 00:21:21,694 tipped them into the diabetes diagnosis. 341 00:21:21,694 --> 00:21:24,124 So, definitely increased hyperglycemia. 342 00:21:24,824 --> 00:21:25,094 Sam: Good. 343 00:21:25,184 --> 00:21:29,474 And then you mentioned some of the, like the psycho behavioral issues as well. 344 00:21:29,474 --> 00:21:32,638 You know, lack of sleep, increased appetite, up all night. 345 00:21:32,638 --> 00:21:37,058 And then behavioral disturbances that can occur from even short term use as well. 346 00:21:37,448 --> 00:21:37,748 Evan: Correct. 347 00:21:38,168 --> 00:21:38,498 Sam: All right. 348 00:21:38,538 --> 00:21:41,658 And then touching on what to tell the patient. 349 00:21:41,658 --> 00:21:45,533 So let's say we have come to an agreement that there might be, 350 00:21:45,933 --> 00:21:49,323 I'd say not strong evidence, but might be some evidence for using 351 00:21:49,323 --> 00:21:51,483 short-term steroids in this condition. 352 00:21:51,763 --> 00:21:55,213 What's the best approach for discussing all of those things? 353 00:21:55,393 --> 00:21:58,633 Do you just run down the list really quickly with the patient and say, I 354 00:21:58,633 --> 00:22:01,583 am gonna give you the steroid, but you gotta be aware you might have blood 355 00:22:01,583 --> 00:22:03,173 clots, it might worsen your blood sugar. 356 00:22:03,173 --> 00:22:06,163 You may not sleep, you may be hungry a lot and eat and have some weight 357 00:22:06,163 --> 00:22:09,323 gain and have some swelling and you're at higher risk for bony fractures and 358 00:22:09,323 --> 00:22:11,003 infections in the next two months. 359 00:22:11,093 --> 00:22:13,973 Do you just run through it like that or do you make it more specific 360 00:22:13,973 --> 00:22:16,643 to the person sitting in front of you, or how do you approach that? 361 00:22:16,663 --> 00:22:17,083 Evan: Yeah. 362 00:22:17,383 --> 00:22:20,593 I don't think I go over all those side effects honestly. 363 00:22:20,613 --> 00:22:22,563 But I do think about who's in front of me. 364 00:22:22,563 --> 00:22:24,273 Is it someone with diabetes? 365 00:22:24,273 --> 00:22:27,003 And I'm definitely gonna talk about the sugars. 366 00:22:27,373 --> 00:22:30,193 Does someone have psychiatric diagnoses? 367 00:22:30,193 --> 00:22:33,253 Then I'm gonna be talking more about those issues. 368 00:22:33,423 --> 00:22:36,453 Someone elderly probably we do wanna talk about the bones 369 00:22:36,453 --> 00:22:38,243 and possible infection risk. 370 00:22:38,553 --> 00:22:43,523 So I do somewhat tailor it and I mean, the truth is we don't have time to go over 371 00:22:43,523 --> 00:22:45,893 every possible side effect for everything 372 00:22:45,953 --> 00:22:46,343 Sam: Yeah. 373 00:22:46,343 --> 00:22:49,438 Evan: So, I would say I would tailor it to who's in front of me. 374 00:22:49,958 --> 00:22:52,688 Sam: I mean, I could imagine some scenarios where you run through that list 375 00:22:52,688 --> 00:22:56,398 with a patient and they say, eh, actually on second thought, no thanks you know, 376 00:22:57,008 --> 00:22:57,878 Evan: That has happened. 377 00:22:57,878 --> 00:22:58,358 Definitely. 378 00:22:58,418 --> 00:22:58,628 Yeah. 379 00:22:58,768 --> 00:23:00,228 In my care of urgent care patients. 380 00:23:00,228 --> 00:23:05,188 Sam: And then so do you think with the increased education that you've been doing 381 00:23:05,308 --> 00:23:10,888 and the discussions on steroid use, have you seen a, like a positive change in 382 00:23:10,888 --> 00:23:14,608 provider behavior in your clinicians or your nurse practitioners, your PAs, your 383 00:23:14,608 --> 00:23:18,148 physicians, are they prescribing them less knowing this, or are they just having the 384 00:23:18,148 --> 00:23:19,743 conversation with their patients more? 385 00:23:19,893 --> 00:23:21,213 Have you been able to tell a trend? 386 00:23:21,988 --> 00:23:23,008 Evan: Yeah, good question. 387 00:23:23,008 --> 00:23:27,838 So, well, first of all, in the system I'm at, I'm at Ochsner Health in southeast 388 00:23:27,838 --> 00:23:32,308 Louisiana , centered around New Orleans, but a lot of southeast Louisiana. 389 00:23:32,988 --> 00:23:37,813 Our urgent care department, I'm really thankful they've taken this on. 390 00:23:37,813 --> 00:23:42,593 They've really kind of taken this on wholeheartedly as a quality metric. 391 00:23:42,953 --> 00:23:49,383 And so the care in southeast Louisiana for when patients would come in for 392 00:23:49,383 --> 00:23:55,173 acute respiratory tract infection encounters, maybe 40% of the time patients 393 00:23:55,173 --> 00:24:00,093 would receive a steroid injection, and that's been cut back significantly 394 00:24:00,093 --> 00:24:02,723 to under 5% at  Ochsner Urgent Care. 395 00:24:03,443 --> 00:24:08,153 So, part of the explanation has been education from myself. 396 00:24:08,153 --> 00:24:13,173 We've developed some CME material on this as well online, CME. 397 00:24:13,563 --> 00:24:17,253 And also they include it in their quality metric dashboard. 398 00:24:17,523 --> 00:24:23,269 So, they have that in addition to checking of a UA in patients that they're 399 00:24:23,269 --> 00:24:25,346 treating for urinary tract infections. 400 00:24:25,396 --> 00:24:27,773 Since I'm in primary care, I'm not in their department. 401 00:24:27,773 --> 00:24:32,041 I don't know all the quality metrics, but they do include that in their metrics. 402 00:24:32,091 --> 00:24:37,291 And then in primary care we are in the process of publishing a study where 403 00:24:37,291 --> 00:24:44,211 we showed that providing clinicians with a monthly report on their 404 00:24:44,211 --> 00:24:50,121 inappropriate steroid use, providing them with a report and a one-time 405 00:24:50,251 --> 00:24:52,868 CME continuing medical education. 406 00:24:53,568 --> 00:24:57,048 That was able to effectively decrease steroid use. 407 00:24:57,128 --> 00:25:04,398 So, we're not sure how much of this is conversations that that's being encouraged 408 00:25:04,398 --> 00:25:06,408 between the patient and clinician? 409 00:25:06,618 --> 00:25:09,528 Or is it that just the clinicians not offering it? 410 00:25:09,778 --> 00:25:10,858 So, we're not sure. 411 00:25:10,858 --> 00:25:14,898 But that's a good question of what's actually leading to the decrease. 412 00:25:15,108 --> 00:25:18,108 Sam: And when you label it as inappropriate I'm assuming then 413 00:25:18,108 --> 00:25:21,168 you have a list of diagnoses that you would say, okay, these would 414 00:25:21,168 --> 00:25:22,743 meet criteria and these don't. 415 00:25:23,443 --> 00:25:23,893 Evan: Yes. 416 00:25:23,893 --> 00:25:28,063 Yeah, so we've been focusing mostly on ARTI's, acute respiratory 417 00:25:28,063 --> 00:25:30,223 tract infection encounters. 418 00:25:30,523 --> 00:25:34,303 We exclude patients with asthma or COPD. 419 00:25:34,723 --> 00:25:41,808 And so if somebody comes in with influenza, acute bronchitis, sinusitis, 420 00:25:41,808 --> 00:25:48,808 pharyngitis, otitis media, we include allergic rhinitis as well, which 421 00:25:48,858 --> 00:25:52,248 systemic steroids have not been recommended for allergic rhinitis. 422 00:25:52,768 --> 00:25:56,908 So anytime steroids are given in those situations, and I don't mean 423 00:25:56,983 --> 00:26:03,038 intranasally, but systemic steroids, either oral or intramuscular, we would 424 00:26:03,038 --> 00:26:04,688 define that as inappropriate use. 425 00:26:05,388 --> 00:26:05,628 Sam: Yeah. 426 00:26:05,628 --> 00:26:10,568 I always find it fascinating when we publish data about clinicians and their 427 00:26:10,568 --> 00:26:14,438 prescribing practices and share it with everyone as a group and go, Hey, here's 428 00:26:14,438 --> 00:26:16,088 where you are, here's where your group is. 429 00:26:16,288 --> 00:26:20,708 I think that kind of is very revealing for all matters of quality assurance. 430 00:26:20,708 --> 00:26:24,998 You know, it could be just utilization or imaging or labs or what have you. 431 00:26:24,998 --> 00:26:26,798 I think it reveals some interesting trends. 432 00:26:26,798 --> 00:26:27,098 So. 433 00:26:27,228 --> 00:26:31,898 It's good to hear that that is a model that is applicable in this scenario. 434 00:26:32,188 --> 00:26:36,928 And you're using that now, not just for the IM dosing one 435 00:26:36,928 --> 00:26:38,428 time, but also for prescribing. 436 00:26:39,101 --> 00:26:40,041 Evan: For oral steroids as well, yes. 437 00:26:40,266 --> 00:26:40,566 Sam: Okay. 438 00:26:41,266 --> 00:26:41,866 That's great. 439 00:26:42,076 --> 00:26:45,586 And does it also track the pediatric prescribing, or is 440 00:26:45,586 --> 00:26:47,056 this just solely in adults? 441 00:26:47,746 --> 00:26:49,636 Evan: We've solely been working on adults. 442 00:26:49,721 --> 00:26:52,186 I think pediatrics is important too. 443 00:26:52,486 --> 00:26:57,479 And I mean, again, the repeated nature, especially effects on the 444 00:26:57,529 --> 00:27:02,163 bones, that's even more of a reason to not give in the pediatric setting. 445 00:27:02,253 --> 00:27:05,786 But since I'm not a pediatrician, it hasn't been really something 446 00:27:05,786 --> 00:27:07,001 I've delved into personally. 447 00:27:07,011 --> 00:27:07,371 Sam: Fair. 448 00:27:07,561 --> 00:27:12,141 When we talk about repeated dosing as well for short term courses, what kind 449 00:27:12,141 --> 00:27:13,401 of frequency are we talking about? 450 00:27:13,401 --> 00:27:16,191 Like more than once in a year, more than once in three or four 451 00:27:16,191 --> 00:27:18,071 months or what defines repeated? 452 00:27:18,771 --> 00:27:19,011 Evan: Yeah. 453 00:27:19,011 --> 00:27:25,211 So anecdotally, I've had several patients on the order of a once a year 454 00:27:25,211 --> 00:27:30,201 steroid injection, say, and that's the only thing I could figure out why they 455 00:27:30,201 --> 00:27:32,661 have avascular necrosis of the hip. 456 00:27:32,661 --> 00:27:35,831 So anecdotally, that's been the case for me. 457 00:27:35,957 --> 00:27:40,457 I mean, we definitely have research that shows steroids affects bone 458 00:27:40,457 --> 00:27:45,657 density and we clearly know chronic steroids affect bone density. 459 00:27:45,967 --> 00:27:50,767 And then we know that short term use repeated dosage, the higher 460 00:27:50,767 --> 00:27:54,607 the dose response curve that's there for steroid fractures. 461 00:27:54,947 --> 00:28:00,597 But my understanding on bones is that repeated use over years, even once 462 00:28:00,597 --> 00:28:04,437 a year of a steroid injection, can decrease bone density over time.. 463 00:28:04,812 --> 00:28:08,812 Sam: And then another question, what about when you, and this is probably more 464 00:28:08,812 --> 00:28:11,752 common in the emergency department or in the hospital setting, but you know, it's 465 00:28:11,752 --> 00:28:15,862 frequent for us to encounter steroids as a recommendation from consultants as well. 466 00:28:15,922 --> 00:28:18,112 You know, let's say, let's take neurosurgery for example. 467 00:28:18,272 --> 00:28:22,017 You've got somebody with intractable sciatica and we're trying to find 468 00:28:22,137 --> 00:28:23,757 some way to alleviate the pain. 469 00:28:23,887 --> 00:28:27,347 Sure there's always pain medication but then we're talking about other 470 00:28:27,347 --> 00:28:29,387 ways to kind of augment that effect. 471 00:28:29,607 --> 00:28:33,417 And frequently we get, okay, yeah, put 'em on a Medrol pack or give them some 472 00:28:33,417 --> 00:28:37,297 Decadron for the next 10 days or something and they can follow up in the office. 473 00:28:37,357 --> 00:28:42,487 Have you noticed that that evidence also covers those diagnoses, or is that 474 00:28:42,487 --> 00:28:44,257 more gray, or how do you handle that? 475 00:28:44,607 --> 00:28:47,997 Evan: As far as acute sciatica, there's good evidence that says 476 00:28:47,997 --> 00:28:49,707 that steroids are not effective. 477 00:28:49,707 --> 00:28:52,617 There was a really good randomized controlled trial, 478 00:28:52,617 --> 00:28:53,787 so that's the best study. 479 00:28:53,787 --> 00:28:57,534 We have a placebo matched randomized controlled trial. 480 00:28:57,834 --> 00:29:04,294 It was published in 2017 in JAMA, and it had patients with acute sciatica. 481 00:29:04,504 --> 00:29:09,554 Some received I think it was six days of prednisolone, very similar to prednisone. 482 00:29:10,254 --> 00:29:15,194 And then half received placebo and there was no long-term improvement 483 00:29:15,244 --> 00:29:19,834 in acute sciatica, in pain, or who ended up needing surgery. 484 00:29:20,184 --> 00:29:24,154 So I mean I try not to argue with specialists. 485 00:29:24,154 --> 00:29:25,654 I try not to get into it. 486 00:29:25,654 --> 00:29:28,914 I really just wanna educate people and make them aware. 487 00:29:29,184 --> 00:29:34,504 So, in the line of work I do, if I send someone to a specialist in the 488 00:29:34,504 --> 00:29:38,434 outpatient setting, the specialist will prescribe the steroid. 489 00:29:38,614 --> 00:29:40,264 But I understand what you're saying. 490 00:29:40,264 --> 00:29:45,834 If inpatient or ER, if the specialist says, okay, you do this, that does 491 00:29:45,834 --> 00:29:50,364 kind of tie your hands in a bit because you asked the specialist to weigh in. 492 00:29:50,714 --> 00:29:56,554 But still, I think if we can educate our urgent providers, both ER and urgent care 493 00:29:56,554 --> 00:30:01,801 and hospitalist clinicians as well, if we can educate them on the risks, maybe 494 00:30:01,831 --> 00:30:05,541 they'll decide, oh, even though the specialist recommended this, I don't think 495 00:30:05,541 --> 00:30:07,311 that this is the best for this patient. 496 00:30:07,641 --> 00:30:13,321 And really, when you're the ER doc, when you're the hospitalist, you know the 497 00:30:13,321 --> 00:30:17,281 patient better t han the specialist, you know, all their diagnoses, and 498 00:30:17,281 --> 00:30:22,189 you might know something about them that does tip into the risks of 499 00:30:22,189 --> 00:30:25,846 the short-term steroids are maybe more than the potential benefits. 500 00:30:25,911 --> 00:30:26,271 Sam: Yeah. 501 00:30:26,841 --> 00:30:29,961 Yeah, I'm thinking about my neurosurgery colleagues, my ENT 502 00:30:29,961 --> 00:30:33,881 colleagues, you know, the propensity for prescribing steroids when we're 503 00:30:33,881 --> 00:30:35,711 just kind of out of other options. 504 00:30:35,951 --> 00:30:39,774 Seems like it's higher in those cases, but maybe that's just 'cause we're 505 00:30:39,774 --> 00:30:41,244 not having the conversation honestly. 506 00:30:41,944 --> 00:30:44,524 Evan: Yeah, but you're right about neurosurgery. 507 00:30:44,534 --> 00:30:46,064 They give a lot of steroids. 508 00:30:46,064 --> 00:30:50,294 I don't wanna poke particularly at the neurosurgeons, but they 509 00:30:50,294 --> 00:30:51,824 do give a lot of steroids. 510 00:30:51,884 --> 00:30:57,347 I actually had a patient who suffered from a pulmonary embolism after 511 00:30:57,537 --> 00:30:59,607 receiving multiple doses of steroids. 512 00:30:59,992 --> 00:31:02,752 I can't say a hundred percent it's from the steroids 513 00:31:02,827 --> 00:31:03,247 Sam: Sure. 514 00:31:03,262 --> 00:31:05,272 Evan: or it's from her underlying condition. 515 00:31:05,692 --> 00:31:09,172 But there are a lot of veno and thromboembolism cases 516 00:31:09,172 --> 00:31:11,242 in neurosurgical patients. 517 00:31:11,662 --> 00:31:16,112 So if I were in the neurosurgery world, I would hope that they would start thinking 518 00:31:16,112 --> 00:31:21,079 about what research do we have that really supports the amount of steroids we use. 519 00:31:21,154 --> 00:31:21,754 Sam: Fantastic. 520 00:31:22,454 --> 00:31:28,354 Evan: I do wanna say that for some of the clinicians listening, well, first of 521 00:31:28,664 --> 00:31:34,497 all, I appreciate you listening this far in, I could imagine some of you thinking, 522 00:31:35,247 --> 00:31:37,317 okay, well, we can't give antibiotics. 523 00:31:37,684 --> 00:31:38,884 We can't give steroids. 524 00:31:38,914 --> 00:31:39,584 What can we do. 525 00:31:39,604 --> 00:31:39,894 Sam: Yeah. 526 00:31:40,427 --> 00:31:42,857 Evan: And I don't mean to say, you know, there's nothing 527 00:31:42,857 --> 00:31:44,717 we can do for these things. 528 00:31:45,027 --> 00:31:48,554 There are things we can do, sometimes the patient needs the 529 00:31:48,554 --> 00:31:51,224 right antibiotic for sinusitis. 530 00:31:51,514 --> 00:31:55,311 Sometimes people need to be pointed in the right direction 531 00:31:55,311 --> 00:31:57,171 of what to get over the counter. 532 00:31:57,826 --> 00:32:03,856 Sometimes patients just need education that on average the cough with acute 533 00:32:04,246 --> 00:32:06,796 bronchitis lasts 10 to 20 days. 534 00:32:06,946 --> 00:32:12,736 If I give you a Z-Pak 10 to 20 days, if I gave you a steroid shot, 10 to 20 days, 535 00:32:12,736 --> 00:32:14,882 so sometimes that's what patients need. 536 00:32:14,882 --> 00:32:19,132 So I'm not saying, you know, don't do anything, but we don't wanna do harm. 537 00:32:19,832 --> 00:32:21,422 Sam: Yeah, I think that's great advice. 538 00:32:21,452 --> 00:32:25,807 And it seems like low hanging fruit for some education and some change. 539 00:32:25,807 --> 00:32:29,482 So if you're listening and you're part of a quality assurance project 540 00:32:29,482 --> 00:32:33,962 or looking for one at your hospital system, your urgent care, your ED, even 541 00:32:33,962 --> 00:32:37,502 your primary care clinic, this kind of seems like some low hanging fruit that 542 00:32:37,502 --> 00:32:41,272 you could make a significant change with just a little bit of education on. 543 00:32:41,672 --> 00:32:46,262 I think the list of things that we give steroids for definitely in 544 00:32:46,262 --> 00:32:48,362 the last 20 years has increased. 545 00:32:48,392 --> 00:32:52,932 And as you mentioned, not evidence-based, just more out of frustration for lack 546 00:32:52,932 --> 00:32:54,642 of other ways to alleviate symptoms. 547 00:32:54,642 --> 00:32:57,612 But you know, sometimes having that conversation and just saying, 548 00:32:57,972 --> 00:32:59,682 okay, what is the worst symptom? 549 00:32:59,772 --> 00:33:01,302 And let's see what we can do about that. 550 00:33:01,652 --> 00:33:04,576 Evan: I use that exact same phrase with my patients. 551 00:33:04,576 --> 00:33:06,286 So what's bothering you the most? 552 00:33:06,286 --> 00:33:11,127 So I can target that specific symptom and I think that, you know, maybe 553 00:33:11,127 --> 00:33:14,322 again we don't have scientific proof of why steroids have gone 554 00:33:14,322 --> 00:33:16,319 up over the last 10 to 20 years. 555 00:33:16,709 --> 00:33:19,529 But, part of it is we don't wanna give antibiotics. 556 00:33:19,529 --> 00:33:20,699 We know that's not good. 557 00:33:21,089 --> 00:33:23,219 We don't wanna give pain medicines. 558 00:33:23,309 --> 00:33:28,529 We know that's not good, but sometimes if someone's in excruciating pain, that's 559 00:33:28,529 --> 00:33:30,584 the best thing we could do to help them. 560 00:33:31,289 --> 00:33:34,709 And to help them get through the next one to two weeks. 561 00:33:34,759 --> 00:33:37,069 And sometimes that's just what patients need. 562 00:33:37,069 --> 00:33:42,319 And we shouldn't be afraid to give appropriate analgesic pain 563 00:33:42,319 --> 00:33:46,929 medicine, whether it's tramadol or hydrocodone or an opioid. 564 00:33:47,249 --> 00:33:49,764 I mean, sometimes we just, that's what we have to give to patients. 565 00:33:49,884 --> 00:33:50,214 Sam: Yeah. 566 00:33:50,914 --> 00:33:55,054 And it really does just come down to, you know, okay, what's the worst symptom? 567 00:33:55,304 --> 00:33:57,374 What do we have in our armamentarium to treat it? 568 00:33:57,614 --> 00:33:59,624 And here's the list of side effects. 569 00:33:59,774 --> 00:34:01,484 Which ones do you wanna roll the dice on? 570 00:34:02,184 --> 00:34:02,644 Evan: That's a good point. 571 00:34:02,679 --> 00:34:04,639 Sam: It's kinda you know, we have pain medicines. 572 00:34:04,639 --> 00:34:06,109 Those come with a bunch of risks. 573 00:34:06,139 --> 00:34:07,189 We have steroids. 574 00:34:07,189 --> 00:34:10,009 Those come with risks for short and long-term use. 575 00:34:10,199 --> 00:34:11,129 We could do nothing. 576 00:34:11,129 --> 00:34:13,499 And that comes with its own short-term risk, right? 577 00:34:13,629 --> 00:34:14,949 You know, maybe 10 to 20 days. 578 00:34:15,224 --> 00:34:17,594 I guess it's a good conversation to have. 579 00:34:17,844 --> 00:34:21,827 And it seems like that's ripe for some educational material for patients. 580 00:34:21,997 --> 00:34:25,573 Earlier, you did mention some medical legal concerns with 581 00:34:25,573 --> 00:34:27,223 steroids that I forgot to ask about. 582 00:34:27,263 --> 00:34:32,053 So tell me have you seen any examples of medical legal outcomes from 583 00:34:32,053 --> 00:34:33,853 short term steroid prescribing? 584 00:34:34,553 --> 00:34:35,093 Evan: Yes. 585 00:34:35,117 --> 00:34:40,127 I've definitely seen lawsuits that came up due to fat atrophy. 586 00:34:40,307 --> 00:34:43,877 Again, that's a permanent dimpling of the skin, which can be 587 00:34:44,297 --> 00:34:46,367 rather disfiguring for patients. 588 00:34:46,737 --> 00:34:51,507 There's actually a published study that looked at lawsuits that 589 00:34:51,507 --> 00:34:53,337 came from steroid prescribing. 590 00:34:53,337 --> 00:34:55,767 It was in one of the ENT journals. 591 00:34:56,247 --> 00:35:01,167 And some of the side effects that came up, a lot of them related to infection 592 00:35:01,167 --> 00:35:04,283 risk, so that gets to the sepsis. 593 00:35:04,633 --> 00:35:09,287 So there definitely is a whole literature out there on the medical-legal side 594 00:35:09,392 --> 00:35:09,812 Sam: Gotcha. 595 00:35:09,992 --> 00:35:13,052 So not always at the forefront of our mind for why we do the 596 00:35:13,052 --> 00:35:14,192 things we do with patients. 597 00:35:14,192 --> 00:35:16,862 We definitely want to do no harm, like you mentioned, and be 598 00:35:16,862 --> 00:35:18,332 evidence-based in our practice. 599 00:35:18,422 --> 00:35:23,102 But just one more layer to the equation that yes, there are some real bad 600 00:35:23,102 --> 00:35:27,477 outcomes, and yes, it can be a medical legal concern for our clinicians as well. 601 00:35:28,177 --> 00:35:28,597 Evan: Yes. 602 00:35:28,627 --> 00:35:29,617 Yeah, that is the reality. 603 00:35:30,317 --> 00:35:30,777 Sam: Perfect. 604 00:35:30,897 --> 00:35:31,167 All right. 605 00:35:31,167 --> 00:35:32,427 Now, you mentioned a video. 606 00:35:32,547 --> 00:35:35,667 You've made a video that's now this is a video that's for clinicians 607 00:35:35,667 --> 00:35:37,407 or a video for patients or both? 608 00:35:37,657 --> 00:35:38,857 Evan: I'd say it's for both. 609 00:35:38,857 --> 00:35:40,147 It's three minutes. 610 00:35:40,177 --> 00:35:44,907 And in the way that I think it's for clinicians is how a lot of us 611 00:35:44,907 --> 00:35:49,377 and me, before I started thinking a lot about this topic, thought that 612 00:35:49,557 --> 00:35:53,937 short-term steroids didn't have any of the same side effects as long-term. 613 00:35:53,937 --> 00:35:56,367 So the video definitely talks about that. 614 00:35:56,417 --> 00:35:59,406 And then for patients, it uses patient friendly material. 615 00:35:59,406 --> 00:36:00,636 It's three minutes. 616 00:36:01,036 --> 00:36:02,416 So I think it can be used for both. 617 00:36:02,431 --> 00:36:03,661 Sam: And that's publicly available. 618 00:36:04,336 --> 00:36:04,786 Evan: Yes. 619 00:36:04,786 --> 00:36:05,236 Yeah. 620 00:36:05,236 --> 00:36:12,926 On YouTube, if you just search Ochsner, that's OCHSNER, corticosteroids 621 00:36:12,926 --> 00:36:17,873 that'll show up or I think if you search corticosteroid side 622 00:36:17,873 --> 00:36:21,056 effects, it'll be like number one, two, or three if you search that. 623 00:36:21,121 --> 00:36:21,631 Sam: Awesome. 624 00:36:21,751 --> 00:36:24,571 All right, well, I'll do that search and put that link in the show notes. 625 00:36:24,848 --> 00:36:30,108 And if you're listening and you're you know, a fond prescriber of steroids, this 626 00:36:30,108 --> 00:36:33,978 may be some food for thought just to kind of take a look at that practice, maybe go 627 00:36:33,978 --> 00:36:39,851 back to the evidence base and see if there might be room to adjust your frequency 628 00:36:39,851 --> 00:36:42,611 of prescription for a certain diagnosis. 629 00:36:42,711 --> 00:36:45,531 Well thank you very much for agreeing to be on the podcast. 630 00:36:45,531 --> 00:36:47,601 I found this really quite informative. 631 00:36:47,601 --> 00:36:50,301 I was looking through some of the educational materials you've developed 632 00:36:50,301 --> 00:36:54,001 and like I said, a little bit dismayed that something I've been doing for so 633 00:36:54,001 --> 00:36:58,748 long actually does have some significant short-term harm and, you know, something 634 00:36:58,848 --> 00:37:01,848 I'm definitely gonna have to bring up with patients from now on each 635 00:37:01,848 --> 00:37:06,468 time that we're talking about steroid prescribing as just another cause of 636 00:37:06,468 --> 00:37:07,818 potential short term side effects. 637 00:37:08,518 --> 00:37:09,238 Evan: Well, you're welcome. 638 00:37:09,238 --> 00:37:12,535 Thank you for being open to this and for the listeners. 639 00:37:12,535 --> 00:37:13,615 Thank you for listening. 640 00:37:13,745 --> 00:37:17,755 My point is not to make anybody feel bad about not doing the right thing. 641 00:37:17,755 --> 00:37:19,985 It's just to educate and think twice. 642 00:37:20,764 --> 00:37:21,544 Sam: And that's a wrap. 643 00:37:21,584 --> 00:37:24,204 Thanks for joining us for this episode of EMPlify. 644 00:37:24,224 --> 00:37:28,850 I hope you found it informative, and I want to remind you that ebmedicine.net 645 00:37:29,100 --> 00:37:33,960 is your one stop shop for all of your CME needs, whether that be for emergency 646 00:37:33,960 --> 00:37:35,780 medicine or urgent care medicine. 647 00:37:36,060 --> 00:37:39,590 There are three journals, there's tons of CME, there's lots of 648 00:37:39,620 --> 00:37:43,380 courses, there's so many clinical pathways, all this information at 649 00:37:43,380 --> 00:37:46,220 your fingertips at ebmedicine.net. 650 00:37:46,620 --> 00:37:49,060 Until next time, everyone, I'm your host, Sam Ashoo. 651 00:37:49,400 --> 00:37:49,960 Be safe.