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Outcomes of patients with acute Vogt-Koyanagi-Harada disease treated with intravenous corticosteroid pulse followed by the slow tapering of oral corticosteroid therapy. Int Ophthalmol 2023; 43:431-440. [PMID: 35869402 DOI: 10.1007/s10792-022-02440-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To elucidate the intravenous corticosteroid pulse treatment outcomes of patients with acute Vogt-Koyanagi-Harada (VKH) disease and assess the differences between patients with no inflammation worsening and those with persistent or worsening inflammation. Potential factors responsible for eyes with low visual outcomes were also investigated. METHODS We retrospectively reviewed the clinical records of patients with acute VKH disease who first visited us between 2009 and 2018 and were followed up for > 300 days. Clinical characteristics, treatments, and posttreatment conditions were assessed. Patients were classified into no inflammation worsening (acute-resolved [AR]) and inflammation worsening (chronic-recurrent [CR]) groups based on conditions after 6 months from disease onset. RESULTS This study included 60 eyes from 30 patients (mean age: 52.7 years). Patients were treated with methylprednisolone pulse followed by the slow tapering of oral prednisolone; 73% of patients developed AR and 27% CR, and the best-corrected visual acuity (BCVA) was ≥ 1.0 in 83% of eyes at 6 months following the introduction of treatment. Although the total prednisolone dose was higher in patients with CR disease, no significant difference was noted in the final BCVA. Among the patients, five eyes had a final BCVA of ≤ 0.5 due to anisometropic amblyopia, diabetic maculopathy, pre-existing macular hole, epiretinal membrane, and ellipsoid zone loss. CONCLUSIONS Patients with acute VKH disease treated with corticosteroid pulse appear to demonstrate good visual outcomes, including patients with CR; the majority of eyes with low visual outcomes have pre-existing conditions that explain the low vision.
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Macher S, Bsteh G, Berger T, Höftberger R. Diagnostic approach and treatment regimens in adult patients suffering from antibody-mediated or paraneoplastic encephalitis. Curr Pharm Des 2022; 28:454-467. [PMID: 35100954 DOI: 10.2174/1381612828666220131093259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Identification of patients with antibody-mediated encephalitis poses a diagnostic challenge and any delay in that respect will increase the interval until initiation of immunotherapy and may negatively affect the patient´s clinical outcome. Within this review we focus on therapeutic strategies in antibody-mediated encephalitis and propose how to proceed with patients, who are suspected to have encephalitis of unknown origin. We further briefly outline differences in treatment of paraneoplastic and antibody-mediated encephalitis according to its pathomechanisms.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
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Karn M, Yonghang S, Ghimire S. Corticosteroids in COVID-19: We Should Be Mindful of Their Acute Toxicities. J Clin Pharmacol 2021; 61:1301-1302. [PMID: 34196415 PMCID: PMC8426745 DOI: 10.1002/jcph.1936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Mitesh Karn
- School of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | - Sapana Yonghang
- Department of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | - Sadikshya Ghimire
- Department of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
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Edel Y, Avni T, Shepshelovich D, Reich S, Rozen-Zvi B, Elbaz M, Leibovici L, Molad Y, Gafter-Gvili A. The safety of pulse corticosteroid therapy- Systematic review and meta-analysis. Semin Arthritis Rheum 2020; 50:534-545. [PMID: 31812351 DOI: 10.1016/j.semarthrit.2019.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety. PATIENTS AND METHODS All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality. RESULTS A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids. CONCLUSION Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.
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Affiliation(s)
- Yonatan Edel
- Rheumatology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Department of Medicine C, Beilinson Hospital, Rabin Medical Center, Petah Tikva 49100, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Tomer Avni
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Daniel Shepshelovich
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shelley Reich
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Benaya Rozen-Zvi
- Nephrology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michal Elbaz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Leonard Leibovici
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yair Molad
- Rheumatology unit Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anat Gafter-Gvili
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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Shahidi-Dadras M, Pishgahi M, Tabary M, Kheradmand Z, Araghi F, Dadkhahfar S, Robati RM. Cardiac function in pemphigus vulgaris patients before and after steroid pulse therapy. J DERMATOL TREAT 2019; 32:855-859. [PMID: 31868046 DOI: 10.1080/09546634.2019.1708850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pemphigus vulgaris which is an autoimmune dermatological disorder characterized by vesiculobullous lesions over the skin and mucosae may also give rise to cardiac disease. Global Longitudinal Strain (GLS) measurement may help to predict cardiac dysfunction in these patients. METHOD In this prospective study, the GLS was measured before and after steroid pulse therapy in pemphigus vulgaris patients using 2 D speckle-tracking echocardiography. Moreover, blood pressure, pulse rate, and corrected QT (cQT) interval were recorded before and after steroid pulse therapy. RESULTS We included 23 pemphigus patients. The mean age of patients was 34.5(±6.4). Mean GLS decreased significantly after the administration of steroid pulse therapy. The mean GLS decreased regardless of age, however, the patients with the age range of 40-50 years showed the highest change in GLS. There was no interaction between gender and GLS change. Mean cQT increased significantly after pulse therapy (p=.007). Heart rate increased significantly from 88.5 ± 10.8 to 97.0 ± 13.4 (p<.001). Mean systolic and diastolic blood pressure did not show any significant change. CONCLUSIONS The steroid pulse therapy may associate with the progression of cardiac dysfunction in pemphigus patients. GLS, as a predictor, may be a valuable marker of cardiac subclinical dysfunction in this condition.
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Affiliation(s)
| | - Mehdi Pishgahi
- Department of Cardiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zohreh Kheradmand
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farnaz Araghi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahar Dadkhahfar
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza M Robati
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Yanovsky RL, McLeod M, Ahmed AR. Treatment of pemphigus vulgaris: part 1 - current therapies. Expert Rev Clin Immunol 2019; 15:1047-1060. [PMID: 31566020 DOI: 10.1080/1744666x.2020.1672535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: While biologic agents that can be used for treating pemphigus vulgaris (PV) are increasing, themajority of the world's PV patients can afford only corticosteroids (CS) and some immunosuppressive agents (ISA). Areas covered: The spectrum of side effects encountered when PV patients receive high-dose, long-term CS and ISA are presented based on total dose and duration of therapy. The steroid-sparing effect of individual ISA as documented in published studies and their clinical outcomes, in terms of duration of remissions, frequency of relapses and time to relapse, are presented, so that comparisons are possible. Thus, rational choices can be made for the individual patient. Expert opinion: In 2019, the majority of PV patients globally will continue to be treated with CS and ISA. This review will help clinicians and patients become aware of when to anticipate which side effects and if possible, to prevent or avoid them. It provides guidelines to maximize the clinical benefits of ISA in inducing and maintaining remission and minimizing side effects by monitoring them.
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Affiliation(s)
| | - Michael McLeod
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA
| | - A Razzaque Ahmed
- Department of Dermatology, Tufts Medical Center , Boston , MA , USA.,Center for Blistering Diseases , Boston , MA , USA
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Pishgahi M, Dadkhahfar S, Robati RM, Kheradmand Z, Shahidi-Dadras M, Zargari O, Elpern DJ. Electrocardiographic changes after high-dose corticosteroid pulse therapy in pemphigus patients. J DERMATOL TREAT 2018; 29:802-805. [PMID: 29668335 DOI: 10.1080/09546634.2018.1466980] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The objective of the current study was to evaluate the effect of intravenous methylprednisolone pulse therapy on myocardial repolarization alterations, especially QT dispersion in anticipation of cardiovascular risks in patients with pemphigus vulgaris. METHODS The current study is a prospective-controlled study on the electrocardiographic changes after methylprednisolone pulse therapy in 50 patients with pemphigus vulgaris. RESULTS A total of 50 patients (28 female and 22 male) were included in our study. The mean heart rate was significantly higher in male patients both before (92 ± 10.80 versus 82.75 ± 12.01 ms) and after pulse therapy (102.73 ± 14.26 versus 91.07 ± 15.02 ms) (p value < .01). The value of heart rate was significantly greater after receiving steroid pulse therapy. Corrected QT dispersion before pulse therapy was 19.92 ± 8.2 ms that increased to 40.68 ± 18.12 ms after treatment (p value < .001). CONCLUSION Our study shows that there is a relationship between pulse steroid infusion and increased predisposition to the occurrence of cardiac arrhythmias. QT dispersion could be a good marker to assess this risk in these patients.
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Affiliation(s)
- Mehdi Pishgahi
- a Department of Cardiology , Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Sahar Dadkhahfar
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Reza M Robati
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Zohreh Kheradmand
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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Ferraro D, Camera V, Vitetta F, Zennaro M, Ciolli L, Nichelli PF, Sola P. Acute coronary syndrome associated with alemtuzumab infusion in multiple sclerosis. Neurology 2018; 90:852-854. [PMID: 29602915 DOI: 10.1212/wnl.0000000000005417] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 01/19/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Diana Ferraro
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy.
| | - Valentina Camera
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Francesca Vitetta
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Mauro Zennaro
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Ludovico Ciolli
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Paolo Frigio Nichelli
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Patrizia Sola
- From the Department of Biomedical, Metabolic and Neurosciences (D.F., V.C., L.C., P.F.N.), University of Modena and Reggio Emilia; and Neurology Unit (F.V., P.S.) and Cardiology Unit (M.Z.), Azienda Ospedaliero-Universitaria di Modena, Italy
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Sellner S, Kocabey S, Zhang T, Nekolla K, Hutten S, Krombach F, Liedl T, Rehberg M. Dexamethasone-conjugated DNA nanotubes as anti-inflammatory agents in vivo. Biomaterials 2017; 134:78-90. [DOI: 10.1016/j.biomaterials.2017.04.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/12/2017] [Accepted: 04/15/2017] [Indexed: 12/24/2022]
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10
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Prevention and management of glucocorticoid-induced side effects: A comprehensive review. J Am Acad Dermatol 2017; 76:201-207. [DOI: 10.1016/j.jaad.2016.02.1241] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 12/15/2022]
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Bradycardia Associated with Steroid Use for Laryngeal Edema in an Adult: A Case Report and Literature Review. Case Rep Cardiol 2016; 2016:9785467. [PMID: 27999689 PMCID: PMC5143689 DOI: 10.1155/2016/9785467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/31/2016] [Indexed: 11/17/2022] Open
Abstract
Steroids are used for specific indications in the perioperative period to reduce laryngeal or spinal cord edema, or for prophylaxis and treatment of postoperative nausea and vomiting. Given the other potential causes for hemodynamic alterations in the perioperative setting, it is important for physicians to be aware of cardiovascular side effects of short term steroids. Changes in blood pressure and heart rate, cardiac dysrhythmias, and even death have been described in patients receiving short term intravenous steroids. Bradycardia has been reported following short term methylprednisolone and dexamethasone therapy in both adult and pediatric patients. There are only two case reports in the literature of bradycardia following short term intravenous dexamethasone use in adult patients. This is the first case report that describes bradycardia following the use of dexamethasone in the postoperative setting for management of laryngeal edema in an adult. Telemetry and twelve lead electrocardiograms revealed sinus bradycardia and correlated directly with administration of dexamethasone in our patient. Bradycardia resolved following discontinuation of dexamethasone. We advocate for hemodynamic monitoring in patients receiving more than one dose of intravenous steroid therapy in the perioperative period, especially those with known cardiac and hepatic comorbidities and those taking medications with negative chronotropic effects.
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Kundu A, Fitzgibbons TP. Acute symptomatic sinus bradycardia in a woman treated with pulse dose steroids for multiple sclerosis: a case report. J Med Case Rep 2015; 9:216. [PMID: 26400725 PMCID: PMC4581459 DOI: 10.1186/s13256-015-0701-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/31/2015] [Indexed: 11/14/2022] Open
Abstract
Introduction Sinus bradycardia has been reported after administration of pulse dose steroids, although most cases have occurred in children and are asymptomatic. We report a case of acute symptomatic sinus bradycardia due to pulse dose steroids in a woman with multiple sclerosis. Interestingly, this patient also suffered from inappropriate sinus tachycardia due to autonomic involvement of multiple sclerosis. Case presentation A 48-year-old Caucasian woman with multiple sclerosis and chronic palpitations due to inappropriate sinus tachycardia was prescribed a 5-day course of intravenous methylprednisolone for treatment of an acute flare. Immediately following the fourth dose of intravenous methylprednisolone, she developed dyspnea, chest heaviness, and lightheadedness. She was referred to the emergency department where an electrocardiogram showed marked sinus bradycardia (40 beats per minute). Initial laboratory test results, including a complete blood count, basic metabolic profile and cardiac biomarkers, were normal. She was admitted for observation on telemetry monitoring. Her heart rate gradually increased and her symptoms resolved. Her outpatient dose of atenolol, taken for symptomatic inappropriate sinus tachycardia, was resumed. Conclusions Our patient’s acute symptoms were attributed to symptomatic sinus bradycardia due to pulse dose steroid treatment. Although several theories have been suggested to explain this phenomenon, the exact mechanism still remains unknown. It does not warrant any specific treatment, as it is a self-limiting side effect that resolves after discontinuing steroid infusion. Young patients who are free of any active cardiac conditions can safely be administered pulse dose steroids without monitoring. However, older patients with active cardiac conditions should have heart rate and blood pressure monitoring during infusion. Our patient also suffered from inappropriate sinus tachycardia, a manifestation of autonomic involvement of multiple sclerosis that has not been previously described. This case has implications for the pathogenesis and treatment of dysautonomia in patients with multiple sclerosis.
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Affiliation(s)
- Amartya Kundu
- Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Timothy P Fitzgibbons
- Department of Medicine, Cardiovascular Division, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, Brown JP, Cohen A, Kim H. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol 2013; 9:30. [PMID: 23947590 PMCID: PMC3765115 DOI: 10.1186/1710-1492-9-30] [Citation(s) in RCA: 674] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 07/25/2013] [Indexed: 02/06/2023] Open
Abstract
Systemic corticosteroids play an integral role in the management of many inflammatory and immunologic conditions, but these agents are also associated with serious risks. Osteoporosis, adrenal suppression, hyperglycemia, dyslipidemia, cardiovascular disease, Cushing’s syndrome, psychiatric disturbances and immunosuppression are among the more serious side effects noted with systemic corticosteroid therapy, particularly when used at high doses for prolonged periods. This comprehensive article reviews these adverse events and provides practical recommendations for their prevention and management based on both current literature and the clinical experience of the authors.
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Affiliation(s)
- Dora Liu
- Western University, London, ON, Canada.
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Szwebel TA, Le Jeunne C. Risques cardiovasculaires d’une corticothérapie. Presse Med 2012; 41:384-92. [DOI: 10.1016/j.lpm.2012.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 01/04/2012] [Accepted: 01/09/2012] [Indexed: 11/15/2022] Open
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Abstract
BACKGROUND Systemic glucocorticoids are used in dermatologic practice for various diseases including connective tissue disorders, bullous diseases, and many other dermatologic conditions. Patients with these diseases are at times treated with long-term courses of glucocorticoids, which place them at increased risk for glucocorticoid-induced side effects. Therefore, dermatologists must be knowledgeable of risks related to glucocorticoid use and be familiar with guidelines to manage them. OBJECTIVE To provide an update of recent advances in the prevention and treatment of major glucocorticoid-induced side effects. METHODS Review of the literature. RESULTS Data regarding the prevention and treatment of glucocorticoid-induced side effects are presented. CONCLUSION This review should help dermatologists optimally manage and prevent glucocorticoid-induced side effects.
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Kerdel F, Flores J, Kirsner R, Falanga V. Pulse corticosteroid therapy for cutaneous diseases. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639709160511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Feldman-Billard S, Héron E. Tolérance systémique des corticoïdes en ophtalmologie : influence de la voie d’administration. J Fr Ophtalmol 2008; 31:1026-36. [DOI: 10.1016/s0181-5512(08)74751-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Renal colic affects up to 12% of the population. Initial management of most patients is expectant. Acute symptom management of renal colic is best accomplished with a combination of parenteral opioids and NSAIDs. The elderly patient with a kidney stone should be screened for contraindications to NSAID therapy, such as renal failure or previous peptic ulcer disease. Use of parenteral opioids is often necessary during the acute setting, and downward-adjusted doses and monitoring are necessary to prevent associated confusion and respiratory depression. Novel therapy with desmopressin may also be effective for symptom control at the initial presentation, without the adverse effects of opioids or NSAIDs. However, use of desmopressin in the elderly must be undertaken cautiously, given the potential adverse effects of this agent. Many small, distal ureteral stones are treated initially with watchful waiting for the first 2-4 weeks after presentation. The patient should have effective, non-parenteral analgesics for use at home. Included in these agents are oral or suppository NSAIDs and oral opioids. Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious. alpha-Adrenoceptor antagonists such as the alpha(1A/)(1)(D)-selective tamsulosin are well tolerated in the elderly and increase the rate of spontaneous stone passage by approximately 50% for small distal stones. These agents also appear to decrease the severity of renal colic. Corticosteroids and calcium channel antagonists are also effective but their use in the elderly is not recommended as first-line therapy.
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Affiliation(s)
- Blayne K Welk
- Department of Urologic Sciences, University of British Columbia, Providence Healthcare, Vancouver, British Columbia, Canada
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Ji Yeon K, Ahn M. Side Effects of Intravenous Methylprednisolone Pulse Therapy in Eye Diseases. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.1.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kim Ji Yeon
- Department of Ophthalmology, Chonbuk National University, College of Medicine, Jeonju, Korea
| | - Min Ahn
- Department of Ophthalmology, Chonbuk National University, College of Medicine, Jeonju, Korea
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Gursoy A, Cesur M, Erdogan MF, Corapcioglu D, Kamel N. New-onset acute heart failure after intravenous glucocorticoid pulse therapy in a patient with Graves' ophthalmopathy. Endocrine 2006; 29:513-6. [PMID: 16943591 DOI: 10.1385/endo:29:3:513] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Revised: 01/19/2006] [Accepted: 01/20/2006] [Indexed: 11/11/2022]
Abstract
A 53-yr-old previously healthy man was admitted to our hospital for thyrotoxicosis without ophthalmopathy. Initial therapy with propylthiouracil caused an acute elevation of liver enzymes. Then, he received a first course of 131I therapy (20 mCi). At the end of 6-mo follow-up after 131I, he was still thyrotoxic and developed moderately severe ophthalmopathy. The patient refused thyroid surgery and decided to undergo second course of 131I therapy (30 mCi). Concomitantly with the 131I, we opted to give high-dose pulse glucocorticoid therapy (PGT) to prevent further deterioration of GO. The patient was started on intravenous methylprednisolone pulse therapy 1 g daily in a cycle (one cycle every 2 wk, each cycle comprising two infusions on alternate days). After the end of the second day of PGT administration, he suddenly developed onset of acute pulmonary edema and hypertension. There was no previous history of cardiac disorder or conditions predisposing to cardiac failure other than thyrotoxicosis. A presumptive diagnosis of fluid overload and/or hypertension- induced acute heart failure was made. After prompt investigations excluding cardiogenic causes, we thought that this condition was triggered by PGT that was superimposed on thyrotoxicosis-related hemodynamic instability. Graves' patients with uncontrolled thyrotoxicosis should be under careful surveillance when PGT is planned. To our knowledge, this is the first reported case of life-threatening acute pulmonary edema caused by PGT in GO.
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Affiliation(s)
- Alptekin Gursoy
- Department of Endocrinology and Metabolic Diseases, Ankara University, School of Medicine, Ankara, Turkey
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Feldman-Billard S, Lissak B, Kassaei R, Benrabah R, Héron E. Short-term tolerance of pulse methylprednisolone therapy in patients with diabetes mellitus. Ophthalmology 2005; 112:511-5. [PMID: 15745783 DOI: 10.1016/j.ophtha.2004.10.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 09/23/2004] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To assess the short-term tolerance of pulse methylprednisolone in patients with diabetes. DESIGN Retrospective study in a national eye center. PARTICIPANTS Eighty patients with type 2 diabetes, half of them also treated for hypertension, who received 3-day pulse methylprednisolone between January 1999 and December 2002 for eye disorders and were monitored according to a written protocol. MAIN OUTCOME MEASURE Potentially serious side effects, serial blood glucose measurements, and hypoglycemic interventions during pulse therapy. RESULTS Each pulse induced about 10 hours later a mean 2-fold peak increase of blood glucose. According to a 14-mmol/l (250 mg/dl) threshold glucose level for intervention, rapid insulin was required in 27 of 27 (100%) and 24 of 53 (45%) patients with glycosylated hemoglobin levels higher than 8% and up to 8%, respectively. In the latter group, patients older than 70 years had a 3-fold increased risk of requiring insulin. Significant side effects were systolic and/or diastolic blood pressure elevation > or = 180/110 mmHg (n = 6), ketosis without acidosis (n = 5), silent myocardial ischemia (n = 1), and disorientation (n = 1). All side effects were transient or controlled successfully by medical intervention. No infectious complication occurred during the treatment period. CONCLUSIONS Pulse methylprednisolone is globally well tolerated in diabetic patients, but requires strict blood glucose and clinical monitoring.
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Affiliation(s)
- Sylvie Feldman-Billard
- Service de Médecine Interne, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France.
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22
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Chibane S, Feldman-Billard S, Rossignol I, Kassaei R, Mihoubi-Mantout F, Héron E. [Short-term tolerance of three days pulse methyprednisolone therapy: a prospective study in 146 patients]. Rev Med Interne 2005; 26:20-6. [PMID: 15639322 DOI: 10.1016/j.revmed.2004.09.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 09/30/2004] [Indexed: 11/25/2022]
Abstract
AIM To study the immediate tolerance of high-dose intravenous pulse steroids. PATIENTS ET METHOD: Prospective study over a six months period in 146 consecutive patients treated by three pulses of 250, 500 or 1000 mg/d methylprednisolone for various eye diseases. Daily monitoring including: standardized questionnaire, electrocardiogram, automated blood pressure measurements, fasting blood glucose and kaliemia. RESULTS One hundred and twenty-nine patients (88,4%) had one ore more side effect(s), mainly transient and of mild intensity, the first one being neuropsychological disturbances (insomnia in half the patients). Myocardial ischemia was observed in three patients (2,1%) with known coronary insufficiency or high cardiovascular risk, blood pressure levels of at least 180/110 mmHg were recorded in five hypertensive patients (3,4%), bradycardia occurred in 14 patients (9,7%), symptomatic in one. After the first pulse, we observed a mean 54+/-30% increase of fasting glucose (P <0,001), followed during the next pulses by a spontaneous slow return toward baseline values in non diabetic patients, contrasting with additional hyperglycemic effects in diabetics, and a mean 5,4+/-10,3% increase of kaliemia (P <0,001) staying unchanged during the next pulses, and suggesting a rapid potassium efflux from the cell as a direct effect of methylprednisolone. CONCLUSION Severe complications of pulse methylprednisolone, mainly cardiovascular, are strongly related to underlying comorbidities. Glucose monitoring is necessary only in diabetic patients. Potassium movements suggest a risk of hypokalicystia, of potential danger in patients with cardiac disease. A close clinical, blood pressure and electrocardiographic monitoring is needed during the whole treatment.
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Affiliation(s)
- S Chibane
- Service de médecine interne, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75571 Paris cedex 12, France
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Abstract
Pulse therapy with high-dose glucocorticoids was introduced 20 years ago as a treatment modality for autoimmune disease and transplant rejection. The most popular dermatological indication for pulse therapy is severe pemphigus. We reviewed the sequelae of 14 patients with pemphigus who were treated by pulse therapy. Seven of them reached complete remission, although three of them needed a new pulse course due to disease flare-up. Adverse events were minor and confined to 60% of all patients: temporary facial flushing during pulse administration, sleep disturbances during the first night after pulse administration, and mood changes occurred during the week of pulse therapy. The study showed the possibility of oral instead of an intravenous mute of dexamethasone pulse administration, which makes double-blind placebo-controlled trials ethically feasible. Fifty per cent of the patients reached complete remission. This retrospective study does not allow claims on the steroid-sparing effect.
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Affiliation(s)
- G G Tóth
- Center for Bullous Skin Diseases, Department of Dermatology, Groningen University Hospital, The Netherlands.
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25
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Abstract
High-dose intravenous (i.v.) methylprednisolone has been used therapeutically in a number of medical fields to avoid the complications and side effects of long-term glucocorticoid (GC) therapy and because of the perception that high-dose i.v. methylprednisolone may have "special" therapeutic effects. It is possible that aggressive early therapy with GCs allows for a more rapid taper of GCs and therefore prevents some of the dose-related side effects associated with long-term use. Some of the neurologic and rheumatologic literature related to multiple sclerosis and lupus nephritis suggest that i.v. methylprednisolone has therapeutic effects that are different from those of conventional doses of oral prednisone. There is still considerable debate about this in nondermatologic fields, and extrapolation of the role of pulse i.v. methylprednisolone to dermatologic disease, where trials are lacking, is difficult. Given this subset of possible candidates of this therapy as suggested by anecdotal reports, there is at least a rationale for considering the use of this modality in a subset of patients.
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Affiliation(s)
- S Sabir
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
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Abstract
Thirty patients (20 males, 10 females) with widespread alopecia areata (25 extensive alopecia areata, 5 alopecia areata) for a mean period of 4.2 years were included in the study. All patients above 12 years were administered 5 mg dexamethasone oral pulse on two consecutive days every week. Three children (< 12 years) received 2.5 mg to 3.5 mg dexamethasone oral biweekly pulse. Patients who had received treatment for a minimum period of 12 weeks were evaluated for terminal hair growth. Complete to excellent (75-95%) hair growth was observed in 16 (63.3%) patients. Growth was good (50-74%) in 2 cases and poor (< 50%) in 3 (10%) cases. Six (20%) patients has no growth of terminal hair. Complete to excellent growth of hair was obtained after a mean period of 5.35 months (range 3-10 months). Relapse occurred in one case each after three and six months but hair regrew with re-treatment. Side effects of corticosteriods were frequent, seen in 8 (26.6%) patients, but were mild. In only one case, treatment had to be discontinued. We propose that twice weekly 5 mg dexamethasone oral pulse for six months may be considered as one of the modalities in the treatment of extensive long standing alopecia areata.
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Affiliation(s)
- V K Sharma
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, India
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Affiliation(s)
- G Nicholson
- Department of Anaesthesia, St George's Hospital Medical School, London, UK
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Robson LS, Bain C, Beck S, Guthrie S, Coyte PC, O'Connor P. Cost analysis of methylprednisolone treatment of multiple sclerosis patients. Can J Neurol Sci 1998; 25:222-9. [PMID: 9706724 DOI: 10.1017/s0317167100034053] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intravenous methylprednisolone (IVMP) is the treatment of choice for multiple sclerosis (MS) patients undergoing acute exacerbation of disease symptoms and yet its cost has not been accurately determined. Determination of this cost in different settings is also pertinent to consideration of cost-saving alternatives to in-patient treatment. METHODS Cost analysis from the point of view of the health care system of IVMP treatment of MS patients receiving treatment in association with a selected Toronto teaching hospital in fiscal year 1994/95 was carried out. Costs of any concurrent treatments were excluded. RESULTS Total cost for 92 patients, based on a 4 dose regime, was estimated to be $78,527. The the cost per patient was $1,1181.84 for in-patients (IP), $714.64 for out-patients of the MS Clinic (OP) and $774.21 for patients whose treatment was initiated in the Clinic, but completed in the home (HC). Sensitivity analyses indicated: 1) IP treatment was in all cases more expensive than that of OP or HC; 2) the cost savings of OP vs. HC was sensitive to assumptions made regarding Clinic overhead, Clinic nursing costs and Home Care Program overhead. CONCLUSION Alternatives to in-patient care must be considered carefully. In this study, both out-patient and in-home treatment were cost-saving alternatives to in-patient treatment, but large differences in the cost of hospital out-patient vs. in-home care could not be demonstrated.
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Affiliation(s)
- L S Robson
- Institute for Work and Health, Toronto, Canada
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Dawe RS, Naidoo DK, Ferguson J. Severe bullous pemphigoid responsive to pulsed intravenous dexamethasone and oral cyclophosphamide. Br J Dermatol 1997; 137:826-7. [PMID: 9415254 DOI: 10.1111/j.1365-2133.1997.tb01131.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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