Steroid Usage, the subject is controversial in individuals who have had adverse events from Fluoroquinolones. While it is true that administering steroids with fluoroquinolones can be problematic (1), administering them afterwards is subject to much hearsay. I have often heard “you can’t take steroids after you have been floxed” or “floxed individuals should avoid steroids for the rest of their lives” but these rumors don’t necessarily ring true. I have talked to many floxies who, out of medical necessity, have taken steroids since their adverse events and the results are were very mixed. Keeping in mind that there are always exceptions to the rules, the general overall responses to steroids based on the information I receives is:
Inhaled steroids (including nasal steroids): Overall, individuals who took short acting steroids such as those used for breathing, etc… seemed to tolerate them pretty well. Sometimes the type of medication needs to be adjusted based on personal toleration such as brief pain exacerbation, etc… I have had no reports of adverse reactions to nasal steroids.
Oral Steroids: Overall, individuals who took synthetic corticosteroids such as prednisone seem to tolerate them pretty well in low doses. For some who take a blister pack that is then titrated down, they report feeling worse when taking a higher dose. The resolution of symptoms caused by the higher dose seems to vary in time based on personal physiology. Oral hydro-cortisone was tolerated better than prednisone.
Topical Steroids: Overall, the use of over the counter and prescription topical steroids have a pretty good reported track record especially if used over small areas. I have had a couple reports of severe reactions to topical steroids used over a very large area of skin, such as the entire back, and one report of a severe relapse after a small amount of topical steroid used, although the mechanism for the latter is unexplainable and could be related to something else. In 2 of the three cases the individuals were able to return to baseline functioning after discontinuation and a period of adjustment. Bio-identical hydro-cortisone has a better track record of toleration than Triamcinolone, which is a long-acting synthetic corticosteroid.
Injectable Steroids: This fall into two subcategories: Systemic IM injections/IV vs local injections.
IM/IV: I have talked to several individuals who have used dexamethasone (10 mg) via IM injections and they have reported no symptom relapse. Another individual receive dexamethasone via IV (20 mg)and had no relapse.
Local Injections: Injectable steroids, such as corticosteroids, used for direct administration into joints etc… have the worse track record, with some folks reporting very long lasting pain, including nerve pain, in the joint after administration and some reporting relapses that lasted several years. I have never been able to understand the mechanism for this. It is my guess that dosing a high level of steroid locally in tissue overwhelms the fragile nerves in the area. One male floxie reported severe long lasting pain and reduction in mobility after an injection into a shoulder joint. To my knowledge this situation did not resolve.
It is not uncommon for steroids injected into areas of high nerve density to cause severe problems. Epidural corticosteroids have quite serious and permanent adverse events associated with them, and are not approved by the FDA for such use. In many cases the FDA reports that patients did not recover from epidural steroid reported adverse events. (1)
In some cases, Fluoroquinolones may cause pain in the absence of inflammation. Some doctors, because of their discipline, may assume that inflammation is the culprit and administering steroids as palliative care, which, in some, can make matters worse. It is my opinion, that people seem to fair better in this scenario if there is provable inflammation occurring, such as seen in significantly elevated inflammatory markers or scans. Again, I have spoken to a few individuals where doctors used injections into joints and the floxed folks reported long lasting injuries. In these cases, these folks told me that the had no quantifiable inflammation and were given the steroid injection as palliative care in an attempt to reduce existing paint and limited mobility that was originally cause by the Fluoroquinolones.
Bottom line; make sure that you are well informed before any steroid usage. I have spoken with individuals who have had severe symptoms from just one pill and others who have tolerated large doses of steroids just fine. In a nutshell it seems smaller doses are tolerated better than larger doses but many factors play a role in toleration after having an adverse event to FQ’s. Concomitant medications and supplements, length of time since the FQ reaction, and your overall physical state, all factor into toleration of medications. Discuss all concerns you have with the physician who is prescribing this type of medication.