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#5139 - 06/11/10 12:28 PM Re: Dexamethasone and HAPE [Re: Bob R]
KevinR Offline


Registered: 11/03/09
Posts: 595
Loc: Manchester, NH
Good summary, Bob. Thanks for taking the time to post it.

I'd read about the positive affects of aspirin in preventing altitude sickness for a few years, and have wondered whether there's any measurable protective effect from the 81mg daily dose many of us take for protection for cardiac problems, including stroke. My hunch is that the benefit of the aspirin re: altitude has less to do with its blood thinning properties and more to do with some as yet un-determined action. And, the daily dosage is much lower - 81mg vs. 325mg x 3. But, pure conjecture on my part.


Edited by KevinR (06/11/10 01:14 PM)
Edit Reason: qualify the setting where aspirin is used for altitude

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#5140 - 06/11/10 12:34 PM Re: Dexamethasone and HAPE [Re: Bob R]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
Thanks, Bob.
Your experience and input are always appreciated.

CaT
_________________________
If future generations are to remember us with gratitude rather than contempt, we must leave them more than the miracle of technology. We must leave them a glimpse of the world as it was in the beginning, not just after we got through with it.
- Lyndon Johnson, on signing the Wilderness Act into law (1964)

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#5144 - 06/11/10 06:22 PM Re: Dexamethasone and HAPE [Re: CaT]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
I was asked by PM to respond. Thanks.

First, one of my favorite quotes from one of the greats in the mountaineering literature:

One man acclimatises quickly, another slowly...The whole process appears to be analogous to sea-sickness about which predictions are impossible.
Eric Shipton, Upon That Mountain page 376

Going beyond that, please see the High Altitude Tutorial at http://www.ismmed.org/np_altitude_tutorial.htm#HAPE


Is the original question on this thread still whether or not to treat HAPE with Dex or other steroids?


To answer some specific questions about HAPE and HACE as life-threatening complications of AMS, here are some thoughts from my knowledge as a physician and specifically a high altitude medical team member who has seen and helped with these problems on the mountain. Maybe some time I can post my little study "Brains and Video Games at High Altitude." Harvey


Primary option for treatment is descent, descent, descent. First option should be descent, depending of course on situation, weather, ambulatory status, etc. Then there is oxygen by bottle vs. pressurized air by Gamow bag. These two are Greater Ranges stuff.

Diamox is sometimes thrown in the mix but is mainly used to accelerate acclimatization especially early on, whereas Dex (or another steroid) is used for complications HACE, HAPE and is far more powerful.

Since HAPE and HACE often overlap in the same patient (especially if they have HACE) and since steroids are beneficial in both (more so in HACE than HAPE), then I personally would treat a patient ill with either of those problems with Dex and not quibble about the potential of overtreating or risking side effects. On the mountain, sometimes you just gotta shotgun it, and get down as quickly as possible. Otherwise you might be dead soon. Real soon. The risk of death from either HAPE or HACE is extraordinarily high. I've seen that. Why wait for it to worsen? (in just hours). Treat it hard, treat it now. Of course going down is often enough by itself, but what if you are no longer walking, night falls, or your rescuer breaks a leg? HAPE and HACE are rare at moderate altitudes like the Sierras, but with a susceptible individual, and bad conditions like nasty weather, high work load, other illness or injury, dehydration, etc, the risk level increases. It happens occasionally on Rainier and Whitney, as described recently at http://www.whitneyportalstore.com/forum/...age=2#Post76972

Inhaled steroids: They help stabilize lung linings for "reactive airways" like cold-induced asthma or some benefit for HAPE. Sometimes it is not clear what the hacking, coughing climber actually has at 18,000 feet where everyone else is also coughing. Inhaled steroids have less systemic (whole body) effect and since for HAPE or HACE you need to hit it hard, then we use big dose parenteral (injected) or oral route. (On the ill fated 1996 Everest disaster, prepackaged injectable dex was used .... just forget sterile technique, uncover the needle and shoot right through the down suit.)

Nifedipine: Cardiac/bp med. It had some greater popularity for a while in the past since it acts as a pulmonary artery vasodilator. Used preventatively (in selected persons such as those with prior HAPE episode) , it helps treat the rise in pressure in the lung vessels that occurs more in some folks than others at high altitude, this being a risk factor for HAPE. Also was used acutely to treat that pressure response once HAPE was suspected. Not as widely accepted now. When I stopped at the medical clinic in Khumbu in 2000 we had disagreements then on its benefit. (I know that my HAPE-susceptible climbing partner did far better on Aconcagua with it than without it on Denali, but that's just one person). Usually administered orally. Under the tongue, it can drop blood pressure. Best to leave this to medical team.

Viagra has also been used as a pulmonary artery dilator drug (rather than its customary use) although I don't know its current status in the high altitude field.

Have I personally advised/helped/evacuated family, friends, or team clients with AMS/HAPE/HACE/death/all - yes
Have I ever personally had AMS ? a few times at 10-14,000 ft
Have I ever use Diamox for acclimatization? Sometimes
Does the literature and my experience support Diamox for AMS--yes.
Have I ever had such massively bad headache that I worried about HACE ? yes, at 19,000 ft and stopped.
Do I carry emergency dex or prednisone (steroids)?

Hope this helps some.

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#5147 - 06/11/10 10:32 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Wow, that was a great summary, and yes, it answered my original post (i.e., whether Dex can be used in an emergency to treat HAPE that actually present).

Yes, it was a very specific question. I am one of those sulfa-sensitive folks (so no Diamox without specific testing), and I am not planning to use drugs for prophylaxis. Hence my curiosity about uses for Dex in an emergency (as opposed to prophylactic) situation. Tons on the internet re HACE; less info re HAPE.


Edited by Akichow (06/11/10 11:16 PM)

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#5151 - 06/12/10 06:05 AM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
Bob R, Harvey - great stuff, and very informative reads. I was not aware of the prophylactic benefits of aspirin at altitude. My wife is a poster child for AMS, especially with abrupt ascents without acclimation. We're heading to the Sierra in less than a month for her first real taste of serious hiking above 10K', and I've been a bit concerned about how she'll handle it since she's sulfa-sensitive. Aside from obvious acclimation time, the points you two raise give me a little more ammunition for the AMS war chest. Having dex on hand just in case sounds like a great plan B, after acclimation, ginko and ASA as plan A.

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#5154 - 06/12/10 09:40 AM Re: Dexamethasone and HAPE [Re: Bulldog34]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Just a note on the sulfa issue. When talking about sulfa allergies, one is almost always talking about developing rashes with sulfa antibiotics, which has sulfa molecules in a particular configuration.

Sulfa exists in other configurations in other drugs, examples of which would be sulfonureas, for decades the main diabetes oral meds, COX-2 inhibitors such as Celebrex, and diuretics such as lasix and HCTZ.....and Diamox. However, the "sulfa allergic" people don't actually seem to react to these other configurations, and those other drugs are routinely prescribed to sulfa allergic people.

I would consider it reasonable for a sulfa allergic person to take Diamox, although I'd do a trial of it at home, first, before using it in the field. Others might differ.

here is more info:

http://www.clinicalcorrelations.org/?p=374

"Based on these findings it is not clear that an allergy to a sulfonamide antibiotic places a patient at risk specifically for an allergy to a sulfonamide nonantibiotic but rather places the patient at an increased risk of developing an allergy to other medications in general."

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#5156 - 06/12/10 10:31 AM Re: Dexamethasone and HAPE [Re: Ken]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
Outstanding Ken - we'll try that. If she can tolerate prophylactic Diamox, that beats the hell out of attacking AMS after the fact. Nausea was her her main complaint with sulfa drugs but, of course, that was back in her teen years and she's avoided it ever since. You know how those "allergies" go - "if I took it once, and had something bad happen a few hours late, it was the drug." She may be fine with it, so we'll give it a shot.

Thanks!

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#5162 - 06/13/10 02:41 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
Originally Posted By: Harvey Lankford

Do I carry emergency dex or prednisone (steroids)?

Ha! I just noticed that I failed to answer my own question.
(Must be lingering effects of hypoxia).

The answer is yes.

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#5163 - 06/13/10 02:59 PM Re: Dexamethasone and HAPE [Re: Bulldog34]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Oh, it's worth mentioning that nausea, while a common side effect of many medications, is not an allergic reaction, although people often think it is. So, it's even safer.


Originally Posted By: Bulldog34
Outstanding Ken - we'll try that. If she can tolerate prophylactic Diamox, that beats the hell out of attacking AMS after the fact. Nausea was her her main complaint with sulfa drugs but, of course, that was back in her teen years and she's avoided it ever since. You know how those "allergies" go - "if I took it once, and had something bad happen a few hours late, it was the drug." She may be fine with it, so we'll give it a shot.

Thanks!

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#5164 - 06/13/10 03:03 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
KevinR Offline


Registered: 11/03/09
Posts: 595
Loc: Manchester, NH
Originally Posted By: Harvey Lankford
Originally Posted By: Harvey Lankford

Do I carry emergency dex or prednisone (steroids)?

Ha! I just noticed that I failed to answer my own question.
(Must be lingering effects of hypoxia).

The answer is yes.


Am considering starting to carry emergency dex - would you consider 10 pills a reasonable amount? In this article the recommended dosage is "Two doses of 4 mg, 6 hours apart". Any benefit to sublingual vs. swallowing the pills?

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#5171 - 06/13/10 06:39 PM Re: Dexamethasone and HAPE [Re: KevinR]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
I have not seen sublingual route for dex listed on any of my sources.

Intramuscular dex is listed for even more emergent situations like imminent death or patient unconscious.

You can find various ranges in dose regimens for treating such as 4-8mg now, then 4-6mg every 4-6hrs. Patients response and descent to safer altitude determines duration of Rx. Remember that 4 mg Dex is about 130 mg of cortisone equivalent so it is big dose. You mentioned 10 pills, you would likely be either dead or cured by then. Save some for the other guy.

Remember that dex only covers up AMS symptoms - it does not cure the problem. The usage I refer to is for the more appropriate problem - HAPE and HACE.

Finally, no drug is a substitute for descent.

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#5174 - 06/13/10 08:17 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I can't believe the casualness about taking Dex. It is a POWERFUL drug and as Harvey mentions 4mg of dex is like 10 doses of prednisone and 130mg of cortisone.
I had one doctor prescribe it for me and acted like it was no big deal.Reading up about it gives the usual warnings that accompany all meds. I then saw a specialist who went ballistic when he heard I was given Dex for pain. He was adament that the 4mg I was taking once or twice a month was not a low dose and had serious dangerous side effect mostly of adrenal compromise.This whole idea of trying to trick the body or override its warning signals to accomplish physical feats is getting crazy.Even taking ibuprophen daily so that you can work out without pain is crazy.Taking Dex to climb to altitude well what price are you willing to pay with your overall health?


Edited by Rod (06/13/10 08:18 PM)

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#5177 - 06/13/10 09:31 PM Re: Dexamethasone and HAPE [Re: Rod]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
The thread relates to emergency use of Dex to treat actual, manifest HAPE.

While overreliance on the internet surely has its dangers, I very much appreciate the patience and willingness of this board's more expert members to be a resource, and to share data and their own experiences.

Now if only someone had a lead on an MD in San Francisco who is knowledgeable about high altitude medicine, and who sees patients, who would be willing to do a consult.


Edited by Akichow (06/13/10 09:50 PM)

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#5181 - 06/13/10 10:37 PM Re: Dexamethasone and HAPE [Re: Akichow]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I answered your question if you had HAPE and the only drug you had was dex should you take it.Now KevinR is talking about taking 10 doses of 4mg Dexamethasone.

You still don't know anything about the drug,whether you should use it in a hypothetical case of HACE or HAPE.I think the experts have weighed in on what your first order of business is. That is high altitude experience. Second is understanding and rcognizing the signs and sytoms of AMS including HAPE or HACE. Discusing whether to use a powerful steroid like Dexamethasone should happen between you and a knowledgable doctor one on one. Not here on a message board.
Most importantly it has been made clear that the best treatment for suspected AMS is descent.While Mt Whitney has caused cases of AMS we are not talking Mt Everest here where there are professional doctors with experience injecting Dex intra-muscularly for serious cases of life and death due to HAPE and HACE.


Edited by Rod (06/13/10 10:41 PM)

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#5183 - 06/13/10 11:21 PM Re: Dexamethasone and HAPE [Re: Rod]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
Akichow wrote:
> Now if only someone had a lead on an MD in San Francisco who is knowledgeable about high altitude medicine, and who sees patients, who would be willing to do a consult.

I think you missed Ken's reply:
> On this page is a list of Wilderness Medicine faculty at Stanford:
    http://emed.stanford.edu/fellowships/wilderness.html



Rod wrote:
> Now KevinR is talking about taking 10 doses of 4mg Dexamethasone.
Rod, I think he's asking how much he might carry, not how many he should take. Sounds like 10 4mg pills would be plenty-- I'd consider half that.

Talking to a friend who teaches college-level business law, I asked about carrying Dex just in case one encountered a party where someone was suffering from signs of Cerebral Edema. He just shook his head at the idea of handing over a prescription drug to a stranger on a trail. It was his opinion that I could get myself in deep legal trouble doing that. I guess I'd have to put it on a rock, point it out to the party, then get the heck out of there before they got my name or description!

I sure appreciate this discussion. While everyone must always talk over their needs with their prescribing doctor, it is especially good to ALSO discuss all the pros and cons like we can here. But nobody should take any of the information here as the truth. Everyone must first verify the information for themselves -- as in talking to their doctor -- before they act. And read the disclaimer.

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#5186 - 06/14/10 07:44 AM Re: Dexamethasone and HAPE [Re: Steve C]
KevinR Offline


Registered: 11/03/09
Posts: 595
Loc: Manchester, NH
Originally Posted By: Steve C
Rod wrote:
> Now KevinR is talking about taking 10 doses of 4mg Dexamethasone.
Rod, I think he's asking how much he might carry, not how many he should take. Sounds like 10 4mg pills would be plenty-- I'd consider half that.


To clarify - yes, Steve has it right. And FWIW - I would more likely be carrying it to assist others. Am not against self-medicating, but I work hard at doing things to prevent the onset of AMS, mainly making the effort to get to at least 10K+' every couple of weeks year-round. Before I'd made that post I'd googled the drug, and had found only .5 and 1mg dosages - apparently it's available in higher doses as well. So, as Steve suggests, even 4 tablets at 4mg strength might be adequate for a single emergency.

I've taken Wilderness First Aid many times at SOLO in Conway, NH, and in that setting the focus is on emergencies often found in the mountains of northern New England, which quickly enters sub-Arctic conditions with a bit of elevation gain. The emphasis is more on topics like the prevention and treatment of hypothermia, broken bones, and allergic reactions to bee stings. I don't recall ever discussing HACE or HAPE during those sessions.

Steve's friend raises a good point about liability - people in CA seem far more likely to sue each other than those in New England (or at least that's the perception), and since I consider myself "a Vermonter living in California", I have some difficulty making that adjustment.


Edited by KevinR (06/14/10 07:45 AM)

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#5187 - 06/14/10 07:54 AM Re: Dexamethasone and HAPE [Re: Steve C]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Thanks, saw it, and thanked him for it. That is a link to a fellowship program in Stanford. Still trying to determine if there is an MD closer to where I am (SF/Berkeley), though willing to go to Stanford if need be.

Again, thanks for all the great responses. Internet bulletin board or not, this is a great resource.

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#5188 - 06/14/10 08:59 AM Re: Dexamethasone and HAPE [Re: KevinR]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Just to be clear Dexamethasone is not SAR in a bottle.Unless you are a licensed doctor to prescribe medication I would advise against giving anyone other than yourself a powerful drug such as Dex. I am not sure anyone should be giving it to themselves without thourough understanding of the effect of that drug on themself and the proper indication for its use.

As I stated a single 4mg pill of Dex is not a low dose.If you came across a stranger or all of a suuden noticed someone in your group was in trouble would you know how much dex to give them? Would you know how much you should take yourself? One of the most important things a doctor does before ever prescribing any drug is to take a complete history of a person and to know their complete medical history and reactions or allergies to meds.

Its complicated.There are 12,000 medications errors everyday in hospitals in the USA.This includes too much,not enough,wrong medication and bad complications of mixing meds which are contraindicated for each other.This is in a controlled medical environment.Please be careful with meds for yourself but especially if ever considering giving them to someone else.

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#5191 - 06/14/10 10:12 AM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
One of the adages in medicine is "No one should die without the benefit of Steroids". While a joke, is partially true.

Remember that the problem that we are talking about here, is LIKELY to cause the death of the person in a short period of time. LIKELY. The potential side effects of a single 4mg dose of dex is, for all practical purposes, none. A person suffering from HACE or HAPE will be very difficult to obtain a history from. The administering of dex would be covered by good sam laws.

Placing a med on a rock, then leaving.....bad idea. By placing the med, you have affirmatively attended to the person, and you are legally required to stay around until relieved by a higher provider, the patient dismisses you. Remember the clinical entity we're talking about is dire, with the person LIKELY to die shortly without intervention. If you leave, you lose your protection.

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#5202 - 06/14/10 12:08 PM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
We are talking Whitney Zone here correct? What are the chances in the WZ that you are going to come across someone in dire need about to die from HAPE or HACE and that you happen to have Dex in your pocket?
There is almost no place on the MMWT that if you start to feel bad you can't stop and rest or decide to turn around and descend.We aren't talking Camp 2,3 or 4 on Everest are we? I want to get this clear in my mind what we are talking about here.

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