Pulse Therapy Regimen Research Articles

Emerging paradigm shift toward proactive topical treatment of psoriasis: A narrative review.

Psoriasis (PsO) requires safe and effective long‐term management to reduce the risk of recurrence and decrease the frequency of relapse. Topical PsO therapies are a cornerstone in the management of PsO though safety concerns limit the chronic, continuous use of topical corticosteroids and/or vitamin D3 analogs. Evidence‐based guidelines on optimal treatment targets and maintenance therapy regimens are currently lacking. This review explores the evidence supporting approaches to maintenance topical therapy for PsO including continuous long‐term therapy, chronic intermittent use, step‐down therapy, sequential or pulse therapy regimens, and proactive maintenance therapy. Several unaddressed questions are discussed including how and when to transition from acute to maintenance therapy, strategies for monitoring long‐term treatment, the role of topical maintenance therapy in the context of systemic and biologic therapies, risks of maintenance therapy, prescribing a topical preparation suitable for patients' preferences and skin type, and key concepts for patient education to maximize long‐term outcomes. Overall, emerging evidence supports a paradigm shift toward proactive treatment once skin is completely clear as a strategy to enhance disease control without compromising safety.

A study on the outcome of pulse therapy in vesicobullous disorders at a tertiary care centre in Chidambaram, Tamilnadu

Introduction: With the advent of pulse therapy and adjuvant immunosuppressive drugs, the outcome and prognosis of vesicobullous disorders have been improved to a greater extent. Different regimen protocol has been tried and this descriptive study was carried out to assess the outcome of various pulse therapy regimens in vesicobullous disorder at our centre. Methods: A total of 26 vesicobullous patients were enrolled for the study. Diagnosis was made clinically and confirmed by histopathology. They received treatment with Dexamethasone-Cyclophosphamide pulse (DCP) or Dexamethasone -Azathioprine pulse (DAP) or Dexamethasone pulse (DP) therapy and were followed up for clinical remission and side effects of therapy. Results: There was a total of 26 patients comprising 69.23% females and 30.77% males and 50% were between the age group of 40-50 years. Pemphigus vulgaris was the commonest clinical type seen in 69.23%.DCP was given for 22(84.62%) patients, dexamethasone pulse in 3(11.54%) and DAP in one (3.85%). In DCP group 77.27% of patients were in Phase I and 22.73% achieved clinical remission. One patient was refractory to DCP and required rituximab infusion. Weakness, headache, vomiting and weight gain were the commonest side effects encountered in our study. Avascular necrosis of femur and reactivation of pulmonary tuberculosis were the major side effects noticed in one patient each. Conclusion: DCP therapy prove to be an excellent therapeutic regimen in case of vesicobullous disorders to attain faster recovery sparing the adverse effect of corticosteroids. DAP can be an useful therapeutic option in patients who were unmarried or in reproductive age group. Keywords: Pemphigus vulgaris, Dexamethasone-cyclophosphamide pulse. Dexamethasone-azathioprine pulse, Dexamethasone pulse

Pulse therapy: Opening new vistas in treatment of pemphigus

Pemphigus is comprised of a group of life-threatening autoimmune diseases that is characterized by circulating IgG antibodies targeting several types of keratinocyte antigens. After introduction of systemic steroids, survival has improved dramatically. However, mortality and morbidity were still very high due to side effects of steroids. Pulse therapy is defined as discontinuous/intermittent intravenous infusion of very high doses of corticosteroids along with certain immunosuppressive agents over a short period. This therapy was introduced to minimize the side effects of conventional corticosteroid therapy. The target is to achieve a faster response and stronger efficacy and to decrease the need for long-term use of systemic corticosteroids. As a result, this therapy has gained its popularity since three decades. The purpose of this article is to review the various available pulse therapy regimens with dosage, indications and contraindications and side effects.

Pulse therapy – A newer approach

Pulse therapy is defined as discontinuous/intermittent intravenous infusion of very high doses of corticosteroids along with certain immunosuppressive agents over a short period. It has gained its popularity since last three decades due to the advantage of minimizing the adverse effects of conventional corticosteroid therapy, and their action is supposed to be mediated through nongenomic actions within the cell. The aim of pulse therapy is to achieve a faster response and stronger efficacy and to decrease the need for long-term use of systemic corticosteroids. This paper intends to review the various available pulse therapy regimens with dosages, indications, contraindications, and adverse effects.

The choice of medication for treatment of patients with chronic pelvic inflammatory diseases

Patients with chronic pelvic inflammatory diseases are often exceeding 2/3 among women seeking for the obstetrician-gynecologist help. To determine the therapeutic strategy it is need clear ideas about the most common cause of pelvic inflammatory diseases and methods of their treatment. In practice, the most frequently are chlamydia and mycoplasma infection, gonorrhea rate is gradually reduced. Among the antibacterial agents with a wide spectrum of activity macrolides are the most popular in the treatment of uncomplicated forms of pelvic inflammatory diseases. Among them azithromycin has the best bio-availability, high efficiency and the possibility for pulse therapy. On the Ukrainian pharmaceutical market represented more than 20 azithromycin drugs. Hemomycin is the only azithromycin generic drug in Ukraine with establishing bioequivalence. The comparative study of hemomycin efficiency (main group) and other generic azithromycin medications registered in Ukraine (comparison group) in the treatment of 124 patients with chronic salpingoophoritis and cervicitis of chlamydial etiology was performed. After treatment in women of the main group there was almost complete reduction of clinical symptoms. In the comparison group positive dynamics was significantly less pronounced. In the main group the efficiency of chlamydial infection treatment was 100%, while in the comparison group 16.1% of cases marked failure. Restoration of normal vaginal biotope was reported in 95.6% of patients in the main group and in the comparison group in 23.2% of patients remained cocci flora. Hemomycin is superior in their effectiveness comparatively to other generic azithromycin drugs with pulse therapy regimen application. The appointment of hemomycin provides complete elimination of chlamydial infection, the completion of the inflammatory tissue response, vaginal flora restoration and protective properties of cervical mucous. According to the pharmacoeconomic qualities and clinical efficiency hemomycin is the drug of choice for antibacterial therapy of genital chlamydiosis.

Azathioprine pulse therapy in the treatment of psoriasis nail: A case series

Abstract Background Various treatments available for treating nail changes in psoriasis are able to clear the lesions but relapse is common. While treating psoriasis with azathioprine pulse therapy, it was observed that the lesion of nails including pitting, dystrophy, etc. was also cleared. Aim To check whether intermitted high dose (IHD) with continuous low dose azathioprine given to clear psoriasis could also clear the nail changes and produce prolonged remission. Methods 7 out of 60 psoriasis patients treated with azathioprine pulse therapy (APT) had psoriatic lesion on nails also. All the 60 patients received azathioprine pulse therapy for treating psoriasis, which contain azathioprine 500 mg given on 3 consecutive days and was repeated every month on the same date along with azathioprine100 mg orally in between the IHD. The entire treatment schedule was divided into four phases. Phase I continued till complete clearance of all lesions on the skin. In Phase II, 9 more APTs are given. In Phase III, only azathioprine 100 mg is continued for 9 months. In Phase IV, 100 mg was also stopped and patients were followed up without any treatment. Results Out of 7 patients, 5 had pitting of nails which cleared in 2–13 months. All the nails having pitting are in remission from 14 to 106 months. One patient had dystrophy of all nails of 2-yr duration, which cleared in 3 months. However, he developed relapse along with relapse of psoriasis after 26 months in remission, which subsequently cleared in 10 months on continuing APT and he is in remission since 62 months. White nails in 1 patient cleared in 17 months, and she/he is in remission since 17 months. Conclusion Azathioprine pulse therapy regimen is able to put psoriatic nail changes into prolonged remission.

Prolonged remission of psoriasis with azathioprine pulse therapy

Background:Although various therapies used for the treatment of psoriasis are able to produce remission, yet relapses, a common problem, remains frequent. It was observed that treatment with intermittent high dose (IHD) and continuous low dose (CLD) azathioprine can produce prolonged and durable remission in psoriasis.Aims:To see the long term effect of azathioprine pulse therapy (APT) in psoriasis.Methods:Ten patients with psoriasis who has completed more than 5 years in remission with azathioprine pulse therapy are being taken in the study. They were given IHD azathioprine (500 mg on 3 consecutive days which is repeated every month) with CLD azathioprine (100 mg orally) daily in between IHD. The entire treatment schedule was divided into four phases. During phase I, treatment with IHD and CLD azathioprine was started and continued till complete clearance of lesions after which, patients proceeded to Phase II. In phase II, they continued to get treatment with IHD and CLD. After continued remission for a period of nine months, they entered into phase III, when the treatment with IHD was stopped, but CLD continued. If there was no recurrence after nine months of phase III treatment, CLD was also withdrawn, and patients were followed-up without any treatment (Phase IV).Results:All 10 patients completed treatment and are in remission for more than five years without any treatment.Conclusions:Out of 60 patients in phase IV, 10 patients were in continuous remission for more than five years, after all treatment had been stopped. Thus, azathioprine pulse therapy regimen produces prolonged remission in psoriasis.

Azathioprine Pulse Therapy in the treatment of psoriatic arthritis: A case series

Background/objectiveTreatment available for treating psoriasis of joint are able to clear the lesions but relapse is common. While treating psoriasis with Azathioprine Pulse Therapy, it was observed that the involvement of joints (arthritis of small and big joints) also cleared. To see whether intermittent high dose (IHD) and continuous low dose (CLD) azathioprine given to clear psoriasis also clear the joint involvements and produce prolong/permanent remission. MethodsSix out of 60 psoriasis patients treated with azathioprine pulse therapy (APT) had joints involvement. All received azathioprine pulse therapy for treating psoriasis which contain azathioprine 500 mg given on three consecutive days and was repeated every month on the same date along with azathioprine100 mg orally in between the IHD. The entire treatment was divided into four phases. Phase I, continued till clearance of all lesions of psoriasis. In phase II nine more APT is given. In phase III only azathioprine100 mg was continued for 9 months. In phase IV azathioprine100 mg was also stop and patients were followed up without any treatment for any recurrence till the end of the study. ResultSix patients with joint pain and arthritis cleared in 1–12 months and are in remission since 35–95 months. ConclusionsThus azathioprine pulse therapy regimen is able to put psoriatic arthritis into prolong/permanent remission.

Prolonged remission of psoriasis with azathioprine pulse therapy

BackgroundVarious therapies used for the treatment of psoriasis though are able to produce remission but relapses remain the common problem. Treatment with Azathioprine Pulse Therapy (intermittent high dose (IHD) and continuous low dose (CLD) azathioprine) can produce prolonged and durable remission in psoriasis was observed. MethodsSixty patients with psoriasis were treated with monthly IHD azathioprine (500 mg on 3 consecutive days), CLD azathioprine (100 mg orally) was given daily in between IHD. The entire treatment schedule was divided into four phases. During phase I, treatment with IHD and CLD azathioprine was continued till complete clearance of lesions, when patients proceeded to phase II while continuing treatment with IHD and CLD. After continued remission for a period of 9 months, treatment with IHD was stopped, but CLD was continued (Phase III). After 9 months of phase III treatment, CLD was also withdrawn, and patients were followed-up without any treatment (Phase IV). ResultsForty five patients completed treatment and are in remission without any treatment. ConclusionsOut of 45 patients in phase IV, 25 patients are in continuous remission for more than 3 years (maximum 93 months), 9 are in remission for 1–3 years, while 11 are less than 1 year in continuous remission after all treatment was stopped. Thus azathioprine pulse therapy regimen produced prolonged remission in psoriasis.

Combination pulse therapy with methotrexate and dexamethasone in patients with early rheumatoid arthritis and poor prognostic factors: an open-label randomized trial

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

Puls-therapy with metilprednisolon in Grave's orbitopathy

There are different intravenous (iv) glucocorticoid (GC) schedules to treat active Graves’ Orbitopathy (GO). There is one study compared the efficacy of two different pulse-therapy regimens (Sanchez-Ortiga R. et al, 2009): first regimen - traditional therapy, second – GC dose dependents on body weight. Both regimens were effective, but percentage clinical improvement with second regimen was 92% vs 100% with second regimen.Design. The present study compares the efficacy of two different intravenous methylprednisolone (ivGC) dosing regimens: 1000 mg of ivGC daily for 5 days (group I, n = 20) or weekly for 5 weeks (group II, n = 16). Comparisons were made for efficacy according to СAS, exophthalmos, diplopia in 1, 4, 12, 24, 52 weeks after treatment withdrawal. Results. Both regimens had a beneficial effect on soft tissue, exophthalmos. In the first regimen peak of effectiveness occurred between 4 and 24 weeks, in the second regimen- between 4 and 12 weeks. The daily regimen led quickly to reduce the degree of diplopia than weekly dosing regimen. However, in the first group more patients were reported diplopia progression compared with the second group.Conclusion. Both schedules were equally effective and can be used in clinical practice.

Calcipotriene ointment and halobetasol ointment in the long-term treatment of psoriasis: Effects on the duration of improvement

Background: Weekend therapy with superpotent topical corticosteroids has been used for the long-term treatment of psoriasis. Recently, calcipotriene ointment has been added to this regimen for use on weekdays, but there are no long-term studies of that combination. Objective: The purpose of this study was to determine whether the addition of weekday calcipotriene to a pulse therapy regimen of weekend superpotent corticosteroids results in a longer duration of remission of plaque psoriasis. Subjects: This was a double-blind, placebo-controlled, parallel-group study. Forty-four patients with mild to moderate psoriasis were treated with calcipotriene ointment in the morning and halobetasol ointment in the evening for 2 weeks. Thereafter, 40 patients who were at least moderately (50% or greater) improved were randomized to 2 treatment groups. After 2 weeks of treatment with calcipotriene ointment in the morning and halobetasol ointment in the evening, 20 patients were randomized to receive halobetasol ointment twice daily on weekends and calcipotriene ointment twice daily on weekdays, and 20 patients were randomized to receive halobetasol ointment twice daily on weekends and placebo ointment twice daily on weekdays. Results: Seventy-six percent of patients applying halobetasol ointments on weekends and calcipotriene ointment on weekdays were able to maintain remission for 6 months compared with 40% of patients applying halobetasol ointment on weekends only with the vehicle on weekdays. Conclusion: The addition of calcipotriene ointment applied on weekdays to a weekend pulse therapy regimen of superpotent corticosteroids can increase the duration of remission of psoriasis. (J Am Acad Dermatol 1998;39:447-50.)

Itraconazole for the treatment of onychomycosis.

The broad spectrum of activity of itraconazole in vitro manifests itself clinically with the drug being effective for the treatment of onychomycosis caused by dermatophytes, Candida and some non-dermatophyte molds. The pharmacokinetics of itraconazole in the nail results in drug remaining at therapeutic levels for 6-9 months after completion of therapy. An overview of studies where continuous or pulse itraconazole therapy has been used in the treatment of fingernail and toenail onychomycosis. Following continuous therapy at 200 mg/day for 3 months for toenail onychomycosis (n = 1741), the rates of clinical cure, clinical response and mycologic cure were: (meta-average +/- 95% standard error (SE)), 52 +/- 9%, 86 +/- 2%, and 74 +/- 3%, respectively, at follow-up 12 months following start of therapy. In fingernail onychomycosis (n = 211), the duration of therapy was 6 weeks and the corresponding efficacy rates at follow-up, 9 months after start of therapy, were meta-average (+/- S.E.) 82 +/- 5%, 90 +/- 2%, and 86 +/- 3%, respectively. In toenail onychomycosis treated with 3 pulses of therapy (n = 1389), the clinical response, clinical cure and mycologic cure were observed in meta-average (+/- S.E.) 58 +/- 10%, 82 +/- 3%, and 77 +/- 5% patients, respectively, at follow-up 12 months after the start of therapy. In fingernail onychomycosis treated with 2 pulses of therapy (n = 210), at follow-up 9 months after the start of therapy, the corresponding efficacy rates were meta-average (+/- S.E.) 78 +/- 10%, 89 +/- 6%, and 87 +/- 8%, respectively. Both the continuous and pulse therapy regimens are safe with few adverse effects. Compared to continuous therapy, the pulse regimen has an improved adverse-effects profile, is more cost-effective, and is preferred by many patients.

Pulse Therapy

• Three patients with pyoderma gangrenosum were treated with suprapharmacologic doses of methylprednisolone sodium succinate using a five-day pulse therapy regimen. This therapy produced a dramatic remission with minimal side effects. The effects of pulse therapy are reviewed, and its role in severe steroid-responsive dermatoses is discussed. (<i>Arch Dermatol</i>1982;118:76-84)