Author: Linda Sanders, MD PGY3
Temple University Hospital
Originally Published: Modern Resident, December 2015/ January 2016
A randomized controlled trial (RCT) in which 269 patients with lumbar radiculopathy on MRI and low back pain were given a 15-day course of prednisone versus placebo demonstrated an improved disability score at three weeks after receiving steroids. By comparison, a RCT of 67 patients presenting to the ED with musculoskeletal pain from a twisting or bending injury not thought to be radicular in nature demonstrated no benefit in pain or disability with prednisone at one week. Thus, steroids may benefit patients with lumbar radiculopathy but have no demonstrated benefit in those with musculoskeletal back pain.
A Cochrane review of eight RCTs comparing steroids to placebo demonstrated that patients given oral or intramuscular steroids for pharyngitis were three times more likely to have resolution of pain within 24 hours with a number needed to treat of 3.7. Most trials used a single dose of dexamethasone and all eight studies gave both groups antibiotics. Thus there is no data demonstrating the benefit of steroids without antibiotics.
In an attempt to identify a subgroup of patients with bacterial meningitis that benefit from steroids, van de Beek, et al. performed a meta-analysis of 2,029 patients from five RCTs comparing the use of dexamethasone versus placebo for bacterial menigitis.6 Patients of all ages were included and received dexamethasone for two to four days. There was no significant reduction in mortality but there was some reduction in hearing loss among survivors. This study had surprisingly negative results compared to two prior meta-analyses from 2004 and 2011, which demonstrated a mortality benefit and hearing loss reduction.[7,8] A large multinational RCT is still needed to answer this question.
The inflammatory response in pneumonia may account for worsening pulmonary dysfunction leading to ARDS and treatment failure. A previous Cochrane review investigated the use of steroids for pneumonia, demonstrating a mortality benefit. However, this study had a small sample size and used studies of low quality. In an expansion of this review, Siemieniuk, et al. published a meta-analysis of 13 RCTs comparing the use of steroids versus placebo for hospitalized adults with community acquired pneumonia. This study demonstrated a mortality benefit for those patients with severe pneumonia and a reduction in the cases of mechanical ventilation and ARDS in cases of less severe pneumonia. It is unclear which patients with pneumonia would derive the most benefit from steroids.
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- Eskin B, Shih RD, Fiesseler FW, Walsh BW, Allegra JR, Silverman ME, Cochrane DG, Stuhlmiller DF, Hung OL, Troncoso A and Calello DP. Prednisone for emergency department low back pain: A randomized controlled trial. J Emerg Med 2014 Jul; 47(1): 65-70.
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