High-dose Pulse Corticosteroid Research Articles

Back to the Basics: Response of Alopecia Areata Universalis to Intravenous High-Dose Pulse Corticosteroid Therapy.

Back to the Basics: Response of Alopecia Areata Universalis to Intravenous High-Dose Pulse Corticosteroid Therapy.

The effects of high-dose corticosteroids for multiple sclerosis relapse on blood pressure: A pilot study

BackgroundMultiple sclerosis (MS) relapses are often treated with short pulses of high dose corticosteroids. Previous literature demonstrates corticosteroids can increase blood pressure (BP). There are few studies regarding effects of high dose, pulse corticosteroids on BP when treating MS relapses. ObjectiveTo investigate the effect of high dose pulse corticosteroids for MS relapses on BP and determine factors that may influence development of acute hypertension. MethodsIn this open-label pilot study, adult patients with a diagnosis of MS were enrolled if determined to be having a relapse that would meet criteria for corticosteroid treatment. BP was monitored sequentially over the course of their corticosteroid treatment and correlations were made with demographic data, including past medical and family history. Results22 subjects contributed data. Higher daytime BP was noted in subjects with a past personal (p = 0.007) or family history of hypertension (p = 0.037). Nighttime BP recordings did not show the normal 10% drop and nocturnal diastolic BP was within a hypertensive range during corticosteroid treatment. ConclusionMS patients may be at risk of increased BP when treated with corticosteroids for relapses. Those with a past or family history of hypertension may be at higher risk and may warrant more frequent monitoring.

Fungal Infections of the Central Nervous System.

This article summarizes current knowledge on the epidemiology, clinical presentations, diagnosis, and management of selected fungal infections of the central nervous system (CNS). Key syndromes, differential diagnoses, and therapeutic interventions according to host immune status and exposure are reviewed. Advancements in imaging of the brain and spinal cord, and molecular DNA and antigen-based laboratory diagnostics afford improved sensitivity for CNS mycoses. Newer therapeutic strategies may improve outcomes if provided early and host immunosuppression is abrogated. Adjunctive corticosteroid use for disabling neuroinflammation and cerebral edema in the setting of microbiological control may be considered. In addition, nonspecific presentations and absence of fevers in patients without human immunodeficiency virus suggest that screening for Cryptococcus meningitis be performed in all patients with subcortical dementias using a simple CSF or serum antigen test. CNS fungal infections comprise a wide spectrum of clinical syndromes, including abscesses, meningitis/meningoencephalitis, focal masses, stroke/vasculitides, immune reconstitution inflammatory syndrome (IRIS), and spinal pathologies such as arachnoiditis. The main etiologies include Aspergillus, Cryptococcus, Candida, Mucorales, dematiaceous molds, and dimorphic endemic fungi, with the route of acquisition being respiratory or traumatic inoculation with subsequent spread hematogenously or contiguously. Proper management focuses on early effective antifungal therapy and surgery for large or compressive mass lesions. While adjunctive recombinant cytokine or growth factor use has been supported in certain hosts with refractory infections, IRIS-like reactions may occur, suggesting alternative approaches such as high-dose pulse corticosteroids followed by taper.

Pulse Corticosteroid Therapy for Alopecia Areata in Children: A Retrospective Study

Background/Objective: Alopecia areata may occur at any age, though usually before the age of 20 years. Treatment often consists of systemic steroids administered as high-dose bolus infusions. This study sought to investigate the effectiveness and side effects of intravenous high-dose pulse corticosteroids in children with alopecia areata and to identify prognostic factors for successful treatment. Methods: Patients treated with pulse corticosteroids for alopecia areata in 2001-2008 at the day care unit of a tertiary pediatric medical center were identified by computerized file search and clinical treatment and outcome data were collected. Results: The sample included 24 children (16 female, 8 male) with a mean age of 8.5 ± 4.6 years at diagnosis; 8 (33%) had multifocal disease,10 (42%) multifocal disease with ophiasis, 4 (17%) alopecia totalis and 2 (8%) alopecia universalis. Nail involvement was noted in 9 patients (38%). Mean duration of disease was 22 ± 27 months. Patients were treated with 8 mg/kg body weight intravenous methylprednisolone on 3 consecutive days at 1-month intervals. After a mean of 5.65 ± 1.95 courses, 9 patients (38%) had a complete response, 7 (29%) a partial response and 8 (33%) no response. Of the 16 responders, 13 (81%) relapsed at 9.5 ± 12 months after the last course; 3 patients had side effects, none of which were severe. Three positive prognostic factors were identified: short disease duration (≤6 months), younger age at disease onset (<10 years) and multifocal disease (as opposed to severe, diffuse variants). Conclusions: Careful patient selection is necessary to achieve maximal benefit from pulse corticosteroid treatment for alopecia areata in children.

Favorable effect of immunomodulator therapy on bone mineral density in multiple sclerosis

Osteoporosis is a complication of multiple sclerosis (MS), especially if corticosteroid therapy is given. Little is known about the effect on bone of immunomodulatory therapy (IMT) for MS. We sought to evaluate bone mass in patients with MS on IMT. We measured bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) in 37 patients with MS who received IMT. Different IMTs were administered: interferon beta-1a in 70%, interferon beta-1b in 27% and Glatiramer in 3%. High-dose pulse corticosteroid therapy (intravenous methylprednisolone 500 mg) was given to 81% ranging from 1 to 17 courses. Both mean BMD Z-score at spine of 0.53 (CI, 0.15-0.92; P = 0.0084) and mean BMD Z-score at femur of 0.72 (CI, 0.42-1.01; P < 0.0001) were significantly greater than zero. IMT may have a favorable effect on bone in patients with MS even in the presence of pulse steroid therapy.

Poor long term outcome of severe alopecia areata in children treated with high dose pulse corticosteroid therapy

Poor long term outcome of severe alopecia areata in children treated with high dose pulse corticosteroid therapy

Precordial T-wave inversion of “cardiac memory” pattern after high-dose methylprednisolone pulse therapy

‘‘Cardiac memory’’ (CM) refers to T-wave abnormalities that manifest on resumption of a normal ventricular activation pattern after a period of abnormal ventricular activation, such as ventricular pacing, transient left bundlebranch block, ventricular arrhythmias, or Wolf–Parkinson– White syndrome [1]. Pacing-induced T-wave inversion (TWI), the most common clinical example of CM, is usually localized to precordial and inferior leads [1, 2]. Postpacing CM often produces striking precordial TWI that may persist for long periods of time after the pacing is discontinued, thus obscuring their causal relationship. As a result, TWI due to CM represents an important confounder in the diagnosis of myocardial infarction [2, 3]. Diagnostic features to differentiate by vector direction analysis pacinginduced CM from TWI that results from ischemia and infarction have been described only recently: the combination of (a) positive TaVL, (b) positive or isoelectric TI, and (c) maximal precordial TWI [ TWIIII was 92% sensitive and 100% specific for CM, discriminating it from ischemic precordial TWI [4]. The use of corticosteroids with caution is recommended in patients with congestive heart failure because long-term use has been associated with fluid retention and hypertension. Potentially severe side effects of high-dose pulse corticosteroid therapy are noted. Problems included arrhythmias, myocardial infarctions, and sudden death [5]. In one early report, most of the patients had underlying renal disease and/or were undergoing renal transplantation; all of the patients having the cardiovascular reactions associated with the corticosteroid received individual doses of at least 250 mg of methylprednisolone or its equivalent. However, cause–effect relationship between high-dose corticosteroid therapy and severe cardiovascular reactions has not been scientifically proven by a controlled trial [6]. Severe complications of pulse methylprednisolone, mainly cardiovascular, are strongly related to underlying comorbidities. In one recent study of 146 consecutive patients treated by three pulses of 250, 500 or 1,000 mg/day methylprednisolone for various eye diseases, 88.4% had one ore more side effect(s), mainly transient and of mild intensity; myocardial ischemia was observed in 2.1% with known coronary insufficiency or high cardiovascular risk; blood pressure levels of at least 180/110 mmHg were recorded in 3.4%; bradycardia occurred in 14 patients (9.7%), with symptomatic in one patient [7]. We report a case of a young adult who developed atypical angina at rest associated with precordial ECG changes with TWI after a 4 days pulse methylprednisolone therapy. On May 20, 2007, the 26-year-old man was admitted because of the feeling of a lump of gradual onset in the throat and with pain radiating to the jaw. There was no chest discomfort. Symptoms were constantly present, aggravated by swallowing but otherwise independent of daily activities and neither worsened by respiration nor exacerbated when lying down. There were no associated complaints like belching, vomiting, diaphoresis, dyspnea, syncope or palpitation. Five days before, on May 15, a 4 days course of high dose methylprednisolone therapy of 1,000 mg per day intravenously had been initiated for the treatment of idiopathic orbital inflammatory syndrome (IOIS) also known as J. Rottensteiner A. Kaneppele I. Stockner G. Panizza C. J. Wiedermann (&) Division of Internal Medicine 2, Department of Internal Medicine, Central Hospital of Bolzano, Lorenz Bohler Street 5, 39100 Bolzano (BZ), Italy e-mail: christian.wiedermann@asbz.it

Oral Versus High-Dose Pulse Corticosteroids for Problematic Infantile Hemangiomas: A Randomized, Controlled Trial

Oral systemic corticosteroids are the mainstay of treatment for problematic hemangiomas; however, current information is based on anecdotal experience and retrospective studies. We aimed to determine whether systemic steroids are efficacious in proliferating hemangioma and to compare the efficacy and safety of 2 corticosteroid treatment modalities. Twenty patients with problematic hemangiomas of infancy were randomly assigned to either daily oral prednisolone or monthly intravenous pulses of methylprednisolone. Their clinical outcomes (improvement using a visual analog score) and adverse events were compared at 3 months from baseline and 1 year of age. Data on possible surrogate markers of angiogenesis were available for the first 3 months. At 3 months, orally treated patients had a median visual analog score of 70 compared with 12 in the intravenous group. This response pattern was similar at the patients' first birthday: 50.0 vs -1.5. Additional treatment beyond 3 months was needed for 65% of the patients (7 in the intravenous and 6 in the oral group). Six of 8 patients with impaired vision at enrollment had an improved function at 1 year (4 patients in the intravenous group and 3 patients in the oral group). Of the 4 surrogate markers of angiogenesis measured (plasma basic fibroblast growth factor, vascular endothelial growth factor, vascular cellular adhesion molecule 1, endoglin, and urine basic fibroblast growth factor), the only 2 that decreased over time were vascular cellular adhesion molecule 1 and endoglin. Patients in the oral group had a higher rate of adverse effects, such as hypertension (18.6% vs 13.1%), abnormal cortisol (78% vs 60%), and growth retardation. Systemic corticosteroids are efficacious in stopping the proliferation of hemangiomas. The oral corticosteroids offered more clinical and biological benefit than the pulse steroids with higher risk of adverse effects.

High-dose pulse corticosteroids for SARS

High-dose pulse corticosteroids for SARS

High-Dose Pulse Corticosteroid Therapy in the Treatment of Severe Alopecia areata

Objective: The present monocenter prospective study was designed to evaluate the efficacy of intravenous high-dose methylprednisolone pulse therapy in patients with severe alopecia areata (AA). Methods: 30 patients (aged 14–56 years) were treated with methylprednisolone (8 mg/kg body weight) intravenously on 3 consecutive days at 4-week intervals for at least 3 courses. Results: 67% of patients with AA plurifocalis showed >50% regrowth of hair. None of the patients with AA totalis or universalis and only 1 patient with ophiasic AA responded to therapy. In patients with AA plurifocalis, higher response rates could be observed in those suffering from long-term disease compared to patients treated during their first episodes of AA (73 vs. 57%). Conclusion: High-dose methylprednisolone pulse therapy is an effective and well-tolerated treatment for patients with severe AA plurifocalis but might be less beneficial for patients with ophiasic AA, AA totalis or universalis.

Efficacy of cyclosporin A for idiopathic pulmonary fibrosis

In an 11-year-old girl with severe dyspnoea and cyanosis, idiopathic pulmonary fibrosis (IPF) was diagnosed. The PaO2 of blood could be maintained between 50 mm Hg and 70 mm Hg with a high dose pulse corticosteroid therapy, although this dose could not be reduced. Azathioprine in addition to prednisolone provoked deterioration. Twelve weeks after admission, cyclosporin A (Cs A), a known immunosuppressant, was started together with prednisolone. The PaO2 reverted to normal within 1 month and prednisolone could be tapered off within 6 months. Two years after admission, the patient is free of symptoms on continuous Cs A therapy. This case seems to be the first case successfully treated with Cs A.