番茄社区

NEW ORLEANS -- Almost a fourth of patients with upper respiratory infections (URIs) received intramuscular corticosteroids (IMCS) despite a lack of evidence to support the practice, a review of more than 150,000 cases showed.

Use of IMCS varied widely by medical specialty, ranging to as high as 49% of URI patients treated by urgent care personnel. Patients who received an initial IMCS injection were more likely to have a follow-up visit for URI within 60 days, and more than half received another IMCS injection.

Nurse practitioners (NPs) had the highest rate of IMCS use, followed by physician assistants (PAs), and physicians, Sean M. Parsel, DO, of Tulane University in New Orleans reported here at the American Academy of Otolaryngology-Head & Neck Surgery Foundation meeting.

"We performed a multivariable logistic regression analysis, which confirmed a significantly increased risk for a repeat encounter within 60 days after intramuscular corticosteroid administration, possibly due to decreased efficacy," said Parsel. "The analysis showed no increased risk by diagnosis, provider type or specialty, or patient demographics."

IMCS have a long history of empiric use for URI symptoms, particularly in ambulatory settings. However, little scientific or clinical evidence supports the practice, said Parsel. No FDA-approved indication exists for use of IMCS to treat URI, and long-term use of steroids confers well-documented complication risks.

To add contemporary data to the issue, Parsel and colleagues retrospectively reviewed records of patients treated for URI in ambulatory settings within the Ochsner Health System from 2013 through 2017. The analysis included patients with diagnoses of acute sinusitis, acute pharyngitis, acute otitis media, and URI not otherwise specified.

The data showed that 153,848 patients had an initial encounter for a URI-associated diagnosis. Parsel said 34,600 patients (23%) received IMCS, of whom 1,380 (4%) had a follow-up encounter within 60 days for a URI-related diagnosis. Of the 119,248 patients who did not receive IMCS during an initial encounter, 2,408 (2%) had a follow-up encounter within 60 days.

Overall, 751 of 3,788 patients (19.8%) who had repeat encounters within 60 days received IMCS injections. Parsel said 53% of patients who received IMCS injections during the initial encounter had another IMCS injection at the follow-up visit. In contrast, 25 of the 2,408 (1%) who had follow-up visits without a prior IMCS injection received IMCS at the follow-up.

Patients who received IMCS at the initial clinical encounter most often had a diagnosis of acute sinusitis (69%), followed by acute pharyngitis (37%), including those who had more than a single diagnosis. In the group that did not receive IMCS during the initial encounter, 69% had an acute pharyngitis diagnosis and 37% had acute sinusitis (including those with multiple diagnoses).

Family medicine specialists and internists accounted for the largest proportion of IMCS use during the initial encounter (39% and 37%, respectively), followed by urgent care. Family medicine doctors accounted for 36% of patients who did not receive IMCS at the first visit, followed by internists (26%) and emergency medicine physicians (25%).

The frequency of IMCS use during the initial visit was highest in the urgent care setting (49.1%) and lowest in the emergency department (0.85%). Among different types of providers, NPs administered IMCS in 34.5% of cases, PAs in 26.2%, and MDs in 18%.

At the follow-up visits, acute pharyngitis and acute sinusitis still accounted for most of the diagnoses, and the frequency of IMCS use among NPs, PAs, and physicians was similar to the initial encounter. Use of IMCS decreased among internists (29% to 23%), family physicians (24% to 20%), urgent care clinicians (49% to 22%), and otolaryngologists (20% to 8%).

The multivariable analysis yielded an odds ratio of 1.74 for use of IMCS during a repeat encounter among patients who received IMCS during the initial visit, meaning that patients who received one IMCS injection were 74% more likely to receive a second one, said Parsel.

Asked about data related to complications associated with IMCS use, Parsel said the analysis is the first of a multiphase evaluation and that subsequent studies will examine other aspects of IMCS use, including complications.

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