Journal Club: Steroids for Everything?

Author: Linda Sanders, MD PGY3
Temple University Hospital
Originally Published: Modern Resident, December 2015/ January 2016

Back Pain
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.[3] 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.[2] Thus, steroids may benefit patients with lumbar radiculopathy but have no demonstrated benefit in those with musculoskeletal back pain.

Pharyngitis
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.[4] 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.

Meningitis
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.

Pneumonia
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.[1] 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.[5] 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.

References:

1. Chen Y, Li K, Pu H and Wu T. Corticosteroids for pneumonia. Cochrane Database Syst Rev 2011: CD007720.
2. 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.
3. Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA, Carragee E and Avins AL. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015 May 19; 313(19):1915-23.
4. Hayward G, Thmopson MJ, Perera R, Glasziou PP, Del Mar CB and Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2012 Oct 17;(10): CD008268.
5. Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M and Guyatt GH. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: A systematic review and meta-analysis. Ann Intern Med 2015 Oct 6;163(7)519-28.
6. van de Beek D. Farrar JJ, de Gans J, Mai NT, Molyneux EM, Peltola H, Peto TE, Roine I, Scarborough M, Schultsz C, Thwaites GE, Tuan PQ and Zwinderman AH. Adjunctive dexamethasone in bacterial meningitis: A meta-analysis of individual patient data. Lancet Neurol 2010 Mar;9(3):254-63.
7. van de Beek D, de Gans J, McIntyre P and Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis 2004; 4: 139-43.
8. van de Beek D, de Gans J, McIntyre P and Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2007; 1: CD004405.