Methylprednisolone pulse therapy in the treatment of polyarteritis nodosa

Vasculitides throughout history and their clinical treatment today

Therapeutic management of the vasculitides is closely linked to modern rheumatologic advances, particularly as it relates to the discovery and first clinical use of glucocorticoids. These compounds were introduced in the late-1940s for the treatment of rheumatoid arthritis, but soon after, clinicians in Europe and the United States realized that they could have a significant positive impact in systemic vasculitides. However, once it was realized that glucocorticoid use was associated with a high degree of morbidity, the search for better immunosuppressive agents with similar efficacy but improved safety profiles was on. During the past several years, several agents have been utilized for the therapeutic management of systemic vasculitides, and the list keeps growing with the development of newer compounds that have retained efficacy but with a better safety profile.

Efficacy of dexamethasone pulse therapy in progressive systemic sclerosis

BACKGROUND

Systemic sclerosis is a disease of unknown etiology for which no specific treatment is effective. Pulse therapy with corticosteroids has been tried for various autoimmune disorders with minimal side effects. We undertook this study to determine the efficacy of dexamethasone pulse therapy in progressive systemic sclerosis (PSS).

METHODS

Five women with PSS between the ages 30 and 60 years, received 100 mg dexamethasone in 500 mL of 5% dextrose by slow intravenous infusion over 3 hours for 3 consecutive days, once a month.

RESULTS

All patients had symptomatic and clinical improvement. The vital capacity improved in three and posttreatment histopathologic regression was seen in two patients.

CONCLUSIONS

Dexamethasone pulse therapy may provide an additional option for treating systemic sclerosis.

Pulse methylprednisolone therapy in the treatment of Wegener's granulomatosis

Five patients with Wegener's granulomatosis were treated with high-dose intravenous methylprednisolone (MTP) pulse therapy. Three out of five patients received MTP pulse therapy as the initial treatment and remission was achieved. Renal biopsy after the treatment confirmed the improvement of kidney involvement in 2 cases. Although the other two patients received MTP pulse therapy when a relapse occurred, the therapy could not suppress the progression of the disease. These observations suggest that MTP pulse therapy when given early may make it possible to suppress the progression of kidney involvement and improve the prognosis of the disease. Furthermore, it may also decrease the total doses of oral steroids and cyclophosphamide because of a strong anti-inflammatory and immunosuppressive action and consequently diminish the side effects. In conclusion MTP pulse therapy as the initial treatment may be beneficial in treating patients with Wegener's granulomatosis.

Dexamethasone-cyclophosphamide pulse therapy in pemphigus

Fifty patients with pemphigus (45 pemphigus vulgaris, 5 pemphigus foliaceus) were treated with dexamethasone-cyclophosphamide pulse therapy. The pulse consisted of 136 mg dexamethasone dissolved in 5% dextrose given in a drip over a period of 1-2 hours on 3 consecutive days. In addition, 500 mg cyclophosphamide was added in the drip on the first day. Such pulses were given at monthly intervals. In between the pulses patients were given 50 mg cyclophosphamide orally each day. The results were encouraging, the chief advantage being freedom from side effects of corticosteroid therapy. The lesions healed in 3-4 days and the patients were able to resume their work within one week. Further scope of such therapy in pemphigus is discussed.

Survey of the long term incidence of osteonecrosis of the hip and adverse medical events in rheumatoid arthritis after high dose intravenous methylprednisolone

A prospective, randomised, double blind, matched cohort survey using retrospective data was undertaken to assess the long term incidence of osteonecrosis of the hip and adverse medical effects occurring after intravenous pulsed methylprednisolone used in the treatment of rheumatoid arthritis over the period 1977-86. One hundred and forty three patients were matched for age, sex, duration and severity of the disease, erosive and serological status. Information was obtained by direct questioning and from hip x rays, the latter being read independently by two 'blind' radiologists. Two definite cases of osteonecrosis were identified, one in both the treated and control groups and three possible cases (radiological disagreement) in the treated group. Adverse medical events, when analysed by systems, were similar in both groups. This study did not provide evidence of increased osteonecrosis of the hip or adverse medical events in the treated group compared with the control group.

Methylprednisolone therapy in multiple sclerosis: a profile of adverse effects

A retrospective analysis of 350 treatment courses using high dose pulsed intravenous methylprednisolone for relapses of multiple sclerosis revealed a low number of adverse effects. This study confirms that high dose methylprednisolone is a safe therapeutic option in multiple sclerosis.

Sarcoidosis with hydrocephalus: report of a case successfully treated with a ventriculo-peritoneal shunt and methylprednisolone pulse therapy

We describe a female patient with systemic sarcoidosis and hydrocephalus. She was initially satisfyingly treated with peroral steroids. When she later deteriorated, the treatment had to be changed due to side-effects. High dose intravenous methylprednisolone pulse therapy was tried with some, but insufficient, improvement. Therefore, a ventriculoperitoneal shunt operation was performed with immediate improvement. After that she was treated with intravenous methylprednisolone and her condition has remained proper and stable for 5 years. The possibility that pulse therapy might have contributed to the favourable course in our patient is discussed.

A double blind controlled trial of methylprednisolone infusions in systemic lupus erythematosus using individualised outcome assessment

Twenty one patients with severe systemic lupus erythematosus (SLE) were treated with three daily infusions of either 100 mg or 1 g of methylprednisolone on a randomised double blind basis. Nine patients with unsatisfactory outcome subsequently received the alternative therapy. Patients were rated for improvement on a four point scale using individualised criteria. On three occasions patients improved to 'ideal', on 12 there was 'useful' improvement, on 11 the patient remained static, and on four occasions there was deterioration. There was no significant difference between the clinical states after the two doses. The results suggest that any additional benefit of 1 g of methylprednisolone over 100 mg by repeated infusion in the treatment of active SLE is probably not enough to justify the potential hazards and cost involved.

'Pulsed' immunosuppressive therapy in the treatment of immunologically induced corneal and scleral disease

'Pulsed' immunosuppressive therapy, using methylprednisolone with or without cyclophosphamide, has effectively controlled severe destructive corneal and scleral disease that had been unresponsive to oral steroids. Thirty-seven patients have been treated in this manner and the results, complications and possible mechanism of action are discussed.

Systemic bioavailability and pharmacokinetics of methylprednisolone in patients with rheumatoid arthritis following 'high-dose' pulse administration

The absolute and relative bioavailability of two methylprednisolone formulations (capsules and suspension) was determined along with its pharmacokinetics in four arthritic female patients, following an unconventional high-dose pulse of 1 g. Plasma concentrations of the drug were measured by a sensitive and specific high-performance liquid chromatographic (HPLC) procedure. The disposition of methylprednisolone from plasma following intravenous (i.v.) infusion of its succinate ester appeared monoexponential with a mean half-life of 2.4 h and an apparent volume of distribution (Vd) of 50 l (0.87 l/kg). The total body clearance (Cl) averaged 15.12 l/h. Absolute bioavailability was assessed by comparing the areas under the plasma concentration time curves (normalized to dose) following oral administration of capsule or suspension with those of intravenous administration. No significant difference (p greater than 0.2) was observed when systemic availability (f, expressed in per cent) following administration of drug in capsule (f = 49.35 per cent) was compared with that obtained following the administration of drug in a suspension (f = 58.26 per cent). The difference in the observed and predicted f may be due to incomplete absorption, hepatic and/or extrahepatic metabolism of methylprednisolone. Subjective evaluation showed no side effects of this high-dose pulse therapy in any of the patients.

Effects of high-dose i.v. steroid (pulse) therapy on acute serum sickness in rabbits

We investigated the effect of high doses (50 mg/kg/day) of i.v. methylprednisolone ("pulses") on a model of acute serum sickness in rabbits, using bovine serum albumen as antigen and endotoxin as an adjuvant. The pulses were given on 2 consecutive days at one of the following times during antigen elimination: Days 1 and 2, Days 5 and 6, and Days 8 and 9. Methylprednisolone did not alter antibody production, or the size of circulating immune complexes. Pulses given at any period inhibited the fibrinoid necrosis associated with arteritis, but did not otherwise lessen the histopathological changes. Pulses given on Days 1 and 2 or at the end of immune elimination on Days 8 and 9 increased proteinuria and haematuria, and tended to increase histopathological changes, whereas pulses given at the onset of immune elimination on Days 5 and 6 in contrast reduced haematuria, but had a variable effect on proteinuria and organ damage. In this model high-dose steroids produced no consistent amelioration of the disease, apart from reduced fibrinoid necrosis, and at some times there was a tendency for the disease to be exacerbated.

Methyl prednisolone pulse therapy in the treatment of systemic lupus erythematosus

Twenty patients with active systemic lupus erythematosus (SLE) were treated with methyl prednisolone pulse therapy (MPPT) and followed up for up to 24 weeks (mean 18 weeks). Beneficial effects of MPPT were observed principally on arthralgia, pleuritic pain, vasculitic skin rash, pyrexia, and lymphadenopathy. The serological tests showing the most improvement were ds DNA binding and the serum C3 level. MPPT was found to be both safe and easy to administer. It may be of value in treating patients with SLE whose disease is not controlled by moderate doses of corticosteroids and may also enable the dose of maintenance corticosteroids to be reduced appreciably.

A double-blind placebo-controlled trial of methylprednisolone pulse therapy in active rheumatoid disease

To confirm the findings of uncontrolled trials that methylprednisolone pulse therapy (MPPT) is a safe treatment for active rheumatoid disease, a double-blind trial was conducted in which 20 patients with active rheumatoid disease were randomly allocated to receive an infusion of either 1 g methylprednisolone or placebo. Methylprednisolone produced significant improvement in all clinical variables measured, a benefit which was sustained for at least 6 weeks. The placebo produced only transient improvement in some of the clinical variables measured. when the 10 placebo groups patients were later given an infusion of 1 g methylprednisolone, they too showed significant clinical benefit. The methylprednisolone also gave rise to improvements in some haematological and biochemical variables.

Successful renal transplantation in a patient with anaphylactic reaction to Solu-Medrol (methylprednisolone sodium succinate)

Following the intravenous infusion of Solu-Medrol (methylprednisolone sodium succinate), anaphylactic shock developed in a 41 year old man on two consecutive occasions, six weeks apart. Intracutaneous testing with different components of he Solu-Medrol Mix-O-Vial demonstrated that the patient was allergic to methylprednisolone sodium succinate but not to other ingredients. In view of the recent increase in the popularity of steroid pulse therapy, we believe that all clinicians should be aware of this unusual and potentially fatal reaction to Solu-Medrol.

The treatment of severe glomerulopathies in children using high dose intravenous methylprednisolone pulses

Thirty-five patients, 29 with severe proliferative glomerulonephritis and six with either steroid resistant or steroid dependent nephrotic syndrome, were treated with high dose bolus infusions of methylprednisolone (pulses) followed by prednisone given orally in more conventional doses for 6 mo or longer. Twenty-one of the 29 patients with severe proliferative glomerulonephritis had sustained improvement in renal function after treatment. In addition, pulse treatments reduced proteinuria and urine sediment abnormalities in these patients. Those who did not respond had a long duration of disease before receiving pulse therapy. Five of six patients with the nephrotic syndrome had reduction in proteinuria and three of these patients entered prolonged remission after treatment. Few side effects occurred with pulse therapy. Our observations suggest that the use of steroid pulses may limit or prevent long-term major loss of renal function in many patients with severe proliferative glomerulonephritis. It may be effective also in treatment of some patients with steroid refractory or frequently relapsing nephrotic syndrome. This therapeutic approach deserves continuing evaluation.