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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