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September Intro: 'Roid Rage'

Andy Little, DO and Matthew DeLaney, MD, FACEP, FAAEM

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The summary below is from an episode of ERcast: Clinical Perspectives

Short-course oral corticosteroids are not benign; even a typical six-day outpatient burst is linked to sepsis, venous thromboembolism, and fracture. In emergency care, steroids clearly help in asthma, COPD, and croup, while evidence is weak, mixed, or absent for common cold, musculoskeletal pain, sinusitis, sciatica, migraine, and pharyngitis.

Steroids in Emergency Care

  • Short-course harm signal: A large cohort of 1.5 million adults found outpatient steroid bursts were common and associated with sepsis, venous thromboembolism, and fracture, a risk-benefit reset worth hearing in the episode.
  • Best-supported indications: The clearest wins are asthma, COPD, and croup, where dexamethasone remains a high-yield ED steroid and a single dose can match longer bursts in obstructive disease.
  • Route evidence gap: Oral dexamethasone performs as well as IM in moderate croup, and there is little evidence that routine IV or IM 'steroid shots' outperform PO for most common indications.
  • Poor-use cases: There is no good evidence supporting steroids for acute musculoskeletal pain or the common cold, two settings where practice often runs ahead of data.
  • Mixed-benefit syndromes: Sciatica may show modest functional improvement without meaningful pain relief, and adverse effects are common. We get into where that tradeoff may still matter on the show.
  • Adjunctive symptom roles: For migraine, parenteral dexamethasone cuts recurrence by about 26%, and for pharyngitis steroids improve 24- to 48-hour symptom relief, but these are adjuncts rather than universal first-line moves.

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References:  

  1. Dequin PF, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941.  PMID: 36942789 
  2. Waljee AK, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415. PMID: 28404617
  3. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. 2000;106(6):1344-1348. PMID: 11099587
  4. Venekamp RP, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2011;(12):CD008115. PMID: 22161418
  5. Goldberg H, et al. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015;313(19):1915-1923. PMID: 25988461 
  6. Colman I, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336(7657):1359-1361. PMID: 18541610
  7. Hayward G, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268. PMID: 23076943
  8. Hayward GN, et al. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA. 2017;317(15):1535-1543.  PMID: 28418482

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