Self Limiting
Some thoughts on colds and chills
As a physician in primary care (Puskesmas) for the time being, I met so many patients with self-limiting diseases in the clinic. What it means to be self-limiting is that it can resolve spontaneously across the natural history of the disease. This kind of disease does not rely on medication or surgery to convalesce. Minor ailments like the common cold, flu, headache, and sore throat are the example of them.
Because of the self-limiting nature, we could choose not be giving any medication to the patient (if the patient refuses to take it). In the majority of cases, we still prescribe symptomatic drugs that can ease the symptoms while the body attempt to recover itself. If one got a fever, we prescribe antipyretics like acetaminophen (paracetamol). If one has a productive cough, some mucolytics (like N-acetylcysteine) can be useful. Giving causal therapy (drugs that are intended to overcome the root of the disease, like antibiotics or antiviral) is generally discouraged. It is because it is redundant (they will be better either way without it), and using such drugs without solid indications can elicit antimicrobial resistance.
The tricky part of self-limiting disease is not whether it will heal (it will), but when. It can be said that most self-limiting disease does not severely impair our ability to work and make a living, but it can be sure it is annoying. We can still work on our laptops with little chills or colds, and if we sneeze every time, we can just wear a mask. But still, our productivity will decline compared to when we are in our peak physical condition.
We are frequently advised by our parents or relatives to take a rest when getting sick. Granted, in this age of intense productivity and work rate, a day off or two will help when we get chills and lethargic. However, most of the time we curse that we have the ailment. We say to ourselves “suck it up” and carry on with our jobs, because it conflicts with our career interests. Perhaps, we even work harder to distract ourselves from the looming disease. No wonder in certain cases, what should be a mild self-limiting cold that could resolve by a day’s rest could exacerbate into a more severe condition that requires hospitalization and IV fluids.
So, the problem is that we know that some condition that strike is self-limiting, but we don’t want to let them limit us for a while. We are too impatient for that. A simple cold can become a huge hurdle when we are up for a career-defining project that we are working on. We want to get it off as quickly as possible so we can work on our usual baseline.
The problem is different for parents, which put more attention to their children than anything else. The sight of a then-active and cheerful child who is now becoming languid and lethargic is alarming for parents. As a doctor, I cannot blame the parents’ frequent clinic visitations for the slightest inconvenience to their children. If only, it marks how much they care for their children. But it is also our responsibility to educate them about the natural course of the disease, and the fact that their children have to face the disease and let the disease run its course until convalescence.
But of course, some parents are just too anxious about their sick children. They want the disease to resolve quickly, so their little ones can be spared from the frustrating anorexia and occasional reflux. So after the first visits, they are usually back to the clinic after a couple of days, complaining that their children are still sick, and still don’t want to eat anything.
So the doctors are resorting to using the all-versatile-but-frequently-misused-drug: glucocorticoids or simply, steroids. Dear laypeople who read this: it is basically Dexamethasone, Prednisone, and Methylprednisolone that you may have ingested some time in your life when you are sick. Those small pills may taste bitter on your tongue but do wonders to relieve your symptoms.
The reasoning behind this prescription is simple. When people getting self-limiting diseases such as colds, the annoying symptoms come not from the source of the sickness itself (i.e. virus) but from our body’s reactions to combat the disease (fever, runny nose, cough). There is inflammation inside our body that aims to kill the pathogens inside our body. Glucocorticoids act as an anti-inflammatory agent, suppressing our body’s reactions to these microbes. So while the annoying symptoms recede, less can be said about whether the bugs are completely eliminated.
The use of steroids in self-limiting diseases has been nothing short of controversial. There are only a few studies that analyze the effect, and the results are inconclusive. Even a Cochrane systematic review only study the use of intranasal steroid (the ones that you puff into your nose). While systemic steroids can effectively withdraw the symptoms, there are many adverse effects that can come with it, like high blood sugar, high blood pressure, and even mood disturbances.
I myself am reluctant to use such drugs in these self-limiting cases, but I understand if other physicians may prescribe it to reduce follow-up visitation and reduce ailment duration (a controversial claim that has not been backed by data). But the question of whether a doctor prescribes steroid is not a medical question, but rather a philosophical one.
Some time in our lives, we must have heard the common wisdom “time heals everything” when we are encountering heartbreak, grief, or even in this case, physical malady. But I kind of disagree with this notion. We live in a world of four dimensions: three of them are space (width, length, height), and one is time. Time gives room for us to heal, a temporal aspects that gives us a larger perspective on life. For physical disease, it can mean giving period for the body to fight for itself. But for mental and spiritual ailment, it gives us the capacity to be bigger, older, and wiser as a person.
So how do you (as a patient) see this disease? Do you see it as a simple discomfort that should be endured until it recedes spontaneously, or as a nuisance and joy killer that must be eliminated as soon as possible?
Some diseases are meant to be endured. Like joy and grief, it is a part of life.
