Drugs for the doctor's bag

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Editor, – I refer to the article 'Drugs for the doctor's bag' by Professor J. Murtagh (Aust Prescr 1996;19:89-92). I wonder if you could clarify for me the basis for the use of intravenous hydrocortisone in asthma rather than a parenteral form of a synthetic glucocorticoid. The former can produce very significant plasma and extra cellular fluid volume expansion, whereas the latter does not. In older patients where there may be an element of cardiac compromise, it would seem prudent not to expand volume.

Judith A. Whitworth
Professor and Head
Department of Medicine
St George Hospital
University of New South Wales
Sydney, N.S.W.

Professor J. Murtagh, the author of the article, comments:
I am aware that there is a tendency for increased plasma volume expansion with intravenous hydrocortisone compared with synthetic glucocorticoid. However, it seems to be more theoretical than practical. It must be remembered that almost all the patients presenting with severe acute bronchial asthma are young people and, in practice, the use of hydrocortisone has never been a problem for me or my colleagues.

This has been standardised teaching for many years and is recommended in the 'Respiratory Drug Guidelines'.1 Furthermore, it was and still is readily available on the Emergency Drug (Doctor's Bag)Supplies.

However, I have no problem with the advantage of using a synthetic glucocorticoid for the very severe asthmatic attack and would certainly use it for the older patient especially those with an associated cardiac decompensation problem. Dexamethasone injection has been available on the Doctor's Bag Supplies for many years.