Steroids in Pre-Hospital Medicine

Of the many steroidal agents available, few are more popular in pre-hospital emergency medicine than Solu-Medrol and Solu-Cortef. It is a common misconception that these two medications are interchangeable, although each may be used for a variety of conditions. Solu-Medrol is methylprednisolone sodium succinate or (MP) and Solu-Cortef is Hydrocortisone sodium succinate or (HC).  Both are synthetic steroidal hormones and have similar responses. However there are differences both positive and negative which must be considered. Both MP and HC are Glucocorticoids.

What are Glucocorticoids, what do they do and why do I care?

Glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor. Steroid hormones can be grouped into five groups by the receptors to which they bind: glucocorticoids, mineralocorticoids, androgens, estrogens, and progestagens. The first two glucocorticoids and mineralocorticoids are of particular interest when describing parental forms of Methylprednisilone (MP) and Hydrocortisone (HC). Mineralocorticoids are synthesized from cholesterol. Glucocorticoids are a steroid synthesised from Mineralocorticoid and cholesterol.

Since these steroids are synthesized from cholesterol they are fat soluble and can easily pass through the cell membrane. The synthetic analogs, Methlprednisilone (MP) and Hydrocortisone (HC), stimulate signaling cascades through the cell membranes and invoke a nongenomic reaction. This stimulation causes rapid effects as opposed to the intracellular binding to nuclear receptors by other steroids which cause a slow genomic action. Steroid hormones are generally carried in the blood bound to specific carrier proteins.  Glucocorticoids inhibit the two main products of inflammation, prostaglandins and leukotrienes. In addition, glucocorticoids also suppress both COX-1 and COX-2 much like NSAIDs, potentiating the anti-inflammatory effect. These actions of (MP) and (HC) are a predominant, yet non-inclusive, reason why they are used in emergent medical conditions. Some of the more common usages of (MP) and (HC) are respiratory exacerbations, allergenic responses, shock(s), and acute adrenocortical insufficiency.

So these Glucocorticoids are obviously useful, are they dangerous?

As with all medications it is important to understand any adverse reactions they present. Glucocorticoid agents such as (MP) and (HC) have very similar negative effects. Of the hundreds of effects few are considered imperative with short term therapy. However there are adverse reactions that may rarely be observed during short term therapy which should be considered. Of these hyperglycemia, hypotension, hypertension, seizures, and CHF (in susceptible patients) are of particular importance. The incidence of these reactions are extremely low but should, nevertheless, be considered.

Ok I get it but which one is better?

There’s no simple answer to this question. Each medication has advantages and drawbacks. Making an informed decision of which medication to use can be a daunting task. I have no intention of suggesting one medication over another here. My intent is to provide a basic explanation of the differences of both MP and HC. Obviously this decision will ultimately lie in the hands of your medical director. For many departments new medications and treatment modalities are presented to your medical control authority for consideration. Providing them with clear and concise information will lead to a mutually beneficial outcome. Some questions must be asked before a conclusion can be made.

Are steroids in a pre-hospital setting really necessary?

This question has sparked a lot of controversy. Both sides have very valid points. Steroids do not have the immediate action as many of the medications employed by most pre-hospital care providers. Typically the majority of medications have an immediate effect and essentially a short term half life. Steroids do not fall into this category, with the exception of treatment of adrenocortical insufficiency. Careful consideration must be given to the efficacy of pre-hospital administration. One must weigh the “risks versus reward” of any medication given to a patient. Steroidal agents have been commonly used in emergency departments worldwide for many years. Yet in many cases a patient undergoes diagnostic procedures prior to the administration. Differentiating between congestive heart failure and acute exacerbation of COPD for example is a common dilemma faced by many pre-hospital care providers. Paramedics do not have the luxury of a radiology department nor a radiologist to confirm one or the other. A differential diagnosis must be made through minimal objective signs. With that said Paramedics must be very diligent with their subjective interview to compensate for the lack of objective information. The lack of objective procedures and the relatively delayed effect of steroids have led many providers to abandon the use of these agents in the field.

Not all situations encountered by the provider are difficult to diagnose. One common example is allergic reactions. Although there are other differential diagnoses for allergic reactions most emergency departments commonly administer steroidal agents in conjunction with antihistamines as a method of diagnosis without the use of other ancillary departments such as laboratory and radiology. This is but only one example where steroids in the field may be considered a viable addition to the provider’s arsenal.

What will I be utilizing these medications for?

As previously stated there are conditions which can be difficult to diagnose without objective studies. Others can be diagnosed with a thorough history and physical of the patient. There is no reason one must assume that steroids have to be used for every possible condition presented to the provider. The medical control authority must determine which condition steroids are and are not to be used. By adding steroids to your protocols simply means you have additional options for treating the broad spectrum of conditions presented.

Which one is actually safer?

Again both HC and MP are essentially identical in regards to contraindications, side effects, and precautions. There seems to be no differentiation of safety for either.

Side by Side Steroidal Comparison

Actions are based on Anti-Inflammatory results

*Relative potency value, based on Hydrocortisone = 1 and Methylprednisolone, NOT HC and MP

Goodman and Gilman. The Pharmacological Basis of Therapeutics.6th Ed.

 Documenta Geigy. Scintific Tables. 6th Ed.

 Goth, Medical Pharmacology. 8th Ed.

In conclusion, it is apparent that even though HC and MP are very similar they both have positive and negative aspects. The positive effects for pre-hospital administration of steroids are becoming widely apparent. I expect to see a trend of steroidal agents being used in the field by the more progressive agencies in the future. However without specific studies used to p