Sunday, August 18, 2013

A Steroid "Burst"

We recently received an e-mail from overseas commenting that a steroid “burst” does not translate well.  It sounds too violent, like an explosion.  Now that we think about it, a steroid “burst” does sound like something one might see at a Fourth of July fireworks display!  But you know what we are referring to: that time-limited course of prednisone or methylprednisolone (Medrol) taken by mouth to quiet a flare of out-of-control asthma.  Most persons with asthma have a love-hate relationship with oral steroids.  Love: the medicine helps you breathe normally again, “better than ever,” at a time when your other medications seemed no longer to work.  Hate: it often has unpleasant side-effects, such as stomach discomfort, moodiness, agitation, sleeplessness, and, of course, the “hungry horrors.”

What may have struck you … as it does us … is that no one seems to know the exactly “right” way to prescribe a steroid “burst.”  Sometimes you are given 40 mg of prednisone to start, sometimes 60 mg.  If you went to the Emergency Department to receive your first dose, it may have been given intravenously at twice the amount, as methylprednisolone (Solu-Medrol) 125 mg.  After the first dose you may have been given 5 days of treatment, 14 days, or longer.  And the dose may have been reduced from its initial large amount to zero in various ways – by 10 mg/day every day or every two days, by 20 mg every 4 days, by inclusion of the low dose of 5 mg/day or not, etc.  Or perhaps your doctor likes the Medrol dose-pack, a pre-programmed 6-day tapering schedule in a package of tablets clearly laid out with each day’s decreasing dose.  And most recently you may have been sent home with 50 mg/day for 5 days, then stop.  No taper to off, just stop

As you might surmise, such a variety of approaches reflects lack of scientific knowledge.  The best way to prescribe a short course of oral steroids has not been carefully studied in scientific trials, and it may be that there is no one “right way” to use steroids.  Some people and some exacerbations of asthma may require more medicine for longer periods of time, others may do well with less medicine for shorter duration.  A recent experiment among more than 300 people with chronic obstructive pulmonary disease (COPD, the chronic obstructive lung disease of cigarette smokers) found that 5 days of prednisone at 40 mg/day was as effective as a two-week course of treatment [Leuppi, et al., Journal of the American Medical Association 2013; 309:2223-31], but COPD is not asthma.  It is uncertain whether the same outcome would hold true among persons experiencing flare-ups of their asthma.

What we do know may surprise you.  Despite the time-honored approach of reducing the dose of prednisone in stepwise decreases – the “steroid taper” -- research has shown that abrupt discontinuation of oral steroids achieves the same asthma control and prevention of recurrences as a slow steroid taper, as long as after the oral steroids you continue preventive treatment with inhaled steroids.  When used for a brief period (fewer than 2-3 weeks), there is no medical reason that the dose of oral steroids has to be slowly decreased.  It is o.k. to reduce the dose in stepwise fashion, but it is not necessary for biologic reasons.
In the absence of scientific data, we are free to share with you what we think is a reasonable general approach, acknowledging that other recommendations may someday be found to be just as good or even better (in which case we will change our approach!).   During a severe asthma flare-up we begin with prednisone between 40 and 60 mg/day (40 mg/day for smaller people, 60 mg/day for larger people).  The tablets can be taken altogether in a single, once-a-day dose.  It then makes most sense to continue treatment at this dose until you are all better or almost all better (as guided by your symptoms or, even better, by finding that your measured peak flow has returned back to its usual value when you are well), and then stop the prednisone or quickly reduce the dose to zero over a few days.  Typically, your medical provider will make a guess as to how long it will take for you to recover from your asthma attack and prescribe a specific duration of treatment.  A severe asthma flare usually abates with treatment over 1-2 weeks; milder attacks resolve more quickly.  Sometimes your provider will allow you to adjust the duration of treatment on your own according to your response to it.  Once you are better, we anticipate that you will continue to feel well and maintain good lung function if you continue taking your inhaled steroid and, where possible, avoid the triggers that set off your asthma attack in the first place.

15 comments:

  1. wow. I've always heard that oral steroids have to be decreased over time, which meant that my nephew would have to take more steroids than he needed to treat an acute asthma attack...but now this may not be the case. This is something that my brother would be very interested in hearing. Thanks so much for posting!

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  2. Very important topic and you just did an amazing job presenting it in a simple and clear manner.

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  3. I recently started taking prednisone and I definitely do not like the side effects! Great post, thanks for sharing!

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  4. Very informative post, I will definitely remember this. Thanks for sharing!

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  5. This is the post just what I was looking around. I've been suffering by asthma attack from several years, My doctor suggested me Serevent Inhaler Generic to use. and now hopeful for getting relief. Thanks

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    1. This is the BEST article I've ever read about this topic. Your analysis of the research and common understanding about this medication is comprehensive and clear. As someone who responds quickly to Prednisone but does not handle the side effects of a taper very well, it's nice to (finally) have a resource to help my doctor and I determine the best way for me to take it, come off of it, and suffer the least negative impact. Thank you so much for writing this.

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  6. good article.
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  7. Thank you for a well-written and easy to understand bit of info. Love-hate relationship is right! It was just under 40 years ago that first I had to take Prednisone. I dread the very thought of it, but my asthma is so terrible right now, I must try a burst. One of the worst side effects of taking corticosteroids is the feeling of "Ah, so this is how it is to breathe normally." I only wish I could feel that way without the steroids. My heart goes out to anyone who has to deal with taking steroids. Best wishes to you all.

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  8. So you're saying I can discontinue 30 mg of prednisone after 3 weeks without taper? This would be good news.

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  10. I've been diagnosed with adrenal insufficiency, following two years of feeling very will after every prednisone taper. I have asthma, have been using advair, and seeing an asthma specialist regularly. She decided to test my cortisol when I complained that these symptoms (lack of appetite/weight loss, nausea, dizziness, severe muscle cramping, severe fatigue and an increase in frequency and severity of what had been mild seizures for 20 years). Turns out my am serum cortisol was way below the ref range, and my ACTH was on the low side. I'm now not able to taper lower than 5 mg pred without all these symptoms returning. As well, I had an adrenal crisis as result of a viral infection, and needed emergency treatment for my low cortisol. I've since become aware that although the tapers as described in this article work just fine for a lot of asthmatics, there are others just like me, for whom they don't work, and in fact leave us with Secondary Adrenal Insufficiency. I think it is critically important to warn patients who are taking steroids for asthma, that if the classic symptoms of adrenal sufficiency don't abate after tapering off pred or dex, they need to have both cortisal and ACTH levels. Adrenal insufficiency can be a life threatening condition!

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  12. My husband was diagnosed several years ago with emphysema. He was able to quit smoking and we stayed on top of any illness. He has been hospitalized with pneumonia every year. His breathing has been getting worse but oxygen levels stay in the 97 to 98 range except when he's in hospital. For a year now he has been passing out. It is only for 1 to 3 minutes and was only when he would start coughing. The doctor changed his medications around but he passes out when breathing a bit hard. Also his feet swell up and are numb all the time. He then started using a cane. i searched for alternative treatment before i was introduced to Health herbal clinic by a friend here in the United states she told me they have successful herbal treatment to Emphysema and other lungs diseases. I spoke to few people who used the treatment here in USA and they all gave a positive response, so i immediately purchased the Emphysema herbal formula for my husband and he commenced usage, its totally unexplainable how all the symptoms totally dissapeared, his cough was gone and he no longer experience shortness of breath(dyspnea), contact this herbal clinic via their email healthherbalclinic@ gmail. com Or website www .healthherbalclinic. weebly. com. Herbs are truely gift from God

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  13. I was just given a Medrol dose pack for an asthma exacerbation. In the past, I've received 40mg of prednisone for 5-10 days. I notice the dosages in the Medrol dose pack are a lot lower - 24mg on the first day and declining thereafter. Is there any research on whether these lower doses are equally effective?

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