Controversies on the Use of Steroids in Systemic Sclerosis

The use of corticosteroids in patients with systemic sclerosis (SSc) always requires caution (especially because corticosteroids are a risk factor for scleroderma renal crisis [SRC]), and is often controversial. This review focuses on the main area of controversy, that is whether corticosteroids should be prescribed in patients with early diffuse cutaneous SSc (dcSSc). The arguments for and against corticosteroids in this clinical situation are presented, along with two case histories to illustrate the clinical dilemma. In favour of corticosteroids, is that these might suppress the musculoskeletal manifestations and itch that are so disabling in early disease, the argument against is that patients with early dcSSc are those at highest risk of SRC. That current opinion is divided amongst clinicians is evidenced by a roughly even split between patients previously prescribed and those not prescribed corticosteroids in the recent European Scleroderma Observational Study of early dcSSc (43% of 326 patients were on corticosteroids at their baseline visit or had previously been prescribed these). Other clinical situations in which corticosteroids may be considered in patients with SSc (mainly overlap syndromes and pulmonary involvement) are briefly discussed. Finally, some additional concerns relating to corticosteroid use specifically in patients with SSc are highlighted.

Recovery from severe dysphagia in systemic sclerosis - myositis overlap: a case report

BACKGROUND

Dysphagia is common in inflammatory myopathies and usually responds to corticosteroids. Severe dysphagia requiring feeding by percutaneous endoscopic gastrostomy is associated with significant morbidity and high mortality.

CLINICAL CASE

A 56-year old African Black woman initially presented with systemic sclerosis (SSC) - myositis overlap and interstitial lung disease. She responded to high dose corticosteroids and cyclophosphamide followed by azathioprine, with improvement in her lung function and regression of the skin changes. Six years later she had a myositis flare with severe dysphagia. Her myositis improved after high doses of corticosteroids, azathioprine and two doses of intravenous immunoglobulin (IVIG). As her dysphagia persisted, she was fed via a percutaneous endoscopic gastrostomy (PEG) tube and given a course of rituximab. Her dysphagia gradually resolved and the PEG tube was removed within two months. She received another dose of rituximab six months later and continued low dose prednisone and azathioprine. Her muscle power improved, weight returned to normal and she remained well 20 months after hospital discharge.

CONCLUSION

Our patient with SSC-myositis overlap and severe dysphagia requiring PEG feeding, improved with high dose corticosteroids, azathioprine, two courses of IVIG and rituximab, and remained in remission 20 months after hospital discharge.

CIRSE Standards of Practice Guidelines on Gastrostomy

PURPOSE

Surgical Gastrostomy has been around since the 19th century but in 1980 the first successful percutaneous endoscopic gastrostomy was reported. A year later the first successful percutaneous gastrostomy was performed using fluoroscopic guidance. The technique for percutaneous insertion and the equipment used has been refined since then and it is now considered the gold standard for gastrostomy insertion. Here we present guidelines for image-guided enteral feeding tubes in adults.

MATERIAL AND METHOD

We performed a review and analysis of the scientific literature, other national and international guidelines and expert opinion.

RESULTS

Studies have shown fluoroscopic techniques have consistently higher success rates with lower rates of major complications than endoscopic techniques. However, the Achilles' heel of many fluoroscopic techniques is the requirement for smaller gastrostomy tube sizes resulting in them being more prone to blockages and thus requiring further intervention.

CONCLUSION

Radiological feeding tube insertion is a safe and effective procedure. Success rates are higher, and complication rates lower than PEG or surgical gastrostomy tube placement and innovative techniques for gastric and jejunal access mean that there are very few cases in which RIG is not possible. The principal weakness of radiologically inserted gastrostomies is the limitiation on tube size which leads to a higher rate of tube blockage. Per-oral image-guided gastrostomies have to an extent addressed this but have not been popularised. Currently many centres still consider endoscopic gastrostomies as the first line unless patients are too unwell to undergo this procedure or previous attempts have failed, in which case radioloically inserted gastrostomies are the technique of choice.

Long-term outcome of patients with systemic sclerosis requiring home parenteral nutrition

BACKGROUND & AIMS

Patients with systemic sclerosis may develop intestinal failure requiring home parenteral nutrition. However, few outcome data have been reported. This study aimed to review the outcome of patients with systemic sclerosis receiving home parenteral nutrition.

METHODS

Records of all patients with systemic sclerosis who commenced home parenteral nutrition, at a national intestinal failure unit were retrospectively reviewed. Disease characteristics, survival and outcome data were evaluated.

RESULTS

Twenty five patients (20% male; median age: 55 years) were included over a 22-year period (37,200 central venous catheter days). All patients had small intestinal involvement. Prior to home parenteral nutrition, 16 failed enteral feeding. Nine patients were trained to self-administer their home parenteral nutrition; carers/relatives were trained for the remainder. Cumulative survivals on home parenteral nutrition at 2, 5 and 10 years were 75%, 37%, and 23%. Sixteen patients died from causes unrelated to home parenteral nutrition. Two patients were weaned off home parenteral nutrition. Seven patients survive on home parenteral nutrition (median: 41 months; range 9-178). Central venous catheter-related complications were low; these included occlusion (0.70 episodes per 1000 central venous catheter days), sepsis (0.19 episodes per 1000 central venous catheter days) and central venous thrombosis (0.11 episodes per 1000 central venous catheter days).

CONCLUSIONS

This is the longest, largest reported series of patients with systemic sclerosis receiving home parenteral nutrition. It shows that home parenteral nutrition can be used safely and effectively in patients with very severe systemic sclerosis-related gastrointestinal involvement.