By: Dr. Steve McGuire 

Night School at the Old Boston City Hospital: ‘Roid Rant – On the ED use of Steroids.

 

There are only a few things I know about the world. Sunrise in the east, sunset in the west. Death and taxes. It’s time to say ‘Bye’ to ‘bae’, it’s played.

This installment of Night School, is utilitarian. We use steroids all the time in the ED, including in COPD, Asthma, Pharyngitis, CNS injuries/infections. Probably will use them more, e.g. in most pneumonia, according to recent reviews (1,2).

We know they have anti-inflammatory properties, but we’re often guilty of neglecting their mineralocorticoid activities.

But which do you use and how much of them? Many of us, the relatively unexperienced, are accustomed to prednisone. Less seem to know the dosing of dexamethasone (my favorite), methylprednisolone (aka Solu-medrol), or even hydrocortisone. It’s noteworthy that hydrocortisone is the steroid upon which all others are compared.

Many times in the resuscitation room, steroids are ordered and given. Unfortunately, the dose is not always considered.  It’s easy to ask, “Can we give her Solu-medrol?” The dosing often goes unsaid and unquestioned.  125mg is a convenient dose, but rarely the right one.

See the following table for equivalent dosing regimens. For ease of use, I give the doses for our typical 70-100kg patient.

 

Glucocorticoid Approximate equivalent dose(3) (mg) Half-life (hr)
Hydrocortisone 200 8-12
Cortisone 250 8-12
Methylprednisone (solu-Medrol) 40 18-36
prednisolone 50-60 18-36
prednisone 50-60 18-36
Dexamethasone
(decadron)
8-10 36-54

 

In short, would you ever give 150mg of prednisone to your asthmatic or COPD patient? Not likely. Don’t give the equivalent in methylprednisone, just because Solu-Medrol comes in 125mg vials.

 

References

  1. Wan, You-Dong et al. Efficacy and Safety of Corticosteroids for Community-Acquired Pneumonia CHEST, Volume 149, Issue 1, 209-219.
  2. Bi J, Yang J, Wang Y, Yao C, Mei J, Liu Y, et al. (2016) Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis. PLoS ONE 11(11): e0165942.
  3. Meikle AW, Tyler FH. Potency and duration of action of glucocorticoids. Effects of hydrocortisone, prednisone and dexamethasone on human pituitary-adrenal function. Am J Med. 1977 Aug;63(2):200-7.

 

Faculty Author: Steve McGuire, DO