Doc: Steroids, antibiotics prescribed together a trend?

Dear Dr. Roach: In late spring of 2016, I had a sinus infection and was prescribed an antibiotic and prednisone. I was told that the steroid would increase the effectiveness of the antibiotic. After reading the patient insert for prednisone, I elected to take only the antibiotic, with excellent results.

Since that time, three of my friends also were prescribed antibiotics by three different doctors for various conditions; all were also prescribed prednisone to take with it. Two of them did take the prednisone, resulting in really unpleasant side effects.

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This week I went to another doctor, was diagnosed with acute nasopharyngitis and was told to take an antibiotic and prednisone. When I said I didn’t want to take the prednisone, the doctor informed me that he NEVER prescribes antibiotics without prednisone.

I was prescribed clindamycin and methylprednisolone. I again elected not to take the steroid.

Can you tell me if this dual prescribing is a widespread medical trend or just a local one? Is there really a good reason for prescribing antibiotics and prednisone together, and am I being foolish not to follow doctor’s orders?

E.D.

Dear E.D.: There have been two recent systematic reviews on the use of oral steroids, such as prednisone or methylprednisolone, in combination with antibiotics in treatment of acute sinusitis. These studies have shown a speedier recovery in those taking the combination of steroids and antibiotics than in those who take antibiotics alone, and I suspect that is why your doctors, and those of your friends, have been prescribing them.

However, there is a downside to steroids, as you note. It’s not just the unpleasant immediate side effects, such as jitteriness and difficulty sleeping; steroids can have serious side effects in the short term (confusion and even psychosis are well known). In the long term, the list of possible side effects is very long, so the benefit must always be weighed against the possible harm.

This is particularly the case in people at high risk for side effects, such as diabetics (in whom sugar levels routinely go up when taking steroids) or those with high blood pressure (which often is exacerbated by steroid use).

Personally, I prefer to use nasal steroids in combination with antibiotics. They have many of the benefits of oral steroids with few of the side effects. Nasal steroids don’t work as quickly as oral steroids, however.

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In any case, I can’t condone you not following your doctor’s recommendations. I certainly do recommend that you have a discussion about the benefits versus the harms, and I’d also recommend that you ask about nasal steroids.

Dear Dr. Roach: I have read that atrial fibrillation gives you a greater chance of getting dementia. Do you agree?

K.N.

Dear K.N.: People with atrial fibrillation are at higher-than-average risk for developing dementia. However, it’s not clear if the atrial fibrillation causes dementia or whether it is because some of the risks for developing dementia are also risks for developing atrial fibrillation. What is clear is that people who are not treated well for atrial fibrillation (specifically, those people whose anticoagulation dosage is frequently too much or too little) have a greater risk for dementia than those whose atrial fibrillation is well-controlled. This is yet another reason that both patients and doctors should take particular care with anticoagulation. It isn’t clear whether the newer anticoagulant drugs will have less risk of dementia.

Email questions to ToYourGoodHealth@med.cornell.edu.

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