Initial Dose Of Prednisolone Research Articles

Post biologic scenario in pemphigus patients at a tertiary care institution

<p class="abstract"><strong>Background:</strong> Rituximab is increasingly used for the treatment of pemphigus. Data derived from single center studies following a uniform treatment protocol are limited. The effect of demography and disease type on treatment response is poorly characterized. Aim of this study was to assess the efficacy, adverse effects of rituximab, adjuvants and follow up in pemphigus patients.</p><p class="abstract"><strong>Methods:</strong> Author undertook a retrospective review of records of 26 pemphigus patients (pemphigus vulgaris 25 and pemphigus foliaceus 1) who had received rituximab infusion. Oral prednisolone was administered in doses up to 0.5 mg/kg of body weight after infusion and tapered over the next 3-4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and AZT were continued for one year after clinical remission was achieved.<strong></strong></p><p class="abstract"><strong>Results:</strong> Complete remission was observed in 23 (88.5%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Three patients experienced relapse after a mean duration of 26 months. Infectious complications like candidiasis and furunculosis developed in two patients. Two patients had hypotension during infusion.</p><p class="abstract"><strong>Conclusions:</strong> Rituximab is an effective agent in the treatment of pemphigus and also for a long duration of remission with a lower initial dose of oral prednisolone. Severe side effects were rare.</p>

1172The increased serum level of troponin T after immunosuppression therapy reflects sustained myocardial FDG accumulation in cardiac sarcoidosis

Abstract Background and purpose Fluorine-18-flurodeoxyglucose positron emission computed tomography (18FDG-PET CT) is the sole but time-consuming and expensive examination assessing active inflammatory myocardium noninvasively in patients with cardiac sarcoidosis (CS). Though immunosuppression is used to treat CS, little is known about the cardiac biomarkers for determining therapeutic effect to immunosuppression therapy other than 18FDG-PET. Methods From Aug 2016, we prospectively enrolled 50 sarcoidosis patients with positively accumulated of FDG in the heart. The initial dose of prednisolone was 30mg/day, wherefrom the dose was tapered down 5mg/month until 6 months. After 6 months, follow-up 18FDG-PET was performed. Using 18FDG-PET images, we calculated total lesion glycolysis (TLG; SUVmeam x metabolic volume) and compared it to various cardiac markers. Non-responder was defined as TLG reduction rate <70% after immunosuppression therapy. Results In 50 CS patients, 41 patients had serial 18FDG-PET before and 6 months after immunosuppression therapy. 18FDG-PET images were acquired following 7 day's carbohydrate limitation and after at least 18-h fasting (mean free fatty acid level right before 18FDG-PET acquisition was 1.03 mEq/L). The mean age and plasma brain natriuretic peptide (BNP) level were 61.9 years old, 184 pg/mL at baseline, respectively. Because of immunosuppression therapy, TLG was significantly reduced from 195.3 (38.6–339.6) to 1.1 (0.01–7.37), p<0.001). Six (14.6%) patients were classified as NR group and the level of TnT at post therapy was significantly higher in NR group than responder-group (R-group) (0.021 (0.012–0.027) ng/ml vs 0.0095 (0.006–0.013) ng/ml, p=0.039) (Figure), while there were no significant differences between NR-group and R-group in the levels of ACE, sIL-2R, BNP, Dd, EF. Figure 1 Conclusions 1) By immunosuppression therapy using prednisolone for CS, about 85% patients showed significant reduction of increased myocardial FDG accumulation. 2) The sustained high level of serum TnT at post 6 months therapy indicates persistent inflammation of sarcoidosis in the heart, which could be an expedient marker for determining therapeutic effect.

MiR-1 is a novel biomarker for polymyositis/dermatomyositis-associated interstitial lung disease

Objectives: Although intensive immunosuppressive treatment is necessary for the severe cases with polymyositis (PM)/dermatomyositis (DM), the prognostic factors or disease activity indices for PM/DM have not been established. Here we investigated the association between serum microRNA-1 (miR-1) level and clinical course of patients with PM/DM.Methods: We retrospectively reviewed baseline clinical and laboratory findings, treatment regimens and outcomes in patients with PM/DM. The serum samples were collected from PM/DM patients and healthy controls (HC). Serum miR-1 levels were determined by quantitative real-time PCR.Results: Twenty-two patients were recruited. The average serum miR-1 level was significantly higher in the PM/DM as compared to HC (p = .0085) and was decreased by treatment (p = .032). We divided the PM/DM-ILD patients into two groups, high and normal miR-1 groups. Although there were no significant differences in the clinical data and the initial prednisolone (PSL) dose between the two groups, PSL dose at 16 weeks, cumulative PSL dose until 16 weeks, and frequency of serious infections were significantly higher in the high miR-1 group as compared to the normal group (p = .025, .036, and .026, respectively).Conclusion: We propose serum miR-1 as a promising novel biomarker for predicting therapeutic response in PM/DM-ILD.

1641-P: Development and Validation of a Clinical Predictive Score for Insulin Requirement during Glucocorticoid Treatment

Insulin is often administered for glucocorticoid (GC) -induced hyperglycemia. We have developed and validated a scoring system to predict insulin requirement for optimal control of hyperglycemia during GC treatment through retrospective studies. The Developing set: 303 adults out of 2718 patients, undergoing their first treatment of prednisolone (PSL) with a dosage of 5 mg/day or more for 4 weeks at least, were divided into 2 groups depending on with or without administration of insulin during GC treatment. Risk factors for insulin requirement were identified by a stepwise logistic regression analysis after univariate analyses of clinical parameters before GC treatment between the 2 groups. We constructed a point-addition scoring system, consisting of several categories and their coefficients in each risk factor, derived from another multivariate analysis. We validated it to validation sets A (n=44) and B (n=77) in another two facilities, respectively. Male, FPG, HbA1c, serum CRE, and an initial dose of PSL were identified as the risk factors. The AUC by ROC analysis of the total scores when the Developing set was scored, showed 0.94. The sensitivity, specificity, and accuracy were 90%, 88%, and 88%; 88%, 67%, and 71%; 83%, 76%, and 77% in the Developing set, Validation set A, and B, respectively if the cut off value of the total scores was defined as 19 points. The scoring system: Table is useful. Disclosure M. Kawashima: None. Y. Kitada: None. K. Kajita: None. I. Mori: None. T. Ishizuka: None. D. Murakami: None. H. Okada: None. H. Morita: None. Funding Sanofi; Eli Lilly Japan K.K.

Insufficient Use of Corticosteroids without Immunosuppressants Results in Higher Relapse Rates in Takayasu Arteritis.

Although prednisolone (PSL) and immunosuppressants are key drugs for Takayasu arteritis (TA) treatment, there is limited evidence on the optimal PSL dose. The aim of this study was to investigate the correlation between the initial PSL dose and relapse in TA. We enrolled 105 patients with TA who satisfied the criteria of the Japanese Circulation Society and American College of Rheumatology from 1990 to 2015. The clinical characteristics and outcomes of patients with TA were retrospectively evaluated. The relapse-free period was assessed according to the difference in initial treatments. Relapse was observed in 57 (59.4%) of 96 patients treated with immunosuppressive therapy at diagnosis during a median followup of 56 months. Male sex and younger age of onset were significantly associated with relapse. Although ≤ 30 mg/day PSL monotherapy was preferably prescribed for patients with lower inflammatory markers, compared with > 30 mg/day (87.2% vs 52.6%), a significantly higher relapse rate was observed in the ≤ 30 mg/day group (HR 1.78; p = 0.047). Further, the relapse-free period was longer in patients treated with ≥ 50 mg/day PSL compared with those treated with ≤ 40 mg/day PSL. Combination therapy improved the relapse-free period compared with PSL monotherapy in the short term. The initial PSL dose was not associated with adverse events. A higher dose of PSL was associated with a significant decrease in the relapse rate. The effect of combination therapy on relapse needs to be further investigated. Lower-dose PSL monotherapy is an undesirable strategy for remission induction in TA, despite low disease activity.

Factors associated with discontinuation of glucocorticoids after starting biological disease-modifying antirheumatic drugs in rheumatoid arthritis patients

Objectives: Glucocorticoids (GCs) are effective treatments for rheumatoid arthritis (RA) but long-term use has adverse effects. This study aimed to elucidate whether GCs can be discontinued by introducing biological disease-modifying antirheumatic drugs (bDMARDs) and the factors influencing the outcome.Method: We included RA patients who had been orally taking GCs at the initiation of bDMARDs. The changes in GC dose after starting bDMARDs were evaluated and the GC discontinuation rate was analyzed using Kaplan–Meier analysis. The factors associated with discontinuation of GCs were assessed by Cox hazard models.Results: Eighty RA patients were included in the study. The dosage of oral prednisolone (PSL) was significantly reduced from 5.0 to 3.0 mg/day by 3 months (p = .013). GCs were discontinued in 31.3% of patients and the median time until GC discontinuation was 10.1 months. The GC discontinuation rate was significantly higher in patients with Class 1 and 2 (p = .024), with an initial PSL dose <5 mg/day (p = .040), and with low DAS28(ESR) (p = .038). In multivariate analyses, higher DAS28(ESR) (odds ratio, 0.200; p = .039), and higher PSL dose (odds ratio, 0.748; p = .029) were significantly associated with less frequent GC discontinuation.Conclusion: DAS28(ESR) high and PSL dose were factors associated with discontinuation of GC use after starting bDMARDs.

Development and validation of a scoring system for prediction of insulin requirement for optimal control of blood glucose during glucocorticoid treatments

AimsWe have developed and validated a novel scoring system to predict insulin requirement for optimal control of blood glucose during glucocorticoid (GC) treatments, by retrospective analyses of clinical parameters before GC treatment. MethodsThree hundred-three adults (the Developing set) undergoing their first treatment of prednisolone (PSL) were divided into two groups, depending on treatment with or without insulin. Independent risk factors for insulin requirement were identified by a stepwise logistic regression analysis after univariate analyses between the two groups. We constructed a point-addition scoring system consisting of several categories and their coefficients in each risk factor derived from another logistic regression analysis. We validated it to two validation sets, A and B. ResultsMale, higher levels of fasting plasma glucose (FPG), HbA1c, and serum creatinine (CRE) and a higher initial dose of PSL were identified as the risk factors. The sensitivity, specificity, and accuracy were 90.0%, 88.1%, and 88.4%; 87.5%, 66.7%, and 70.5%; 83.3%, 76.1%, and 76.6% in the Developing set, Validation set A, and Validation set B, respectively, when the scoring system was applied. ConclusionsThe scoring system is a valid and reliable tool to predict insulin requirements in advance during GC treatment.

Successful Treatment of Autoimmune Urticaria with Low-Dose Prednisolone Therapy Administered for a Few Months: A Case Series of 42 Patients

Background: Chronic spontaneous urticaria (CSU) is defined as symptoms of urticaria persisting for 6 weeks or more without obvious cause. Autologous serum skin test (ASST) positivity in patients with CSU is considered to be associated with autoimmune urticaria (AIU). Methods: In this retrospective study we retrieved the medical records of 1,073 urticaria patients seen at the Department of Dermatology and Allergology of Szeged University between January 2005 and February 2014. Forty-two patients (36 female and 6 male) met the study criteria by having CSU and giving positive results in the ASST. Our aim was to assess the clinical efficacy and safety of low-dose oral prednisolone therapy administered to patients with antihistamine-refractory ASST-positive CSU for a few months. Patients were given an initial dose (40 mg/day) of prednisolone until the complete resolution of the symptoms, usually 7-10 days, and then the dose was gradually decreased, as in other autoimmune diseases. Results: Prednisolone therapy lasted for an average of 3.6 months and a complete long-lasting response was achieved in 35 of 42 AIU patients (83.3%). The follow-up period was at least 36 months (3 years) for each AIU patient; the longest follow-up time was 139 months (11.5 years). None of the patients reported any considerable side effects. Conclusion: Based on our results, we suggest that the use of this treatment could be an alternative for the treatment of AIU. Our present results also highlight the need for other therapies in a small percentage of AIU patients. Our results suggest that AIU represents a transient autoimmunity that can be successfully treated with low-dose steroid therapy administered for a few months.

The predictive prognostic factors for polymyositis/dermatomyositis-associated interstitial lung disease

BackgroundInterstitial lung disease (ILD) is the principal cause of death in polymyositis/dermatomyositis (PM/DM). Here we investigated prognostic factors for death and serious infection in PM/DM-ILD using the multicenter database.MethodsWe retrospectively reviewed baseline demographic, clinical and laboratory findings, treatment regimens and outcomes in patients with PM/DM-ILD. The distribution of ILD lesions was evaluated in four divided lung zones of high-resolution computed tomography images.ResultsOf 116 patients with PM/DM-ILD, 14 died within 6 months from the diagnosis. As independent risk factors for early death, extended ILD lesions in upper lung fields (odds ratio (OR) 8.01, p = 0.016) and hypocapnia (OR 6.85, p = 0.038) were identified. Serious infection was found in 38 patients, including 11 patients who died of respiratory or multiple infections. The independent risk factors were high serum KL-6 (OR 3.68, p = 0.027), high initial dose of prednisolone (PSL) (OR 4.18, p = 0.013), and combination immunosuppressive therapies (OR 5.51, p < 0.001).ConclusionThe present study shows the progression of ILD at baseline is the most critical for survival and that infection, especially respiratory infection, is an additive prognostic factor under the potent immunosuppressive treatment.

Treatment Response and Outcome with Two Different Prednisolone Regimens in Autoimmune Hepatitis

Beyond available guidelines, therapy of autoimmune hepatitis (AIH) shows wide variation among physicians. We compared two regimens for treatment naive AIH: one recommended protocol with an initial prednisolone dose of 30mg/day and our own 40mg/day prednisolone with a slow dose tapering protocol. We analyzed the safety, response rates, and outcomes for two groups of treated patients. We retrospectively evaluated data of 71 AIH patients including, group I (n=32, prednisone 30mg/day) and group II (n=39, prednisone 40mg/day). All patients also received azathioprine. The frequency of complete biochemical response was significantly higher in group II than in group I (69.2 vs. 43.8%, p=0.031) after 3months of therapy, but not after 6 and 12months (79.5 vs. 59.4%, p=0.065 and 89.5 vs. 80.6%, p=0.30). In patients with severe interface hepatitis, the complete response rates were significantly higher in group II than in group I after 3 (63.6 vs. 23.1%, p=0.02) and 6months (72.7 vs. 38.5%, p=0.046), but not after 12months of therapy (86.4 vs. 69.2%, p=0.221). Relapses were observed in 50% of group I and in 35.9% of group II during maintenance therapy (p=0.23). Overall survival was significantly better in group II than in group I (100 vs. 87.5%, log-rank, p=0.048). No severe steroid-related side effects were observed in either group. Our real-world experience suggests that an initial prednisolone dose of 40mg/day with a slower tapering protocol induces earlier biochemical response, tends to result in less relapses during maintenance, and is associated with a better disease outcome.

High-dose prednisolone after intravenous methylprednisolone improves prognosis of acute exacerbation in idiopathic interstitial pneumonias.

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) (AE-IPF) is a poor prognostic disorder. AE is also reported to occur in other idiopathic interstitial pneumonias (IIPs). There are limited data available regarding the effectiveness of treatment for AE-IIPs. The objective of this study was to clarify the prognostic impact of the initial dose of prednisolone (PSL) for treating AE-IIPs. Eighty-five patients with AE-IIPs, diagnosed according to the criteria of the Japanese Respiratory Society, were enrolled in this study (IPF/non-IPF: 63/22 patients) from 2004 to 2013. We performed multivariate Cox proportional hazard regression analysis to identify poor prognostic factors. HRCT patterns at the onset of AE-IIPs were classified as diffuse or non-diffuse. We evaluated the prognostic significance of the initial dose of PSL by adjusting for other prognostic factors. Median survival time (MST) after AE-IIPs diagnosis was 49 days. MST of AE-IPF and AE-non-IPF was 39 and 49 days, respectively. A diffuse HRCT pattern, lower serum IgG and higher serum surfactant protein-D at AE diagnosis, long-term oxygen therapy (LTOT) before AE and positive pressure ventilation (PPV) use for AE were significant poor prognostic factors for all patients, as were LTOT before AE and lower serum IgG for no-PPV patients. High-dose PSL ≥ 0.6 mg/kg was a significant prognostic factor for no-PPV patients after adjusting for other prognostic factors. We concluded that a dose of PSL ≥ 0.6 mg/kg after i.v. high-dose methylprednisolone therapy should be recommended for the treatment of AE-IIPs.

Fewer subsequent relapses and lower levels of IL-17 in Takayasu arteritis developed after the age of 40years.

BackgroundThe clinical characteristics of Takayasu arteritis (TAK) developing in individuals older than 40 years (TAK >40) are little-known.MethodWe retrospectively analyzed 43 patients with TAK treated at three hospitals in Japan from April 2000 to March 2016. From medical records we collected baseline variables at diagnosis including clinical symptoms, laboratory data, and subsequent relapses. We compared these indices in the patients with TAK onset at >40 years of age (TAK >40) to those with TAK onset ≤40 years (TAK ≤40). Multiplex cytokine/chemokine bead assays were performed using preserved serum supernatants from 24 patients with TAK and 40 healthy donors.ResultsOf the 43 patients, 20 had TAK >40; this group had significantly fewer instances of orthostatic hypotension (2 (10%) vs. 10 (43%), p = 0.019), carotid bruit (7 (35%) vs. 16 (70%), p = 0.034), and chest pain (0 (0%) vs. 6 (26%), p = 0.023) compared to patients with TAK ≤40 (n = 23). The initial prednisolone dose was significantly lower in TAK >40 (median 30 mg vs. 40 mg per day, p = 0.024). Assessed by the log-rank test, the relapse-free survival rate after remission was significantly higher in the patients with TAK >40 (p = 0.029). The interleukin 17 levels were significantly lower in patients with TAK >40 compared to patients with TAK ≤40 and healthy donors.ConclusionCompared to TAK ≤40, TAK >40 could be treated by lower initial doses of prednisolone to achieve remission, and with fewer relapses. These differences might be due to the difference of T helper 17 (Th17) activity suggested by the cytokine profiles.

Clinical efficacy of rituximab in the treatment of pemphigus: A retrospective study.

Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. The primary objective was to assess the efficacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modified in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3-4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the first dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

Standard Treatment in Adults: Which Steroid? Or without Steroids?

Key Messages: (1) Standard treatment of autoimmune hepatitis in adults should be steroid based. In early trials, prednisolone +/- azathioprine was superior to the azathioprine mono-therapy (which was not significantly better than placebo). Prednisolone plus azathioprine has similar efficacy to, but is better tolerated than a higher-dose of prednisolone alone and therefore has become standard therapy. (2) In most treated patients, serum transaminases and globulin/IgG fall, but percentage attaining normal values within 6 months varies between 10 and 90%. Patients failing to do so have a worse longer-term outcome. (3) A higher initial prednisolone dose (1 mg/kg/day) plus azathioprine achieved 76% serum transaminase normalisation after 6 months but needs longer-term evaluation. (4) Histological remission (minimal hepatitis on re-biopsy) lags behind transaminase normalisation by 6-12 months and is achieved in 55-70% of patients after 24-36 months prednisolone. This lag and the inefficacy of azathioprine mono-therapy justifies continuing prednisolone (5-10 mg/day), even after transaminase normalisation, for a total of >2 years. (5) Repeat biopsy should be considered because 40-60% of patients still have (usually mild) persisting inflammation, despite normal serum transaminases and IgG. In such patients, fibrosis is less likely to regress and long-term mortality is higher. (6) In a large trial, non-cirrhotic treatment-naïve patients given budesonide (9 mg/day) plus azathioprine were more likely to achieve normal serum ALT after 6 months than those receiving prednisolone plus azathioprine and had less side effects. This trial was short term in nature and lacked follow-up histology. Budesonide is recommended in non-cirrhotic patients who develop prednisolone-related side effects. In an open study of mycophenolate plus prednisolone, 88% of treatment-naïve patients achieved normal serum transaminases. However, half relapsed during or after steroid withdrawal and only one of eight re-biopsied patients achieved histological remission. Mycophenolate is teratogenic, limiting its use in younger women. Conclusion: Despite its limitations, no regime has yet been shown clearly to be better than prednisolone and azathioprine-based therapy.

High triglyceride is a risk factor for silent osteonecrosis of the femoral head in systemic lupus erythematosus.

The purpose of this study was to clarify the factors related to silent osteonecrosis of the femoral head (ONFH) in patients with systemic lupus erythematosus (SLE). Seventy-eight patients with SLE were selected on the basis of having been newly diagnosed and requiring high-dose prednisolone, including pulse therapy with methylprednisolone, as the initial treatment. All the patients initially underwent MRI at 3 months after the start of corticosteroid treatment to detect any early changes in the femoral head. These examinations were then performed again 3 months later. Laboratory parameters were evaluated at the start of steroid treatment and at 1 month thereafter. By 3 months after the start of corticosteroid treatment, silent ONFH was diagnosed by MRI in 21 patients (26.9 %), being bilateral in 11 patients and unilateral in 10. The occurrence of silent ONFH was not related to SLE disease activity index, serological activity, or renal function; it was also unrelated to body mass index (BMI), body surface area (BSA), and the initial dose of prednisolone per unit body weight. However, the total cholesterol level at 4 weeks after the start of steroid treatment tended to be higher in patients with silent ONFH. Patients with a higher triglyceride level showed a significantly higher frequency of silent ONFH both before (p = 0.002) and 4 weeks after (p = 0.036) steroid initiation.A high triglyceride level is an important risk factor for silent ONFH in patients with SLE, and large-scale epidemiologic surveys of such early events are needed in this patient population.

Current smoking is an independent risk factor for new-onset diabetes mellitus during highdose glucocorticoid treatment.

Although high-dose glucocorticoids have been reported to cause new-onset diabetes mellitus (glucocorticoid-induced diabetes mellitus), its risk factors have remained to be determined. We investigated the risk factors related to glucocorticoid-induced diabetes mellitus diagnosed within 2 months after the high-dose treatment (newly treated with an initial high dose of > 20 mg prednisolone (PSL) equivalent per day for at least more than 6 months) in collagen vascular diseases. A total of 2,631 patients with collagen vascular diseases was registered between 1986 and 2006 in the Chiba-Shimoshizu Rheumatic Cohort. We analyzed 681 patients newly treated with high-dose glucocorticoid who did not have diabetes mellitus and/or its previous diagnosis (age: 46.3 ± 16.7 years, PSL dose: 40.0 ± 14.1 mg/day). Glucocorticoid-induced diabetes mellitus was diagnosed by two or more glucose measurements in patients with fasting glycaemia ≥ 7 mmol/L and 120 minutes post-load glycaemia ≥ 11.1 mmol/L. Glucocorticoid-induced diabetes mellitus was observed in 26.3% of patients, and the glucocorticoid-induced diabetes mellitus group had higher age, higher BMI, lower rates of females and systemic lupus erythematosus, higher rates of smoking, alcohol use, and microscopic polyangiitis. Multivariate logistic regression analysis demonstrated that the risk of glucocorticoid-induced diabetes mellitus was independently higher in every 10-year increment of initial age with adjusted odds ratio (OR) 1.556 (95% confidence interval: 1.359 - 1.783), in every 1 kg/m2 increment of BMI with OR 1.062 (1.002 - 1.124), in current smoking with OR 1.664 (1.057 - 2.622), and in every 10 mg increment of initial dose of prednisolone with OR 1.250 (1.074 - 1.454). High-dose glucocorticoids caused diabetes mellitus with high prevalence within a short period, and current smokers should be considered at higher risk of glucocorticoidinduced diabetes mellitus in addition to age, BMI, and initial dose.

Recovery of renal function after glucocorticoid therapy for IgG4-related kidney disease with renal dysfunction.

BackgroundAlthough renal dysfunction in IgG4-related kidney disease (IgG4-RKD) shows rapid resolution with glucocorticoid therapy, little is known about the appropriate initial glucocorticoid dose for induction therapy or long-term renal outcome.MethodsWe retrospectively examined the differences in recovery of renal function according to the dose of glucocorticoid used for induction therapy and the long-term renal outcome in 43 patients with definite IgG4-RKD (mostly IgG4-tubulointerstitial nephritis), in whom the estimated glomerular filtration rate (eGFR) before glucocorticoid therapy was <60 ml/min.ResultsMost patients were treated with glucocorticoid alone and had been maintained on glucocorticoid. The initial dose of prednisolone employed was ≤0.6 mg/kg/day (mean 0.47) in 27 patients (group L), and >0.6 mg/kg/day (mean 0.81) in 16 patients (group H). In both groups, the pretreatment eGFR was significantly improved at 1 month after the start of glucocorticoid therapy and the degree of improvement showed no significant inter-group difference. Relapse of IgG4-RKD occurred in 16.7 % of the group L patients and 13.3 % of the group H patients (p = 0.78). Among 29 patients who were followed up for over 36 months (mean 74 months) and had been maintained on glucocorticoid, none showed progression to end-stage renal disease and there was no significant difference between eGFR at 1 month after treatment and eGFR at the last review.ConclusionIn glucocorticoid monotherapy for IgG4-RKD, a moderate dose is sufficient for induction, and recovery of renal function can be maintained for a long period on low-dose maintenance, although relapse can occur even in patients receiving maintenance therapy.

Efficacy of short-term prednisolone treatment in patients with chronic eosinophilic pneumonia.

In patients with chronic eosinophilic pneumonia (CEP), dramatic improvements are seen in response to corticosteroid therapy; however, relapse is common after treatment has ceased. The optimal duration of corticosteroid therapy remains unclear. In a randomised, open-label, parallel group study, eligible patients with CEP received oral prednisolone for either 3 months (3-month group) or 6 months (6-month group), followed by 2 years observation. All patients were treated with an initial dose of prednisolone of 0.5 mg·kg(-1)·day(-1), which was then tapered and discontinued at either 3 or 6 months. The primary end-point was relapse during the follow-up period. In the final analysis, there were 23 patients in the 3-month group and 21 patients in the 6-month group. All patients showed a good response to prednisolone treatment. There were 12 (52.1%) relapses in the 3-month group and 13 (61.9%) relapses in the 6-month group. No significant difference was found in the cumulative rate of relapse (p=0.56). All relapse cases showed improvement upon resumption of prednisolone treatment. No difference was observed in the rate of relapse between the 3- and 6-month prednisolone treatment groups for patients with CEP.

Prednisolone Dosing Regimen for Treatment of Subacute Thyroiditis.

The rate of recurrence of subacute thyroiditis (SAT) during prednisolone (PSL) therapy is approximately 10 to 20%. However, there is little or no information on the time period to relapse following administration of a tapered dose of PSL and the factors associated with such relapse. The aim of this study was to determine the correlation between SAT recurrence and PSL tapering regimen used in the treatment of SAT. This study was a medical record-based retrospective study and involved 26 patients (3 men, 23 women) who received PSL therapy for SAT. The primary endpoint was the association between recurrence and number of days required to taper daily PSL dose to 5 mg. The secondary endpoint was the relationship between recurrence and several variables including age, clinical score, free thyroxine, inflammatory reaction, thyroglobulin, total treatment time, total dose of PSL and presence or absence of creeping thyroiditis. The SAT recurrence rate was 15.3%. There was no significant difference in the initial PSL dose between the non-recurrence and recurrence groups (27.5 mg vs 24.5 mg, P = 0.302). However, for the primary endpoint, significant differences were found between the two groups in time required for tapering PSL to 5 mg/day (non-recurrence: 44.3 ± 15.3 days, recurrence: 19.0 ± 11.9 days, P = 0.012). None of the clinical variables evaluated correlated significantly with SAT relapse. In conclusion, to prevent recurrence of SAT, consideration should be given to the period required for PSL tapering to 5 mg/day.

Long-term Trial of Corticosteroid Therapy for the Recurrence of Cerebral Amyloid Angiopathy-related Hemorrhages : A Case Study Using [11C] BF-227 Amyloid-PET

Aim:To clarify a long-term preventive effect of corticosteroid therapy for the recurrence of cerebral amyloid angiopathy(CAA)-related hemorrhages. Subjects and methods:Cases consisted of one male and two females,being consistent with the diagnosis of G3 to G4 in Boston validation criteria of CAA.To detect cerebral Aβamyloidosis,they underwent positron emission tomography combined with a novel amyloid specific tracer, BF-227, all showing positive brain shadow.A 66-year-old man(case 1)with a diagnosis of G3 was given an initial dose of prednisolone at 50 mg/ day.The dose was gradually reduced and was tapered off6 months later,but after the next 6 months cerebral hemorrhage recurred.He again received similar corticosteroid therapy.A 69-year-old woman(case 2)with a diagnosis of G3 was given dexamethasone 16 mg/day after suffering recurrent cerebral hemorrhages.A week later dexamethasone was switched to prednisolone 30 mg/day and the dose of this corticosteroid was gradually reduced,until being kept at 8 mg/day.Another 75-year-old woman (case 3)with a diagnosis of G4 was given an initial dose of prednisolone at 30 mg/day and the dose of this corticosteroid was gradually reduced and has been kept at 8 mg/day. During the observation periods they were evaluated by clinical manifestations and T2 MR images:the total area of microbleeds was assessed by computer-assisted morphometry. After treatment two cases received a second PET scan and the regional standard uptake value ratio (SUVR)of BF-227 at the occipital lobe was compared with the previous one. Results:Case 1 suffered a small hemorrhage in the left frontal lobe at 20 months after receiving the corticosteroid therapy and steroid pulse therapy was added.During the remaining 33 months he has been free of cerebral hemorrhages.SUVR in his PET scan showed 2.0 to 2.2 in a 14-month follow-up period and the total area of microbleeds extended from 410.2 to 445.5 mm during the 48-month observation period.Case 2 showed two simultaneous small hemorrhages at 29 months after starting the corticosteroid therapy and her dose of prednisolone was temporally increased.During the remaining 17 months she has not had any strokes and SUVR in her PET showed 1.5 to 1.4 in an 18-month follow-up period. The total area of microbleeds extended from 512.5 to 560.8 mm during the 27-month observation period.Case 3 has been free of cerebral hemorrhages for 22 months after this corticosteroid therapy and the total area of microbleeds ranged from 152. 5 to 154.1 mm during the 13-month observation period. Conclusions:Corticosteroid therapy seems to be clinically effective for the long-term prevention of recurrences of CAA-related hemorrhages but current brain image data are inadequate to lead to this conclusion. This is the first report showing that domestically developed BF227 PET scan is useful in visualizing CAA lesions.Shinshu Med J 62 : 155―165, 2014 (Received for publication February 3,2014;accepted in revised form February 18,2014)