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#4994 - 06/07/10 09:10 PM Dexamethasone and HAPE
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Never mind this question. Folks have suggested there is a limit to use of this bulletin board on issues about which the data is still developing.


Edited by Akichow (06/07/10 11:37 PM)

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#4999 - 06/07/10 10:57 PM Re: Dexamethasone and HAPE [Re: Akichow]
Mike Condron Offline


Registered: 11/05/09
Posts: 215
Loc: Now Manteca, CA
Akichow,
You're asking for advice on some pretty complex and potentially serious medical issues here. I'd direct my inquiries directly to an MD that is familiar with this stuff.
_________________________
Mike

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#5001 - 06/08/10 12:06 AM Re: Dexamethasone and HAPE [Re: Akichow]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
Well, I am sorry you pulled your question and discussion.

There is quite a bit of knowledge in the forums (or is it "fora") regarding Diamox, and it is reassuring to hear people's like or dislike of it, and the discussion of the side effects, even the varying dosage levels. One cannot get that from a ten-minute discussion with a time-pressed doctor. And good luck finding a doctor who knows much about mountaineering illnesses, besides.

There are several doctors who participate in the forums, and I'll bet they both know lots more than the average doctor about the topic, since they are involved in mountaineering.

A few minutes of their time here reaches a good number of hikers. And then the discussion can be found by the search engines, too. More discussion is better.

And everyone knows that information you get on the Internet can be false. (If you don't know it, read the Disclaimer!) But in a forum, when lots of people say nearly the same thing, it makes that information more believable.

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#5005 - 06/08/10 07:04 AM Re: Dexamethasone and HAPE [Re: Steve C]
wbtravis Offline


Registered: 09/22/09
Posts: 1253
Loc: Corner of Jack Benny and Roche...
I have discussed the use of Diamox with two of my primary care physicians neither knew much about the use of the drug for use in the mountains. In fact, the first one said take 250 mg. twice daily the entirety of my a seven day trip.

I've learned a lot on WPSMB and the rest of the internet since that first trip in 2001. My current dosing regiment is substantially different than the aforementioned and different from current orthodoxy but it works pretty well for me.

As for HAPE, I've seen one case in about 20 years coming to the Sierra. AMS continues to be a major issue.

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#5006 - 06/08/10 08:25 AM Re: Dexamethasone and HAPE [Re: Steve C]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Yeah, my question related to Dexamethasone and whether, if it was the only drug you happened to have on you at altitude, there was data to support its use as a treatment for HAPE (not HACE) that has already onset. I see the controversy re use of Dex for prophylactic purposes, but I am just wondering about emergency use of Dex for HAPE, if you happen to be carrying it and nothing else (e.g., nifedepine). Some gov't websites mention it briefly, but I don't see references to DATA to support this use as there are for other uses of Dex.

I do realize that the internet is a mixed source for info; that you can't blindly rely on what people tell you; and that you should consult a medical doctor with knowledge about high altitude medicine about such issues. It also looks like the data is still developing on these issues, so probably not an easy question to answer without about 50-plus caveats. If someone would prefer to PM me with info on this, happy for that too.

Am asking about Dex rather than Diamox because of sulfa issues.


Edited by Akichow (06/08/10 08:27 AM)

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#5008 - 06/08/10 08:46 AM Re: Dexamethasone and HAPE [Re: Akichow]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
I think wbtravis mentioned Diamox to underscore the idea that most doctors just do not know about mountaineering issues, because maybe one in hundreds of their patients ever ask for or need treatment.

So everyone, please do NOT get the two drugs mixed up.

And Akichow, I think your chances of experiencing either HAPE (High Altitude Pulmonary Edema) or HACE (High Altitude Cerebral Edema) are probably less than one in thousands. And if you spend several days at moderate altitude (8-10k) before you climb Whitney, your chances are probably reduced to one in a million.

Looking at Wikipedia's Dexamethasone page, it included this ironic note about its use:

High altitude illnesses

Dexamethasone is used in the treatment of high altitude cerebral edema as well as pulmonary edema. It is commonly carried on mountain climbing expeditions to help climbers deal with altitude sickness. British mountain climber Peter Kinloch was provided with a shot of dexamethasone shortly before his death, after summiting Mount Everest.

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#5035 - 06/08/10 08:31 PM Re: Dexamethasone and HAPE [Re: Steve C]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I can weigh in on this a little since i know something about Dexamethasone.Dex is an oral steroid and a totally totally different type of drug than diamox which is a diuretic.Dex works as an anti-inflamatory drug to reduce swelling where diamox reduces swelling by eliminating fluid through the kidneys.Steroids have serious side effects and should be used strickly under doctors supervision and only for short periods.Some steroids are given in large doses and then quickly tapered off ie. Prednisone packs.Oral steroids are commonly used to reduce chronic pulmonary inflamation.To answer the question in an emergency situation for HAPE and all you had was Dexamethasone I would use it.It is not the drug of choice for prophlactic prevention of altitude sickness.


Edited by Rod (06/08/10 08:36 PM)

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#5036 - 06/08/10 09:27 PM Re: Dexamethasone and HAPE [Re: Rod]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Thanks for these thoughts. In terms of prevention, I am going the slow acclimatization route (2 days, three nights at 9,000 plus feet, with day hikes higher, before tackling the main trail) rather than the drug-as-prophylactic route, a personal decision to be sure.

But does anyone have a suggestion for a doctor with high altitude knowledge in the SF Bay Area? I am thinking a consult might be worthwhile given that my hiking plan this summer will be significantly kicking it up a notch.

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#5040 - 06/09/10 07:13 AM Re: Dexamethasone and HAPE [Re: Akichow]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
How high have you hiked previously, and have you had any prior altitude problems?

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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#5044 - 06/09/10 08:31 AM Re: Dexamethasone and HAPE [Re: CaT]
wbtravis Offline


Registered: 09/22/09
Posts: 1253
Loc: Corner of Jack Benny and Roche...
Bingo, CaT

This really is the rubber meets the road question.

I spent 4 years figuring out I needed to do something before I actually did anything about my AMS problem. I hate taking drugs and only do so after all other means are exhausted.

As for I'm going spend 3 days at elevation before tackling 14,508', this does not guarantee anything. My absolute worse AMS episode happened after extended acclimatization. I had absolutely no problems reaching White Mtn. However, one bit of food and the ca-ca hit the fan, nausea, headache, lack of appetite and malaise. The symptoms went buh-bye back in Big Pine at 4,000' 5 or 6 hours later...not before.

I would never recommend the use of drugs prior to having more than a few problem trips to elevation. The drugs, as stated, have their own set of problems.

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#5045 - 06/09/10 08:33 AM Re: Dexamethasone and HAPE [Re: CaT]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
I do a lot of long distance hiking but little experience above 12,000. No reason, to think I am particularly susceptible to problems, though, so no prophylactic drug use for me.

But, no harm in thinking about these issues and doing an MD consult. So, if someone has a suggestion for MD in SF with high altitude knowledge, please email away.


Edited by Akichow (06/09/10 08:37 AM)

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#5064 - 06/09/10 11:31 AM Re: Dexamethasone and HAPE [Re: Akichow]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
On this page is a list of Wilderness Medicine faculty at Stanford:

http://emed.stanford.edu/fellowships/wilderness.html

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#5070 - 06/09/10 12:50 PM Re: Dexamethasone and HAPE [Re: Akichow]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
With the caveat that everyone reacts to altitude differently, in general, many folks who have altitude issues on the Whitney Main Trail (if they are going to have altitude problems at all), usually begin having them somewhere between Trail Camp (~12,000') and Trail Crest (13,600'), as they are ascending the 97 Switchbacks. There are always exceptions, of course; but this generalization seems to fit what happens for many people who do encounter altitude problems on that trail.

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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#5073 - 06/09/10 01:16 PM Re: Dexamethasone and HAPE [Re: Rod]
SoCal Jim Offline


Registered: 06/09/10
Posts: 29
Loc: Southern California
Dexamethasone has long been available as an injectable med. It is a steroid and can be given IV or IM. It can be almost a miracle drug in its fairly quick onset when injected IM into a person suffering from acute HAPE or HACE. (See examples as written by Jon Krakauer in "Into Thin Air" when they were trying to get Sandy Pittman and Beck Weathers off the mountain.) Points to remember are that it is for use in an emergency in these circumstances; it's not used to prevent AMS. And it's effects are temporary, as in a few hours. The only definitive intervention for a victim of HAPE or HACE is descent, as rapidly as possible.

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#5078 - 06/09/10 02:15 PM Re: Dexamethasone and HAPE [Re: Ken]
Akichow Offline


Registered: 04/07/10
Posts: 659
Loc: SF Bay Area
Great resource, thanks!!!!!!!!!!!!!

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#5096 - 06/09/10 08:54 PM Re: Dexamethasone and HAPE [Re: CaT]
wbtravis Offline


Registered: 09/22/09
Posts: 1253
Loc: Corner of Jack Benny and Roche...
Originally Posted By: CaT
With the caveat that everyone reacts to altitude differently, in general, many folks who have altitude issues on the Whitney Main Trail (if they are going to have altitude problems at all), usually begin having them somewhere between Trail Camp (~12,000') and Trail Crest (13,600'), as they are ascending the 97 Switchbacks. There are always exceptions, of course; but this generalization seems to fit what happens for many people who do encounter altitude problems on that trail.

CaT


Let's see, I've tossed my cookies at June Lake, Whitney Portal, Chickenfoot Lake, Saddlerock Lake and have reached various peaks over 10,000' without any AMS related problems...including Mt. Whitney and the 9 nine peak of the SGW one weekend.

Sometimes there is no rhyme or reason...you just get waylaid or have a great time. That's why, if I'm spending a bunch of time over 8,360', I will do the Diamox thing.

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#5124 - 06/10/10 07:38 PM Re: Dexamethasone and HAPE [Re: Akichow]
John P. Offline


Registered: 03/19/10
Posts: 52
Loc: Palmdale
Just having read "High Crimes" by Micheal Kodas, the author wrote about how certain climbers have taken to using dexamethasone orally in the absence of HAPE or HACE on Everest - more or less a high altitude performance enhancing drug. The benefits can be tremendous such as decreasing inflammation in joints and in the lungs but it also greatly decreases one's already diminished healing ability as well as all but wiping out the immune system. Very scary situation given the prevalence of intestinal infections and pneumonia on these big expeditions.


Edited by John P. (06/10/10 07:40 PM)
_________________________
"Get Busy Living or Get Busy Dying" Andy Dufresne, The Shawshank Redemption

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#5129 - 06/10/10 09:56 PM Re: Dexamethasone and HAPE [Re: John P.]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I know personally the miracle relief of joint and back pain from taking dexamethasone although it is only temporary. The trade off of side effects cancel the overall benefit.Serious drug.It really heats up the debate about who should be attemting high altitude adventures like Everest. If one has to take drugs like Dex then should that person even be there in the first place? Are people who are not physically able to be at altitude being enticed to attempt 20K+ climbs because there are doctors giving drugs to overcome HACE and HAPE? I have a problem with that.Not only immune suppression but adrenal gland compromise make Dex a dangerous drug.It also masks pain and leads to joint degeneration by overriding the pain message of physical exertion.

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#5131 - 06/11/10 05:50 AM Re: Dexamethasone and HAPE [Re: Akichow]
Bob R Offline


Registered: 10/27/09
Posts: 129
Loc: Ridgecrest, California
Here is what Charles Houston MD has to say about HAPE on p. 144 of in his latest (fifth, 2005) edition of Going Higher: Oxygen, Man, and Mountains (available from Amazon):

"Because it is difficult to determine the number of people at risk, we can only approximate the percentage of visitors to mountain areas who develop HAPE. In addition to altitude, there are many other contributing factors, such as speed and method of ascent, level of exercise, and individual susceptibility. Extensive data collected from Mount Kenya, the Mount Everest region, the Indian Himalayas, Peru, Colorado, and the European Alps suggest that anywhere from 0.01 percent to 4.5 percent of the people who go to high altitude develop HAPE. One report from the Sino-Indian war in 1962 gave an incidence of 15 percent. Most cases occur after twenty-four to forty-eight hours at altitude, mainly above 10,000 feet. These disparate findings illustrate the difficulty in interpreting information collected in different ways by different individuals in different situations."

What might this mean for Mt. Whitney? Taking 160 people per day during the summer as a working number (60 overnight + 100 day):

* 0.01% is about one every other month
* 4.5% is about seven per day
* 15% is 24 per day

I have long suspected that unrecognized cases of HAPE (incipient, perhaps) among Mt. Whitney visitors are more frequent than commonly thought. For any number of reasons the afflicted person may turn around and descend, thereby quickly and easily correcting the situation--without ever having been aware of what it was.

-----

And AMS? Houston quotes a number of prior studies. Extracting results that are most meaningful for us, the instances of AMS, in previously unacclimatized people, were (ibid p. 113):

* 40% of those going to 8900' (1989)
* 27% of those going over 9000' (1993)
* 17% of those going to 9500' (1985)
* 42% of those going to 9800' (1990)
* 34% of those going to 12000' (1989)
* 42% of those going to 14000' (1986)

As we all already well know, AMS strikes a large fraction of Whitney visitors. But here are some quantifications. The unacclimatized should learn that AMS is possible--even likely--and know how to prepare in advance for it. And how to deal with it if it hits. Use the search function to find the voluminous information already posted about it on whitneyportalstore.com.

I don't have analogous frequency numbers for HACE. But HACE--the "end stage" or severe AMS--is considerably less common than AMS or HAPE. Nevertheless, the new Mt. Whitney visitor should probably learn a little about it, as well.



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#5132 - 06/11/10 05:50 AM Re: Dexamethasone and HAPE [Re: Akichow]
Bob R Offline


Registered: 10/27/09
Posts: 129
Loc: Ridgecrest, California
Since you say that you have little experience above 12,000', I wonder why you are singling out HAPE and excluding the other two conditions that comprise the spectrum of high altitude illness: AMS and HACE. AMS is certainly far more common than HAPE.

Regarding dexamethasone and other drugs in this context, here is what I wrote on the WPSMB some years back:

-----

A recent question (Aspirin or Ibuprofen or ?) is very pertinent for the unacclimatized Mt. Whitney visitor. It's addressed in a paper in the New England Journal of Medicine (Peter Hackett, MD, and Robert Roach, PhD. "High Altitude Illness", Vol. 345, No. 2 - July 12, 2001). Hackett is probably the best high-altitude pathologist in the world, and Roach is a well-known researcher. This is a survey paper with fully 76 references. If you don't want to wade through what follows, the findings are that aspirin has proven useful in prevention of high altitude headaches, and ibuprofen in treatment.

Headaches are one element of the broader topic of acute mountain sickness (AMS). For the broader question, one paragraph in the paper is long but especially pertinent: "For the prevention of high-altitude illness, the best strategy is a gradual ascent to promote acclimatization. The suggested guidelines are that once above an altitude of 2500 m, the altitude at which one sleeps should not be increased by more than 600 m in 24 hours and that an extra day should be added for acclimatization for every increase of 600 to 1200 m in this altitude. For example, as compared with ascent to an altitude of 3500 m in a one-hour period, a gradual ascent over a period of four days reduced the incidence and severity of AMS by 41 percent. Most experts recommend prophylaxis for those who plan an ascent from sea level to over 3000 m (sleeping altitude) in one day and for those with a history of AMS. Acetazolamide is the preferred drug, and dexamethasone is an alternative; both are unequivocally effective; the dosages vary. The combination was more effective than either alone. Although controversial, small doses of acetazolamide (125 mg twice a day in adults) appear empirically to be as effective as larger doses, with fewer side effects; the minimal effective dose remains uncertain. In two controlled trials, Ginkgo biloba prevented AMS during a gradual ascent to 5000 m and reduced both the symptoms and the incidence of AMS by 50 percent during an abrupt ascent to 4100 m. With respect to headache, prophylactic aspirin (325 mg every four hours for a total of three doses) reduced the incidence from 50 percent to 7 percent. Reports suggest various Chinese herbal preparations might prevent high-altitude illness, but controlled studies are lacking. The notion that overhydration prevents AMS has no scientific basis."

Another paragraph, in part: "A small, placebo-controlled study showed that the administration of acetazolamide reduced the severity of symptoms by 74 percent within 24 hours. Multiple studies have demonstrated that dexamethasone is as effective as or superior to acetazolamide and works within 12 hours. Whether the combination of acetazolamide and dexamethasone, because of their different mechanisms of action, is superior to the use of either agent alone is unknown. In two studies, a single dose of 400 mg or 600 mg of ibuprofen ameliorated or resolved high-altitude headaches."

I'll add a personal opinion. While overhydration may not prevent AMS, I agree with the others: Staying sufficiently hydrated is one of the most important things you can do. It's difficult when you're not feeling well, but drinking at least a half-liter an hour while you're hiking is a good goal - a liter an hour if you're sweating a lot.

(Note 1: The original paper can be viewed here.)

(Note 2: More recent studies have discounted the effectiveness of Gingko biloba treating AMS.)

(Note 3: A good friend of mine, who has been climbing in the Sierra almost as long as I have, suffered badly from AMS on every trip. About 15 years ago, a local physician (also a mountaineer) prescribed a small dose of dexamethasone for him. Now he takes it every time, and does not have any symptoms.)

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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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#5203 - 06/14/10 12:12 PM Re: Dexamethasone and HAPE [Re: Rod]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
Originally Posted By: Rod
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.

Rod, yes we're talking about Mt. Whitney. In the last several weeks, there was a thread on WPSMB about a fellow in a party who was definitely suffering from HACE. The hiker was stumbling and possibly unable to descend due to the conditions in his state. Another hiker gave the party Dex, and it improved the striken's condition to where he was able to descend.

Last year in the Horseshoe Meadows area, there was a teenager who needed to be rescued due to HAPE.

Last year, a hiker died just over Paiute Pass due to altitude issues.

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#5205 - 06/14/10 12:44 PM Re: Dexamethasone and HAPE [Re: Rod]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
Rod, I'm sure severe, deadly cases of HAPE or HACE don't happen nearly as often in the Sierra as they do in the Himalaya or other higher ranges, but I know from personal experience that it happens. Unfortunately it happened to someone I ran across at Cottonwood Lakes last August.

A teenage boy (16, I believe) hiking with a group. I stopped to chat with them for a while, and the boy was definitely suffering from a bad case of AMS (killer headache, nausea, lethargy, dizziness). His friends didn't seem that concerned about him, but I strongly suggested they get him back down to Horseshoe Meadow and then on to Lone Pine. They said they'd watch him and make a call about what to do a little later in the day. We chatted for a while about taking an easy pace, hydrating, eating, etc. All they had for headache was Tylenol, so I left some Advil with them and went on about my hike.

I was shocked to read in the Inyo Register the next day that the boy had to be medi-evaced out and was DOA at the hospital from "AMS", which I'm sure was probably HACE or HAPE. Hours after I left that group, the boy was dead from the altitude at "only" 11K'.

If I had had dex with me, would I have left some with them? I don't really know, in retrospect. The kid was suffering, but it looked like the same thing my wife expereinced her first trip up to 14K' (Pikes Peak). She was fine after getting back down to 7K' (quickly!), and the one personal experience I've felt with AMS went completely away once I descended about 2500 feet. I certainly didn't think this boy's life was in danger but, now that I have that experience in my rearview mirror, I may act differently in the future (assuming I ever have any dex with me, which is a big if).

That experience has definitely changed my perception about AMS - I always thought of the deadliness of AMS progression as being pretty much in the 20K' and above climbing world, but I see it a little differently now.

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#5207 - 06/14/10 12:51 PM Re: Dexamethasone and HAPE [Re: Steve C]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
This thread has morphed into something it did not start out as, and not what the original poster intended. I am repeating here much of what has already been said.

Are we talking here about simple AMS? - no

Was the original question specifically about HAPE only? yes

Is HACE or HAPE a life-threatening emergency - yes

How soon? - now

Is the death rate high? - 20-80% depending on circumstances.

Is it common at Whitney altitudes? - no

Does it happen at Whitney altitudes? - yes

Note: What is the official altitude threshold for altitude illness incl AMS, and complications HAPE, HACE and death -
8,000 feet and above. Yes, only 8,000 feet.

Was the original question about Dex for AMS or HAPE? - HAPE

Are there side effects of Dex? - yes

Are these short term or long term worries? - mostly long

Does a potentially dying HAPE or HACE victim need to worry about these side effects? no, the benefit far outweighs ANY risk.

What would you do if your climbing partner or family member was at altitude, and on the third day woke up with shortness of breath, coughed up pink-tinged fluid, had rattling in the chest, cyanotic blue lips, a heart rate of 140 and a respiratory rate of 40, and was delirious? See below.

If the patient has HAPE or HACE but because of weather, injury, darkness, or whatever, and there is no evacuation possible, and no Gamow bag, and no bottled O2, then please give the dex and conclude this thread here.

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#5208 - 06/14/10 12:56 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
Great conclusion, Harvey.
Thanks.
_________________________
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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#5224 - 06/14/10 03:10 PM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Rod, last year, a very fit climber on a guided trip to climb Langley, developed sypmtoms of HAPE, and in about an hour proceeded to die. This was under about 11k feet.

There is little that is as frustrating as encountering someone dying of something that is easily treated, but can't be, because you don't have the treatment.

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#5236 - 06/14/10 07:20 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Norris Offline


Registered: 06/14/10
Posts: 22
Loc: Del Mar, CA
A recent study found that Cialis (Tadalafil) was nearly as effective as Dexamethasone for prevention of HAPE in the HAPE-susceptible:

http://www.annals.org/content/145/7/497.full.pdf+html


And it would seem that the consensus opinion is still that Nifedipine is effective at both preventing and treating HAPE:

http://books.google.com/books?id=NG21K80G_04C&pg=PA811&lpg=PA811&dq=nifedipine+%2BHAPE
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/altitude-illness.aspx

http://www.mpoullis.net/bsphysiol/altitu...tm#HAPE-therapy

I'd like to see a study comparing all 3 drugs, that would be worthwhile.

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#5238 - 06/14/10 08:15 PM Re: Dexamethasone and HAPE [Re: Norris]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Harvey great consolidation of the questions with good answers.I am aware people suffer and have died from HAPE and or HACE on Whitney.It is not common. So what is the conclusion? Do we all to become instant SARs and carry dex to administer to cases of AMS that may or may not proceed to a deadly or dangerous level.So should we all start packing Dex in our basic 10 now basic 11? It is a tough call IMO.

Norris I have seen those studies. they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


Edited by Rod (06/14/10 08:19 PM)

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#5246 - 06/15/10 05:04 AM Re: Dexamethasone and HAPE [Re: Rod]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
Originally Posted By: Rod
. . . they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


That could make for some tricky hiking . . .

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#5248 - 06/15/10 06:45 AM Re: Dexamethasone and HAPE [Re: Rod]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
Originally Posted By: Rod
Do we all to become instant SARs and carry dex to administer to cases of AMS that may or may not proceed to a deadly or dangerous level.

No, not to simple, uncomplicated AMS.

While Dex helps AMS symptoms quite well, it only covers up the symptoms. It does not help acclimatization. The patient is still at risk for developing complications, therefore Dex could be counterproductive when used for uncomplicated AMS.

Dex, as stated earlier, is for emergency RX of HACE, HACE/HAPE combo, and somewhat for HAPE alone. One of the fastest and best ways it helps is to perk up a patients mental function enough that they are again ambulatory to get themselves down, the preferred option.

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#5250 - 06/15/10 06:55 AM Re: Dexamethasone and HAPE [Re: Bulldog34]
wagga Offline


Registered: 10/07/09
Posts: 2249
Loc: Humbug Reach (Pop. 3)
Originally Posted By: Bulldog34
Originally Posted By: Rod
. . . they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


That could make for some tricky hiking . . .


A lover with a hiking problem?
_________________________
Verum audaces non gerunt indusia alba. - Ipsi dixit MCMLXXII

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#5254 - 06/15/10 07:57 AM Re: Dexamethasone and HAPE [Re: wagga]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

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#5255 - 06/15/10 08:06 AM Re: Dexamethasone and HAPE [Re: Rod]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

Harvey or Ken -- Would the average doctor even Rx Dex at any dosage for their asymptomatic Pt so they can carry it on the trail with them "just in case", and esp. if they knew it might be used for someone else rather than for the Pt requesting it?
_________________________
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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#5257 - 06/15/10 08:37 AM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
No. Hell, most don't go to the bother of taking a first aid course to be able to help other people.


Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

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#5258 - 06/15/10 08:41 AM Re: Dexamethasone and HAPE [Re: CaT]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Originally Posted By: CaT
Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

Harvey or Ken -- Would the average doctor even Rx Dex at any dosage for their asymptomatic Pt so they can carry it on the trail with them "just in case", and esp. if they knew it might be used for someone else rather than for the Pt requesting it?


Hard to speak about averages. Remember, in the office, they are ALL asymptomatic, even if near-death in the field.

You may find it interesting that something like 3% of the people we interviewed in our Whitney study a few years back DID carry dex or the equivalent. I was astonished by that.

The average person would not make such a request. The person who likely would, would be someone who had spent some time reading up on the subject. I've never had such a request. Diamox, yes.

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#5259 - 06/15/10 08:51 AM Re: Dexamethasone and HAPE [Re: Ken]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
Originally Posted By: Ken
The average person would not make such a request. The person who likely would, would be someone who had spent some time reading up on the subject. I've never had such a request. Diamox, yes.

Same here, Ken.
Harvey

PS:Original poster Akichow first brought up the question on this thread and is therefore, by his action, not the average person. I hope we have answered his questions.

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#5260 - 06/15/10 08:58 AM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I guess I should say my final word on the subject.It is unlikely any doctor would prescribe dex to an asymptomatic patient especially if it were for the possiblity to help a random stanger in the mountains.
I am all about personal resonsibility.There are way too many people who try to take short cuts in preparation and over estimate their ability.From climbing Mt. Hood with a hundred year storm on its way to taking a casual stroll up the Main Whitney Trail.Many don't train enough,acclimate enough or investigate enough their own ability at altitude. This age of a drug to fix everything makes us take chances we really shouldn't.It is really unfortunate that people get into trouble on our local 14ers.Dex,Diamox, Cialis/Viagra should not be thought of short cuts to preparation. No one should ever go expecting that some magical life saving drug is in the pocket of a random stranger passing by.

It would be an interesting study to find out the "story" behind everyone who has suffered Hape or HACE in our local 14ers. Did they train,were they experienced? I am sure there are some who did everything right and still got into trouble. I sure would like to know the reasons why people suffered AMS, HAPE or HACE and what they could have done to prevent it.


Edited by Rod (06/15/10 09:08 AM)

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#5264 - 06/15/10 09:29 AM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Well, glad you are able to speak on behalf of the doctors of america. I certainly don't.
I wonder why you asked the question, if you had already made up your mind? In spite of the fact that I tried to *gently* suggest that the scenario you'd suggested is highly unlikely, and has not happened in, what, 50 years of combined experience between Harvey and I.

The more likely, although still not experienced scenario, would be a paramedic, another physician (you know that we generally cannot prescribe meds for ourselves), asked for a prescription for emergency use for themselves or someone they might encounter, I'd give it with no hesitation.

I can't quite fathom your reasoning for bringing up the issue of shortcuts in preparation, in the context of life-saving treatments? Would you come upon a person having a heart attack, and lecture them on inadequate preparation? It's just inappropriate to the situation under discussion, I think.

Your mileage may vary...



Originally Posted By: Rod
I guess I should say my final word on the subject.It is unlikely any doctor would prescribe dex to an asymptomatic patient especially if it were for the possiblity to help a random stanger in the mountains.
I am all about personal resonsibility.There are way too many people who try to take short cuts in preparation and over estimate their ability.From climbing Mt. Hood with a hundred year storm on its way to taking a casual stroll up the Main Whitney Trail.Many don't train enough,acclimate enough or investigate enough their own ability at altitude. This age of a drug to fix everything makes us take chances we really shouldn't.It is really unfortunate that people get into trouble on our local 14ers.Dex,Diamox, Cialis/Viagra should not be thought of short cuts to preparation. No one should ever go expecting that some magical life saving drug is in the pocket of a random stranger passing by.

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#5269 - 06/15/10 10:53 AM Re: Dexamethasone and HAPE [Re: Ken]
SoCal Jim Offline


Registered: 06/09/10
Posts: 29
Loc: Southern California
This thread seems to keep wandering between the indications for emergency uses of meds (injectable dex) and performance-enhancing/AMS-prevention pharmacology. While Diamox has been shown to be fairly safe in common use as a prophylaxis for AMS, the take home should be that there are "no shortcuts to the top" (as per Ed Viesturs). Fitness is key. All meds have risks and side effects and are no substitute for training. And if you're not familiar with emergency use of potent meds such as dex, then you shouldn't be concerning yourself with whether or not to carry and use them.

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#5270 - 06/15/10 11:12 AM Re: Dexamethasone and HAPE [Re: SoCal Jim]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
SoCal Jim wrote:
> Fitness is key.

Actually, Jim, in cases of HAPE and HACE, better fitness might be a negative factor. More fit hikers can ascend more quickly, getting them to the higher altitude danger zone faster. AMS and the more serious problems can hit even the most fit.

It might be better to say "Acclimatization is key."

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#5271 - 06/15/10 11:13 AM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Ken I sense a real attitude against me in your response. That's OK if you think that is an appropiate way to discuss contraversial issues in this forum. I am working through this issue out loud through this thread and it brings up a lot of tough ethical issues.I am not lecturing anyone. I am trying to be open and honest about a real tough issue.
I don't undestand why you can't "fathom" my reasoning for bringing up the issue of short cuts in preparation.I see it as a real and dangerous problem that people think they can short cut their physical peparartion and acclimation knowing performance enhancing drugs might get them by without putting the actual study,and preparation necessary.That model is clearly followed in HS to Pro sports.Many people take the path of least resistance in preparation.

I really don't see the connection to having that opinion and lecturing people who have had a heart attack. That is my opinion and I am entitled to that.That may not have been the origional question asked in this thread but it has morphed into etical considerations of what is appropiate to do in a certain situation.Many discussions start out that way and evolve into peripheral topics.We are just having dialogue. No right or wrong absolutes are being laid out.


Edited by Rod (06/15/10 11:19 AM)

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#5272 - 06/15/10 11:22 AM Re: Dexamethasone and HAPE [Re: Rod]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
Rod wrote:
I see it as a real and dangerous problem that people think they can short cut their physical preparation and acclimation

Rod, people are time-challenged. Most of us try to do the most we can with the least amount of time spent preparing. Aren't most things in life like that?

It is just a fact that serious altitude issues hit a small minority of people in the Sierra. Unfortunately, these people don't have any way of knowing before hand that they are so much more susceptible to the trouble than all the rest. If they did, they could either spend the necessary extra time acclimating or else avoid going to altitude. And since most people do ok at the altitudes, why would anyone expect themselves to be so much more susceptible than the average?

The reality is that these people do get themselves into the seriously dangerous situations. And if someone brought a medication along that could save their life, wouldn't that be a good thing?

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#5274 - 06/15/10 11:37 AM Re: Dexamethasone and HAPE [Re: Steve C]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
All seriousness aside, I still like Rod's thought about the potential use of other vasodilators in mountaineering. If the INFS would issue a couple of Viagra to each hiker with their permit, climbing Whitney might be harder more difficult, but the TRs would be eminently more intriguing . . .

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#5275 - 06/15/10 11:42 AM Re: Dexamethasone and HAPE [Re: Rod]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
Originally Posted By: Rod
I see it as a real and dangerous problem that people think they can short cut their physical preparation and acclimation knowing performance enhancing drugs might get them by without putting the actual study,and preparation necessary.


That is not the use of dex suggested here.

and

all of the study, preparation and acclimatization in the world will not prevent all cases of AMS and its complications. As an example, after his success on Everest in 1953, Ed Hillary later went to Makalu and developed HAPE. If it can happen to Sir Ed, it can happen to me and you.

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#5277 - 06/15/10 01:29 PM Re: Dexamethasone and HAPE [Re: Rod]
DUG Offline


Registered: 09/22/09
Posts: 370
Loc: Wildomar
Originally Posted By: Rod
That is my opinion and I am entitled to that.


Amen brother! Too many times it seems like we can't give our own personal opinion on a topic without being accused of something. Of course, that statement there is just my opinion..............................................DUG

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#5279 - 06/15/10 03:17 PM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Rod, you don't seem to understand that my answers were directed to very narrow questions, and you have responded as though I am discussing a much larger issue, which I'm not. I am addressing myself to the title of this thread, and to a lesser degree to HACE, a related problem.

You then asked a "bait" question about what physicians (of which I am one) would do, then, flatly stated after I'd answered, that that is not what physicians would do (of which I don't think you are one).

Why on earth would I have a problem with your responses?

Do I advocate dex for simple AMS: no

Do I advocate dex as a substitute for acclimatization: no

Do I advocate doing everything possible to avoid a death: yes

Would I recommend Diamox for a person who has a history of HAPE: yes, in addition to acclimatization.

Would I recommend that a person with a history of HAPE carry dex: Yes, they are at high risk, and it may save their life.

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#5281 - 06/15/10 04:21 PM Re: Dexamethasone and HAPE [Re: Ken]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1024
Loc: Richmond, Virginia
This might be a good time to :
(1) Conclude this thread (please)
(2) provide some references for those who want to learn more, and for those who need to learn more.

This is the link I previously posted by International Society Mountain Medicine (Note: this is one of several similar sources. There are some nuances and variations as is expected for the management of a biological/medical problem where there is the mix of science, experience, and judgment.)
http://www.ismmed.org/np_altitude_tutorial.htm

By the grand old man of the mountains, Charles Houston (pronounced House-ton). He was famous in the 1950s for K2/Art Gilkey episode plus the first English language medical report attributing pulmonary edema to HAPE rather than heart failure, later Operation Everest hypobaric chamber tests, and versions of this book which reads well for laymen:
http://www.amazon.com/Going-Higher-Oxyge...2077&sr=8-1

My early-on favorite high altitude physiology book by Californian Herb Hultgren who took cath equipment to the Andes to help unravel the medical mysteries of soroche, the South American word for "ore." Why ore? High altitude miners got AMS, HAPE, reentry HAPE, and Chronic Mountain Sickness (Monge's Disease). The rough equivalent of that in cattle is Brisket disease.
http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dus-stripbooks-tree&field-keywords=herb+hultgren&x=15&y=18

The most current major and comprehensive text for really big bucks by two West Coasters and a Brit.
http://www.amazon.com/High-Altitude-Medi...2941&sr=1-1

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#5285 - 06/15/10 05:39 PM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Actually Ken depending on your personal understanding and knowledge of my profession. I am either a colleague of yours or your worst nightmare. I am a Chiropractor. One of 2 professions licensed to be primary care physicians. I work closely with orthopedic surgeons and medical doctors daily. All of them consider me a colleague.I never baited you with any question. Maybe you are confusing a question in this thread asked by someone else.
Harvey you are a voice of reason. Thanks for your great information.


Edited by Rod (06/15/10 05:44 PM)

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#5287 - 06/15/10 05:53 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1255
Loc: Atlanta
Originally Posted By: Harvey Lankford
The most current major and comprehensive text for really big bucks by two West Coasters and a Brit.
http://www.amazon.com/High-Altitude-Medi...2941&sr=1-1


You ain't kiddin' brother. $150 retail, but the good news is that you can get it used for as little as $92 . . .

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#5289 - 06/15/10 06:15 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Bee Offline


Registered: 09/22/09
Posts: 1261
Loc: Northern California
Originally Posted By: Harvey Lankford
This might be a good time to :
(1) Conclude this thread (please)


By your command.

Folks, I think that it is time to wrap up this topic, archive the reference material, and perhaps continue the discussion under another thread, so that we do not lose the vastly important info contributed by our esteemed trifecta of experts (as the thread veers away from its original query.)

This does not mean that anyone's opinion is of lesser value, rather, it just makes it easier to capture the more scientific data in one thread by closing it now.
_________________________
The body betrays and the weather conspires, hopefully, not on the same day.

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#5291 - 06/15/10 06:18 PM Re: Dexamethasone and HAPE [Re: Bulldog34]
Steve C Offline


Registered: 09/22/09
Posts: 7882
Loc: Fresno, CA
Thanks everyone for all the discussion. There is very much useful information to be found in this thread.

Edit: Golly Bee, you beat me to the switch! Thanks.


Edited by Steve C (06/15/10 06:19 PM)

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#5294 - 06/15/10 07:08 PM Re: Dexamethasone and HAPE [Re: Steve C]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
You both beat me to the switch. cry
_________________________
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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