Multiple Courses Of Corticosteroids Research Articles

Immune-Mediated Sensorineural Hearing Loss in the Pediatric Population.

A case series with chart review of pediatric patients with immune-mediated sensorineural hearing loss, including sudden sensorineural hearing loss and autoimmune-mediated hearing loss, was performed. Ninety-eight patients with sensorineural hearing loss were reviewed, and 41 patients met the inclusion criteria, which included corticosteroid therapy for a decline in sensorineural hearing. The primary outcome was the corticosteroid response rate: 61% of patients responded. The secondary outcome was a sustained response following multiple courses of corticosteroids for additional hearing loss, which correlated with timely corticosteroid treatment: 57% showed sustained response with multiple treatments, but as anticipated, patients were more likely to respond when treated promptly. Sustained responses fell over time with multiple treatments. These data demonstrate pediatric immune-mediated sensorineural hearing loss is corticosteroid responsive in at a rate similar to their adult counterparts and should be considered for similar treatment approaches.

Natural History of Ulcerative Colitis in Patients With Concomitant Primary Sclerosing Cholangitis

Introduction: The natural history of Ulcerative Colitis (UC) in patients with concomitant primary sclerosing cholangitis (PSC) is poorly defined. We aimed to examine whether concurrent PSC and UC status was associated with increased risk of colectomy and requirement for multiple courses of corticosteroids (CS). Methods: We conducted a retrospective study among a cohort of nation-wide VA patients with UC. We first performed univariate comparison between UC patients with and without PSC. We then conducted two case-control analyses to determine the association between PSC status and outcomes related to UC disease course: colectomy for UC disease and receipt of two or more courses of CS after UC diagnosis. The exposure was presence or absence of PSC. Multivariable logistic regression analysis was conducted to estimate odds ratios (OR) and associated 95% confidence intervals (CIs) in each case-control analysis. We examined the following covariates in the multivariable model: duration of follow-up after UC diagnosis, sex, age at UC diagnosis, race, severity of UC, and extent of UC. Results: The analysis included 836 UC patients without PSC and 103 UC patients with PSC. In univariate comparisons, the PSC patients were more likely to have more extensive UC than those without PSC. However, the PSC patients were slightly less likely to have severe UC than non-PSC patients. The PSC patients were younger at diagnosis of UC and had longer period of follow-up after UC diagnosis. In multivaribale logistic regression analysis adjusting for duration of follow-up after UC diagnosis, sex, age at UC diagnosis, race, severity of UC, and extent of UC, PSC status was not associated with the risk of colectomy for UC (AOR 1.18, 95% CI: 0.49-2.84). Furthermore, PSC was not associated with a significantly increased risk of receiving two or more courses of steroids after adjusting for duration of follow-up after UC diagnosis, sex, age at UC diagnosis, race, severity of UC, and extent of UC (AOR 1.37, 95% CI: 0.85-2.22). However, without adjusting for UC extent and severity, PSC was associated with a modestly increased risk for the need for two or more courses of CS (AOR 1.58, 95% CI: 1.01-2.49); without adjusting for disease extent, the AOR was 1.72, 95% CI: 1.09-2.74.Table: Table. Comparison of PSC and non-PSC UC patientsConclusion: UC patients with PSC do not have a more benign disease course than UC patients without PSC. UC patients with PSC may have a modestly increased risk for multiple courses of steroids, and the risk increase appears to be mediated by more extensive UC involvement.

Neonatal Genetic Variation in Steroid Metabolism and Key Respiratory Function Genes and Perinatal Outcomes in Single and Multiple Courses of Corticosteroids.

The aim of the study is to evaluate the association of steroid metabolism and respiratory gene polymorphisms in neonates exposed to antenatal corticosteroids (ACS) with respiratory outcomes, small for gestational age (SGA), and response to repeat ACS. This candidate gene study is a secondary analysis of women enrolled in a randomized controlled trial of single versus weekly courses of ACS. Nineteen single nucleotide polymorphisms (SNPs) in 13 steroid metabolism and respiratory function genes were evaluated. DNA was extracted from placenta or fetal cord serum and analyzed with TaqMan genotyping. Each SNP was evaluated for association via logistic regression with respiratory distress syndrome (RDS), continuous positive airway pressure (CPAP)/ventilator use (CPV), and SGA. CRHBP, CRH, and CRHR1 minor alleles were associated with an increased risk of SGA. HSD11B1 and SCNN1B minor alleles were associated with an increased likelihood of RDS. Carriage of minor alleles in SerpinA6 was associated with an increased risk of CPV. CRH and CRHR1 minor alleles were associated with a decreased likelihood of CPV. Steroid metabolism and respiratory gene SNPs are associated with respiratory outcomes and SGA in patients exposed to ACS. Risks for respiratory outcomes are affected by minor allele carriage as well as by treatment with multiple ACS.

Neonatal Genetic Variation in Steroid Metabolism and Key Respiratory Function Genes and Perinatal Outcomes in Single and Multiple Courses of Corticosteroids

Neonatal Genetic Variation in Steroid Metabolism and Key Respiratory Function Genes and Perinatal Outcomes in Single and Multiple Courses of Corticosteroids

When do the risks of repeated courses of corticosteroids exceed the risks of surgery?

The management of chronic rhinosinusitis with nasal polyposis (CRSwNP) becomes unclear when patients require multiple courses of corticosteroids to maintain quality of life. Repeated courses of corticosteroids carry increased risks to patients. Although endoscopic sinus surgery (ESS) is an effective therapeutic modality, it also carries inherent risks. This study aims to identify the threshold at which the risks of repeated courses of corticosteroid exceed the risks of surgery. An evidence-based risk analysis was simulated using literature-reported complication rates, quality of life changes, and Medicare costs. Simulations were performed from the Medicare patient perspective, societal perspective, and the universal healthcare patient perspective. All 3 simulations demonstrate a breakeven threshold favoring surgery over medical therapy when patients require oral corticosteroids (OCS) more often than once every 2 years in CRSwNP, once per year in CRSwNP/asthma, or twice per year for Samter's triad patients. This represents the first rationalized evidence-based analysis for when surgery should be considered in place of repeated courses of oral corticosteroids. This threshold provides a guide for otolaryngologists to use when making clinical decisions with patients.

A Case of Relapsing Kikuchi-Fujimoto Disease

Kikuchi-Fujimoto disease (KFD) or histiocytic necrotizing lymphadenitis was first described in Japan in 1972. It is described as a benign syndrome most commonly involving cervical lymphadenopathy, fever, and night sweats. The etiology of KFD is unknown but it is thought to be triggered by an autoimmune or viral process with an exaggerated T-cell-mediated immune response. KFD can mimic other serious conditions such as lymphoma, systemic lupus erythematosus (SLE), herpes simplex, and Epstein Barr virus. Diagnosis is confirmed histopathologically. Kikuchi's disease is typically reported to have a self-limiting course, resolving within several months and with a low recurrence rate between 3% and 4%. There is no specific treatment for KFD but any treatment is generally directed towards symptomatic relief with antipyretics and anti-inflammatory medications. In severe cases corticosteroids have been used. Here we describe a case of a previously healthy 26-year-old female that presented with fever and cervical lymphadenopathy. Malignancy and infections were ruled, and she was diagnosed with KFD histopathologically by lymph node biopsy. Her case is a severe case of KFD that despite treatment with multiple courses of corticosteroids and an immune modulating agent, relapsed.

Mycoplasma pneumoniae Periprosthetic Joint Infection Identified by 16S Ribosomal RNA Gene Amplification and Sequencing

Chronic, culture-negative septic arthritis represents a major clinical dilemma. It often results in prolonged courses of antimicrobial therapy, which may or may not have activity against the organism responsible for the infection. It is not possible to cultivate all types of pathogens in vitro with use of traditional laboratory testing methods, but emerging techniques can be helpful to define the etiology of these infections in some cases. We describe a case of a periprosthetic joint infection in a thirty-year-old woman with juvenile rheumatoid arthritis (JRA) and hypogammaglobulinemia, who developed septic arthritis after prolonged pneumonia. She received multiple courses of antimicrobial therapy without improvement of the joint symptoms. The microbiologic diagnosis was made with use of 16S ribosomal RNA (rRNA) gene amplification and sequencing from synovial fluid and tissue. The patient gave permission for this information to be submitted for publication. A thirty-year-old woman with JRA and hypogammaglobulinemia was referred for evaluation of an infection at the site of a total knee arthroplasty. Her JRA had been managed with multiple courses of corticosteroids, infliximab, and, more recently, rituximab. She had undergone bilateral shoulder and knee synovectomy, and right elbow synovectomy, and finally had required left total knee arthroplasty in 2006. In the fall of 2009, the patient was hospitalized because of pneumonia, which had a prolonged course, with several hospitalizations due to recurrences over two months. Chest radiographs confirmed right upper lobe pneumonia, which later progressed to bilateral pneumonia. She was treated with azithromycin and ceftriaxone and initially showed improvement, but she then had a relapse with recurrent symptoms. During the multiple relapses, she was treated with vancomycin and cefepime followed by ertapenem. She had five bronchoscopy procedures. The bronchoscopies all showed purulent secretions, but all cultures were negative, including fungal and mycobacterial cultures. Polymerase chain reaction (PCR) for Mycoplasma pneumoniae …

Thiopurine Immunomodulators in Ulcerative Colitis: Moving Forward with Current Evidence

The goals of treatment for ulcerative colitis (UC) are to induce and maintain corticosteroid-free remission, thereby reducing hospitalizations and surgeries and preventing longer-term disease complications including colorectal cancer. Despite an incomplete evidence base, thiopurine immunomodulators remain a principle therapeutic option for patients failing aminosalicylate monotherapy and requiring multiple courses of corticosteroids. In this review, we outline the current evidence supporting the role of thiopurines in achieving these treatment goals in UC, including discussions of the important safety issues regarding their use. We also explore some of the recent evidence emerging in regards to the risks of lymphoproliferative disease, dosage optimization strategies and the role of thiopurines in achieving mucosal healing in UC and ultimately changing natural history outcomes for our patients.

Successful treatment of pediatric IgG4 related systemic disease with mycophenolate mofetil: case report and a review of the pediatric autoimmune pancreatitis literature

Autoimmune pancreatitis is frequently associated with elevated serum and tissue IgG4 levels in the adult population, but there are few reports of pediatric autoimmune pancreatitis, and even fewer reports of IgG4 related systemic disease in a pediatric population. The standard of care treatment in adults is systemic corticosteroids with resolution of symptoms in most cases; however, multiple courses of corticosteroids are occasionally required and some patients require long term corticosteroids. In these instances, steroid sparing disease modify treatments are in demand. We describe a 13-year-old girl with IgG4 related systemic disease who presented with chronic recurrent autoimmune pancreatitis resulting in surgical intervention for obstructive hyperbilirubinemia and chronic corticosteroid treatment. In addition, she developed fibrosing medianstinitis as part of her IgG4 related systemic disease. She was eventually successfully treated with mycophenolate mofetil allowing for discontinuation of corticosteroids. This is the first reported use of mycophenolate mofetil for IgG4 related pancreatitis. Although autoimmune pancreatitis as part of IgG4 related systemic disease is rarely reported in pediatrics, autoimmune pancreatitis is also characterized as idiopathic fibrosing pancreatitis. All pediatric autoimmune pancreatitis cases reported in the world medical literature were identified via a PUBMED search and are reviewed herein. Twelve reports of pediatric autoimmune pancreatitis were identified, most of which were treated with corticosteroids or surgical approaches. Most case reports failed to report IgG4 levels, so it remains unclear how commonly IgG4 related autoimmune pancreatitis occurs during childhood. Increased evaluation of IgG4 levels in patients with autoimmune pancreatitis may shed further light on the association of IgG4 with pancreatitis and the underlying pathophysiology.

Interleukin‐1 antagonism in acute gout: Is targeting a single cytokine the answer?

Despite the existence of effective treatments, persons with gout continue to experience acute attacks. Among those who had an attack during the previous year, the risk of having at least 1 recurrent attack in the following year is 69% (1). Not surprisingly, persons with gout experience diminished quality of life and work disability (2), related not only to these recurrent flares, but also to the presence of painful and at times disfiguring tophi. Given that gout is a common crystalinduced inflammatory arthritis, with up to 6.1 million US adults having gout at some point in their lifetime (3), this disease presents a substantial public health burden. Management of gout consists of the following 3 strategies: treatment of acute attacks; lowering of serum uric acid levels in order to prevent acute flares and tissue deposition of uric acid crystals (tophi); and prophylaxis against flares, particularly during the initiation of uratelowering therapy, and other strategies to prevent flares. Unfortunately, management of hyperuricemia in gout is suboptimal (4), and inappropriate treatment of acute attacks occurs frequently (1). The recommended options for management of acute attacks include agents that nonspecifically target inflammation, such as nonsteroidal antiinflammatory drugs (NSAIDs), colchicine, corticosteroids, and possibly adrenocorticotropic hormone (ACTH) (5). Although NSAIDs and colchicine are accepted as effective treatments for gout attacks and are typically used as first-line agents for acute attacks (5), there are few placebo-controlled trials of these agents (6,7). In fact, despite its widespread use, oral colchicine was only recently (in 2009) approved by the Food and Drug Administration (FDA) for use in acute gout, an action supported by the results of a recent trial (7). While the relative efficacy of colchicine compared with NSAIDs is not known, the various NSAIDs appear to have similar benefits in acute gout. Unfortunately, NSAIDs and/or colchicine may be poorly tolerated or contraindicated in the presence of certain comorbidities. In such instances, intraarticular corticosteroids may be given for monarticular attacks, while systemic corticosteroids or ACTH may be used for polyarticular attacks or when sites not easily amenable to intraarticular injection are involved. However, the body of evidence for intraarticular corticosteroids and ACTH is poor (8). Systemic oral corticosteroids have recently been evaluated for the treatment of gout in 2 randomized placebo-controlled trials, with 1 trial evaluating prednisolone 30 mg daily and the other prednisolone 35 mg daily, both for 5 days. Both trials demonstrated equivalence to relatively standard regimens of NSAIDs (indomethacin and naproxen, respectively) (9,10). An alternate route for systemic administration of corticosteroids, intramuscular injection, was evaluated for acute gout in 2 studies (11,12). A 60 mg intramuscular triamcinolone dose with optional repeat administration demonstrated equivalent efficacy with its comparators, indomethacin and ACTH, respectively. However, both studies were small and of low quality (13). Most studies in acute gout have evaluated single drug regimens despite the regular use of combination therapies in clinical practice (8), suggesting that such practices merit further examination. While there are several effective management options for acute gout, refractory flares are a problem, particularly for persons with polyarticular and tophaceous gout. As such, multiple courses of corticosteroids are not infrequent among persons with chronic gout. Dr. Neogi’s work was supported by the NIH (National Institute of Arthritis and Musculoskeletal and Skin Diseases grant K23-AR-055127), an Arthritis Foundation Arthritis Investigator Award, an American College of Rheumatology Research and Education Foundation Junior Career Development Award in Geriatrics (T. Franklin Williams Scholar Award), and the Boston Claude D. Pepper Older Americans Independence Center (NIH grant P30-AG-031679). Tuhina Neogi, MD, PhD, FRCPC: Boston University School of Medicine and Boston University School of Public Health, Boston, Massachusetts. Address correspondence and reprint requests to Tuhina Neogi, MD, PhD, FRCPC, Boston University School of Medicine, Clinical Epidemiology Unit, 650 Albany Street, Suite X-200, Boston, MA 02118. E-mail: tneogi@bu.edu. Submitted for publication June 22, 2010; accepted in revised form June 24, 2010.

Rituximab for Multirelapsing, Steroid-Dependent or Steroid-Resistant, Minimal-Change Nephropathy – a Report of Nine Adult Cases

Minimal-change nephropathy (MCN) accounts for 10–15% of cases of the nephrotic syndrome in adults. Frequent relapses occur in 10–25% of cases and steroid dependence is seen in 25–30%. Rituximab is a chimeric mono-clonal antibody directed against CD20-positive B-cells with reported benefit in immune-mediated renal disease. We present six female and three male patients, ranging from 27–70 years of age, with multirelapsing, steroid-dependant or steroid-resistant MCN, with previous multiple courses of corticosteroids (CS) and second-line therapies. Five patients were steroid dependant with the lowest daily CS dose between 5–20 mg/day. All patients were given two doses of rituximab, each a flat dose of 500 mg except for one case who received a dose of 1000 mg. All patients were B-cell depleted before the second dose. No major side effects occurred. Seven of the patients responded to therapy with normalized plasma albumin and no albuminuria enabling discontinuation or tapering of CS significantly below levels where relapses had occurred in the past (P=0.03). One patient reached partial remission and another had no response to therapy. Follow-up was 6–33 months. There were three relapses after 9, 12, and 20 months, respectively. In conclusion, frequency of relapses and steroid dependency or resistance in MCN remain ther-apeutic challenges to physicians. The current case series suggests that B-cell depletion may induce long-lasting remissions and, as a result, has a potential as a steroid-sparing agent in the treatment of steroid-dependent and multire-lapsing MCN patients.

733: Neonatal genetic variation in steroid metabolism genes and perinatal outcomes in single and multiple courses of corticosteroids

733: Neonatal genetic variation in steroid metabolism genes and perinatal outcomes in single and multiple courses of corticosteroids

Bone Metabolism in Fetuses of Pregnant Women Exposed to Single and Multiple Courses of Corticosteroids

To estimate the effect of single and recurrent doses of antenatal corticosteroids on fetal bone metabolism. This was a secondary analysis of a cohort of pregnant women from a previously reported randomized, placebo-controlled, multicenter trial of women at risk for preterm delivery who received weekly courses of betamethasone (active) or placebo after an initial course of corticosteroids. Umbilical cord serum levels of carboxy-terminal carboxy-terminal propeptide of type I procollagen and cross-linked carboxy-terminal telopeptide of type I procollagen were measured to assess the rate of fetal bone formation and resorption, respectively. Analysis was stratified according to number of repeat antenatal study courses of betamethasone or placebo (one to three compared with at least four courses, not including the initial course). Of the 251 umbilical cord serum samples, the median serum carboxy-terminal telopeptide of type I procollagen levels, but not carboxy-terminal propeptide of type I procollagen levels, was significantly lower with repeat betamethasone exposure (55.0 compared with 57.9 micrograms/L, P=.01). In the fetuses exposed to at least four repeat study courses, there was a significant decrease in median carboxy-terminal telopeptide of type-I procollagen levels between repeat betamethasone exposure and placebo (53.4 compared with 58.6 micrograms/L, respectively, P=.04), but there was no difference between groups in the fetuses exposed to 1-3 repeat study courses (57.4 compared with 56.7 micrograms/L, respectively, P=.29). Levels of umbilical cord serum markers of bone resorption but not formation are reduced in fetuses exposed to repeat courses of antenatal betamethasone. Up to four courses of antenatal betamethasone do not seem to affect fetal bone metabolism. II.

Positioning biologic agents in the treatment of Crohnʼs disease

One decade after the emergence of biologic therapy for Crohn's disease (CD), our treatment algorithms are beginning to change. Once reserved for patients with refractory disease, disease unresponsive to conventional therapies, or those requiring multiple courses of corticosteroids, there is increasing evidence that early, aggressive interventions with immunosuppressants or biologic therapies targeting tumor necrosis factor-alpha or alpha-4 integrins can alter the natural history of CD by reducing the transmural complications of structuring and fistulization and the nearly inevitable requisite for surgical resections. More recent trials are beginning to suggest that intervention with combination therapy for selected patients with a poor prognosis may modify the long-term course of CD. Selection of patients with features predicting a complex or progressive course and early, combined intervention is now possible. Future studies are still needed to best identify predictors of response to individual agents with differing mechanisms of action, as well as to optimize the risk-benefit of long-term maintenance therapy.

Antenatal corticosteroids: the controversy continues

Purpose of review Maternal administration of glucocorticoids remains the mainstay of perinatal medicine for the fetus at risk of premature delivery. The reductions of severity of respiratory distress syndrome, incidence of intraventricular hemorrhage, and neonatal death have all been well documented. Findings from both experimental studies in animals as well as clinical investigation in humans have raised issues of concern and controversy. These include the use of repetitive courses of corticosteroids. Questions have been raised regarding the postnatal neurobehavioral and prenatal cardiovascular responses to corticosteroids. The purpose of this review is to address the current data pertaining to these controversies. Recent findings Animal studies reflect the concerns of the use of multiple courses of steroids with alterations of brain growth and histology. Human data suggest that multiple courses of corticosteroids might reduce the risk of respiratory distress syndrome, but at the expense of alterations of lung architecture. There are concerns about decreased somatic and head size. Neurobehavioral abnormalities are more frequently seen in children exposed to multiple courses. In growth-restricted fetuses with evidence of placental dysfunction, there may be a risk of sudden in-utero decompensation. Summary Repetitive courses of corticosteroids have deleterious effects with little improvement in neonatal outcome. A ‘rescue dose’ given to a fetus previously yet remotely treated may be of some benefit. Animal studies suggest acute vascular changes with maternal steroids. This has not been consistently borne out with the indirect assessment using Doppler in the human. A select group of severely growth restricted fetuses with umbilical artery absent end diastolic flow may actually deteriorate with maternal corticosteroids.

Combination therapy with sirolimus (rapamycin) and tacrolimus (FK-506) in treatment of refractory minimal change nephropathy, a clinical case report

Minimal change nephropathy (MCN) is the dominant cause of idiopathic nephrotic syndrome in childhood and accounts for 25% of cases of adult nephrotic syndrome [1]. Each new episode of nephrotic syndrome adversely affects quality of life and is associated with complications including infection, thromboembolism and urinary loss of binding transport proteins. Proteinuria usually remits with high dose corticosteroid treatment; however, a significant minority responds incompletely or relapses frequently, providing a difficult therapeutic challenge. Furthermore, the management of frequent relapses with multiple courses of corticosteroids is associated with appreciable morbidity, including muscle atrophy, skin fragility and growth retardation. We report the use of sirolimus (rapamycin) in combination with tacrolimus (FK-506) to induce and maintain remission successfully in a case of chronic resistant MCN. To our knowledge, this is the first report of sirolimus/tacrolimus combination therapy in the treatment of MCN.

Undesired effects of steroids during pregnancy

Antenatal corticosteroid administration for enhancing fetal lung maturity can be expected to induce negative maternal and fetal side-effects. Maternal short-term effects after multiple courses of corticosteroids are an increase of infections and a higher incidence of endometritis and chorionamnionitis in patients with premature rupture of membranes. A single dose of corticosteroid induces an increase in the count of maternal white blood cells and metabolic effects such as the augmentation of amino acid concentration and of fasting glucose levels in maternal plasma. Negative fetal effects of antenatal corticosteroids are a reduction of fetal body and breathing movements and a reduction of fetal heart rate variation, without any changes in Doppler waveform patterns of fetoplacental vessels. It has been suggested that a multiple course of corticosteroids antenatally might induce negative effects on fetal intrauterine growth and on neonatal birth weight. In addition, multiple courses are associated with an increased risk of early-onset neonatal sepsis.

Undesired effects of steroids during pregnancy

Antenatal corticosteroid administration for enhancing fetal lung maturity can be expected to induce negative maternal and fetal side-effects. Maternal short-term effects after multiple courses of corticosteroids are an increase of infections and a higher incidence of endometritis and chorionamnionitis in patients with premature rupture of membranes. A single dose of corticosteroid induces an increase in the count of maternal white blood cells and metabolic effects such as the augmentation of amino acid concentration and of fasting glucose levels in maternal plasma. Negative fetal effects of antenatal corticosteroids are a reduction of fetal body and breathing movements and a reduction of fetal heart rate variation, without any changes in Doppler waveform patterns of fetoplacental vessels. It has been suggested that a multiple course of corticosteroids antenatally might induce negative effects on fetal intrauterine growth and on neonatal birth weight. In addition, multiple courses are associated with an increased risk of early-onset neonatal sepsis.

Multiple courses of antenatal corticosteroid therapy in patients with preterm premature rupture of membranes.

This study was performed to determine the benefits and risks of multiple courses of corticosteroids in patients with preterm premature rupture of membranes (PPROM). We retrospectively evaluated the pregnancy and neonatal outcomes of women with singleton pregnancies, who were admitted at 24-32 weeks of gestation due to PPROM. Patients were categorized into 3 groups according to antenatal corticosteoid exposure: (1) a non-user group, (2) a single-course group, and (3) a multiple-course group. A total of 170 patients were included in the study, with 50 in the non-use group, 76 in the single-course group, and 44 in the multiple-course group. Univariate analyses showed that clinical chorioamnionitis occurred with highest incidence in multiple-course group (chi2=6.20, p<0.05) and the incidence of neonatal respiratory distress syndrome (RDS) was lowest in the multiple-course group (chi2=10.0, p<0.01). Multiple logistic regression analyses showed that multiple courses of corticosteroids were independently associated with clinical chorioamnionitis (odds ratio=13.15, p<0.05) whereas no significant association was found between RDS and multiple-course corticosteroids after adjusting for confounding variables (odds ratio=0.28, p=0.06). Multiple courses of antenatal corticosteroid therapy were found to be associated with an increased risk of clinical chorioamnionitis and seemed not to reduce the incidence of RDS and other neonatal morbidities in patients with PPROM.

The Use and Abuse of Steroids in Perinatal Medicine

Corticosteroids are one of the most powerful drugs increasingly used in the perinatal and neonatal period. This review discusses the merits and demerits of antenatal as well as postnatal use of steroids. A single course of antenatal corticosteroids in women at risk of premature delivery is highly effective in reducing respiratory distress syndrome (RDS), intraventricular haemorrhage and neonatal mortality and also neurodevelopmental sequelae including cerebral palsy. However, there is less evidence to support the practice of multiple courses of corticosteroids, with some animal and retrospective human studies suggesting an association with neurological impairment and reduction in birth weight as well as lung weight. Postnatal systemic corticosteroids have shown benefits in reducing chronic lung disease and improving survival for infants. However, besides short-term adverse effects, the follow-up studies have raised concern that they may increase the risk of neurodevelopmental disability, particularly cerebral palsy in survivors. Systemic corticosteroids may have a role in infants who had repeated and prolonged intubations and those with pressor-resistant hypotension. Alternative strategies for prevention of chronic lung disease, such as inhaled steroids, methylprednisolone and hydrocortisone, may need further studies with larger sample sizes. Data from animal research have revealed that fetal glucocorticoid exposure may have a role in programming the individual to adult degenerative diseases. Based on the current evidence, it is recommended that women at risk of preterm delivery receive a single course of glucocorticoids. Randomised controlled trials are needed to establish the true effects of multiple courses of antenatal corticosteroids. More research is also needed to study the long-term neurodevelopmental outcome of both multiple courses of antenatal corticosteroids, as well as postnatal corticosteroid therapy.