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July 26, 2009
Steroids are commonly prescribed for sudden hearing loss as well as for autoimmune inner ear disease and vestibular neuritis. The purpose of this page is to outline the usual methodology. We do not discuss their effectiveness or the validity of their indications.
The drugs that are most commonly used include:
|Drug||Equivalent mg||Half life||Usual starting dose|
|dexamethasone (decadron)||0.75||48 (36-54)||4mg (equivalent of 20mg of prednisone, but with longer duration)|
|Methylprednisolone (medrol)||4||24 (18-36)||6-5-4-3-2-1 of 4 mg tablets, equivalent of starting at 30 mg of prednisone.|
There is very little difference with respect to the ultimate results with these drugs and side effects, but they differ in potency and duration of action, and for this reason, the dose must be adjusted. In most cases, the goal will be to start with a 1mg/kg equivalent of prednisone (i.e about 60 mg/day). Oral decadron would seem to us to be a poor choice for a condition in which rapid effects are desirable such as acute hearing loss or vestibular neuritis, as due to it's long half life, it takes 20 days to reach steady state. Of course, one can adjust one's protocol to give more drug at the beginning, as is the case for the "medrol dose pack".
The most common method of administration is by mouth. We will not discuss intravenous administration (faster and stronger, sometimes used for situations where symptoms are very severe such as bilateral deafness associated with autoimmune inner ear disease).
Administration through the ear-drum is discussed elsewhere. This method has the advantage of much less side effects, but the disadvantages of far higher expense and the need for a subspecialty visit for injection through the ear drum.
For the oral method, there are four common protocols that we use in our clinic:
The easiest, safest, and most convenient method of trying steroids is to use a medrol (methylprednisolone) dose pack.
This is a card that contains 6 days of steroids, with less provided each day. The gradual decrease in the amount of steroids each day is called a "taper". The reason to do this is to allow the patient's adrenal glands, which are usually suppressed by the steroids, to gradually return to supplying steroids to the patient on their own. Medrol is slightly stronger than prednsone, so to convert this into "prednisone", when using the 4 mg dose-pack, one just has to multiple by 5. In other words, the medrol dose pack is the equivalent of 30 mg of prednisone, tapering down to 0 over a week. Because the medrol dose pack doesn't contain the usual 1 mg/kg of steroids for most patients, it may simply be too "weak" an intervention to get a good indication as to whether a condition is steroid responsive.
For persons in whom a larger amount of steroids is indicated a longer protocol and more intense protocol is selected.
In general, one starts with 1 mg/kg equivalent of prednisone, maintains for a "pulse" of several weeks or a month, and then tapers down (21 days or 30 days). Longer pulses require longer tapers. Checking the blood pressure to make sure it is not dropping too low and follow up visits during the taper period are often required.
Some patients are "steroid dependent". For example, whenever the steroid dose is decreased below a threshold, hearing starts to deteriorate again. In patients like this, an attempt is made to find a steroid sparing replacement drug (such as methotrexate or Enbrel), but in the meantime, the steroids are reduced to as low an amount as is practical. This is commonly about 5-10 mg/day of predisone.
Steroids have many side effects, that are more common with longer administration.Common ones in the short run (i.e 7 days) include:
Problems that can occur after longer administration, besides the ones that may appear above, include
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