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Ogiwara M, Ihara H, Muto Y, Haba M, Nakazawa H, Hotta S, Jo H, Hayama N, Honma Y, Hoshi S, Fujii M, Takahashi K. The inciting factor for bradycardia in COVID-19 patients: a potential harm of steroid treatment. J Thorac Dis 2024; 16:2835-2844. [PMID: 38883622 PMCID: PMC11170389 DOI: 10.21037/jtd-23-1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/15/2024] [Indexed: 06/18/2024]
Abstract
Background The coronavirus disease 2019 (COVID-19) is a condition caused by the novel severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Although several papers have reported the presence bradycardia in patients with COVID-19, the pathophysiology behind this remains unclear. Therefore, we investigated the presence of bradycardia in patients with COVID-19. Methods We conducted a retrospective cohort study in a total of 153 patients with COVID-19 and 90 patients with influenza who were hospitalized in our hospital from January 1, 2020 to December 31, 2021 and from January 1, 2014 to December 31, 2021, respectively. Data were collected from patient medical records, which included sex, age, duration of hospitalization, pneumonia complications, supplemental oxygen therapy, antiviral treatment, past history, and vital signs. Results After adjustment, the incidence of bradycardia and steroid use in patients with COVID-19 were significantly higher than those in patients with influenza (P=0.007 and P<0.001, respectively). We then compared the detailed characteristics of patients with COVID-19 to evaluate risk factors for bradycardia. Multivariate logistic regression analysis revealed that steroid use was significantly related to bradycardia [P=0.031; odds ratio (OR): 3.67; 95% confidence interval (CI): 1.12-11.96]. Overall, results showed a higher incidence of bradycardia in patients with COVID-19 who received steroid treatment. Conclusions Our results showed that steroid treatment in patients with COVID-19 may be associated with the incidence of bradycardia.
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Affiliation(s)
- Misa Ogiwara
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
| | - Hiroaki Ihara
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Yuki Muto
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
| | - Manami Haba
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Nakazawa
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Saori Hotta
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
| | - Hitomi Jo
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Noriko Hayama
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Yuichiro Honma
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Sakuo Hoshi
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Mitsuhiro Fujii
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
- Department of Respiratory Medicine, Koto Hospital, Tokyo, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University, Faculty of Medicine & Graduate School of Medicine, Tokyo, Japan
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2
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Ahmed M, Oyibo ST, Dalvi S, Cowell R. Hydrocortisone-induced symptomatic sinus bradycardia. Drug Ther Bull 2024; 62:93-95. [PMID: 38316449 DOI: 10.1136/dtb.2024.252878rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
- Mohammed Ahmed
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Success Tobore Oyibo
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Shailesh Dalvi
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Richard Cowell
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
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3
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Tikhomirov R, Oakley RH, Anderson C, Xiang Y, Al-Othman S, Smith M, Yaar S, Torre E, Li J, Wilson LR, Goulding DR, Donaldson I, Harno E, Soattin L, Shiels HA, Morris GM, Zhang H, Boyett MR, Cidlowski JA, Mesirca P, Mangoni ME, D'Souza A. Cardiac GR Mediates the Diurnal Rhythm in Ventricular Arrhythmia Susceptibility. Circ Res 2024; 134:1306-1326. [PMID: 38533639 PMCID: PMC11081863 DOI: 10.1161/circresaha.123.323464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/15/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Ventricular arrhythmias (VAs) demonstrate a prominent day-night rhythm, commonly presenting in the morning. Transcriptional rhythms in cardiac ion channels accompany this phenomenon, but their role in the morning vulnerability to VAs and the underlying mechanisms are not understood. We investigated the recruitment of transcription factors that underpins transcriptional rhythms in ion channels and assessed whether this mechanism was pertinent to the heart's intrinsic diurnal susceptibility to VA. METHODS AND RESULTS Assay for transposase-accessible chromatin with sequencing performed in mouse ventricular myocyte nuclei at the beginning of the animals' inactive (ZT0) and active (ZT12) periods revealed differentially accessible chromatin sites annotating to rhythmically transcribed ion channels and distinct transcription factor binding motifs in these regions. Notably, motif enrichment for the glucocorticoid receptor (GR; transcriptional effector of corticosteroid signaling) in open chromatin profiles at ZT12 was observed, in line with the well-recognized ZT12 peak in circulating corticosteroids. Molecular, electrophysiological, and in silico biophysically-detailed modeling approaches demonstrated GR-mediated transcriptional control of ion channels (including Scn5a underlying the cardiac Na+ current, Kcnh2 underlying the rapid delayed rectifier K+ current, and Gja1 responsible for electrical coupling) and their contribution to the day-night rhythm in the vulnerability to VA. Strikingly, both pharmacological block of GR and cardiomyocyte-specific genetic knockout of GR blunted or abolished ion channel expression rhythms and abolished the ZT12 susceptibility to pacing-induced VA in isolated hearts. CONCLUSIONS Our study registers a day-night rhythm in chromatin accessibility that accompanies diurnal cycles in ventricular myocytes. Our approaches directly implicate the cardiac GR in the myocyte excitability rhythm and mechanistically link the ZT12 surge in glucocorticoids to intrinsic VA propensity at this time.
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Affiliation(s)
- Roman Tikhomirov
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, United Kingdom (R.T., M.S., A.D.)
| | - Robert H Oakley
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health (R.H.O., J.L., L.R.W., D.R.G., J.A.C.)
| | - Cali Anderson
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
| | - Yirong Xiang
- Department of Physics and Astronomy (Y.X., H.Z.), The University of Manchester, United Kingdom
| | - Sami Al-Othman
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
| | - Matthew Smith
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, United Kingdom (R.T., M.S., A.D.)
| | - Sana Yaar
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
| | - Eleonora Torre
- Institut de Génomique Fonctionnelle, Université de Montpellier, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), F-34094 Montpellier France (E.T., P.M., M.E.M.)
| | - Jianying Li
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health (R.H.O., J.L., L.R.W., D.R.G., J.A.C.)
| | - Leslie R Wilson
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health (R.H.O., J.L., L.R.W., D.R.G., J.A.C.)
| | - David R Goulding
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health (R.H.O., J.L., L.R.W., D.R.G., J.A.C.)
| | - Ian Donaldson
- Bioinformatics Core Facility (I.D.), The University of Manchester, United Kingdom
| | - Erika Harno
- Division of Diabetes, Endocrinology and Gastroenterology (E.H.), The University of Manchester, United Kingdom
| | - Luca Soattin
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
| | - Holly A Shiels
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
| | - Gwilym M Morris
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
- Department of Cardiology, John Hunter Hospital, Newcastle, NSW, Australia (G.M.M.)
| | - Henggui Zhang
- Department of Physics and Astronomy (Y.X., H.Z.), The University of Manchester, United Kingdom
| | - Mark R Boyett
- Faculty of Life Sciences, University of Bradford, United Kingdom (M.R.B.)
| | - John A Cidlowski
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health (R.H.O., J.L., L.R.W., D.R.G., J.A.C.)
| | - Pietro Mesirca
- Institut de Génomique Fonctionnelle, Université de Montpellier, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), F-34094 Montpellier France (E.T., P.M., M.E.M.)
| | - Matteo E Mangoni
- Institut de Génomique Fonctionnelle, Université de Montpellier, Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), F-34094 Montpellier France (E.T., P.M., M.E.M.)
| | - Alicia D'Souza
- Division of Cardiovascular Sciences (R.T., C.A., S.A.O., M.S., S.Y., L.S., H.A.S., G.M.M., A.D.), The University of Manchester, United Kingdom
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, United Kingdom (R.T., M.S., A.D.)
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Tripathy SK, Das S, Malik A. Bradycardia after pulse methylprednisolone therapy in a child-Uncommon side effect of a frequently used drug: A case report. J Family Med Prim Care 2023; 12:1006-1008. [PMID: 37448929 PMCID: PMC10336951 DOI: 10.4103/jfmpc.jfmpc_2167_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/21/2023] [Accepted: 04/03/2023] [Indexed: 07/18/2023] Open
Abstract
Corticosteroids are potent anti-inflammatory agents used as a mainstay of therapy in most of the rheumatologic disorders. Common side effects of pulse steroid therapy include hypertension, hyperglycemia, seizure, hypokalemia, and infection. We report a case of an 11-year-old girl with polyarticular Juvenile idiopathic arthritis who developed bradycardia following pulse methylprednisolone therapy. On day 2 of methylprednisolone infusion, she developed bradycardia with a heart rate between 50 and 60/min. ECG was suggestive of sinus bradycardia. There was no evidence of dyselectrolytemia (Na-141 mmol/l, K-3.54 mmol/l, Ca-8.72 mg/l) or sepsis. The patient did not receive methylprednisolone on day 3 and vitals continued to be monitored. Her heart rate improved after 12 hours. In the mid of infusion on day 4, again the patient had bradycardia with a heart rate of 50-60/minute. Since she was hemodynamically stable, we continued the infusion, and bradycardia resolved in the next 8 hours. On follow-up after 2 weeks, she had some improvement in joint symptoms and normal heart rate. As per Naranjo adverse drug reaction probability scale, the adverse reaction in our case was probable with a score of 8. Although bradycardia associated with pulse steroid therapy is benign and is usually reversible following cessation of therapy, a baseline heart rate, ECG, and electrolyte level are suggested before infusion as a cautionary measure to minimize serious adverse events.
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Affiliation(s)
- Saroj K. Tripathy
- Department of Pediatrics, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
| | - Sarthak Das
- Department of Pediatrics, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
| | - Archana Malik
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
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5
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Yoshizane T, Ishihara A, Mori T, Tsuzuku A, Suzuki J, Noda T. Relative bradycardia in patients with moderate-to-severe COVID-19: a retrospective cohort study. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:65. [PMID: 35252761 PMCID: PMC8888813 DOI: 10.1007/s42399-022-01146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/29/2022]
Abstract
Coronavirus-related disease (COVID-19) can result in relative bradycardia; however, there are no reports on relative bradycardia in patients with moderate-to-severe COVID-19 who require oxygen. We retrospectively investigated 45 patients with moderate-to-severe COVID-19 and examined the relationship between heart rate and body temperature at the time of initiating oxygen or mechanical ventilation. For three consecutive days after initiating oxygen therapy, body temperature (day’s highest temperature), heart rate, and other vital signs were measured simultaneously. We checked for relative bradycardia and analyzed the differences between patients with moderate COVID-19 (oxygen requirement ≤ 5 L/min) and those with severe COVID-19 (oxygen requirement ≥ 5 L/min). Of the 45 patients, 28 and 17 had moderate and severe COVID-19, respectively. The heart rate increased with increasing body temperature, and almost all patients satisfied the criteria of relative bradycardia. In Spearman’s rank correlation analysis, body temperature was significantly correlated with heart rate (ρ = 0.483, p = 0.012) in moderately ill patients but not in severely ill patients (ρ = 0.261, p = 0.297). Multiple regression analysis revealed that the severity of COVID-19 and body temperature were independent predictors of heart rate. The predicted change in heart rate was 6.0 beats/min for each 1 °C rise in body temperature. Relative bradycardia was suggested to be a characteristic finding in patients with moderate-to-severe COVID-19 who require oxygen. Additionally, severely ill patients were more likely to develop relative bradycardia than moderately ill patients. Focusing on the relationship between heart rate and body temperature might help clinicians diagnose this disease in patients with worsening respiratory failure.
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Affiliation(s)
- Takashi Yoshizane
- Department of Cardiology, Gifu Prefectural General Medical Center, Noishiki 4-6-1, Gifu City, Gifu, 500-8226 Japan
- Respiratory Support Team, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Atsushi Ishihara
- Respiratory Support Team, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Teruki Mori
- Respiratory Support Team, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Akifumi Tsuzuku
- Department of Respiratory, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Jun Suzuki
- Department of Infectious Disease, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center, Noishiki 4-6-1, Gifu City, Gifu, 500-8226 Japan
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6
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Ahmed M, Oyibo ST, Dalvi S, Cowell R. Hydrocortisone-induced symptomatic sinus bradycardia. BMJ Case Rep 2022; 15:e252878. [PMID: 36375852 PMCID: PMC9664291 DOI: 10.1136/bcr-2022-252878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Steroids are commonly prescribed medications that have a wide range of adverse effects. Bradycardia is one of the rare but significant side effects of steroid use, and only a few cases have been reported with bradycardia as a side effect. In this report, we present a case of a woman in her early 50s who developed severe symptomatic sinus bradycardia following high-dose administration of intravenous hydrocortisone, initiated for acute exacerbation of Crohn's disease. Her symptoms entirely resolved after discontinuation of the steroid. This case highlights the importance of obtaining baseline ECG and cardiac monitoring in patients treated with pulsed high-dose steroids.
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Affiliation(s)
- Mohammed Ahmed
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Success Tobore Oyibo
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Shailesh Dalvi
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
| | - Richard Cowell
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham, Gwynedd, UK
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7
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Sohn SY, Kim SY, Joo IS. Corticosteroid-induced bradycardia in multiple sclerosis and maturity-onset diabetes of the young due to hepatocyte nuclear factor 4-alpha mutation: A case report. World J Clin Cases 2022; 10:7415-7421. [PMID: 36158012 PMCID: PMC9353935 DOI: 10.12998/wjcc.v10.i21.7415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/08/2022] [Accepted: 06/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravenous steroid pulse therapy is the treatment of choice for acute exacerbation of multiple sclerosis (MS). Although steroid administration is generally well-tolerated, cases of cardiac arrhythmia have been reported. Herein, we describe a young woman who developed marked sinus bradycardia and T-wave abnormalities after corticosteroid administration. We also present plausible explanations for the abnormalities observed in this patient.
CASE SUMMARY An 18-year-old woman experienced vertiginous dizziness and binocular diplopia 1 wk prior to admission. Neurological examination revealed left internuclear ophthalmoplegia with left peripheral-type facial palsy. The initial laboratory results were consistent with those of type 2 diabetes. Brain magnetic resonance imaging revealed multifocal, non-enhancing, symptomatic lesions and multiple enhancing lesions. She was diagnosed with MS and maturity-onset diabetes of the young. Intravenous methylprednisolone was administered. On day 5 after methylprednisolone infusion, marked bradycardia with T-wave abnormalities were observed. Genetic evaluation to elucidate the underlying conditions revealed a hepatocyte nuclear factor 4-alpha (HNF4A) gene mutation. Steroid treatment was discontinued under suspicion of corticosteroid-induced bradycardia. Her electrocardiogram changes returned to normal without complications two days after steroid discontinuation.
CONCLUSION Corticosteroid-induced bradycardia may have a significant clinical impact, especially in patients with comorbidities, such as HNF4A mutations.
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Affiliation(s)
- Sung-Yeon Sohn
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - Shin Yeop Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - In Soo Joo
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
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8
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Rollema C, van Roon EN, Ekhart C, van Hunsel FPAM, de Vries TW. Adverse Drug Reactions of Intranasal Corticosteroids in the Netherlands: An Analysis from the Netherlands Pharmacovigilance Center. Drugs Real World Outcomes 2022; 9:321-331. [PMID: 35661117 PMCID: PMC9392821 DOI: 10.1007/s40801-022-00301-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Intranasal corticosteroids are one of the cornerstone treatment options for allergic rhinitis and chronic sinusitis complaints. Safety information in the summary of product characteristics may not be representative for observations in daily clinical practice. The Netherlands Pharmacovigilance Center (Lareb) collects post-marketing safety information, using spontaneous reporting systems. OBJECTIVE Our objective was to analyse reports of adverse drug reactions associated with intranasal corticosteroids reported in the Dutch spontaneous reporting database of the Netherlands Pharmacovigilance Center Lareb to obtain insight into real-world safety data. METHODS We retrospectively examined all adverse drug reactions of intranasal corticosteroids reported to the Netherlands Pharmacovigilance Center Lareb, entered into the database from 1991 until 1 July, 2020. RESULTS In total, 2263 adverse drug reactions after intranasal corticosteroid use were reported in 1258 individuals. Headache (n = 143), epistaxis (n = 124) and anosmia (n = 57) were reported most frequently. Nasal septum perforation (reporting odds ratio 463.2; 95% confidence interval: 186.7-1149.7) had the highest reporting odds ratio, followed by nasal mucosal disorder (reporting odds ratio 104.5; 95% confidence interval 36.3-301.3) and hyposmia (reporting odds ratio 90.8; 95% confidence interval 45.1-182.7). Moreover, 101 (4.5%) reports were classified as serious by Lareb, including reports of Cushing's syndrome, adrenal cortical hypofunction and growth retardation. CONCLUSIONS Many side effects are consistent with the safety information in the summary of product characteristics of intranasal corticosteroids. Several serious (systemic) side effects are reported and it is important to realise that intranasal corticosteroids may contribute to the development. Healthcare providers and patients should be aware of the potential (individual) adverse drug reactions of intranasal corticosteroids. This information could help in discussing treatment options.
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Affiliation(s)
- Corine Rollema
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Henri Dunantweg 2, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands.
| | - Eric N van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Henri Dunantweg 2, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands
- Department of PharmacoTherapy, -Epidemiology and -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Corine Ekhart
- Netherlands Pharmacovigilance Center Lareb, 's-Hertogenbosch, The Netherlands
| | | | - Tjalling W de Vries
- Department of Paediatrics, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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9
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Resolution-promoting autacoids demonstrate promising cardioprotective effects against heart diseases. Mol Biol Rep 2022; 49:5179-5197. [PMID: 35142983 PMCID: PMC9262808 DOI: 10.1007/s11033-022-07230-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/03/2022] [Indexed: 12/12/2022]
Abstract
Abstract Chronic heart diseases have in common an unresolved inflammatory status. In atherosclerosis, myocarditis, myocardial infarction, or atrial fibrillation, mounting evidence suggests that unresolved inflammation contributes to the chronicity, aggravation, and morbidity of the disease. Following cardiac injury or infection, acute inflammation is a normal and required process to repair damaged tissues or eliminate pathogens and promote restoration of normal functions and structures. However, if acute inflammation is not followed by resolution, a chronic and deleterious inflammatory status may occur, characterized by the persistence of inflammatory biomarkers, promoting aggravation of myocardial pathogenesis, abnormal structural remodeling, development of cardiac fibrosis, and loss of function. Although traditional antiinflammatory strategies, including the use of COX-inhibitors, to inhibit the production of inflammation promotors failed to promote homeostasis, mounting evidence suggests that activation of specific endogenous autacoids may promote resolution and perpetuate cardioprotective effects. The recent discovery of the active mechanism of resolution suggests that proresolving signals and cellular processes may help to terminate inflammation and combat the development of its chronic profile in cardiac diseases. This review discussed (I) the preclinical and clinical evidence of inflammation-resolution in cardiac disorders including atrial fibrillation; (II) how and why many traditional antiinflammatory treatments failed to prevent or cure cardiac inflammation and fibrosis; and (III) whether new therapeutic strategies may interact with the resolution machinery to have cardioprotective effects. Graphical abstract RvD D-series resolving, RvE E-series resolving, LXA4 lipoxin A4, MaR1 maresin-1![]()
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11
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Catalá E, Iacoboni G, Vidal-Jordana Á, Oristrell G, Carpio C, Vilaseca A, Cabirta A, Bosch F, Tintoré M, Barba P. Neurotoxicity-associated sinus bradycardia after chimeric antigen receptor T-cell therapy. Hematol Oncol 2022; 40:482-487. [PMID: 35139240 DOI: 10.1002/hon.2976] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The advent of chimeric antigen receptor (CAR) T-cell therapy has changed the therapeutic landscape of relapsed/refractory aggressive B-cell lymphomas. Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are the typical adverse events associated with this therapy. Cardiovascular toxicities have also been reported in this setting. However, there is scarce data regarding the development of sinus bradycardia after CAR T-cell therapy. Here, we detail the clinical course of 4 patients with aggressive B-cell malignancies who received CAR T-cells and developed transient and reversible sinus bradycardia in the context of ICANS. We also discuss several hypotheses behind the pathophysiology of this potential new adverse event.
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Affiliation(s)
- Eva Catalá
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de, Barcelona, 08193, Bellaterra, Spain
| | - Ángela Vidal-Jordana
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gerard Oristrell
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cecilia Carpio
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de, Barcelona, 08193, Bellaterra, Spain
| | - Andreu Vilaseca
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alba Cabirta
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de, Barcelona, 08193, Bellaterra, Spain
| | - Mar Tintoré
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia (CEMCAT), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pere Barba
- Department of Hematology, Vall d'Hebron University Hospital, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de, Barcelona, 08193, Bellaterra, Spain
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12
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Shirvani M, Sayad B, Shojaei L, Amini A, Shahbazi F. Remdesivir-Associated Significant Bradycardia: A Report of Three Cases. J Tehran Heart Cent 2022; 16:79-83. [PMID: 35082876 PMCID: PMC8742862 DOI: 10.18502/jthc.v16i2.7390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
Recently, remdesivir was approved by the United States Food and Drug Administration for patients with Coronavirus disease 2019 (COVID-19). We herein describe 3 patients with COVID-19 who showed significant bradycardia and QTc prolongation after remdesivir administration. Bradycardia did not respond to atropine treatment in 2 of the patients, one of whom received theophylline and the other required a temporary pacemaker. Fortunately, the patients’ heart rate and rhythm returned to normal after the discontinuation of remdesivir, albeit it lengthened their hospital stays. Careful monitoring during remdesivir infusion may decrease the risk of adverse cardiovascular side effects.
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Affiliation(s)
- Maria Shirvani
- Infectious Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Babak Sayad
- Infectious Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Azadeh Amini
- Department of Pharmaceutical Biomaterials and Medical Biomaterials Research Center, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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13
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Miqdad MA, Mohamad A, Ali F, Mourad AR, Alamri A. Methylprednisolone-Induced Symptomatic Sinus Bradycardia in a Multiple Sclerosis Patient: A Case Report. Cureus 2022; 14:e21443. [PMID: 35223228 PMCID: PMC8857754 DOI: 10.7759/cureus.21443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
Abstract
Intermittent high-dose methylprednisolone therapy is widely used for various autoimmune conditions treatment. Common side effects are well known and monitored carefully during therapy. Although cardiovascular adverse events are uncommon, they have been increasingly reported in the literature. This is a case of a 30-year-old female who developed symptomatic sinus bradycardia after receiving three grams of intravenous methylprednisolone pulse therapy for multiple sclerosis flare-ups. Her pulse rate reached 40bpm, together with lightheadedness and chest tightness. An electrocardiogram confirmed sinus bradycardia, for which she was initially managed by splitting the methylprednisolone dose in half; however, 12 hours later, the heart rate decreased further to 35bpm, and her symptoms worsened. Subsequently, the medicine was omitted, and the patient shifted to the intensive care unit for close observation and monitoring. She was treated conservatively with close observation resulted in a gradual normalization of the heart rate. The diagnosis of methylprednisolone pulse-induced bradycardia was made after excluding other common etiologies of sinus bradycardia. This case report aims for careful cardiovascular monitoring in patients receiving high doses of methylprednisolone due to the dose-dependent cardiovascular risks.
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14
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Umeh C, Giberson C, Kumar S, Aseri M, Barve P. A Multicenter Retrospective Analysis on the Etiology of Bradycardia in COVID-19 Patients. Cureus 2022; 14:e21294. [PMID: 35186556 PMCID: PMC8846448 DOI: 10.7759/cureus.21294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction Bradycardia has been reported in the setting of SARS-CoV2 (COVID-19) and appears to be an important cardiac manifestation with an association of mortality. However, the etiology of bradycardia in COVID-19 remains unclear. Therefore, this study aims to retrospectively investigate the potential causes of bradycardia in COVID-19 patients. Method The multicenter retrospective analysis consisted of 1,116 COVID-19 positive patients from March 2020 to March 2021. Bradycardia and severe bradycardia were defined as a sustained heart rate of <60 BPM and <50 BPM, respectively, on two separate occasions, a minimum of four hours apart during the hospitalization. End-of-life bradycardia was excluded from the study. Data were retrieved using a structured query language (SQL) program through the EMR, and data were analyzed using IBM SPSS 27.0 (IBM Corp., Armonk, NY). Logistic regression was used to study the bradycardic event and its association with remdesivir, beta-blockers, or steroids use during the patient's hospital stay. Result In the multivariate analysis, bradycardia was significantly associated with length of hospital stay (p<0.001), mortality (p=0.022), ventilator use (p=0.001), and steroid use (p=0.001). However, there was no significant association between bradycardia and remdesivir use (p=0.066) or beta-blocker use (p=0.789). Conclusion Our study showed that steroid use was protective against developing bradycardia in COVID-19 patients. Furthermore, remdesivir and the use of beta-blockers were not associated with bradycardia in COVID-19 patients. However, bradycardia was associated with both increased mortality and length of stay in the hospital. Therefore, future studies should focus on the mechanism of bradycardia in COVID-19 patients and the effect of bradycardia on patient outcomes.
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Affiliation(s)
| | | | - Sabina Kumar
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Mahendra Aseri
- Data Engineering and Business Intelligence, Hemet Global Medical Center, Hemet, USA
| | - Pranav Barve
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
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15
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Payus AO, Chai AC, Mustafa N. An uncommon side effect of a very commonly used medication: A case report on hydrocortisone-induced bradycardia. Clin Case Rep 2021; 9:e04678. [PMID: 34430027 PMCID: PMC8365536 DOI: 10.1002/ccr3.4678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 11/22/2022] Open
Abstract
Sinus bradycardia is a rare but important side effect of high-dose hydrocortisone. It is a self-limiting condition that recovered spontaneously upon stopping the medication and did not recur with other types of corticosteroids.
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Affiliation(s)
- Alvin Oliver Payus
- Medicine Based DepartmentFaculty of Medicine and Health ScienceUniversiti Malaysia SabahKota KinabaluMalaysia
| | - Ann Chee Chai
- Department of MedicineUniversiti Kebangsaan Malaysia Medical Centre (UKMMC)CherasMalaysia
| | - Norlaila Mustafa
- Department of MedicineUniversiti Kebangsaan Malaysia Medical Centre (UKMMC)CherasMalaysia
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16
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Habib MB, Elshafei M, Rahhal A, Mohamed MFH. Severe sinus bradycardia associated with favipiravir in a COVID-19 patient. Clin Case Rep 2021; 9:e04566. [PMID: 34401155 PMCID: PMC8346599 DOI: 10.1002/ccr3.4566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
The antiviral medication "favipiravir" should be considered as a possible cause of unexplained sinus bradycardia.
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Affiliation(s)
- Mhd Baraa Habib
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | | | - Alaa Rahhal
- Department of PharmacyHamad Medical CorporationDohaQatar
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17
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Vanneman MW, Madhok J, Weimer JM, Dalia AA. Perioperative Implications of the 2020 American Heart Association Scientific Statement on Drug-Induced Arrhythmias-A Focused Review. J Cardiothorac Vasc Anesth 2021; 36:952-961. [PMID: 34144871 DOI: 10.1053/j.jvca.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022]
Abstract
The recently released American Heart Association (AHA) scientific statement on drug-induced arrhythmias discussed medications commonly associated with bradycardia, supraventricular tachycardias, and ventricular arrhythmias. The foundational data for this statement were collected from general outpatient and inpatient populations. Patients undergoing surgical and minimally invasive treatments are a unique subgroup, because they may experience hemodynamic changes associated with anesthesia and their procedure, receive multiple drug combinations not given in either inpatient or outpatient settings, or experience postprocedural inflammatory syndromes. Accordingly, the generalizability of the AHA scientific statement to this perioperative population is unclear. This focused review highlights important aspects of the new AHA scientific statement and their application to the perioperative setting. The authors review medications frequently encountered and given by anesthesiologists and their risk of drug-induced arrhythmias and discuss common anesthetic and adjunctive medications and their associated risks of bradycardia, atrial fibrillation, torsades de pointes, and drug-induced Brugada syndrome. In many instances, the risk of arrhythmia reported by the AHA scientific statement in the general population appeared to be higher than found in perioperative arenas. Furthermore, the authors discuss the arrhythmia risk of additional medications commonly ordered or administered by anesthesiologists that are not included in the AHA scientific statement. As patient and procedural complexity increases and novel anesthetic combinations propagate, further research and observational studies will be required to delineate further perioperative risks for drug-induced arrhythmia.
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Affiliation(s)
- Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Jai Madhok
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jonathan M Weimer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Abstract
Corticosteroid therapy has become an important modality of treatment for diseases in which rapid control of immunoinflammatory processes is required. However, one of the serious, but less known adverse effect of this therapy is cardiac arrhythmias. This includes both tachyarrhythmias and bradyarrhythmias. Corticosteroid use may also be associated with electrolyte imbalances like hypokalaemia by its mineralocorticoid activity. Those side effects are mainly seen with high-dose intravenous methyl-prednisolone or oral pulse dose prednisolone therapy. Here we report our experience in a child with warm idiopathic autoimmune haemolytic anaemia who developed sinus bradyarrhythmias and treatment refractory hypokalaemia during low-dose steroid therapy with reduction in heart rate by 60% of baseline.
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19
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Coen M, Jandus P, Rollason V, Seebach J, Serratrice J. Cinderella side effect: Intravenous corticosteroid-induced bradycardia. Therapie 2020; 76:480-481. [PMID: 32646687 DOI: 10.1016/j.therap.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/01/2020] [Accepted: 06/19/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Matteo Coen
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland; Unit of Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland.
| | - Peter Jandus
- Division of immunology and allergology, Department of Medicine, University Hospitals of Geneva , 1211 Geneva, Switzerland
| | - Victoria Rollason
- Department of anesthesiology, pharmacology, intensive care, and emergency medicine, division of clinical pharmacology and toxicology, Geneva University Hospitals,, 1211 Geneva, Switzerland
| | - Jörg Seebach
- Division of immunology and allergology, Department of Medicine, University Hospitals of Geneva , 1211 Geneva, Switzerland
| | - Jacques Serratrice
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland
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20
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Chinea A, Honeycutt WD, Miller T, Graves D, Jacobs A, Wu J, LaGanke CC. Effect of Alemtuzumab Infusions on Vital Signs: A Prospective Observational Study in Patients with Relapsing-Remitting Multiple Sclerosis. Int J MS Care 2020; 22:53-59. [PMID: 32410899 DOI: 10.7224/1537-2073.2018-076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Alemtuzumab efficacy and safety were established in phase 3 randomized trials. We characterize vital signs during and after the first alemtuzumab infusion course. Methods Patients with relapsing-remitting multiple sclerosis commercially prescribed alemtuzumab 12 mg/day on 5 consecutive days (initial course) were enrolled in this prospective, observational study. Preinfusion medications included methylprednisolone, antihistamine, and antipyretics. Primary end point: change from precourse baseline in vital signs during and 2 hours after each alemtuzumab infusion. Secondary end points: infusion duration and serious adverse events (AEs) starting within 24 hours and within 7 days after infusion (AEs collected up to 15 days after treatment). Potentially clinically significant vital sign abnormalities were based on predefined thresholds from literature review. Results In the 304 patients treated, minimal increases in mean systolic (≤8 mm Hg) and diastolic (≤3 mm Hg) blood pressures from precourse baseline were observed on infusion days 3 to 5. An increase in mean heart rate (20 beats per minute) during the first infusion day normalized by day 2, and smaller increases (5 beats per minute) occurred during subsequent infusions. Serious AEs occurred in two patients (0.7%) during or within 24 hours after infusion and in three patients (1.0%) within 7 days. Mean/median infusion duration was 4 hours. Vital sign abnormalities with potential clinical significance occurred in 62.5% of patients. Conclusions Although most patients had potentially clinically significant vital sign abnormalities, mean changes from baseline during and after infusion of the first alemtuzumab course were clinically insignificant. No new safety signals were detected.
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21
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Steroid-induced Bradycardia During Induction Chemotherapy in Children and Young Adults Diagnosed With Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma. J Pediatr Hematol Oncol 2019; 41:537-541. [PMID: 30994505 DOI: 10.1097/mph.0000000000001483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Systemic corticosteroids are widely used for the treatment of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma. Anecdotal case reports demonstrate bradycardia in patients receiving corticosteroids; however, a more in-depth analysis is lacking. This study aimed to describe the incidence, timing, and outcomes of bradycardia in children with ALL receiving corticosteroids during induction chemotherapy at our center from 2010 to 2016. A total of 153 children were included, with 150 (98%) demonstrating decreased heart rate following steroid administration with a median HR decrease of 23 beats per minute. Bradycardia ≤first percentile for age developed in 90 (59%) patients, with nadir occurring, on average, 7 doses into treatment, corresponding to 79 hours after initiation of therapy. No patient experienced adverse events related to bradycardia. Resolution of bradycardia at outpatient follow-up occurred in 62 of 71 (87%). Examination of nadir heart rate during subsequent hospitalizations in which steroids were not being administered did not demonstrate a significant incidence of bradycardia. Corticosteroid-induced bradycardia is common in children with ALL receiving induction chemotherapy. It was not associated with clinical adverse events and self-resolved without intervention. Therefore, further cardiac assessment may not be warranted in the presence of asymptomatic bradycardia suspected to be secondary to steroid administration.
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22
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Aksakal E, Simsek Z, Aksu U, Birdal O, Ateş ES, Kalkan K, Gulcu O, Demirelli S, Aksakal E, Tas H. Acute cardiac effects of high dose steroid treatment: A speckle tracking echocardiography study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:351-355. [PMID: 30785648 DOI: 10.1002/jcu.22716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 06/09/2023]
Abstract
PURPOSE High-dose steroid therapy (HDST) has frequent side-effects that appear at its cessation and depend on its dose. However, there is a lack of studies about the acute effects of HDST on cardiac function in adult patients. METHODS We included in this study 30 patients who underwent HDST (intravenously at doses ranging from 250 to 1000 mg) and 30 healthy control subjects with similar demographic and clinical characteristics, between September and December 2016. Echocardiographic measurements were made before and during the first 3 hours after the end of treatment, and results were compared between patients and controls. RESULTS There was no difference in baseline biochemical and echocardiographic characteristics between the patient and control groups. While left ventricular global longitudinal strain (LVGLS) and strain rate E were higher after treatment, no significant change was observed in conventional echocardiographic variables. CONCLUSIONS LVGLS, but not conventional echocardiographic variables, showed an increase in cardiac systolic function at the acute phase of HDST.
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Affiliation(s)
- Emrah Aksakal
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Ziya Simsek
- Department of Cardiology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Uğur Aksu
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Oguzhan Birdal
- Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Esma Selva Ateş
- Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Kamuran Kalkan
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Oktay Gulcu
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Selami Demirelli
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Enbiya Aksakal
- Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Hakan Tas
- Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
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23
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Sodero A, Squitieri M, Mazzeo S, Pasca M, Matà S, Pieri F, Bessi V, Sorbi S. Acute Symptomatic Sinus Bradycardia in High-Dose Methylprednisolone Therapy in a Woman With Inflammatory Myelitis: A Case Report and Review of the Literature. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2019; 12:1179547619831026. [PMID: 30828250 PMCID: PMC6390212 DOI: 10.1177/1179547619831026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 12/02/2022]
Abstract
High dose corticosteroid therapy is widely used as attack therapy of inflammatory
central nervous system disorders and can induce several adverse reactions.
Bradycardia is an infrequent event after corticosteroids administration and is
often asymptomatic. We report a case of a woman admitted to the neurological
department of our hospital for paraesthesias of the lower limbs. She received
adiagnosis of inflammatory myelitis and high dose corticosteroid therapy was
prescribed. During the therapy she complained of chest tightness, dyspnoea,
weakness and malaise. An electrocardiogram revealed sinus bradycardia. A
significant increase in body weight, probably due to plasma volume expansion,
was detected. Bradycardia and high blood pressure spontaneously resolved in few
days. We provide a collection and a statistical analysis of literature data
about steroid induced bradycardia. We found that higher total doses are
associated with lower pulse rate and symptomatic bradycardia. Bradycardia is
more frequent in older patients and those with underlying cardiac disease or
with autonomic disturbance. However clinicians must be aware about the
occurrence of symptomatic bradycardia in all patients who undergo high dose
corticosteroid therapy, not only in those at risk, to early detect and treat
this potentially dangerous condition.
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Affiliation(s)
- Alessandro Sodero
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Martina Squitieri
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Salvatore Mazzeo
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Matteo Pasca
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Sabrina Matà
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Francesco Pieri
- Department of Cardiology, Careggi University Hospital, Florence, Italy
| | - Valentina Bessi
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy
| | - Sandro Sorbi
- Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy.,Careggi University Hospital, Neurology unit, Florence, Italy.,IRCCS Don Carlo Gnocchi, Florence, Italy
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24
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Üsküdar Cansu D, Bodakçi E, Korkmaz C. Dose-dependent bradycardia as a rare side effect of corticosteroids: a case report and review of the literature. Rheumatol Int 2018; 38:2337-2343. [PMID: 30276424 DOI: 10.1007/s00296-018-4167-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/25/2018] [Indexed: 12/18/2022]
Abstract
Corticosteroids rank at the first place among the most commonly used immunosuppressive agents in the rheumatology practice. Although their conventional adverse effects including hyperglycemia, hypertension, hyperlipidemia, and osteoporosis are well-recognized and managed, steroid-induced cardiac arrhythmias are known to a lesser extent. In this regard, steroid-associated bradycardia is rarely expected and not very well known. Reported cases of steroid-associated bradycardias in the literature predominantly have emerged during the course of intravenous high-dose (pulse) methylprednisolone (MP) administrations. In this paper, we report a patient who developed sinus bradycardia following 52 mg of oral MP administration, improved once the drug was discontinued but repeated with the re-administration. Hence, the patient was shifted to prednisolone (PRED), and again suffered bradycardia which recovered upon dose reduction. Presenting this case along with other similar rare cases in the literature, our aim is to draw attention of fellow rheumatologists, who widely use steroids, to bradycardia-a rare and dose-dependent side effect of steroids.
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Affiliation(s)
- Döndü Üsküdar Cansu
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey.
| | - Erdal Bodakçi
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
| | - Cengiz Korkmaz
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
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25
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Safety of Dexamethasone for Nausea and Vomiting Prophylaxis in Children Receiving Hematopoietic Stem Cell Transplantation. J Pediatr Hematol Oncol 2018; 40:e278-e282. [PMID: 29702540 DOI: 10.1097/mph.0000000000001186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many children undergoing hematopoietic stem cell transplantation (HSCT) experience chemotherapy-induced nausea and vomiting (CINV) despite receiving prophylaxis. Guideline-consistent CINV prophylaxis includes dexamethasone, but uncertainty with regard to safety potentially limits the use of dexamethasone in children. We describe immediate adverse events (AEs) attributable to dexamethasone given for CINV prophylaxis to children during HSCT conditioning. MATERIALS AND METHODS Children enrolled in a previous prospective study were retrospectively analyzed. Objective parameters related to specific AEs occurring within 5 days of dexamethasone administration were abstracted from health records and graded according to the Common Terminology Criteria for Adverse Events version 4.03 (CTCAE v4.03). Their association to dexamethasone was assessed using the Liverpool Causality Assessment Tool. RESULTS Forty-six children (median age, 10.2 y) were eligible for analysis. The most frequent AEs attributable to dexamethasone (Liverpool Causality Assessment Tool category of probable or definite) were hyperglycemia (63%; CTCAE v4.03 grade 3: 2%), hypertension (52%; CTCAE v4.03 grade 3: 15%), and bradycardia (46%; CTCAE v4.03 grade 3: 0%). Other AEs included dyspepsia or gastroesophageal reflux disease (24%) and alterations in mood and behavior (9%). No AE exceeded CTCAE v4.03 grade 3 in severity. CONCLUSIONS In children undergoing HSCT who received dexamethasone for CINV prophylaxis, immediate AEs attributable to dexamethasone were most often of minor clinical importance and transient.
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Altunbas G, Sucu M, Zengin O. Ventricular repolarization disturbances after high dose intravenous methylprednisolone Theraphy. J Electrocardiol 2017; 51:140-144. [PMID: 28912075 DOI: 10.1016/j.jelectrocard.2017.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE There are no randomized trials evaluating the effects of pulse steroid treatment on cardiac electrophysiologic functions. The data are limited only to case series. In this study, we sought to evaluate the effects of high dose intravenous methylprednisolone therapy on indices of ventricular repolarization. METHODS Fifty patients with various autoimmune and inflammatory disorders were enrolled to the study. Electrocardiography (ECG) was obtained 4h before and 12h after the pulse steroid treatment. All ECGs were thoroughly evaluated by an experienced electrophysiologist. Indices of ventricular repolarization including QTc, JT, Tp-Te, Tp-Te/QTc were measured and compared with before and after-treatment ECGs. RESULTS There were 36 female and 14 male patients. Mean age was 36±13years. Heart rate was significantly reduced after the therapy (87,16±17,45bpm vs 73,86±17,45 p:0,001). QT interval (361,0±29,91 vs 388,20±42,84 p:0,001) and corrected QT interval (QTc) was significantly prolonged (401,60±19,79 vs 413,72±26,38 p:0,01) after pulse steroid therapy. Also, JT interval (273,0±28,73 vs. 299,60±45,66 p:0,001) and JT interval index (JTI%) was significantly prolonged (118,18±17,54 vs. 110,56±13,92 p:0,01). Tp-e interval was significantly prolonged after high-dose steroid treatment (74,60±13,12 vs. 83,80±13,68 p:0.001). The ratio of Tp-Te to QTc was also significantly increased after pulse steroid therapy (0,18±0,03 vs 0,20±0,03 p:0,009). CONCLUSION Our study shows that indices of ventricular repolarization are significantly prolonged after pulse steroid treatment. These findings indicate an increased risk of arrhythmias related to high dose intravenous methylprednisolone therapy.
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Affiliation(s)
- Gokhan Altunbas
- Gaziantep University School of Medicine, Department of Cardiology, Turkey.
| | - Murat Sucu
- Gaziantep University School of Medicine, Department of Cardiology, Turkey
| | - Orhan Zengin
- Gaziantep University School of Medicine, Department of Rheumatology, Turkey
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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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