EM:RAP 2018 September

The guest pointed out several times that the lungs are the same size in the obese and non-obese patient, so "obviously" the appropriate dose of steroids would be independent of obesity. However, this is not so obvious; steroids are lipophilic, that is, a given dose will partition preferentially to lipid tissue. This seems to indicate that a greater dose would be required to achieve the same circulating concentration and delivery to the target organ (e.g. lungs) in an obese patient.

From Jaime Hope, MD: I would like to thank Richard S for his comment. I found a study ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4789098/#!po=41.0714) that does show evidence that some obese asthma patients have altered prednisone metabolism in the forms of poor absorption and/or rapid clearance, as his concerns suggested. Strategies suggested by the study authors to overcome this for asthmatics, rather than increasing prednisone dose, include using methylprednisolone which has higher retention in the lungs, using liquid (rather than pill) preparations of corticosteroids, or delivering the medication intravenously. It is a work smarter, not harder approach in that bigger doses still have a therapeutic ceiling so we alter the strategy to match the patient situation. I appreciate the opportunity to have this discussion and increase my knowledge base. Thank you!

Any thoughts on why steroids do not worsen herpes or pharyngitis? We know they impair wound healing because of their effects on the immune system. It does not seem a far leap to think they would be a bad decision in infection. However, we see they can improve symptoms of pharyngitis and someone with asthma/copd and pneumnonia. Thanks in advance for your thoughts.