[Short-term tolerance of three days pulse methyprednisolone therapy: a prospective study in 146 patients]

BOB-ACG study: Pulse methylprednisolone to prevent bilateral ophthalmologic damage in giant cell arteritis. A multicentre retrospective study with propensity score analysis

INTRODUCTION

Giant cell arteritis (GCA) is complicated in 10 to 20% of cases by permanent visual ischemia (PVI). International guidelines advocate the use of intravenous pulse of methylprednisolone from 250 to 1000mg per day, for three days, followed by oral prednisone at 1mg/kg per day. The aim of this study is to assess whether this strategy significantly reduces the risk of early PVI of the second eye, compared with direct prednisone at 1mg/kg per day.

METHODS

We conducted a multicentre retrospective observational study over the past 15 years in 13 French hospital centres. Inclusion criteria included: new case of GCA; strictly unilateral PVI, prednisone at dose greater than or equal to 0.9mg/kg per day; for the intravenous methylprednisolone (IV-MP) group, total dose between 900 and 5000mg, close follow-up and knowledge of visual status at 1 month of treatment, or earlier, in case of contralateral PVI. The groups were compared on demographic, clinical, biological, iconographic, and therapeutic parameters. Statistical analysis was optimised using propensity scores.

RESULTS

One hundred and sixteen patients were included, 86 in the IV-MP group and 30 in the direct prednisone group. One patient in the direct prednisone group and 13 in the IV-MP group bilateralised, without significant difference between the two strategies (3.3% vs 15.1%). Investigation of the association between IV-MP patients and contralateral PVI through classical logistic regression, matching or stratification on propensity score did not show a significant association. Weighting on propensity score shows a significant association between IV-MP patients and contralateral PVI (OR=12.9 [3.4; 94.3]; P<0.001). Improvement in visual acuity of the initially affected eye was not significantly associated with IV-MP (visual acuity difference 0.02 vs -0.28 LogMar), even in the case of early management, i.e., within the first 48hours after the onset of PVI (n=61; visual acuity difference -0.11 vs 0.25 LogMar). Complications attributable to corticosteroid therapy in the first month were significantly more frequent in the IV-MP group (31.8 vs 10.7%; P<0.05).

DISCUSSION

Our data do not support the routine use of pulse IV-MP for GCA complicated by unilateral PVI to avoid bilateral ophthalmologic damage. It might be safer to not give pulse IV-MP to selected patients with high risks of glucocorticoids pulse side effects. A prospective randomised multicentre study comparing pulse IV-MP and prednisone at 1mg/kg per day is desirable.

The effects of high-dose corticosteroids for multiple sclerosis relapse on blood pressure: A pilot study

BACKGROUND

Multiple sclerosis (MS) relapses are often treated with short pulses of high dose corticosteroids. Previous literature demonstrates corticosteroids can increase blood pressure (BP). There are few studies regarding effects of high dose, pulse corticosteroids on BP when treating MS relapses.

OBJECTIVE

To investigate the effect of high dose pulse corticosteroids for MS relapses on BP and determine factors that may influence development of acute hypertension.

METHODS

In this open-label pilot study, adult patients with a diagnosis of MS were enrolled if determined to be having a relapse that would meet criteria for corticosteroid treatment. BP was monitored sequentially over the course of their corticosteroid treatment and correlations were made with demographic data, including past medical and family history.

RESULTS

22 subjects contributed data. Higher daytime BP was noted in subjects with a past personal (p = 0.007) or family history of hypertension (p = 0.037). Nighttime BP recordings did not show the normal 10% drop and nocturnal diastolic BP was within a hypertensive range during corticosteroid treatment.

CONCLUSION

MS patients may be at risk of increased BP when treated with corticosteroids for relapses. Those with a past or family history of hypertension may be at higher risk and may warrant more frequent monitoring.

Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression

Granulomatosis with polyangiitis (GPA) is a small-vessel necrotizing granulomatous vasculitis typically involving upper airways, lungs, and kidneys, which may lead to end-organ damage and life-threatening complications. Major infections during GPA course represent a considerable concern in the management of the disease. Cytomegalovirus (CMV) infection and disease are rare but significant complications in the course of GPA being associated with high morbidity and mortality rates. Colonic perforation due to CMV colitis is exceedingly rare and has so far almost exclusively been documented in HIV, renal transplant, and systemic lupus erythematosus patients. We reported the case of a patient affected with upper airways-limited GPA who developed acute renal failure from rapidly progressive glomerulonephritis and then experienced colonic perforation due to CMV colitis a few weeks after immunosuppressive treatment with high-dose steroids and cyclophosphamide (CYC) for remission induction of the disease. We also reviewed the literature on CMV-related gastro-intestinal complications in the course of GPA and discussed contributing factors to severe manifestations of CMV infection and its reactivation.

Sinus bradycardia after intravenous pulse methylprednisolone therapy in patients with systemic lupus erythematosus

Sinus bradycardia is reported as an adverse effect of high-dose glucocorticoid therapy. We report three cases of systemic lupus erythematosus, wherein intravenous pulse methylprednisolone was administered. The patients' average baseline heart rate was 72 beats/min, which decreased 30% from baseline at 61 h after beginning the therapy. The average minimum heart rate was 38 beats/min, and this rate continued for 169 h on average. No other causes for bradycardia were found, suggesting that the administration of glucocorticoid pulse therapy resulted in decreased heart rate.

Posterior Reversible Encephalopathy Syndrome due to High Dose Corticosteroids for an MS Relapse

Increased blood pressure is a known adverse effect associated with corticosteroids but little is published regarding the risk with the high doses used in multiple sclerosis (MS). A 53-year-old female with known relapsing remitting MS presented with a new brainstem relapse. Standard of care treatment for an acute MS relapse, 1250 mg of oral prednisone for 5 days, was initiated. She developed an occipital headache and dizziness and felt generally unwell. These symptoms persisted after treatment was complete. On presentation to medical attention, her blood pressure was 199/110 mmHg, although she had no history of hypertension. MRI changes were consistent with posterior reversible encephalopathy syndrome (PRES), demonstrating abnormal T2 signal in both thalami, the posterior occipital and posterior parietal white matter with mild sulcal effacement. As her pressure normalized with medication, her symptoms resolved and the MRI changes improved. No secondary cause of hypertension was found. This is the first reported case of PRES secondary to high dose corticosteroid use for an MS relapse without a history of hypertension and with no other secondary cause of hypertension identified. This rare complication should be considered in MS patients presenting with a headache or other neurological symptoms during treatment for a relapse.

Fatal cytomegalovirus disease after combination therapy with corticosteroids and rituximab for granulomatosis with polyangiitis

The association of cytomegalovirus (CMV) with autoimmune disease is poorly understood with suggested causality and reported viral reactivation coinciding with active inflammation. We report a case of a patient who presented with diffuse alveolar hemorrhage and acute renal failure from rapidly progressive glomerulonephritis ultimately diagnosed with granulomatosis with polyangiitis (GPA). She was acutely managed with plasmapheresis to reduce antibody-mediated end-organ damage, hemodialysis for worsening hyperkalemia and acidosis, and high-dose intravenous methylprednisolone. She was transitioned to oral prednisone and started on weekly rituximab with resultant remission induction over a three-week period at which point she developed reactivation of CMV causing severe fatal lung disease and viremia. The case highlights the multiple factors associated with CMV reactivation in cases of severe systemic inflammatory states and the need for further research to help establish practice guidelines regarding antimicrobial prophylaxis in patients with autoimmune diseases on prolonged courses of corticosteroids and biologic agents.

[Glucose variability in intensive care unit]

Hyperglycemia is significantly associated with increased mortality in critically ill patients and then, strict control of blood glucose (BG) concentration is important. Lowering of BG levels with intensive insulin therapy (IIT) was recommended in order to improve patient outcomes. But recently, some recent prospective trials failed to confirm the initial data, showing conflicting results (significantly increased mortality with IIT, more hypoglycemic episodes). So there is no consensus about efficiency and safety of IIT. Significant associations between glucose variability and mortality have been confirmed by several recent studies. A difference in variability of BG control could explain why the effect of IIT varied from beneficial to harmful. Managing and decreasing this BG variability could be an important goal of BG control in critically ill patients. Clinicians have to consider definitions, physiopathology and impacts of glucose variability, in order to improve patient outcomes.

Hemophagocytic lymphohistiocytosis in adults: diagnosis and treatment

Hemophagocytic lymphohistiocytosis occurring as a primary or acquired disorder is a condition of chaotic and uncontrolled immune system stimulation. Cytotoxic cells and macrophages cause multiorgan damage, hemophagocytosis, and severe systemic inflammation. Clinical manifestations include a fever, organ enlargement, and weight loss. Laboratory tests show bicytopenia or pancytopenia, cytolysis and cholestasis, serum ferritin elevation, and clotting disorders. The reference standard for the diagnosis remains the presence in histological specimens of hemophagocytic macrophages, which may be lacking early in the disease, leading to diagnostic challenges. Inherited forms produce symptoms in early childhood and are fatal in the absence of specific treatment. In adults, the clinical spectrum ranges from mild and self-limited hemophagocytic lymphohistiocytosis to rapidly fatal multiorgan failure. Many questions remain unresolved regarding the diagnosis and treatment in adults. This update is an attempt at providing answers.

The need for nursing instruction in patients receiving steroid pulse therapy for the treatment of autoimmune diseases and the effect of instruction on patient knowledge

BACKGROUND

Many patients who receive steroid pulse therapy go home the same day or the day after steroid administration. Nursing instructions are important for improving patient knowledge related to their diseases and treatments, but the short hospital stay often prevents complete education and guidance regarding the given therapy. The purpose of this study was to investigate the need for nursing instruction in patients receiving steroid pulse therapy for the treatment of autoimmune diseases and the effect of instruction on patient knowledge of their disease and treatment.

METHODS

Patients with systemic lupus erythematosus (SLE) and systemic sclerosis receiving steroid pulse therapy (N = 63) were recruited from a medical center in Taipei. A structured questionnaire was used for data collection before and after nursing instruction, and 1 week as well as 2 weeks after therapy. The need for nursing instruction and knowledge levels were validated using Cronbach's α reliability test.

RESULTS

There was a significant difference (P < 0.001) in the need for nursing instruction among the 4 time points. There was a positive correlation between the need for nursing instruction and body weight change, frequency of treatment, and distress, but there was a negative correlation with knowledge level (β = -0.012, P = 0.003) regarding symptoms. The knowledge level of subjects after nursing instruction was significantly higher than before nursing instruction (80 ± 14.31 vs. 70.06 ± 17.23, P < 0.001).

CONCLUSIONS

This study indicates that nursing instruction is needed by patients receiving steroid pulse therapy, and that by designing and administering nursing instructions according to the priority of patient symptoms, nurses can improve patient knowledge related to their diseases and treatments. In addition, the need for nursing instruction can be affected by patient characteristics.

Use of glucocorticoids in rheumatoid arthritis - pratical modalities of glucocorticoid therapy: recommendations for clinical practice based on data from the literature and expert opinion

OBJECTIVE

To develop recommendations about the use of glucocorticoids in patients with established rheumatoid arthritis (RA) managed in everyday practice, using the evidence-based approach and expert opinion.

METHODS

A three-step procedure was used: a scientific committee used a Delphi procedure to select five questions, which formed the basis for developing the recommendations; a systematic literature review was conducted by searching the Medline and Embase databases and the abstracts of meetings held by the Société Française de Rhumatologie (SFR), American College of Rheumatology (ACR), and European League Against Rheumatism (EULAR); and recommendations were developed and validated by a panel of experts based on the data from the literature review and on their experience. For each recommendation, the level of evidence and extent of agreement among experts were determined.

RESULTS

The five questions pertained to the use of glucocorticoids in RA patients: role for intravenous glucocorticoid bolus therapy, role for intraarticular injections, and practical modalities of glucocorticoid administration and discontinuation. From the literature search, 93 articles were selected based on their titles and abstracts. Of these, 50 were selected for the literature review. Eight recommendations about the use of glucocorticoid therapy in everyday practice in patients with established RA were validated by a vote among all participating experts: bolus glucocorticoid therapy should be reserved for highly selected situations; triamcinolone hexacetonide is the preferred glucocorticoid for intraarticular therapy, and the joint should be rested for about 24h after the injection; for oral glucocorticoid therapy, agents with a short half-life taken once daily should be preferred; and when discontinuing glucocorticoid therapy, the patient and usual physician should be informed of the risk of adrenal insufficiency.

Systemic absorption of triamcinolone acetonide after posterior sub-Tenon injection

PURPOSE

To study systemic absorption of triamcinolone acetonide (TA) after posterior sub-Tenon injection.

DESIGN

Prospective, interventional case series.

METHODS

The study was conducted in a tertiary care teaching hospital on 35 eyes in which posterior sub-Tenon injection of 40 mg TA was administered after conventional extracapsular cataract extraction. Patients who had received any systemic steroid over 6 weeks preceding the period of study or had inflammatory ocular conditions were excluded. Serum TA levels were estimated by high-performance liquid chromatography at 1, 2, 3, 24, and 48 hours and 1, 2, and 6 weeks after injection.

RESULTS

Significant levels of the drug were detected in 45.71% of samples (mean serum levels, 6.94 +/- 8.98 ng/ml; P < .001) at 1 hour after sub-Tenon injection, in 85.71% of samples (mean serum levels, 21.83 +/- 12.92 ng/ml; P < .001) at 2 hours after injection, in 100% of samples (mean serum levels, 47.14 +/- 12.20 ng/ml; P < .001) at 3 hours after injection, in 100% of samples (mean serum levels, 35.49 +/- 13.79 ng/ml; P < .001) at 24 hours after injection, in 62.86% of samples (mean serum levels, 10.46 +/- 10.69 ng/ml; P < .001) at 48 hours after injection, and in 28.57% of samples (mean serum levels, 3.74 +/- 6.45 ng/ml; P = .002) at 1 week after injection. The drug was not detected in any of the samples obtained 2 weeks and 6 weeks later.

CONCLUSIONS

Posterior sub-Tenon injection of 40 mg TA adds statistically significant quantities to physiologic concentration of corticosteroids in peripheral blood. This may be detrimental for patients having certain metabolic diseases like diabetes and preferably should be avoided or administered with caution.

Corticosteroid-induced adverse events in adults: frequency, screening and prevention

Corticosteroids represent the most important and frequently used class of anti-inflammatory drugs and are the reference therapy for numerous neoplastic, immunological and allergic diseases. However, their substantial efficacy is often counter-balanced by multiple adverse events. These corticosteroid-induced adverse events represent a broad clinical and biological spectrum from mild irritability to severe and life-threatening adrenal insufficiency or cardiovascular events. The purpose of this article is to provide an overview of the available data regarding the frequency, screening and prevention of the adverse events observed in adults during systemic corticosteroid therapy (topically administered corticosteroids are outside the remit of this review). These include clinical (i.e. adipose tissue redistribution, hypertension, cardiovascular risk, osteoporosis, myopathy, peptic ulcer, adrenal insufficiency, infections, mood disorders, ophthalmological disorders, skin disorders, menstrual disorders, aseptic necrosis, pancreatitis) and biological (i.e. electrolytes homeostasis, diabetogenesis, dyslipidaemia) events. Lastly, data about the prescription of corticosteroids during pregnancy are provided. This review underscores the absence of data on many of these adverse events (e.g. lipodystrophy, dyslipidaemia). Our intent is to present to practitioners data that can be used in a practical way to both screen and prevent most of the adverse events observed during systemic corticosteroid therapy.

Corticosteroid-induced clinical adverse events: frequency, risk factors and patient's opinion

BACKGROUND

More than 50 years after the introduction of corticosteroids, few studies have focused on corticosteroid-induced adverse events after long-term systemic therapy.

OBJECTIVES

To assess the frequency, risk factors and patient's opinion regarding clinical adverse events occurring early during prednisone therapy.

PATIENTS AND METHODS

We conducted a cohort study in two French centres. All consecutive patients starting long-term (> oir = 3 months), high dosage (> or = 20 mg day(-1)) prednisone therapy were enrolled. The main clinical adverse events attributable to corticosteroids were assessed after 3 months of therapy, by comparison with baseline status. The patient's opinion regarding the disability induced by these adverse events was recorded. Risk factors of frequently observed adverse effects were identified by using logistic regression.

RESULTS

Eighty-eight patients were enrolled and 80 were monitored for at least 3 months (women 76%; mean age 59.1 +/- 18.7 years; giant cell arteritis 39%; mean baseline prednisone dosage 54 +/- 17 mg day(-1)). Lipodystrophy was the most frequent adverse event [63.0% (51.0-73.1)], was considered the most distressing by the patients and was most frequent in women and young patients. Neuropsychiatric disorders occurred in 42 patients [52.5% (41.0-63.8)], necessitating hospitalization in five cases. Skin disorders were noted by 37 patients [46.2% (35.0-57.7)] and were more frequent in women. Muscle cramp and proximal muscle weakness were reported by 32.5% (22.5-43.9) and 15% (8.0-24.7) of patients, respectively. Newly developed hypertension occurred in 8.7% (2.9-20.3) of patients. Lastly, 39% (19.7-61.4) of the premenopausal women reported menstrual disorders.

CONCLUSIONS

Lipodystrophy and neuropsychiatric disorders are common adverse events of long-term prednisone therapy and are particularly distressing for the patients concerned. The impact of these adverse events on adherence to corticosteroid therapy is not known.

Hyperglycemia after repeated periocular dexamethasone injections in patients with diabetes

PURPOSE

To assess the hyperglycemic effect of 3 consecutive daily periocular steroid injections in patients with diabetes.

DESIGN

Retrospective observational study in a national eye center.

PARTICIPANTS

Twenty-five hospitalized patients with type 2 diabetes who received a subconjunctival (n = 11) or a peribulbar injection (n = 14) with 4 mg dexamethasone disodium phosphate once a day for 3 consecutive days for ocular conditions.

METHODS

Baseline patient characteristics were recorded as well as serial blood glucose measurements and hypoglycemic interventions, both performed according to a written protocol.

MAIN OUTCOME MEASURES

Serial blood glucose measurements and hypoglycemic interventions.

RESULTS

Each ocular injection with dexamethasone was followed around 6 hours later by an increase of blood glucose up to a median doubling from baseline (+100% increase) followed by falls until the next injection, toward a median 13% increase from baseline before the next ocular injection. Older age (P<0.05), duration of diabetes (P = 0.01), and microangiopathy or macroangiopathy (P = 0.01) were associated with higher blood glucose rises. Using a 14-mmol/l threshold for intervention, the probability of requiring additional hypoglycemic treatment during ocular steroid therapy in patients with HbA1c >7.5% and up to 7.5% was 100% and 60%, respectively.

CONCLUSIONS

Periocular injections with dexamethasone in patients with type 2 diabetes induce a marked hyperglycemic effect, similar to that observed during intravenous pulse methylprednisolone.