Evan: I've definitely seen lawsuits that came up due to fat atrophy.

Again, that's a permanent dimpling of the skin, which can be rather disfiguring for patients.

Sam: Hi everyone, and welcome to another episode of EMPlify.

I'm your host, Sam Ashoo.

Before we dive into this episode, I want to say thank you for joining us.

I sincerely hope that you find it to be helpful and informative for your clinical practice, and I want to remind you that you can go to ebmedicine.net where you will find our three journals, Emergency Medicine Practice, Pediatric Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of other resources, like the EKG course, the laceration course, interactive clinical pathways, just tons of information to support your practice and help you in your patient care.

And now, let's jump into this month's episode.

Evan: My name is Evan Dvorin.

I'm a physician MD.

I work at Ochsner Health, Ochsner Medical Center in New Orleans, and I'm at our main primary care clinic .

Sam: Thanks for being on the podcast.

You have a special interest in steroid use, which is why you graciously agreed to be on the podcast today.

What brought that about or how did you fall into that special interest?

Evan: So, I trained and first worked in New England.

I went to medical school at Dartmouth Medical School.

And then had my residency at Brigham and Women's Hospital in Boston.

And after that I worked nearby in Boston at Mass General Hospital.

While working there, I, and in my education prior, I really hadn't ever heard of using corticosteroids, also known as steroids, for sinus infections or bronchitis.

I'm well aware of the role for things like asthma, if someone has a flare of asthma or chronic obstructive pulmonary disease, but haven't heard of it for these other, more run of the mill, like common cold type of situations.

And then in 2012 my family, we relocated in New Orleans where I am now.

And I've been at the same clinic ever since.

And corticosteroids are frequently used for these diagnoses that I just mentioned, like sinus infection, a bad cold, bronchitis.

And so it was something that, you know the phrase if you see something, say something, or I saw something and I was taken aback.

I was surprised when patients asked me for a steroid injection or a Medrol dose pack, something I, I just would never have thought of.

And so that's when this interest came alive for me .

Sam: Excellent.

And now you have become sort of the, the steroid educator for your practice and your system there.

Is that right?

Evan: Yes.

Yeah, we could say that.

So I've worked with a few medical students, some residents over the years and also the Ochsner Urgent Care department has taken on this campaign of decreasing inappropriate corticosteroids.

So, it's something that I've definitely educated people in my system about.

Also I've worked on some research studies on this topic, and we've created a video and I've had an interview with the New York Times, so it's kind of something I, I've really have taken a big interest in and wanted to spread the word that this is something that's happening frequently.

I do wanna take a brief moment just to say that I first learned about it here in the South and in my research we found that this is really common in the Southeast in particular, but it's actually throughout the United States.

I guess just in the little area I was practicing in, in Boston, it wasn't common, but it's become more common throughout the United States.

Sam: Great.

And now the audience who listens to our podcast is primarily emergency medicine, but you know, EB Medicine also has an entire collection of urgent care journals and products and courses and a separate podcast there as well.

So we tend to mix audiences.

If you're listening and you work in an emergency medicine environment, or if you work in the urgent care environment, all of this is going to sound very familiar to you.

I don't think this is unique to primary care.

Is that something you've encountered in your research as well?

Kinda the, the similar diagnoses being treated with steroids regardless of setting.

Evan: Yes.

Yeah.

Yeah.

This has been the case in urgent care settings, primary care, and in the emergency room.

I think those three venues are the most common where inappropriate corticosteroids are used.

And we recently started actually looking specifically into emergency department use and we find a high rate of inappropriate use.

Sam: Great.

And now tell me, when we talk about the use of corticosteroids for conditions where it may not be appropriate to prescribe them, would the data that you've collected for the last, you know, decade or so, shows that this prescribing trend is increasing or has just been alarmingly high the entire time?

, Evan: It has been steadily increasing actually.

We don't really have a clear explanation for that.

I mean, I have some ideas but it has been steadily increasing throughout the country.

Sam: And when we're looking at the conditions that they are prescribed for, you mentioned some of them already, things like sinus infections and, you know, URIs, are there other diagnoses that tend to be the high frequency diagnoses?

Evan: Yes.

So outside of just the URI world, sciatica or acute back pain, or rash.

These are some other good examples where it's inappropriately prescribed.

Shingles.

It hasn't been shown that steroids are very effective.

Pharyngitis, I guess that's more in the URI type of world.

Oftentimes a podiatrist, not to poke at the podiatrist, but oftentimes they'll give steroids where it hasn't been shown that it's effective for plantar fasciitis.

So a lot of musculoskeletal areas, it's been used inappropriately as well.

Sam: So, in 20 years of clinical practice, I will say that I found a similar trend in my own prescribing.

And I don't really have a good reason to attribute to that.

I think when I was in residency training, we spent the bulk of our time treating the higher risk diseases, and we had a fast track, and our fast track was actually staffed by an attending physician and a PA.

And so we were rarely exposed to higher volumes of the minor care cases.

But as soon as I graduated and we started working in a busy urban emergency department, all of a sudden that was, you know, something like a half of the cases that I was seeing were not necessarily true emergencies, but I think the notion for me was well.

You know, I've got a patient who's sitting in front of me who is here for a condition that they are either seeking maybe an antibiotic for, and I'm gonna tell them that's not appropriate.

And that was a whole nother conversation.

But then also maybe they have some symptoms and I'm just trying to say, well, you know, I can't really solve your problem, but maybe I can do something to alleviate your symptoms.

And the notion kinda came up of, well this seems like a pretty benign thing to do.

I mean, what is the harm of a short course of steroids?

But that is not the case according to your research.

Right?

Evan: Right.

Well, yeah.

Actually not, not my research, but other people's research and I'd like to share that with you.

So that was also in my education.

The concern was about chronic steroids, just like you're saying.

So, people becoming a cushingoid from being on steroids for months or years.

The weight gain, the immunosuppression.

I think we can all kind of imagine what all that we've learned about the side effects of chronic steroids.

And it turns out that a lot of those side effects, and again, this isn't my research, but I'll just share it with you.

A lot of those similar side effects can also be seen for short-term steroid use.

In short term steroid use your body is not really gonna get adrenally insufficient, so not that one, but short term use can increase someone's risk for infection for sepsis in the next one to two months.

Can increase risk for bone fractures.

Again, I'm just saying in the next one to two months.

And thrombo embolism also an increased risk, again, in the short term, just in the next one to two months after receipt of a short-term steroid use.

And the most common side effects from, again, short-term steroid use.

We're talking about a steroid injection, a Medrol dose pack.

The most common side effects are psychiatric side effects, loss of sleep, anxiety.

Some people who already have psychiatric problems or a severe depression, steroids can really tip their symptoms into a severe situation.

Sam: And when we talk about short term use, we're talking about things like, you know, five to seven day courses of prescribing here.

Evan: Exactly.

Sam: So all of those things can still occur even in the one week course of a prescription for, you know, your typical URI.

Evan: Right.

Yeah.

So one thing that I've looked up and seen in the published literature is that there's a dose response curve too, that the higher someone's short-term steroid use, the higher chance of those side effects.

So, that's the case.

But also it does look like after two months, most of these short-term side effects , will attenuate and go away.

I say most except for the bones.

So repeated short-term use over somebody's lifetime will have an impact on bone density.

Can increase the risk for avascular necrosis.

But most of the side effects are gonna go away.

Sam: Now you mentioned a timeframe of two months.

That's the typical period for how long it takes for the side effects of the short-term prescribing of steroids to kind of go away.

Evan: That is what it looks like.

Yeah.

One study was published in 2016 showing increased risk of infection.

In 2017, a British medical journal that was a study that showed increased risk for the venous thromboembolism, fracture, and sepsis over the one to two month period

Sam: Yeah, and that one particularly surprises me 'cause I don't really think about severe immunosuppression from a few days of steroid use.

Especially lingering for two months, so tell me more about that one.

Evan: Yeah, I've actually seen this with several patients where, let's use the sinusitis example, and that's where I've seen it a few times, where someone was given a steroid injection or a Medrol dose pack and a Z-pack azithromycin for sinusitis and in a lot of those situations, the patient's symptoms got much worse and they may have developed actually fevers and worsened sinus discharge, so that's something anecdotally I've seen I'm not sure I'd use the term immunocompromise, but there is definitely some sort of hit to the immune system just with a short term steroid, which makes sense, just about how steroids work.

And so you could imagine if someone has a lingering bacterial sinusitis and if it's not treated with azithromycin since most of the bacteria will be resistant to that, and at the same time they're given a steroid, that definitely increases the odds that that bacteria is gonna win the short term battle, at least.

Sam: And now you mentioned sepsis as well.

So when we talk about sepsis, we think of, you know, those people who end up in the emergency department and end up being hospitalized.

Was there a significant trend in the risk there for sepsis after short term steroids?

Evan: Yeah.

So, that study in the British Medical Journal, a group from Michigan led that study and they used a retrospective analysis, so looking at all comers, with the Optum database of just millions of people and prescribing.

And with that database were able to look at people's underlying diagnoses and when they'd received steroids and not, and the researchers, they did as good of a job as they could to try to get rid of any confounders.

And after correcting for the same amount of patients with autoimmune disease or, they actually excluded cancer patients, they were able to see that there was an increased risk of sepsis.

It wasn't a high number.

We're talking about out of thousands of patients, there were maybe a, I don't know the exact number, but, there definitely was a statistically significant difference in those that developed sepsis who were exposed to corticosteroids versus those that were not.

Sam: Hmm.

And was there a trend or were they able to find a trend that correlated with like past medical history or other confounding illnesses?

Or is it just all comers who had a short course of steroids?

Evan: Yeah, I'm not an expert enough in the biostats part, but they were able to correct for underlying health issues, and after correcting for that, which is not perfect in a retrospective analysis, but after correcting for that, they did have a statistically significant increased risk of sepsis.

So I think of things like sepsis as if I'm going to give patient a short term steroid, there's not a large risk but you could be putting someone to some degree in harm's way.

And so you have to kind of couple that with what's the evidence base for using a steroid.

You know what, if someone has a bad asthma flare.

It's clear that steroids in a bad asthma flare can really, maybe help prevent an ER visit or a severe asthma flare where they're in the ICU.

So in that case, the benefits makes sense.

But in something like sinusitis or bronchitis, I'm talking about acute bronchitis and a non asthmatic, the evidence actually shows that steroids are not effective.

If you're gonna give something to someone where there's not evidence to show its use and there's actually evidence that showing it's not effective, then even this low risk of sepsis, in my mind, it's not worth it.

Sam: Yeah.

It also brings up the question of whether or not you should be discussing that with the patient before you prescribe it.

So in those scenarios, let's say you have someone who's maybe borderline for their benefit for steroids and they're asking for the prescription, do you intentionally have that conversation and tell them, Hey, you know, your benefit may be marginal, but you have to know that there is some risk to this and you know, is there a way to quantify that risk for them, or do you just tell 'em it's low, but present.

Evan: Yeah, well, I mean it depends on the person in front of you.

Are they already on some immunosuppressives?

Have they already had a pneumonia once and is there something about their immune system that may put them at an even higher risk for complications?

So, I think in general, yes, we should inform patients.

And that gets to one of the other risks a lawsuits and we could talk about that in a minute, but definitely important to inform patients about the risks and also we shouldn't feel strong armed into giving steroids.

Sam: Hmm.

Evan: That's important.

Really one of the key messages that I try to convey is above all else do no harm.

Sam: Hmm.

Evan: The do no harm is really where we should be practicing.

Of course there's areas of uncertainty, but as much as possible, we should be in the realm of do no harm when we're making decisions and talking with patients.

Sam: Yeah, it's, I mean, I gotta say it is a little frustrating that there are these short term side effects to steroids because it seems so ubiquitous for so many things.

I can think of teenagers with severe pharyngitis or you know, people with maybe not necessarily a diagnosis of asthma, but they've got a severe case of bronchitis.

They have a little bit of wheezing or yeah, sure they have recurrent sinusitis.

And maybe their own past experience says, Hey, I want this course of steroids, and I came to you because I know I've been here a million times and asked for the antibiotics.

And you always say no.

But now I know the steroids make me feel better.

This kind of brings a whole new dimension to that discussion, doesn't it?

Evan: Yes.

Yeah, definitely.

Research on antibiotics shows that it takes about maybe a minute at most to educate the patient about reasons not to give them antibiotics.

And thankfully a lot of patients have gotten that message.

Not all, of course, not all.

And the story of steroid stewardship, which I think we're only in the infancy of this field, is very similar to antibiotic stewardship and so hopefully over time more patients will be educated about the risks.

In my experience, most patients are reasonable, and most of them, they just wanna feel better.

And if I can educate them in under a minute about that, actually this hasn't been shown to help them feel better, I could give them the YouTube video we made, which is a patient and provider friendly video.

Most people are okay with that.

Do I occasionally have a patient who's still dissatisfied?

Yes.

I mean, I'm not gonna lie and say all my patients are happy campers and happy to come back.

But I really try to uphold the, you know, do no harm.

Sam: I'm curious.

Sometimes in the emergency department, we will do one time dosing or single time dosing of steroids like dexamethasone, something longer acting.

Do those adverse effects also occur with single dosing of steroids, like a one-time dose for a child or adolescent?

Evan: Are you talking about like an injection

Sam: Yeah, or oral.

I mean, sometimes we'll give Dexamethasone oral for its bioavailability is the same.

But still, you know, something that's a steroid in this scenario.

Evan: Yeah, so the injections, they have a few other things to keep in mind.

One side effect from steroid injections is fat atrophy.

And that does happen.

I'm not sure how frequently, but we're giving the injection, if it's not clearly in the intramuscular space, if it's given a little more superficially, that could lead to fat atrophy and a permanent dimpling of the skin.

So that is something that does happen.

And then the other thing with steroid injections is a lot of patients, when they come see us in the ER or in urgent care, they're at their peak of symptoms, which kind of makes sense.

They're, like, I've been, you know, dealing with this at home forever, and I just had enough of it.

And a lot of times people are better the next day or two after they leave the urgent setting.

And so some patients , we always want them to finish their antibiotic course, but sometimes they don't 'cause they think they're feeling better.

Same with the steroid, the oral dose pack.

I was feeling better.

I didn't feel like I had to finish the Medrol dose pack, and that's where people have these leftover medicines.

So I'm not at all advocating for that situation.

But the thing with a steroid injection is once you give the injection, the patient a day or two later can't decide, you know, I'm actually doing better.

I don't have to finish this.

They really have a large dose.

Most steroid injections are, I think about the equivalence of maybe 60 milligrams of prednisone.

And, they're different dosing obviously, but it is a large burst of steroid in the body.

And so injections can impart this risk.

But again, repeated injections in the short term are worse than just one injection, given that dose response relationship for short term steroids.

Sam: Huh.

Okay, so sepsis is an increased occurrence in the following two months, you said, after a short-term use of steroids, bony fractures, and localized reactions including dimpling, if they're giving injections, any other short-term side effects?

Evan: Yeah.

Increased blood glucose especially in people with diabetes.

I've had several patients where they did not have known diabetes and after receiving steroids they probably had some sort of insulin resistance and then this tipped them into the diabetes diagnosis.

So, definitely increased hyperglycemia.

Sam: Good.

And then you mentioned some of the, like the psycho behavioral issues as well.

You know, lack of sleep, increased appetite, up all night.

And then behavioral disturbances that can occur from even short term use as well.

Evan: Correct.

Sam: All right.

And then touching on what to tell the patient.

So let's say we have come to an agreement that there might be, I'd say not strong evidence, but might be some evidence for using short-term steroids in this condition.

What's the best approach for discussing all of those things?

Do you just run down the list really quickly with the patient and say, I am gonna give you the steroid, but you gotta be aware you might have blood clots, it might worsen your blood sugar.

You may not sleep, you may be hungry a lot and eat and have some weight gain and have some swelling and you're at higher risk for bony fractures and infections in the next two months.

Do you just run through it like that or do you make it more specific to the person sitting in front of you, or how do you approach that?

Evan: Yeah.

I don't think I go over all those side effects honestly.

But I do think about who's in front of me.

Is it someone with diabetes?

And I'm definitely gonna talk about the sugars.

Does someone have psychiatric diagnoses?

Then I'm gonna be talking more about those issues.

Someone elderly probably we do wanna talk about the bones and possible infection risk.

So I do somewhat tailor it and I mean, the truth is we don't have time to go over every possible side effect for everything

Sam: Yeah.

Evan: So, I would say I would tailor it to who's in front of me.

Sam: I mean, I could imagine some scenarios where you run through that list with a patient and they say, eh, actually on second thought, no thanks you know,

Evan: That has happened.

Definitely.

Yeah.

In my care of urgent care patients.

Sam: And then so do you think with the increased education that you've been doing and the discussions on steroid use, have you seen a, like a positive change in provider behavior in your clinicians or your nurse practitioners, your PAs, your physicians, are they prescribing them less knowing this, or are they just having the conversation with their patients more?

Have you been able to tell a trend?

Evan: Yeah, good question.

So, well, first of all, in the system I'm at, I'm at Ochsner Health in southeast Louisiana , centered around New Orleans, but a lot of southeast Louisiana.

Our urgent care department, I'm really thankful they've taken this on.

They've really kind of taken this on wholeheartedly as a quality metric.

And so the care in southeast Louisiana for when patients would come in for acute respiratory tract infection encounters, maybe 40% of the time patients would receive a steroid injection, and that's been cut back significantly to under 5% at  Ochsner Urgent Care.

So, part of the explanation has been education from myself.

We've developed some CME material on this as well online, CME.

And also they include it in their quality metric dashboard.

So, they have that in addition to checking of a UA in patients that they're treating for urinary tract infections.

Since I'm in primary care, I'm not in their department.

I don't know all the quality metrics, but they do include that in their metrics.

And then in primary care we are in the process of publishing a study where we showed that providing clinicians with a monthly report on their inappropriate steroid use, providing them with a report and a one-time CME continuing medical education.

That was able to effectively decrease steroid use.

So, we're not sure how much of this is conversations that that's being encouraged between the patient and clinician?

Or is it that just the clinicians not offering it?

So, we're not sure.

But that's a good question of what's actually leading to the decrease.

Sam: And when you label it as inappropriate I'm assuming then you have a list of diagnoses that you would say, okay, these would meet criteria and these don't.

Evan: Yes.

Yeah, so we've been focusing mostly on ARTI's, acute respiratory tract infection encounters.

We exclude patients with asthma or COPD.

And so if somebody comes in with influenza, acute bronchitis, sinusitis, pharyngitis, otitis media, we include allergic rhinitis as well, which systemic steroids have not been recommended for allergic rhinitis.

So anytime steroids are given in those situations, and I don't mean intranasally, but systemic steroids, either oral or intramuscular, we would define that as inappropriate use.

Sam: Yeah.

I always find it fascinating when we publish data about clinicians and their prescribing practices and share it with everyone as a group and go, Hey, here's where you are, here's where your group is.

I think that kind of is very revealing for all matters of quality assurance.

You know, it could be just utilization or imaging or labs or what have you.

I think it reveals some interesting trends.

So.

It's good to hear that that is a model that is applicable in this scenario.

And you're using that now, not just for the IM dosing one time, but also for prescribing.

Evan: For oral steroids as well, yes.

Sam: Okay.

That's great.

And does it also track the pediatric prescribing, or is this just solely in adults?

Evan: We've solely been working on adults.

I think pediatrics is important too.

And I mean, again, the repeated nature, especially effects on the bones, that's even more of a reason to not give in the pediatric setting.

But since I'm not a pediatrician, it hasn't been really something I've delved into personally.

Sam: Fair.

When we talk about repeated dosing as well for short term courses, what kind of frequency are we talking about?

Like more than once in a year, more than once in three or four months or what defines repeated?

Evan: Yeah.

So anecdotally, I've had several patients on the order of a once a year steroid injection, say, and that's the only thing I could figure out why they have avascular necrosis of the hip.

So anecdotally, that's been the case for me.

I mean, we definitely have research that shows steroids affects bone density and we clearly know chronic steroids affect bone density.

And then we know that short term use repeated dosage, the higher the dose response curve that's there for steroid fractures.

But my understanding on bones is that repeated use over years, even once a year of a steroid injection, can decrease bone density over time..

Sam: And then another question, what about when you, and this is probably more common in the emergency department or in the hospital setting, but you know, it's frequent for us to encounter steroids as a recommendation from consultants as well.

You know, let's say, let's take neurosurgery for example.

You've got somebody with intractable sciatica and we're trying to find some way to alleviate the pain.

Sure there's always pain medication but then we're talking about other ways to kind of augment that effect.

And frequently we get, okay, yeah, put 'em on a Medrol pack or give them some Decadron for the next 10 days or something and they can follow up in the office.

Have you noticed that that evidence also covers those diagnoses, or is that more gray, or how do you handle that?

Evan: As far as acute sciatica, there's good evidence that says that steroids are not effective.

There was a really good randomized controlled trial, so that's the best study.

We have a placebo matched randomized controlled trial.

It was published in 2017 in JAMA, and it had patients with acute sciatica.

Some received I think it was six days of prednisolone, very similar to prednisone.

And then half received placebo and there was no long-term improvement in acute sciatica, in pain, or who ended up needing surgery.

So I mean I try not to argue with specialists.

I try not to get into it.

I really just wanna educate people and make them aware.

So, in the line of work I do, if I send someone to a specialist in the outpatient setting, the specialist will prescribe the steroid.

But I understand what you're saying.

If inpatient or ER, if the specialist says, okay, you do this, that does kind of tie your hands in a bit because you asked the specialist to weigh in.

But still, I think if we can educate our urgent providers, both ER and urgent care and hospitalist clinicians as well, if we can educate them on the risks, maybe they'll decide, oh, even though the specialist recommended this, I don't think that this is the best for this patient.

And really, when you're the ER doc, when you're the hospitalist, you know the patient better t han the specialist, you know, all their diagnoses, and you might know something about them that does tip into the risks of the short-term steroids are maybe more than the potential benefits.

Sam: Yeah.

Yeah, I'm thinking about my neurosurgery colleagues, my ENT colleagues, you know, the propensity for prescribing steroids when we're just kind of out of other options.

Seems like it's higher in those cases, but maybe that's just 'cause we're not having the conversation honestly.

Evan: Yeah, but you're right about neurosurgery.

They give a lot of steroids.

I don't wanna poke particularly at the neurosurgeons, but they do give a lot of steroids.

I actually had a patient who suffered from a pulmonary embolism after receiving multiple doses of steroids.

I can't say a hundred percent it's from the steroids

Sam: Sure.

Evan: or it's from her underlying condition.

But there are a lot of veno and thromboembolism cases in neurosurgical patients.

So if I were in the neurosurgery world, I would hope that they would start thinking about what research do we have that really supports the amount of steroids we use.

Sam: Fantastic.

Evan: I do wanna say that for some of the clinicians listening, well, first of all, I appreciate you listening this far in, I could imagine some of you thinking, okay, well, we can't give antibiotics.

We can't give steroids.

What can we do.

Sam: Yeah.

Evan: And I don't mean to say, you know, there's nothing we can do for these things.

There are things we can do, sometimes the patient needs the right antibiotic for sinusitis.

Sometimes people need to be pointed in the right direction of what to get over the counter.

Sometimes patients just need education that on average the cough with acute bronchitis lasts 10 to 20 days.

If I give you a Z-Pak 10 to 20 days, if I gave you a steroid shot, 10 to 20 days, so sometimes that's what patients need.

So I'm not saying, you know, don't do anything, but we don't wanna do harm.

Sam: Yeah, I think that's great advice.

And it seems like low hanging fruit for some education and some change.

So if you're listening and you're part of a quality assurance project or looking for one at your hospital system, your urgent care, your ED, even your primary care clinic, this kind of seems like some low hanging fruit that you could make a significant change with just a little bit of education on.

I think the list of things that we give steroids for definitely in the last 20 years has increased.

And as you mentioned, not evidence-based, just more out of frustration for lack of other ways to alleviate symptoms.

But you know, sometimes having that conversation and just saying, okay, what is the worst symptom?

And let's see what we can do about that.

Evan: I use that exact same phrase with my patients.

So what's bothering you the most?

So I can target that specific symptom and I think that, you know, maybe again we don't have scientific proof of why steroids have gone up over the last 10 to 20 years.

But, part of it is we don't wanna give antibiotics.

We know that's not good.

We don't wanna give pain medicines.

We know that's not good, but sometimes if someone's in excruciating pain, that's the best thing we could do to help them.

And to help them get through the next one to two weeks.

And sometimes that's just what patients need.

And we shouldn't be afraid to give appropriate analgesic pain medicine, whether it's tramadol or hydrocodone or an opioid.

I mean, sometimes we just, that's what we have to give to patients.

Sam: Yeah.

And it really does just come down to, you know, okay, what's the worst symptom?

What do we have in our armamentarium to treat it?

And here's the list of side effects.

Which ones do you wanna roll the dice on?

Evan: That's a good point.

Sam: It's kinda you know, we have pain medicines.

Those come with a bunch of risks.

We have steroids.

Those come with risks for short and long-term use.

We could do nothing.

And that comes with its own short-term risk, right?

You know, maybe 10 to 20 days.

I guess it's a good conversation to have.

And it seems like that's ripe for some educational material for patients.

Earlier, you did mention some medical legal concerns with steroids that I forgot to ask about.

So tell me have you seen any examples of medical legal outcomes from short term steroid prescribing?

Evan: Yes.

I've definitely seen lawsuits that came up due to fat atrophy.

Again, that's a permanent dimpling of the skin, which can be rather disfiguring for patients.

There's actually a published study that looked at lawsuits that came from steroid prescribing.

It was in one of the ENT journals.

And some of the side effects that came up, a lot of them related to infection risk, so that gets to the sepsis.

So there definitely is a whole literature out there on the medical-legal side

Sam: Gotcha.

So not always at the forefront of our mind for why we do the things we do with patients.

We definitely want to do no harm, like you mentioned, and be evidence-based in our practice.

But just one more layer to the equation that yes, there are some real bad outcomes, and yes, it can be a medical legal concern for our clinicians as well.

Evan: Yes.

Yeah, that is the reality.

Sam: Perfect.

All right.

Now, you mentioned a video.

You've made a video that's now this is a video that's for clinicians or a video for patients or both?

Evan: I'd say it's for both.

It's three minutes.

And in the way that I think it's for clinicians is how a lot of us and me, before I started thinking a lot about this topic, thought that short-term steroids didn't have any of the same side effects as long-term.

So the video definitely talks about that.

And then for patients, it uses patient friendly material.

It's three minutes.

So I think it can be used for both.

Sam: And that's publicly available.

Evan: Yes.

Yeah.

On YouTube, if you just search Ochsner, that's OCHSNER, corticosteroids that'll show up or I think if you search corticosteroid side effects, it'll be like number one, two, or three if you search that.

Sam: Awesome.

All right, well, I'll do that search and put that link in the show notes.

And if you're listening and you're you know, a fond prescriber of steroids, this may be some food for thought just to kind of take a look at that practice, maybe go back to the evidence base and see if there might be room to adjust your frequency of prescription for a certain diagnosis.

Well thank you very much for agreeing to be on the podcast.

I found this really quite informative.

I was looking through some of the educational materials you've developed and like I said, a little bit dismayed that something I've been doing for so long actually does have some significant short-term harm and, you know, something I'm definitely gonna have to bring up with patients from now on each time that we're talking about steroid prescribing as just another cause of potential short term side effects.

Evan: Well, you're welcome.

Thank you for being open to this and for the listeners.

Thank you for listening.

My point is not to make anybody feel bad about not doing the right thing.

It's just to educate and think twice.

Sam: And that's a wrap.

Thanks for joining us for this episode of EMPlify.

I hope you found it informative, and I want to remind you that ebmedicine.net is your one stop shop for all of your CME needs, whether that be for emergency medicine or urgent care medicine.

There are three journals, there's tons of CME, there's lots of courses, there's so many clinical pathways, all this information at your fingertips at ebmedicine.net.

Until next time, everyone, I'm your host, Sam Ashoo.

Be safe.