Glucocorticoids in Autoimmune Bullous Diseases: Are Neutrophils the Key Cellular Target?

Effects of Methylprednisolone on Myocardial Function and Microcirculation in Post-resuscitation: A Rat Model

Background

Previous studies have demonstrated that inflammation and impaired microcirculation are key factors in post-resuscitation syndromes. Here, we investigated whether methylprednisolone (MP) could improve myocardial function and microcirculation by suppressing the systemic inflammatory response following cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA).

Methods

Sprague-Dawley rats were randomly assigned to (1) sham, (2) control, and (3) drug groups. Ventricular fibrillation was induced and then followed by CPR. The rats were infused with either MP or vehicle at the start of CPR. Myocardial function and microcirculation were assessed at baseline and after the restoration of spontaneous circulation. Blood samples were drawn at baseline and 60-min post-resuscitation to assess serum cytokine (TNF-α, IL-1β, and IL-6) levels.

Results

Myocardial function [estimated by the ejection fraction (EF), myocardial performance index (MPI), and cardiac output (CO)] improved post-ROSC in the MP group compared with those in the control group (p < 0.05). MP decreased the levels of the aforementioned pro-inflammatory cytokines and alleviated cerebral, sublingual, and intestinal microcirculation compared with the control (p < 0.05). A negative correlation emerged between the cytokine profile and microcirculatory blood flow.

Conclusion

MP treatment reduced post-resuscitation myocardial dysfunction, inhibited pro-inflammatory cytokines, and improved microcirculation in the initial recovery phase in a CA and resuscitation animal model. Therefore, MP could be a potential clinical target for CA patients in the early phase after CPR to alleviate myocardial dysfunction and improve prognosis.

Postarrest Steroid Use May Improve Outcomes of Cardiac Arrest Survivors

OBJECTIVES

To evaluate the ramifications of steroid use during postarrest care.

DESIGN

Retrospective observational population-based study enrolled patients during years 2004-2011 with 1-year follow-up.

SETTING

Taiwan National Health Insurance Research Database.

PATIENTS

Adult nontraumatic cardiac arrest patients in the emergency department, who survived to admission.

INTERVENTIONS

These patients were classified into the steroid and nonsteroid groups based on whether steroid was used or not during hospitalization. A propensity score was used to match patient underlying characteristics, steroid use prior to cardiac arrest, the vasopressors, and shockable rhythm during cardiopulmonary resuscitation, hospital level, and socioeconomic status.

MEASUREMENTS AND MAIN RESULTS

There were 5,445 patients in each group after propensity score matching. A total of 4,119 patients (75.65%) in the steroid group died during hospitalization, as compared with 4,403 patients (80.86%) in the nonsteroid group (adjusted hazard ratio, 0.74; 95% CI, 0.70-0.77; p < 0.0001). The mortality rate at 1 year was significantly lower in the steroid group than in the nonsteroid group (83.54% vs 87.77%; adjusted hazard ratio, 0.73; 95% CI, 0.70-0.76; p < 0.0001). Steroid use during hospitalization was associated with survival to discharge, regardless of age, gender, underlying diseases (diabetes mellitus, chronic obstructive pulmonary disease, asthma), shockable rhythm, and steroid use prior to cardiac arrest.

CONCLUSIONS

In this retrospective observational study, postarrest steroid use was associated with better survival to hospital discharge and 1-year survival.

Intra-Arrest Administration of Cyclosporine and Methylprednisolone Does Not Reduce Postarrest Myocardial Dysfunction

Objective

To determine whether the administration of intra-arrest cyclosporine (CCY) and methylprednisolone (MP) preserves left ventricular ejection fraction (LVEF) and cardiac output (CO) after return of spontaneous circulation (ROSC).

Methods

Eleven, 25-30kg female swine were randomized to receive 10mg/kg CCY + 40mg MP or placebo, anesthetized and given a transthoracic shock to induce ventricular fibrillation. After 8 minutes, standard CPR was started. After two additional minutes, the experimental agent was administered. Animals with ROSC were supported for up to 12h with norepinephrine as needed. Echocardiography was performed at baseline, and 1, 2, 6 and 12h post-ROSC. Analysis was performed using generalized estimating equations (GEE) after downsampling continuously sampled data to 5 minute epochs.

Results

Eight animals (64%) achieved ROSC after a median of 7 [IQR 5-13] min of CPR, 2 [ IQR 1-3] doses of epinephrine and 2 [IQR 1-5] defibrillation shocks. Animals receiving CCY+MP had higher post ROSC MAP (GEE coefficient -10.2, P = <0.01), but reduced cardiac output (GEE coefficient 0.8, P = <0.01) compared to placebo. There was no difference in LVEF or vasopressor use between arms.

Conclusions

Intra-arrest cyclosporine and methylprednisolone decreased post-arrest cardiac output and increased mean arterial pressure without affecting left ventricular ejection fraction.

The expanding role of immunopharmacology: IUPHAR Review 16

Drugs targeting the immune system such as corticosteroids, antihistamines and immunosuppressants have been widely exploited in the treatment of inflammatory, allergic and autoimmune disorders during the second half of the 20th century. The recent advances in immunopharmacological research have made available new classes of clinically relevant drugs. These comprise protein kinase inhibitors and biologics, such as monoclonal antibodies, that selectively modulate the immune response not only in cancer and autoimmunity but also in a number of other human pathologies. Likewise, more effective vaccines utilizing novel antigens and adjuvants are valuable tools for the prevention of transmissible infectious diseases and for allergen-specific immunotherapy. Consequently, immunopharmacology is presently considered as one of the expanding fields of pharmacology. Immunopharmacology addresses the selective regulation of immune responses and aims to uncover and exploit beneficial therapeutic options for typical and non-typical immune system-driven unmet clinical needs. While in the near future a number of new agents will be introduced, improving the effectiveness and safety of those currently in use is imperative for all researchers and clinicians working in the fields of immunology, pharmacology and drug discovery. The newly formed ImmuPhar (http://iuphar.us/index.php/sections-subcoms/immunopharmacology) is the Immunopharmacology Section of the International Union of Basic and Clinical Pharmacology (IUPHAR, http://iuphar.us/). ImmuPhar provides a unique international expert-lead platform that aims to dissect and promote the growing understanding of immune (patho)physiology. Moreover, it challenges the identification and validation of drug targets and lead candidates for the treatment of many forms of debilitating disorders, including, among others, cancer, allergies, autoimmune and metabolic diseases.

Glucocorticoids as an emerging pharmacologic agent for cardiopulmonary resuscitation

Although cardiac arrest (CA) constitutes a major health problem with dismal prognosis, no specific drug therapy has been shown to improve survival to hospital discharge. CA causes adrenal insufficiency which is associated with poor outcome and increased mortality. Adrenal insufficiency may manifest as an inability to increase cortisol secretion during and after cardiopulmonary resuscitation (CPR). Several studies suggest that glucocorticoids during and after CPR seem to confer benefits with respect to return of spontaneous circulation (ROSC) rates and long term survival. They have beneficial hemodynamic effects that may favor their use during CPR and in the early post-resuscitation period. Moreover, they have anti-inflammatory and anti-apoptotic properties that improve organ function by reducing ischemia/reperfusion (I/R) injury. However, glucocorticoid supplementation has shown conflicting results with regard to survival to hospital discharge and neurological outcome. The purpose of this article is to review the pathophysiology of hypothalamic-pituitary-adrenal (HPA) axis during CPR. Furthermore, this article reviews the effects of glucocorticoids use during CRP and the post-resuscitation phase.