Survey of the long term incidence of osteonecrosis of the hip and adverse medical events in rheumatoid arthritis after high dose intravenous methylprednisolone

The Pathophysiological Sequence of Glucocorticoid-Induced Osteonecrosis of the Femoral Head in Male Mice

In search of the sequence of pathogenic events leading to glucocorticoid-induced osteonecrosis, we determined the molecular, biomechanical, cellular, and vascular changes in the femur of C57BL/6 mice receiving prednisolone for 14, 28, or 42 days. The femoral head, but not the distal femur, of mice treated for 14 days showed a decrease in the expression of the hypoxia-inducible factor (Hif)-1α and vascular endothelial growth factor (VEGF), the number of osteoblasts, and bone formation rate and strength and showed an increase in osteoclasts. These changes were accompanied by conversion of the normal dendritic vasculature to pools of edema as detected by magnetic resonance imaging, providing robust diagnostic evidence of early osteonecrosis. At that time point, there were no detectable changes in bone density, cortical or cancellous bone architecture, midshaft or distal cancellous bone, or osteocyte apoptosis. In mice treated for 28 days, femoral head cancellous density, cortical width, and trabecular thickness decreased, and by 42 days the femoral heads had full-depth cortical penetrations and cancellous tissue osteonecrosis. These results indicate that the femoral head is a particularly sensitive anatomical site to the adverse effects of glucocorticoid excess on bone and that decreases of Hif-1α and VEGF expression, bone vascularity, and strength precede the loss of bone mass and microarchitectural deterioration, thus rendering the femoral head vulnerable to collapse.

Effect of Pulsed Methylprednisolone on Pain, in Patients with HTLV-1-Associated Myelopathy

HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is an immune mediated myelopathy caused by the human T-lymphotropic virus type 1 (HTLV-1). The efficacy of treatments used for patients with HAM/TSP is uncertain. The aim of this study is to document the efficacy of pulsed methylprednisolone in patients with HAM/TSP. Data from an open cohort of 26 patients with HAM/TSP was retrospectively analysed. 1g IV methylprednisolone was infused on three consecutive days. The outcomes were pain, gait, urinary frequency and nocturia, a range of inflammatory markers and HTLV-1 proviral load. Treatment was well tolerated in all but one patient. Significant improvements in pain were: observed immediately, unrelated to duration of disease and maintained for three months. Improvement in gait was only seen on Day 3 of treatment. Baseline cytokine concentrations did not correlate to baseline pain or gait impairment but a decrease in tumour necrosis factor-alpha (TNF-α) concentration after pulsed methylprednisolone was associated with improvements in both. Until compared with placebo, treatment with pulsed methylprednisolone should be offered to patients with HAM/TSP for the treatment of pain present despite regular analgesia.

The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses

INTRODUCTION

Infection is a major cause of morbidity and mortality in patients with rheumatoid arthritis (RA). The objective of this study was to perform a systematic review and meta-analysis of the effect of glucocorticoid (GC) therapy on the risk of infection in patients with RA.

METHODS

A systematic review was conducted by using MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials database to January 2010 to identify studies among populations of patients with RA that reported a comparison of infection incidence between patients treated with GC therapy and patients not exposed to GC therapy.

RESULTS

In total, 21 randomised controlled trials (RCTs) and 42 observational studies were included. In the RCTs, GC therapy was not associated with a risk of infection (relative risk (RR), 0.97 (95% CI, 0.69, 1.36)). Small numbers of events in the RCTs meant that a clinically important increased or decreased risk could not be ruled out. The observational studies generated a RR of 1.67 (1.49, 1.87), although significant heterogeneity was present. The increased risk (and heterogeneity) persisted when analyses were stratified by varying definitions of exposure, outcome, and adjustment for confounders. A positive dose-response effect was seen.

CONCLUSIONS

Whereas observational studies suggested an increased risk of infection with GC therapy, RCTs suggested no increased risk. Inconsistent reporting of safety outcomes in the RCTs, as well as marked heterogeneity, probable residual confounding, and publication bias in the observational studies, limits the opportunity for a definitive conclusion. Clinicians should remain vigilant for infection in patients with RA treated with GC therapy.

Juvenile idiopathic arthritis: current and future treatment options

Juvenile idiopathic arthritis is the most common rheumatic disease in children. The management of juvenile idiopathic arthritis has improved in recent decades, and morbidity due to the disease is significantly decreased. In particular, the use of more effective drugs and their combination has changed the course of the disease in many patients. The increasing knowledge of inflammation mechanisms has lead to the development of new agents that target specific cytokines interfering with the inflammatory cascade. In particular, anti-TNF agents seem effective: etanercept is the only one licensed for juvenile idiopathic arthritis, and Phase III trials on two other anti-TNF agents, infliximab and adalimumab, are ongoing. This review discusses the current practice in the medical management of juvenile idiopathic arthritis, and potential new agents are discussed.

Management of complications of glucocorticoid therapy

Corticosteroids are commonly employed in the treatment of a wide variety of pulmonary disorders, including asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, sarcoidosis, and pulmonary vasculitides; as well as in the lung transplant population. Frequently, steroid-induced complications contribute significantly to morbidity and diminished quality of life, often overshadowing the impact of the underlying lung disease. This article will discuss the more commonly encountered complications of corticosteroids in the context of the method of delivery, events occurring with chronic use, and events related to withdrawal.

The diagnostic challenge of acute polyarthritis

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Reappraisal of Rasmussen's syndrome with special emphasis on treatment with high doses of steroids

Eight patients with Rasmussen's syndrome and epilepsia partialis continua were treated with high doses of steroids, including pulses of methylprednisolone and prednisone in decreasing doses. Three patients exhibited clinical, radiological, or histological evidence of bilateral involvement. Epilepsy and focal deficit decreased within six months in seven patients. Only five patients, in whom steroid treatment had begun less than 15 months after the onset of epilepsia partialis continua, experienced a lasting effect although they had periodic episodes of transient relapse. Treatment with high doses of steroids seems advisable during the first year after onset of epilepsia partialis continua, before hemiplegia has developed and in cases with bilateral involvement.

Pierre Joseph Pelletier (1788-1842) and Jean Bienaime Caventou (1795-1887)

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Avascular osteonecrosis in patients with SLE: relation to corticosteroid therapy and anticardiolipin antibodies

Sixty-nine unselected SLE patients were studied to evaluate the prevalence of avascular osteonecrosis (AVN) and its relationship with steroid therapy and with anticardiolipin antibodies (aCL). All the patients were under treatment with corticosteroids. AVN occurred in seven occurred in seven of the 69 patients (10.14%) and was not related to corticosteroid intake. Seventeen of the 69 patients were also treated with methylprednisolone pulse therapy (MPPT) and cumulated the highest corticosteroid doses but none of them suffered from AVN. Excluding the 17 MPPT-treated SLE patients, corticosteroid intake was significantly higher in the AVN-SLE patients. Abnormal IgG and/or IgM aCL serum levels were found in two of the seven AVN-SLE patients and in 24 of the 62 non-AVN SLE, without a statistically significant difference. None of the seven AVN-SLE patients showed features of antiphospholipid syndrome. We conclude that in SLE patients a continuous high-dose steroid treatment may be considered a risk factor for AVN. On the contrary, MPPT regimen may reduce this risk. Anticardiolipin antibodies might represent an added factor which could play a role in some patients but not in all.

Corticosteroid pulse therapy in active rheumatoid arthritis

The infusion of high doses of corticosteroids (corticosteroid pulse therapy, CPT) is used to treat refractory rheumatoid arthritis (RA). In the first part of this article, literature on the efficacy of CPT is reviewed, and different CPT regimens (high-dose, low-dose, oral CPT) are compared. Several CPT regimens are beneficial in RA, the clinical effect lasting 4 to 10 weeks. Only high-dose CPT (1,000 mg methylprednisolone intravenously) has been shown to bridge the gap between the start and the effect (lag time) of a disease-modifying antirheumatic drug initiated at the same time. A retrospective study on the incidence of short-term and long-term side effects of CPT in 50 patients with RA who received a total of 78 pulse regimens is described in the second part. Side effects occurred frequently, but in most cases they were mild. The possible relationship between CPT and osteonecrosis of the femoral head is discussed. It is concluded that CPT is beneficial in RA. A substantial number of patients suffer side effects of varying severity.

High-dose intravenous methylprednisolone therapy associated with osteonecrosis in patients with systemic lupus erythematosus

Osteonecrosis is related to the use of steroids in patients with systemic lupus erythematosus (SLE); its association with the use of 'pulses' of methylprednisolone (PMP) is not clear at present. In a retrospective analysis of 190 patients with SLE we found that 19% of 36 patients treated with PMP had osteonecrosis compared with 6% of 154 patients without that treatment (P < 0.04). Risk factors associated with osteonecrosis were PMP treatment, cushingoid appearance, steroid doses > or = 40 mg/day during the first month of treatment, a ratio of steroid dose in grams/year > or = 12, hematuria and proteinuria. In a stepwise regression model, when cushingoid appearance was excluded, PMP became the only significant factor (P = 0.045). We conclude that osteonecrosis can be considered a long-term complication of PMP treatment in SLE patients.

A study of adverse effects of high-dose intravenous (pulse) methylprednisolone therapy in patients with rheumatic disease

OBJECTIVE

To determine the frequency of significant adverse effects associated with high-dose intravenous methylprednisolone therapy (HIVMP) given as methylprednisolone 1 g/d for three consecutive days.

DESIGN

Retrospective study of consecutive patients.

SETTING

Department of Veterans Affairs Medical Center (VAMC), university teaching hospital, and private outpatient clinic.

PATIENTS

Eighty-four patients given HIVMP for systemic rheumatic disease.

MEASUREMENTS

Subjective complaints were elicited via a standardized questionnaire that identified adverse effects through organ system review. Medical records were reviewed for adverse effects occurring within two weeks of HIVMP therapy.

RESULTS

Two hundred seventy-five HIVMP treatments were examined by either patient questionnaire (76 patients) and/or chart review (78 patients). Sixty-five patients described symptoms after HIVMP treatment. Most symptoms were transient in duration, mild in severity, and required no medical treatment. Chart review found 42 possible complications occurring within two weeks of HIVMP therapy. In 18 instances medical intervention was required for problems that included hypertension, seizures, gastric erosions, sepsis, and other infections. It is impossible to attribute all of the complications to HIVMP alone because of underlying disease, use of other medications at the time of therapy, or both.

CONCLUSIONS

HIVMP has an acceptably low risk of significant adverse effects.

Pulse methylprednisolone therapy in rheumatoid arthritis

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