Paradoxical Reaction to Prednisone

[Jaybay]

My 76-year-old mother finally got slapped last week with all her neglected and denied medical issues.  Her lumbar spine looks like someone wrung it out like a wet dishrag.  Spinal compression at 3 different levels and every disc ruptured.  She lost the ability to walk for more than two steps without severe pain.  This is a woman who has a pain tolerance like nothing I've ever seen, and for her to beg to go the hospital speaks volumes.

She was put on IV steroids in the hospital and it's been a miracle not only physically but mentally.  Mom has high blood pressure treated very well with tenex, which is an adrenaline blocker.  While on steroids her BP was completely normal and I suspect it's because steroids interfere with adrenal gland function.  Am I right on that point?

Mom was sent home with a predisone dose pack for a few days and once it ran out, the pain came back along with the unreasonable fits of temper.  The surgeon refuses to prescribe more steroids before her surgery is scheduled sometime next month.  Any particular reason why a doctor would so resist a very low dose of steroids for a few weeks?  We couldn't get an answer out of him other than a big fat NO.

Surgery cannot be scheduled until her bone marrow biopsy results come in.  Mom was severely anemic (hemoglobin at 7.2 on admission) and has been for a good 5 years.  All benign causes are ruled out so now we're looking at some form of leukemia.  And the dominoes keep tumbling down...

Mom is also a natural redhead, and I understand that the gene causing red hair, particularly in women can cause some odd reactions to narcotics and anesthesia.  They tend to have a huge tolerance to pain, but not to pain medications.  This describes my Mom to a T.  She can't take even a crumb of a narcotic without vomiting.  I'm very concerned about pre-op and post-op pain management for this reason.  Any reccomendations?

[valb68]

A related discussion, redheads and paradoxical reactions was started.

[Jaybay]

Thank you so much!  I needed an in-depth analysis and obviously came to the right place.  :-)

[J T Junig, MD PhD]

Hi Jay-- I'm sorry to hear about your mother.  The concern over steroids comes from several angles.  First, steroids are very unpredictable;  one never knows who will get real 'loopy' on them and who won't.  Some people get severely depressed and suicidal;  others become manic and out of control;  others become psychotic.  These psychiatric effects can occur immediately, or after weeks of treatment.  Second, steroids can have profound and negative effects on the body, even in low doses;  blood sugar is elevated, sometimes to dangerous levels;  blood pressure can be raised (I'm not sure why the BP dropped with your mother;  they only suppress the adrenal glands because of the feedback from high blood levels of steroids, so yes, the adrenals are suppressed, but that does NOT result in lower adrenal steroids;  rather it occurs BECAUSE of HIGH adrenal steroids).  One of the worst side effects is the sudden loss of blood supply to the head of the femur, causing 'avascular necrosis', a condition that requires a hip replacement and that is unpredictable.  

Steroids significantly increase gastric acidity, and some people can develop bleeding ulcers very quickly from steroids.

More predictable is the suppression of adrenal glands by giving steroids;  this occurs even from relatively short courses of steroids and so they are usually given in the form of a pulse followed by a taper, to allow adrenal function to return before the steroids are fully discontinued.

Because of all of these things, the general rule with steroids is to get the patient off them as quickly as possible, and use them ONLY when absolutely necessary, particularly when they are given systemically.  Your mother may be a candidate for epidural steroids, although it would be a difficult procedure given her history, as it is hard to find a route to the epidural space in the presence of significant arthritis.  With epidural steroids only a small amount of steroid gets into the systemic circulation, so side effects are a bit less.

We are learning more and more about the differences in different people in regard to how they react to narcotics, but at this point our ability to predict things is still very low.  The general rule with someone like your mother is to 'start low and go slow' when giving pain medication.

I wish you and her the best!

[Jaybay]

Forgot to add that Mom is currently taking 20 mg of Lyrica at night.  It took a couple weeks for side effects to wear off (double vision, dizziness, sleeping all the time).

As for the steroids, I was expecting roid rage and that's the paradox: it's been just the opposite.  LOL!