9- "Dexamethasone and Corticoids."
In a ward for dying AIDS patients, where options
in terms of pain management are limited, some side effects of corticoids (salt-water
retention, decalcification of bones, addiction...) are simply not contraindications
for high-dose/extended use of corticoids, because avoiding these side effects
is less important than relieving suffering.
The good...
- The best and fastest drug against severe
depression and poor psychological state (nxx004) is 1cc IM/SC of dexamethasone
early each morning. It is particularly useful to remember this when
we know that even the best antidepressive drug needs 2 weeks or more to become
active! When a patient is admitted in our ward, for the first four days
we give him one pill (10mg) of prednisone to help him accept the terrible
reality he will see around him and in which he is suddenly thrust...
See "27-Dpression"
- The only way (and last chance!) to help many patients who
cannot take any drugs orally and for whom we
do not have IM/SC drugs is a high dose of dexamethasone (4cc IM morning+2cc midday) -see
the "32-Unable
to Eat". A good alternative is a nasogastric feeding tube (but
we do not have enough workers to implement such a work intensive policy)
- The best drug to reduce dyspnea (with or without bronchospasm) in a very
short time is a high dose of dexamethasone
(for example 4cc IM morning+2cc midday, but more if necessary). (See
"12-Dyspnea")
- To help patients with no appetite or uninterested by food
you can give prednisolone 4-20mg in the early
morning before breakfast… We often do it for short periods (egg:
4 days each 10 days) if there is no contraindication.
- For patients who are suffering, who are in agony with severe
pain and without curative care, high dose dexamethasone
makes them suffer less, and also increases receptivity for painkillers and
sometimes even makes patients a little bit euphoric. (See "18-Last Step")
- For many noninfectious skin diseases like severe
psoriasis, allergy, or generalized eczema, we can often give a "new
skin" to patients in 4-5 days with only a high dose of IM dexamethasone.
- For many severe and chronic multiple-infection skin problems
(see "15-Cochonoma Vaginalis/Penis"),
the only way to recover is to give anti-mycotic + antibiotic + high dose dexamethasone for 5-10 days (usually we stop using
dexamethasone when the wound becomes dry).
(See "30-Dermato" & "26-Psoriasis")
But!!!
The bad...
- Corticoids increase mycotic problems (if necessary you can
use in conjunction with fluconazole)
- Patient suspected of having active CMV
(i.e., recent deterioration of visual acuity) is absolute contraindication
for receiving corticoids (dexa and prednisone as well)…
-? And Herpes + dexa? -
Answer is not clear. In Europe, they do not like association; but in
America some authors recommend dexa for zoster?
Our experience:
The majority of our patients have herpes lesions. Many of them have had
treatment with dexa for a few days or, more rarely, for more than one week because
of cataclysmic dyspnea, cataclysmic depression, last step, some dangerous dysphagia
or other reason. However, I was never able to associate the use of corticoid
with the degradation or emergence of herpes lesions. No more simplex,
no more zoster, no herpetic stomatitis... Even patients who reach last
stage never show increasing signs or symptoms of herpes even when receiving
very high doses of dexa. Now, we no longer consider herpes as a contra
indication for corticoids. (Unfortunately we cannot say the same for CMV!!!
We had at least one bad experience.)
Rules
- It is clearly better to follow the circadian cycle when giving
corticoids. Only give in the morning if possible: corticoids will be
more active and for longer period (without increasing doses). But in
some dyspneic situations, it makes sense to give corticoids in the afternoon
and night time of course.
- A lot of dexamethasone for a few days (preferably only in
the morning and not for the rest of the day, if possible) is always better
than a little bit over many days! (This is especially true for skin
diseases like cataclysmic psoriasis. The effect of dexa will continue
a few days after you stop dexa!)
Adjuvant treatment with corticosteroids in treating
tuberculosis.
The administration of corticosteroids should be considered
as a last challenge when patient seems to be dying more from TB drugs than from
TB
Corticosteroids should be given only when accompanied
by appropriate antituberculosis therapy
For instance, give dexa by mouth 4 pills in morning + 2 pills midday during
5 days and observe general condition + T°curve (Therapists need experience with
TB!!!)
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