Study Suggests Frequent Improper Use of Systemic Corticosteroids for Respiratory Illnesses

Acute respiratory tract infections include laryngitis (inflammation of the larynx), otitis (inflammation of the ear), pharyngitis (inflammation of the throat), rhinitis (irritation and swelling of the nasal mucous membranes), sinusitis (inflammation of the sinuses) and tonsillitis (inflammation of the tonsils). Sometimes bronchitis (inflammation of the lining of the bronchial tubes) also is classified as an acute respiratory tract infection.

Certain acute respiratory tract infections are caused by bacteria and, thus, require treatment with antibiotics. However, the majority of these infections are viral in nature and do not require treatment. Therefore, efforts in recent years have focused on discouraging improper use of antibiotics for these illnesses.[1]

However, a recent study[2] published in the June issue of the Journal of the American Medical Association Internal Medicine (JAMA Internal Medicine) revealed high rates of systemic (oral and injectable) corticosteroid prescriptions among patients diagnosed with acute respiratory tract infections in the U.S. This is a disturbing finding because clinical guidelines do not recommend routine use of corticosteroids for treating these infections.

About corticosteroids

Corticosteroids (also called glucocorticoids) are a family of adrenal steroid drugs.[3] Systemic formulations of these drugs include dexamethasone (generic only), hydrocortisone (CORTEF, SOLU-CORTEF), methylprednisolone (A-METHAPRED, DEPO-MEDROL, MEDROL, SOLU-MEDROL) and prednisone (RAYOS).

Because of their strong anti-inflammatory and immunosuppressive properties, systemic corticosteroids are essential in the treatment of numerous conditions, such as allergic reactions, asthma, chronic obstructive pulmonary disease (COPD), inflammatory bowel diseases (including Crohn’s disease), lupus and rheumatoid arthritis.[4] They also are widely used after organ transplantation and for treating certain types of cancer.

The benefits of corticosteroids must be balanced against their multiple, potentially serious adverse effects, especially when they are taken at high doses for extended periods. One recent study showed that even short-term exposure to corticosteroids (up to 29 days, with a median of only 6 days) can increase the risk of serious adverse effects, such as sepsis and fractures.[5]

The most common adverse effects associated with corticosteroids include adrenal suppression, high blood pressure, swelling, decreased bone density (increasing the risk of fractures), eye disorders (such as cataracts and glaucoma), heart disease, increased blood sugar levels (diabetes), infection, lipodystrophy (abnormal distribution of fat in the body), muscle breakdown, psychiatric effects (such as agitation, anxiety, depression, insomnia, mania and suicidal thoughts), slowed wound healing, skin fragility, ulcer in the stomach or duodenum, and weight gain.[6],[7]

The new study[8]

The JAMA Internal Medicine study was conducted by researchers from New Orleans, La. They used retrospective observational data from two sources. The first data source was the National Ambulatory Medical Care Survey (NAMCS), which is nationally representative of the medical care services provided in nonfederal office-based settings in the U.S.[9] The second data source was an office-visit database from a large health care system in Louisiana. The researchers examined the use of corticosteroids in adults with acute respiratory tract infections in each database.

They focused on oral corticosteroid prescriptions in the NAMCS database because it does not provide information on injectable prescriptions. However, the researchers did examine corticosteroid injections in the Louisiana database, which contained this information. They defined acute respiratory tract infection as allergic rhinitis, bronchitis, pharyngitis, influenza, otitis, pneumonia, sinusitis and upper respiratory infection.

In the NAMCS database, there were approximately 107,500 office visits for adults with acute respiratory tract infections from 2012 to 2013. Of those, nearly 11 percent involved prescriptions for an oral corticosteroid. Notably, these prescriptions varied significantly by region, from 8 percent of such office visits in the Midwest to approximately 14 percent of such visits in the south.

In the Louisiana database, there were nearly 33,000 office visits for adults with acute respiratory tract infections in 2014. Of those, 23 percent included prescriptions for a corticosteroid injection. However, prescription practices for these patients differed widely among physicians: 17 percent never prescribed a corticosteroid injection, whereas 13 percent prescribed such injections more than 40 percent of the time for patients diagnosed with these infections. In a note that accompanied the study,[10] Dr. Deborah Grady (a JAMA Internal Medicine editor) commented that the aforementioned findings are alarming given the lack of evidence that corticosteroids are beneficial for treating acute respiratory tract infections and because even short courses of corticosteroids can result in harmful adverse effects. However, the editor cautioned that these results are based on secondary administrative data that may be incomplete or inaccurate. Therefore, she called for additional research to confirm these findings among other patients with acute respiratory tract infections in the U.S. and to learn about effective interventions to minimize such use if it is confirmed.

What You Can Do

If you develop an acute respiratory tract infection and you do not have a chronic lung disease, such as asthma or COPD, do not use systemic corticosteroids to treat your symptoms. Instead, try non-pharmacological approaches, including rest and drinking plenty of fluids.

References

[1] Centers for Disease Control and Prevention. Adult treatment recommendations. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html. Accessed September 27, 2018.

[2] Dvorin EL, Lamb MC, Monlezun DJ, et al. JAMA Intern Med. 2018;178(6):852-854.

[3] WorstPills.org. Drug profile: glucocorticoids. /monographs/view/114. Accessed September 27, 2018.

[4] Sarnes E, Crofford L, Watson M, et al. Incidence and US costs of corticosteroid-associated adverse events: a systematic literature review. Clin Ther. 2011;33(10):1413-1432.

[5] Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357(Apr 12):j1415. doi:10.1136/bmj.j1415.

[6] Poetker DM, Reh DD. A comprehensive review of the adverse effects of systemic corticosteroids. Otolaryngol Clin North Am. 2010;43(4):753-768.

[7] Sarnes E, Crofford L, Watson M, et al. Incidence and US costs of corticosteroid-associated adverse events: a systematic literature review. Clin Ther.em> 2011;33(10):1413-1432.

[8] Dvorin EL, Lamb MC, Monlezun DJ, et al. JAMA Intern Med.em> 2018;178(6):852-854.

[9] National Center for Health Statistics. National Ambulatory Medical Care Survey. March 29, 2017. https://www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed September 27, 2018.

[10] Grady D. Inappropriate use of steroids for acute respiratory infection. JAMA Intern Med. 2018;178(6):854.