Bulking up on steroids vs. chilling out inflamed lungs
Bulking up on steroids vs. chilling out inflamed lungs
Clinicians can help dispel the myth
In the minds of your patients, or their parents, steroids may conjure images of hyped-up, supermuscled athletes dying of heart failure.
The popular perception of steroid therapy and the reality are often miles apart in the minds of concerned parents, says Jane Conley, MD, a pediatrician and allergy fellow at Children’s Memorial Medical Center in Chicago.
Conley presented a paper on her study of parental fears of steroid therapy at the annual meeting of the American Academy of Allergy, Asthma and Immunology in March.
"All the things parents hear in the media about anabolic steroids frighten them. Parents are often confusing anabolic and corticosteroids. For a great many people, the steroid use in athletes strikes fear in their hearts when they think about their own children," Conley says.
The misconceptions sometimes aren’t even corrected by health care professionals, says Jaci Santee, project coordinator for the asthma case management program at the Cerrogordo County Health Department in Mason City, IA.
"We had a pharmacist who told parents they shouldn’t fill the prescription for corticosteroids given to them by their doctor because it would make their child swell up like a balloon," Santee recalls.
"We forgot to include pharmacists in our educational program," Santee says. "But we’ve fixed that now."
In her survey of the parents of 50 patients, Conley devised a questionnaire to be administered orally to parents by a health care professional.
She found that 44% of parents expressed fears about side effects not associated with the use of corticosteroids, including: liver damage, tumors and cancer, pressure in chest, internal bleeding, delayed cognitive development, learning disabilities, delayed physical development, poor appetite, kidney and bladder problems, blood thinning, and heart murmurs.
She also found that parental knowledge about the use of corticosteroids was unrelated to the parent’s age, sex, level of education, ethnic background, or socioeconomic status. Even parents who had themselves been diagnosed with asthma were no better informed than those without asthma.
While Conley’s ongoing study is small, nationally recognized experts say such parental fears are widespread.
Such fears are easily addressed by presenting the facts, says Thomas Plaut, MD, a consulting asthma specialist in Amherst, MA, and author of the industry standard educational booklet One Minute Asthma: What You Need to Know, and Children with Asthma: a Manual for Parents.
In November, the U.S. Food and Drug Admini-stration (FDA) issued a directive requiring a label to be placed on children’s inhaled corticosteroids, warning that children who use the drugs "may reduce their rate of growth." In response, Plaut wrote a letter to health care professionals.
"The new FDA labeling for inhaled steroids scares parents and stresses professionals," Plaut wrote. He noted his concern that "Fear of growth retardation may lead doctors to prescribe inhaled steroids less frequently and parents to discontinue their child’s medicine."
Benefits far exceed risks
In a similar letter to parents of his patients, Plaut wrote, "One study showed that children who took inhaled steroids grew three-tenths of an inch less in a year than children who did not. The effect on final adult height has not been established."
His letter told parents, "The benefits to be gained from taking them far exceeded the risk."
"I won’t tell them they don’t need to worry a speck," Plaut says. "But I tell them they ought to worry about the side effect of not using inhaled steroids: emergency room visits and hospitalizations."
Conley says the oral administration of the questionnaire gives clinicians an opportunity to "identify [parents’] fears and lay those fears to rest."
She contends it is as important to dispel myths about steroids as to provide correct information.
"We as doctors may not be aware of some of these fears. If you’re not aware of it you can’t address it," she says.
Health care professionals need to take some time with patients, identifying misconceptions and giving correct information, Conley says.
The time spent on education will improve compliance, Conley says. "There are a lot of reasons not to comply. We are assuring here that fear is not one of them."
The bottom line is "most kids are supposed to use inhaled steroids every day and virtually everybody says they do, but a lot of studies say they don’t," she adds.
If a parent still resists giving steroids to a child after the need for the medication is explained, Conley suggests taking more time. "We talk, we try to come to an agreement together," she says.
"Most parents will give the steroids given that we all want their child to have a normal life, to go to school and not have too many missed days, to participate in sports, even to blow into a trumpet in the school band," she says. "We don’t want to have kids say, I can’t do it.’ "
Cut the risks
Plaut adds that the best way to address the fear is to tell parents how they can "cut the potential risk to an absolute minimum."
"I point out that inhaled steroids are the most effective asthma medicine that is available," he says.
Plaut has four reminders for parents to help them help their children achieve the best possible control and thereby require the least possible amount of medication:
• Reduce triggers in the environment to reduce the amount of medicine needed.
• Always have the child use a holding chamber or spacer when taking inhaled steroids by metered dose inhaler.
• Always have the child rinse the mouth with water and spit after taking a dose of inhaled steroids.
• Continue to monitor the child’s asthma status with the Peak Flow or Signs Diary [available from PediPress at (800) 611-6081]. With this information, the child’s doctor will be able to establish the lowest dose of inhaled steroids to maintain excellent asthma control.
Parents can help their children find that lowest effective dosage, Plaut says, by gradually reducing the amounts taken until symptoms re-appear, then "increase the dosage to the preceding step."
While most asthmatics need oral steroids from time to time to maintain control, only about 5% of all asthmatics have such a severe form of the disease that they need oral steroids every other day, a level at which the more serious side effects might be anticipated.
Santee and Linda Read, RN, BSN, who work together with disadvantaged families in the Cerrogordo County Public Health Department’s program in rural Iowa, say they have been able to dispel myths and alleviate fears because they have built a relationship of trust with their patients.
"I help them go directly to where they need to be by convincing them to try the inhaled steroids for just a week," says Read. "In many cases, they see such a change, they convince themselves it’s a good thing. When a child and a parent can sleep through the night, maybe for the first time since birth, that speaks volumes. When a child can play outside for more than five minutes without wheezing, they are persuaded."
Plaut concludes, "I try to get them to commit to trying inhaled steroids for a month. The improvement is very clear at this point with almost everyone. That takes a tremendous amount of pressure off them because they are afraid they will be stuck with it forever."
[Jane Conley can be reached at (773) 880-4233, Jaci Santee and Linda Read at (515) 421-9307, and Thomas Plaut at (413) 549-3918.]
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