Steroid Devil

Steroids: Angel or Demon?

Steroids Everywhere

If you have suffered with allergies or asthma for any time, you have likely been prescribed a steroid medication of some kind, either as a steroid nasal spray, a steroid inhaler, a steroid eye drop, a steroid cream, or even a steroid tablet or injection.

Are all these steroids safe?   Don’t they have a lot of side effects, cause woman to grow beards, athletes to hit home runs or go berserk, and make you fat?

A Brief Biochemistry Review

Steroids are a class of chemicals produced naturally by plants and animals.  There are hundreds of different steroids but in humans they fall into three general categories:  sex hormones, corticosteroids, and anabolic steroids.

The sex hormones include testosterone and estrogen and orchestrate much of our lives, often without us knowing it.

The anabolic steroids are a class of synthetic (man made) chemicals with properties similar to testosterone – both the good and the bad.

The corticosteroids include chemicals related to cortisol, an important hormone produced naturally by our adrenal glands and the only steroid class used to treat allergies.

Dealing with a Bad Day

Cortisol is a stress hormone; it’s job is to help us deal with stressful events in life. This stress response begins in a part of the brain called the hypothalamus.  When it senses stress or believes that it needs to get you ready for something stressful, the hypothalamus produces corticotrophin releasing hormone or CRH.  CRH tells the pituitary gland (the master control gland) to wake the adrenal gland up and get to work making more cortisol.   This link between our brain and adrenal gland is called the HPA or hypothalamus-pituitary-adrenal axis.

The HPA plays a very important role in helping us deal with life, from the day-to-day stress of just getting up in the morning to facing the trauma of a major illness or injury.

Cortisol To The Rescue

In fact, one of the most important jobs for cortisol is to regulate our immune system’s response to a serious illness.  Inflammation is the body’s way of dealing with injury and infection.  When we are fighting an infection, the inflammatory response recruits a powerful army of weaponized cells that search out and destroy an invading pathogen with an arsenal of deadly chemicals.  In injury, inflammation increases blood flow to the injured area and allows healing and clotting factors in the blood to move to the injured part (this is why an sprained ankle gets red and swollen). We could not survive without the armed forces of our immune defense and yet these same weapons can injure us if not carefully kept in check.  This is the role of cortisol.

Cortisol keeps inflammation from getting out of hand.   Inflammation that is inappropriate and gets out of hand is a pretty good definition for allergy. Wouldn’t it be nice if we had a medicine that could control this inappropriate inflammation?    Once we realized that our bodies were already making the perfect treatment for the problem of allergy, it was not long before the world of steroid medications was born.

The good news is that because our immune system is designed to be regulated by cortisol, corticosteroids are some of the most powerful medications currently available for the treatment of allergies and asthma.

The bad news is that our bodies are not designed to experience high levels of corticosteroids for more than a few days.  Some of the effects of cortisol that are likely beneficial during brief periods of extreme stress, such as regulation of fat and sugar metabolism, can cause excessive weight gain and problems with diabetes if used in high dose on a daily bases to control a chronic disease.

Topical use of a corticosteroid such as in a nasal spray, asthma inhaler, or cream, can have the same beneficial anti-inflammatory effect with minimal systemic  side effects.  High doses of topical steroids can still be a concern in some individuals, particularly children, were even small amounts of absorbed corticosteroid can have an effect on growth.  In all cases, the minimal amount of steroid for the shortest amount of time required to control symptoms is the goal.

Sneezing

Over The Counter Allergy Medications

You feel miserable!

Your eyes are so itchy that you have rubbed them raw and you have fits of sneezing so violent you are afraid you have permanently damaged your ears.  Mucous drips on your keyboard while you try to work and you can’t sleep or taste your food because your nose is plugged shut.   Your mouth is so dry from mouth breathing that it feels like a small furry mammal has taken up residence.

You need relief but you are too busy to get in to see a doctor or the next available appointment is not until the allergy season will be long over.

You might be asking: “What can I get at a local Walgreens, CVS, or Costco that will give some relief?”

Here are a few suggestions:

Antihistamines

Get Zyrtec 10 mg (cetirizine) or Allegra 180mg (fexofendine).  Do not get the “D” version of either.

Zyrtec is best but can make you a little drowsy so be careful at work or school or if you will be driving.  Allegra works well and will not make you drowsy but is a pretty big pill to swallow.  These will help the sneezing and itching and to some degree the dripping.   They will not unstuff your nose.

Nasal Steroids

Yes it’s a steroid…however it is topical with very little systemic side        effects, and is the only thing that will safely unplug your nose.   (Read more about steroids)

No nasal steroid works quickly; it will be several days to a week before you see improvement and you have to use them every day.   Flonase (fluticasone) and now Rhinocort (budesonide) are the best.  They both have a smell but neither is deal breaker.  All nasal steroids can cause burning and possible a bloody nose with regular use.  They should not be used in children under 12 without checking with a doctor first.

Eye Drops

Naphcon A works quickly and will temporarily relieve the itching and redness.  Any topical medication with a decongestant (like Naphcon) can cause rebound issues if you use it daily for more than about a week.   For symptoms lasting longer than that, you are much better off getting a prescription eye drop.

Oral Decongestants

Decongestants have issues.  For any but short term, as needed use, the side effects can outweigh the benefits.   There are only two decongestants still on the market: pseudoephedrine and phenylephrine. Pseudoephedrine (Sudafed) is considerable more effective than phenylephrine, which many believe to be so under dosed in the OTC products that it is not much better than placebo.  Pseudoephedrine is now a controlled medication so you can only get a few at a time and you have to sign for what you get.  Oral decongestants can cause cottonmouth, raise your blood pressure and heart rate, keep you up at night, and make it hard to pee (particularly if you happen to have a prostate).

In my opinion, decongestants are more helpful for cold and sinus symptoms.  In fact, OTC medications that use the words, “cold and sinus”, typically contain a decongestant and medications that use the word “allergy” usually contain an antihistamine.

If medications are not helping or if you are wondering if there is an alternative to having to take medications (OTC or otherwise) for the rest of your life, it is time to make an appointment with an allergist.

I just might know one to recommend.

Exercise Induced Bronchospasm: Treatment

As every athlete involved in an aerobically taxing sport knows, effective breathing can be key.  Muscles will not keep working  (and you won’t keep going) if you can’t breath. Oxygen delivery to working muscles depends on several factors, but the ability to rapidly move a large volume of air in and out of the lungs is critical.   When oxygen demand exceeds supply, an effort can continue for only a short period before you must slow down or stop.   No gas, no go. That’s the law!

Exercise induced bronchospasm (EIB) causes tightening of involuntary muscles surrounding medium to small airways.  This narrowing of thousands of tiny airways limits the rate at which air can be moved into and out the lung.  The “button” that turns on brochospasm in susceptible athletes is a receptor in the lining of the airways that respond to rapid changes in the temperature and humidity of the airway, conditions that frequently occur with such sports as running and biking out of doors.   Rapidly breathing cold, dry air is a particularly strong trigger.  Fortunately, the airways not only have an “on” button that when pushed tells the airway muscles to tighten, but also an “off” button that will relax the tightened airways, relieving the obstruction and allowing air to flow freely.  This muscle- relaxing button is called a beta-receptor.   Not only are these beta-receptors found throughout the airways, but also in the heart and nervous system where, as you might imagine, they have different effects.

The most important medication used in the treatment of asthma is albuterol, a beta agonist.  In other words albuterol “pushes” beta-receptor buttons causing rapid relaxation of the airway muscles and bronchodilation.  Because of the beta-receptors in the heart and nervous system, albuterol can also cause an increase in heart rate and a sensation of nervousness.

Not surprisingly, the most frequently used treatments for EIB is albuterol.   Two inhalations of albuterol fifteen minutes prior to an exercise cession will provide prevent bronchospasm for up to four hours.   Albuterol can also be used when needed to provide rapid relief of asthma symptoms such as wheezing, chest tightness, and shortness of breath within five minutes.   Albuterol is so effective in preventing exercise-induced bronchospasm that response to treatment with albuterol is often used as a test to confirm EIB.   If a patient is suspected of having EIB but does not improve with albuterol before exercise, an alternative diagnosis should be considered.

Albuterol is very effective in preventing symptoms of EIB but it does have limitations.  In athletes who train daily, albuterol can become less effective over time so that, not only does it become less effective in preventing EIB but can also become less effective during an asthma attack.  This is unlikely to be a problem if albuterol is not used daily.

Because of the concerns associated with daily use of albuterol, it is suggested that an athlete with EIB who exercises daily use an inhaled corticosteroid in addition to the albuterol.  Although steroids are not bronchodilators, they are very effective controllers of inflammation and are felt to maintain the effectiveness of albuterol after several weeks of daily use; inhaled steroids may also effectively control EIB without the need for albuterol.

Another medication that has been used for EIB is monteleukast or Singulair.   Monteleukast is preferred by many because it is a tablet (chewable for children) rather than an inhaler, can be used daily, and does not have the concerns associated with an inhaled steroid.  It does not benefit all who use it and many find it significantly less effective than albuterol or an inhaled steroid.

Albuterol is called a short-acting-beta agonist (SABA) because of it relatively short (four-six hours) duration of action.  Long-acting-beta agonists are also available which provide protection from EIB for up to 10 hours.   This would seem to be ideal for many athletes although because of the concern about loss of effectiveness with daily use and the possibility that this kind of medication could mask a worsening asthma attack, it has been recommended that LABAs not be used without the concomitant use of an inhaled corticosteroid.  Fortunately, there are several products available that combine an inhaled corticosteroid with a LABD including Advair, Serevent, and Dulera.   The LABD in Serevent and Dulera can work as quickly as albuterol and can therefore be used as a very effective daily treatment for EIB.

Several non-pharmacologic treatment options may be effective in some with EIB. These include warming up slowly before a hard workout to create a “refractory” state in the airways, preventing bronchospasm and wearing a mask to limit exposure to cold, dry air.

For patients with allergies who also have EIB, adding an antihistamine may be helpful.

How to Use an Asthma Inhaler and Nebulizer

The following instructional videos will help you learn the proper use of asthma inhalers, a spacer, and nebulizer

How to Use the Nebulizer Machine – Demonstration

How to Use a Metered Dose Inhaler – Demonstration

How to Use a Diskus for Asthma Relief – Demonstration

How to Use the Pulmicort Flexhaler

How to Use an Inhaler with a Spacer ACP Foundation

Asthma Inhaler at 11 months old, Delaney can do it!!!

Medication Guide

Allergy and Asthma Medication Guide (AAAAI)

Antihistamines

Nasal Sprays

Eye Medications

Skin Medications

Asthma Medications

Inhaled steroids

Long Acting Bronchodilators (LABA)