Corticosteroids for ARTIs Lack Proven Benefit

Evan Dvorin, MD

Clinical practice guidelines do not recommend treating acute respiratory tract infections (ARTI) with systemic steroids, but a recent study reveals that some medical professionals are prescribing systemic corticosteroids at high rates in ambulatory settings across the nation.

“Many people are receiving an unproven intervention which can leave important short term and lasting adverse side effects,” study author Evan Dvorin, MD, a practicing physician at Ochsner Medical Center in Jefferson, LA, told MD Magazine.

Symptoms of ARTI include sore throat, cough, and congestion of either the sinuses or lungs. While some studies have shown that steroids helped resolve sore throats faster, others have indicated that steroids show no effectiveness for sinusitis or bronchitis. There is also a risk of adverse events within 30 days of short-term steroid use.

Authors conducted a retrospective observational study of adults who were diagnosed with ARTI (otitis, upper respiratory infection, sinusitis, bronchitis, allergic rhinitis, influenza, and pneumonia) during an outpatient encounter at one of the primary clinics in the Ochsner Health System (OHS) in 2014 and as reported in the National Ambulatory Medical Care Survey (NAMCS) from 2012-2013.

Analysis of the NAMCS data showed close to 11% of patients receiving ambulatory care were given a steroid prescription. These numbers varied by region; there was a 13% prevalence in the South and 8.3% prevalence in the Midwest. The chances for steroid prescription increased if the patient had a medical history of chronic obstructive pulmonary disorder (COPD) or asthma (OR 2.62; 95% CI; 2.24 - 3.06), diagnosis of bronchitis (OR 1.73; 95% CI; 1.22 - 2.46), and an encounter with a nurse practitioner (NP) (OR 1.65; 95% CI; 0.79 - 3.42) or physician assistant (PA) (OR 1.74; 95% CI; 0.98 - 3.06).

Of patients getting primary care for ARTI in OHS, 23% received steroid injections. The probability for steroid injection were higher if the patient had a medical history of COPD (OR 1.47; 95% CI; 1.31 - 1.64), diagnosis of sinusitis or otitis (OR 2.10; 95% CI; 1.89 - 2.33), allergic rhinitis (OR 1.42; 95% CI; 1.30 - 1.56), upper respiratory infection (OR 1.17; 95% CI; 1.05 - 1.30), or bronchitis (OR 1.82; 95% CI; 1.67 - 1.99), or an encounter with an NP (OR 1.61; 95% CI; 1.53 - 1.71).

Chances for steroid injection were decreased with patients who were non-white (OR 0.88; 95% CI; 0.83 - 0.93), insured by Medicare (OR 0.80; 95% CI; 0.68 - 0.95) or Medicaid (OR 0.75; 95% CI; 0.69 - 0.81). They were also decreased for patients with a medical history of diabetes (OR 0.73; 95% CI; 0.67 - 0.79) and/or osteoporosis (OR 0.88; 95% CI; 0.79 - 0.98), as well as those that have been seen by a PA (OR 0.78; 95% CI; 0.71 - 0.86) and a diagnosis of pneumonia (OR 0.55; 95% CI; 0.46 - 0.64).

In addition, there was a considerable variation in clinician use of steroids, with 17% never prescribing injections and 13% prescribing injections over 40% of the time.

“We hope that increased awareness of how common this unproven, costly, and potentially dangerous practice is can lead to the creation of a campaign that will result in a decrease of corticosteroid use for ARTIs,” Dvorin said.

Dvorin added that further research should explore corticosteroid injection nationally for ARTIs and the patient and provider characteristics that may influence the pattern. This will help better target an educational campaign against inappropriate corticosteroid use.

“We also need more studies that look into outcomes, short-term and long-term, for steroid use in ARTIs and repeated exposure of individual patients to steroids for these diagnoses,” Dvorin said.

The study, "High Frequency of Systemic Corticosteroid Use for Acute Respiratory Tract Illnesses in Ambulatory Settings," was published online in JAMA Internal Medicine last month.

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