A study of adverse effects of high-dose intravenous (pulse) methylprednisolone therapy in patients with rheumatic disease

Pulse versus Non-pulse Steroid Regimens in Patients with Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

BACKGROUND

Systemic steroids are associated with reduced mortality in hypoxic patients with COVID-19. However, there is no consensus on the doses of steroid therapy in these patients. Several studies showed that pulse dose steroids (PDS) could reduce the progression of COVID-19 pneumonia. However, data regarding the role of PDS in COVID-19 is still unclear. Therefore, we performed this meta-analysis to evaluate the role of PDS in COVID-19 patients compared to non-pulse steroids (NPDS).

METHODS

Comprehensive literature search of PubMed, Embase, Cochrane Library, and Web of Science databases from inception through February 10, 2022 was performed for all published studies comparing PDS to NPDS therapy to manage hypoxic patients with COVID-19. Primary outcome was mortality. Secondary outcomes were the need for endotracheal intubation, hospital length of stay (LOS), and adverse events in the form of superimposed infections.

RESULTS

A total of ten observational studies involving 3065 patients (1289 patients received PDS and 1776 received NPDS) were included. The mortality rate was similar between PDS and NPDS groups (RR 1.23, 95% CI 0.92-1.65, P=0.16). There were no differences in the need for endotracheal intubation (RR 0.71, 95% CI 0.37-1.137, P=0.31), LOS (MD 1.93 days; 95% CI -1.46, 5.33; P=0.26), or adverse events (RR 0.93, 95% CI 0.56-1.57, P = 0.80) between the two groups.

CONCLUSION

Compared to NPDS, PDS was associated with similar mortality rates, need for endotracheal intubation, LOS, and adverse events. Given the observational nature of the included studies, randomized controlled trials are warranted to validate our findings. This article is protected by copyright. All rights reserved.

Long-term effects of early pulse methylprednisolone and intravenous immunoglobulin in patients with dermatomyositis and polymyositis

OBJECTIVE

To evaluate the long-term effects of pulse intravenous methylprednisolone (IVMP) or intravenous immunoglobulin (IVIG) administered during the first year of diagnosis in dermatomyositis (DM) and polymyositis (PM) patients.

METHODS

This is a retrospective single-center cohort study of patients with DM/PM followed for up to 4 years from 2001 to 2017. We used Cox regression models to estimate hazard ratios (HRs) and assess the effects of early pulse IVMP or IVIG on 3 outcomes: complete clinical response, corticosteroid discontinuation, and survival. Analysis was adjusted for clinical, laboratory, and treatment covariates.

RESULTS

A total of 204 patients were included and categorized into 4 initial treatment groups: pulse IVMP (n = 46), pulse IVMP+IVIG (n = 55), IVIG (n = 10), and without IVMP or IVIG (n = 93). The groups of early pulse IVMP and pulse IVMP+IVIG had a higher HR for complete clinical response in the multivariate models (HR = 1.56, 95% CI = 1.05-2.33, p = 0.029; and HR = 1.58, 95% CI = 1.02-2.45, p = 0.041, respectively). Only the group of pulse IVMP+IVIG had a significant association with corticosteroid discontinuation in the multivariate analysis (HR = 1.65, 95% CI = 1.02-2.68, p = 0.043). Early pulse IVMP or IVIG had no impact on mortality.

CONCLUSION

Despite having a more severe disease profile, patients with DM/PM submitted to pulse IVMP or pulse IVMP+IVIG during the first year of diagnosis had a higher HR for complete clinical response, whereas the combination of pulse IVMP+IVIG had an association with corticosteroid discontinuation. Prospective long-term studies are warranted to confirm these benefits of early pulse IVMP and IVIG on patients with DM/PM.

Development of an evidence-based regimen of prednisolone to treat giant cell arteritis - the Norwich regimen

We have reviewed the literature to form a bespoke regimen for daily oral prednisolone (DP) in GCA. Initial DP in clinical trials is 40-60 mg daily, but relapse rates are 67-92%. Cumulative prednisolone (CP) of 3.2 and 3.9 g (at 6 months) resulted in a relapse rate of 83 and 67%, respectively; and 3 and 3.9 g (at 12 months) resulted in 92 and 82% relapse, respectively. CP was 6.2-7.1 g in the first year. Mean DP was 18.8 mg at 3 months and 6.6-7.4 mg at 12 months. The duration of treatment with prednisolone for GCA was 22-26 months. The CP to achieve discontinuation was 6.5-12.1 g. Using these data, the Norwich regimen starts DP at 1 mg/kg/day of lean body mass, discontinuing over 100 weeks. For the average UK woman, initial DP is 45 mg daily, reaching 21 mg daily by 12 weeks and 6 mg daily by 52 weeks. The CP for the average UK woman would be 6.5 g at 52 weeks and 7.4 g to discontinuation.

Efficacy of Steroid Pulse Therapy for Autoimmune Pancreatitis Type 1: A Retrospective Study

Autoimmune pancreatitis (AIP) is treatable with steroids, but relapse is frequent. The efficacy of steroid pulse therapy has been shown for various autoimmune diseases, but has not become established therapy. In this study, we reviewed the efficacy of steroid pulse therapy in 24 subjects who were diagnosed with AIP type 1 at our hospital. Patient characteristics, time-course of serum IgG4, and the cumulative relapse-free survival rate were compared between patients who received oral steroid therapy (oral group) and those who were treated with steroid pulse therapy (pulse group). Serum IgG4 was reduced significantly after therapy in both groups and the 5-year cumulative relapse-free survival rates in the two groups did not differ significantly (oral group 46.9%, pulse group 77.8%). However, in a subset of cases with diffuse pancreatic swelling, this rate was significantly lower in the oral group (33.3% vs. 100.0%, p = 0.046). These results suggest that steroid pulse therapy is effective for prevention of relapse in AIP patients with diffuse pancreatic swelling.

Refining clinical features and therapeutic options of new daily persistent headache: a retrospective study of 63 patients in India

The aim of this retrospective study was to provide data on the clinical features and treatment outcomes of patients with NDPH (fulfilling Kung et al.'s criteria). A total of 63 patients were observed during a 5-yr period (2007-2012). More than one-third (35 %) patients had migrainous features; 65 % patients fulfilled the ICHD-II criteria. Both groups were similar in most clinical and epidemiological features. However, migrainous features were more common in patients with a prior history of episodic migraine (though statistically not significant). After a median follow-up of 9 months, 37 % patients showed "excellent" response (no or less than 1 headache per month). Another 30 % patients had "good" response (>50 % reduction in headache frequency or days per month). Excellent response was more in patients with a history of less than 6 months duration (statistically not significant). Patients with a recognized trigger showed better prognosis. Response was better in patients who received intravenous therapy of methyl prednisolone and sodium valproate. We suggest prospective and controlled studies to confirm our observations.

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.

Post-infectious new daily persistent headache may respond to intravenous methylprednisolone

New daily persistent headache (NDPH) is a subtype of chronic daily headache (CDH) that starts acutely and continues as a daily headache from the onset. It is considered as one of the most treatment refractory of all headache syndromes. The pathophysiology is largely unknown. Viral infections, extracranial surgery, and stressful life events are considered as triggers for the onset of NDPH. A few patients may have the onset of their symptoms during an infection. Here we report nine patients with NDPH like headache. All of them had a history suggestive of extracranial infections a few weeks prior to the onset of headache. All patients received intravenous methyl prednisolone (IV MPS) for 5 days. Intravenous MPS was followed by Oral steroids for 2–3 weeks in six patients. The relief of headache started between the second and fifth days of infusion in all patients. The steady improvement in headache continued and seven patients experienced almost complete improvement within 2 weeks. Two other patients showed complete improvement between 6 and 8 weeks after initiation of IV MPS therapy. We conclude that NDPH-like headache may occur as a post infectious process following a recent infection. We also speculate on the possible mechanisms of headache in our patients.

Pulse steroid therapy

Intravenous supra-pharmacological doses of corticosteroids are used in various inflammatory and autoimmune conditions because they are cumulatively less toxic than sustained steroid treatment at lower quantitative dosage. Their action is supposed to be mediated through non-genomic actions within the cell. Common indications for use in children include steroid resistant and steroid dependent nephrotic syndrome, rapidly progressive glomerulonephritis, systemic vasculitis, systemic lupus erythematosus, acute renal allograft rejection, juvenile rheumatoid arthritis, juvenile dermatomyositis, pemphigus, optic neuritis, multiple sclerosis and acute disseminated encephalomyelitis. Methylprednisolone and dexamethasone show similar efficacy in most conditions. Therapy is associated with significant side effects including worsening of hypertension, infections, dyselectrolytemia and behavioral effects. Adequate monitoring is essential during usage.

Intravenous pulse methylprednisolone therapy for acute treatment of serpiginous choroiditis

PURPOSE

To evaluate the safety and efficacy of high-dose intravenous steroid therapy (HDIST) for the acute treatment of vision-threatening serpiginous choroiditis.

METHODS

Retrospective review of the records of five patients with serpiginous choroiditis who were treated with HDIST (1 g methylprednisolone for three days) in addition to their standard immunosuppressive treatment. The visual acuities and improvement of ocular signs after HDIST were evaluated.

RESULTS

Twelve episodes of macula-threatening choroiditis in five patients with serpiginous choroiditis were treated during a seven-year period. All patients responded to HDIST with evidence of a decrease in intraocular inflammation immediately after and complete restoration of visual acuity within 10 days of commencing treatment. In one patient, medical intervention was required because of gastric distress. During the follow-up, three out of five patients experienced new attacks and two patients developed subretinal neovascularization.

CONCLUSION

HDIST is effective in controlling severe vision-threatening serpiginous choroiditis and in improving visual function in a short period of time. However, the effect of this treatment in long-term disease control is uncertain.

Standard-dose and short-term corticosteroid therapy in immunoglobulin-resistant Kawasaki disease

Six patients with Kawasaki disease (KD) were treated with prednisolone (1 to 2 mg/kg/day) for 3 days (from days 10 to 12 after the onset of the illness) after apparently unsuccessful treatment with intravenous immunoglobulin (IVIG, 2 g/kg/dose and additional 1 g/kg/dose). Five patients responded immediately to the first course of prednisolone infusion. One patient failed to respond to the first course of prednisolone therapy, but he did respond to the second 3-day course of therapy. None of the patients demonstrated a further progression of coronary artery dilatation or any adverse effects. Standard-dose and short-term corticosteroid therapy therefore appears to be a safe and effective treatment for patients with IVIG-resistant KD.

Short-term tolerance of pulse methylprednisolone therapy in patients with diabetes mellitus

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.

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

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.

First report of supraventricular tachycardia after intravenous pulse methylprednisolone therapy, with a brief review of the literature

The occurrence of supraventricular tachycardia after high-dose intravenous methylprednisolone pulse therapy (HIVMPT) in a patient with active rheumatoid arthritis is described for the first time. This case report further expands the range of arrhythmias that can occur with HIVMPT. Other arrhythmias previously reported to occur after HIVMPT include atrial fibrillation, atrial flutter, junctional rhythm, and ventricular tachycardia. To the best of our knowledge, supraventricular tachycardia has not been reported previously, although severe bradycardia, hypotension, asystole, cardiovascular collapse, and sudden death have been documented. A review of the literature indicates that these case reports not withstanding, HIVMPT is generally safe, and cardiovascular toxicity is rare. However, close supervision with repeated measurements of blood pressure, electrocardiogram, and blood electrolytes is mandatory during and immediately after HIVMPT, especially for patients with pre-existing cardiovascular disease, and the lowest effective dose of methylprednisolone should be infused at a slow rate.

Tolérance glycémique des bolus intraveineux de méthylprednisolone en milieu ophtalmologique

INTRODUCTION

Short-term, high-dose intravenous methylprednisolone therapy, also called pulse methylprednisolone, is widely used in a variety of inflammatory eye diseases. Monitoring blood glucose during this therapy is recommended. We evaluated the clinical implications of glycemia monitoring during repeated pulse methylprednisolone for eye disease.

PATIENTS AND METHODS

During the year 2000, 224 patients received 120-1 000 mg daily intravenous methylprednisolone for 3 consecutive days for acute optic neuritis (n=91), severe uveitis (n=35), ocular infectious diseases (n=22), corneal graft rejection (n=17) and miscellaneous disorders (n=59). Serial morning fasting blood glucose, i.e., before the first pulse and the day after each pulse, and specific hypoglycemic drug interventions were recorded.

RESULTS

All patients showed a median 50% increase in fasting glucose after the first pulse with no significant difference between diabetic and nondiabetic patients. Thereafter, the 196 nondiabetic patients showed a spontaneous decrease in their fasting glucose towards baseline values despite the following infusions. However, none of them required hypoglycemic intervention. In contrast, the 28 diabetic patients demonstrated further increases in blood glucose levels and seven received rapid-release treatment.

CONCLUSION

Glucose tolerance of pulse methylprednisolone was excellent in nondiabetic patients; close glycemia monitoring seems necessary only for patients with diabetes.

Intravenous pulse methylprednisolone therapy in eye disease: effect on glucose tolerance

PURPOSE

To determine which subjects need close glycemic monitoring during intravenous pulse methylprednisolone therapy for eye disease.

DESIGN

Retrospective study in a national eye center.

PARTICIPANTS

Two hundred twenty-four subjects who received over a one-year period 250 to 1000 mg daily intravenous methylprednisolone over 3 consecutive days for ophthalmologic conditions.

METHODS

Blood glucose monitoring during pulse methylprednisolone therapy followed a protocol written in 1995. We analyzed the effects of 3 days of pulse methylprednisolone therapy on glucose tolerance and their clinical implications in diabetic and nondiabetic subjects treated during 2000.

MAIN OUTCOME MEASURE

Serial morning fasting blood glucose; that is, before the first pulse and the day after each pulse, blood glucose self-monitoring for diabetic subjects and specific hypoglycemic drug interventions were recorded.

RESULTS

All subjects showed a median 50% increase in fasting glucose after the first steroid infusion, without a significant difference between diabetic and nondiabetic subjects. Thereafter, the 196 nondiabetic subjects showed spontaneous decreases of their fasting glucose toward baseline values despite the following infusions, whereas the 28 diabetic subjects (all type 2) demonstrated further increases of blood glucose, and 7 received rapid-release insulin to maintain blood glucose lower than 14 mmol/l. All 5 diabetic subjects with baseline glycosylated hemoglobin >/==" BORDER="0"> 8.3% required insulin therapy.

CONCLUSIONS

Close glycemic monitoring seems necessary only for subjects with diabetes during intravenous pulse methylprednisolone therapy for ophthalmologic conditions. The probability of subjects with type 2 diabetes requiring insulin during this therapy does seem to be positively related to the level of pretreatment glycosylated hemoglobin.

Corticosteroid-induced psychotic and mood disorders: diagnosis defined by DSM-IV and clinical pictures

The authors investigated long-term outcome and treatment strategy of corticosteroid-induced psychotic and mood disorders as defined by DSM-IV. Review of medical records of 2,069 referral patients revealed 18 applicable patients. Their clinical characteristics, longitudinal courses, and treatments were studied. The authors identified 15 patients with mood disorder and 3 patients with psychotic disorder. Increasing doses or resumption of corticosteroids had the strongest influence on the psychiatric course. These two corticosteroid-induced psychiatric disorders may have different pathophysiological substrates closely related to patient vulnerability. Effective psychopharmacological treatment options were indicated with consideration being given to the underlying diseases.

Update on systemic glucocorticosteroids in dermatology

Although dermatology now has the most extensive group of systemic medications available for the treatment of skin diseases at any time, GCSs remain the most important agents for managing inflammatory disorders. It is important that the dermatologist have a broad knowledge of guidelines for clinical use, pharmacology, and adverse effects of these drugs. Acute and chronic side reactions should be well recognized. An understanding of the HPA axis and reasons for administering GCSs in different ways is of great value. A good medical history should be taken on any patient treated with GCSs, including knowledge of conditions that would make GCSs inadvisable and other concomitant systemic medications that might produce drug interactions. During the course of therapy, physical examination should include all systems pertinent to side effects caused by these agents, including frequent evaluations of weight and blood pressure. Blood chemistries should be performed on a regular basis, including glucose, electrolytes, and serum lipids. Osteoporosis is one of the most significant adverse affects to be evaluated, with bone mineral density studies recommended on an annual basis for persons continuing on GCS therapy. If hip or other joint pain develops, MR imaging is the most specific and sensitive radiologic examination for evaluating the possibility of osteonecrosis. An ophthalmology examination should be performed every 6 to 12 months to detect early cataract or glaucoma development. Any early signs of infection should be evaluated by appropriate smears, wet preparations, and cultures. Many other studies, including gastrointestinal and pulmonary examinations, may be dictated by specific acute situations. It is important to begin early prevention of the bone loss that occurs with GCS-induced osteoporosis. The 1996 guidelines of the American College of Rheumatology, including adequate calcium and vitamin D intake, should be followed. Hormonal replacement, a bisphosphonate, calcitonin, or a thiazide diuretic may be indicated. Restriction of sodium in the diet is important, as well as adequate potassium intake. The diet should be low in saturated fat and calories and should be high in vegetable protein. Because osteoporosis is so prevalent with GCSs, keeping the patient as active as possible with mild-to-moderate exercise is important. Whenever possible, exposure to persons with infectious processes should be avoided, and proper treatment should be instituted at the initial signs of systemic or cutaneous infection. Oral doses of GCSs are best taken with food to prevent gastrointestinal irritation, and agents for gastric acidity occasionally may be indicated. Significant trauma should be prevented, as should severe exposure to the sun. Many situations may call for consultation with other medical or surgical subspecialists. The patient must be aware of the importance of regular physician evaluations and reporting of any adverse effects while on long-term GCSs. A good relationship and understanding between the patient and physician are vital in minimizing potential problems from these agents. If the dermatologist maintains the proper guidelines of care, patients on GCSs have the highest benefits and lowest risks possible.

Pulse glucocorticoids

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.

Side effects of immunosuppressant therapies used in neurology

This article provides an overview of the clinically relevant complications of the main immunosuppressants currently used in the treatment of neurologic disorders with suspected or established immune etiology. The most serious complications are discussed in detail, including pathophysiology and preventative measures. An intimate knowledge of these complications proves helpful in the day to day practice of the neurologist supervising immunotherapy.

Effects of methylprednisolone on the GABA- and glutamate-induced currents: relevance to glucocorticoid-induced neurotoxicity and brain aging

We have previously shown that both epidural administration and microinjection of methylprednisolone (MP) produces neuronal hyperexcitability in the murine spinal cord in vivo. In this study, the whole-cell patch-clamp technique was used to describe and characterize MP-induced neuronal hyperexcitability. Exposure of 10- to 18-day old dissociated spinal cord cultures to 65 microM-8 mM MP caused a concentration-dependent increase in the firing rate. MP (1 mM) increased the frequency of spontaneous excitatory postsynaptic currents (sEPSCs) and spontaneous inhibitory postsynaptic currents (sIPSCs). The amplitude of the sEPSCs was also increased in response to 1 mM MP, whereas sIPSCs became smaller in size in the presence of MP. MP (1 mM) reduced the amplitude of the gamma-aminobutyric acid (GABA)-induced currents, whereas it increased the amplitude of the glutamate-induced currents. And finally; MP (1 mM), by itself, did not change the overall postsynaptic membrane conductance. These observations suggest that (1) MP can act as an excitatory agent in vitro, (2) it can act at the presynaptic as well as the postsynaptic level, and (3) it affects spinal cord neurons by influencing the ligand-gated (GABA and glutamate) channels.

Severe adverse cardiovascular effects of pulse steroid therapy: is continuous cardiac monitoring necessary?

Pulse steroid therapy (PST) has been used in dermatology to treat a variety of severe inflammatory disorders. Dermatologists have usually recommended that patients be hospitalized for continuous cardiac monitoring during PST administration, although specialists in other fields have administered PST in an outpatient setting. We reviewed the literature concerning serious adverse cardiovascular effects of PST. These were rare and have been mainly reported in nondermatologic patients, typically those with kidney or heart disease. Although outpatient administration of PST may be a safe practice for some dermatologic patients, we cannot make a firm recommendation without a prospective trial.