Question: My father is 69 and has been asthmatic since 1986. He takes four asthma medications, prednisone, albuterol, Serevent and theophylline, at least twice a day. He has been hoarse for several weeks now and has an endoscopy planned next week to see if they can determine why his vocal chords are inflamed. This also happened to him last year. They found a benign polyp and removed it. Two days ago, he was scheduled for an endoscopy, but it was cancelled when his blood pressure dropped to 62/58. Nothing like this ever happened before. A series of cardiac tests revealed nothing, but they thought he was severely dehydrated. Can you tell me this is common after prolonged use of these types of steroids? Should he anticipate more of this in the future?
Dr. Hibberd's Answer:
Hoarseness in an asthmatic or lung disease patient is easily blamed on the oral steroid. We tend to avoid oral steroids for all but short term use, and prefer inhaled steroids that have far greater safety margins. I share your concern about his hoarseness, and agree that endoscopic visualization of his larynx, vocal cords and tracheobronchial airway is mandatory to look for infection or benign or malignant growths.
All patients who use inhaled steroids are at an increased risk for yeast (commonly seen as thrush) overgrowth in their mouths especially if they do not rinse out their mouths after using the inhaler. Generally you should avoid swallowing the rinse.
Oral steroids are more risky when used for the long-term as opposed to a safer, brief pulse for four to eight days. Continued oral steroids (prednisone) are associated with increased risk of sudden death or collapse if not carefully weaned to avoid adrenal insufficiency, as well as complications including exacerbation of diabetes, accelerated atherosclerosis, immune suppression, worsening osteoporosis, truncal obesity, skin pigment changes, and growth delays and avascular necrosis.
The episode when his blood pressure dropped concerns me. It should be evaluated before any repeat attempts to induce anesthesia.
Theophylline preparations have increased cardiac risks, and they are not used very often. Remember that all patients on long-term oral steroids require a stress dose of cortisone at times of illness and operations to make up for the inevitable adrenal insufficiency that is seen with prolonged oral or injectible steroid therapy. Cortisone is a stress hormone and required in increased amounts during times of stress or illness.
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