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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: 7235
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: 1239
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: 7235
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: 1239
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: 22
Loc: Santee, CA
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: 1239
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)
_________________________
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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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