Tuesday, 3 July 2012

Steroid cover for patients on long term steroids

A student asked me recently how I actually use evidence in my clinical practice. I think this is a good question as there's no point in teaching what EBD is but not showing how to apply it.

In several of my blogs I raise queries that arise typically from discussions with students. These often alert me to gaps in my knowledge of the current best evidence - even if I can regurgitate something I was once taught / read that sounds plausible.

Well this afternoon I had a moment of uncertainty regarding what we were taught to call 'steroid cover'. That is, when I was an undergraduate I was taught that patients on long term steroids may require a supplementary dose around the time of a stressful surgical event. I don't actually know what is taught to the undergraduates today but there was certainly a gap in my 'up-to-date' knowledge that I needed to sort out.

The patient I saw this afternoon is a not a well lady and is on a fairly high dose of steroids so I thought I had better just check that I wasn't about to send her into adrenal insufficiency and shock as a result of me taking out a tooth.

So I went to the TRIP database and plugged in 'steroids dental treatment' and this lead me to this:

And clicking through led me to a TRIP answer here.

But further down the TRIP page was this:

 Now this looked helpful but was way out of date. If something is 8 years old there's a possibility some new evidence has come to light since. However, if one clicks through to Pubmed it often shows similar articles on the right hand side. So this is what I saw:

That link on the side was for a 2008 systematic review. Still not ideal time wise but 4 years younger...However, on the right of this page there was a link to a more recent Cochrane review:

You can click through to the Cochrane review here.

I generally prefer to read Cochrane reviews because they are on the whole better done and a lot stricter on the trials they allow into the review. I therefore feel more confident with their conclusions.

The first review above had included randomised controlled trials (RCTs) and cohort studies whereas the Cochrane review only allowed RCTs. Basically, though, they both concluded there wasn't much evidence to support the use of steroid cover. However, the Cochrane review is cautious because in the 2 RCTs it included there were only 37 patients and so the evidence is not strong. The non-Cochrane review had over 300 patients but a large proportion were patients followed up after not giving them steroid cover - none of whom developed an adrenal crisis.

So to answer the student's question about how I use EBD I have in about 5-10 minutes established that the evidence is weak on the use of supplementary corticosteroids and so rather than use a poorly-substantiated intervention (extra steroids) I will take the tooth out with her having taken just her normal steroid dose. 

Now maybe all you students are saying "yeah - that's what they taught us in the Human, Health and Disease course", but this illustrates that like me you will find yourself in the future unsure whether what you were taught as undergraduates is still relevant. Don't be ashamed to ask the questions and admit to up-to-date knowledge gaps.