Sudden death after treatment with pulsed methylprednisolone

Ventricular repolarization disturbances after high dose intravenous methylprednisolone Theraphy

OBJECTIVE

There are no randomized trials evaluating the effects of pulse steroid treatment on cardiac electrophysiologic functions. The data are limited only to case series. In this study, we sought to evaluate the effects of high dose intravenous methylprednisolone therapy on indices of ventricular repolarization.

METHODS

Fifty patients with various autoimmune and inflammatory disorders were enrolled to the study. Electrocardiography (ECG) was obtained 4h before and 12h after the pulse steroid treatment. All ECGs were thoroughly evaluated by an experienced electrophysiologist. Indices of ventricular repolarization including QTc, JT, Tp-Te, Tp-Te/QTc were measured and compared with before and after-treatment ECGs.

RESULTS

There were 36 female and 14 male patients. Mean age was 36±13years. Heart rate was significantly reduced after the therapy (87,16±17,45bpm vs 73,86±17,45 p:0,001). QT interval (361,0±29,91 vs 388,20±42,84 p:0,001) and corrected QT interval (QTc) was significantly prolonged (401,60±19,79 vs 413,72±26,38 p:0,01) after pulse steroid therapy. Also, JT interval (273,0±28,73 vs. 299,60±45,66 p:0,001) and JT interval index (JTI%) was significantly prolonged (118,18±17,54 vs. 110,56±13,92 p:0,01). Tp-e interval was significantly prolonged after high-dose steroid treatment (74,60±13,12 vs. 83,80±13,68 p:0.001). The ratio of Tp-Te to QTc was also significantly increased after pulse steroid therapy (0,18±0,03 vs 0,20±0,03 p:0,009).

CONCLUSION

Our study shows that indices of ventricular repolarization are significantly prolonged after pulse steroid treatment. These findings indicate an increased risk of arrhythmias related to high dose intravenous methylprednisolone therapy.

Atrial Fibrillation Due to Oral Methylprednisolone in a Patient with Membranoproliferative Glomerulonephritis

Cardiac adverse effects of intravenous pulse methylprednisolone administration are well known, but there is little information about the cardiac side effects of oral methylprednisolone in the literature. We present a 41 year-old man with membranoproliferative glomerulonephritis in whom developed atrial fibrillation after oral methylprednisolone therapy.

The diagnosis and treatment of giant cell arteritis

BACKGROUND

Giant cell arteritis (GCA) is the most common systemic vasculitis in persons aged 50 and above (incidence, 3.5 per 100,000 per year). It affects cranial arteries, the aorta, and arteries elsewhere in the body, e.g., in the limbs.

METHODS

We selectively review the pertinent literature, including guidelines and recommendations from Germany and abroad.

RESULTS

The typical symptoms of new-onset GCA are bitemporal headaches, jaw claudiacation, scalp tenderness, visual disturbances, systemic symptoms such as fever and weight loss, and polymyalgia. The diagnostic assessment comprises laboratory testing (erythrocyte sedimentation rate, C-reactive protein), imaging studies (duplex sonography, high-resolution magnetic resonance imaging, positron-emission tomography), and temporal artery biopsy. The standard treatment is with corticosteroids (adverse effects: diabetes mellitus, osteoporosis, cataract, arterial hypertension). A meta-analysis of three randomized controlled trials led to a recommendation for treatment with methotrexate to lower the recurrence rate and spare steroids. Patients for whom methotrexate is contraindicated or who cannot tolerate the drug can be treated with azathioprine instead.

CONCLUSION

Giant cell arteritis, if untreated, progresses to involve the aorta and its collateral branches, leading to various complications. Late diagnosis and treatment can have serious consequences, including irreversible loss of visual function.

Effects of methylprednisolone infusions on vital signs in children with headaches

OBJECTIVES

Intravenous methylprednisolone (IVMP) infusions have been associated with adverse cardiovascular effects. Inconsistent monitoring practices in a pediatric hospital led to questions about patient safety and allocation of nursing resources. This study describes vital sign changes in children and monitoring practices related to IVMP.

METHODS

This retrospective chart review received Institutional Review Board approval. Children aged 5 to 17 years receiving IVMP from January 2006 to January 2009 were included. Seventy-four patients with 94 hospital admissions were evaluated. Data collected included systolic blood pressure, diastolic blood pressure, and heart rate, as well as the time and dosage of IVMP. Frequency of vital sign monitoring as ordered and as performed was described. Interrater reliability was calculated, and descriptive statistics were used in the data analysis.

RESULTS

At baseline, about half of the patients had vital signs out of normal range for age. After the first dose, vital signs fluctuated, with a majority having greater than 10% changes from baseline as increases, decreases, or both. Time of initial 10% change in vital signs ranged from immediately after the dose to 135.5 hours later. Increased vital sign changes were seen in the older patients and in patients receiving higher doses. Monitoring of vital signs occurred more frequently than was ordered. Only 1 patient had a specific order for monitoring with IVMP.

CONCLUSIONS

The patients included in this study experienced documented fluctuations in vital signs. A prospective study to evaluate the relationship of IVMP and patient safety will assist in standardizing vital sign monitoring guidelines.

Hepatic immunosuppressive effects of systemically administered novel dextran-methylprednisolone prodrugs with peptide linkers in rats

The hepatic immunosuppressive activities of two novel dextran prodrugs of methylprednisolone (MP) containing one (DMP1) or five (DMP5) amino acids as linkers were studied in rats. At various times (0-2 weeks) after intravenous administration of single 5 mg/kg (MP equivalent) doses of each prodrug or MP succinate (MPS), livers were isolated and immunologically stimulated ex vivo with lipopolysaccharide. The concentrations of tumor necrosis factor (TNF)-α in the outlet perfusate were then quantitated to assess immune response. Additionally, the concentrations of DMP1, DMP5, and/or MP were measured in the liver. MPS, DMP5, or DMP1 injections caused a maximum of 48.9%, 63.5%, or 85.7% decrease in the TNF-α secretion into the perfusate, with the time above the 50% inhibitory effect being <5, <24, or 120 h, respectively. Additionally, the area under the effect-time curve for DMP1 was 11-fold or fourfold higher than that after the administration of MPS or DMP5, respectively. Relatively high concentrations of DMP1 were present in the liver even at the last sampling time of 2 weeks. These data suggest that a single intravenous dose of DMP1 produces an intense and sustained immunosuppression in the liver for a relatively long time, which may be useful in liver transplantation.

The antibody targeting the E314 peptide of human Kv1.3 pore region serves as a novel, potent and specific channel blocker

Selective blockade of Kv1.3 channels in effector memory T (T(EM)) cells was validated to ameliorate autoimmune or autoimmune-associated diseases. We generated the antibody directed against one peptide of human Kv1.3 (hKv1.3) extracellular loop as a novel and possible Kv1.3 blocker. One peptide of hKv1.3 extracellular loop E3 containing 14 amino acids (E314) was chosen as an antigenic determinant to generate the E314 antibody. The E314 antibody specifically recognized 63.8KD protein stably expressed in hKv1.3-HEK 293 cell lines, whereas it did not recognize or cross-react to human Kv1.1(hKv1.1), Kv1.2(hKv1.2), Kv1.4(hKv1.4), Kv1.5(hKv1.5), KCa3.1(hKCa3.1), HERG, hKCNQ1/hKCNE1, Nav1.5 and Cav1.2 proteins stably expressed in HEK 293 cell lines or in human atrial or ventricular myocytes by Western blotting analysis and immunostaining detection. By the technique of whole-cell patch clamp, the E314 antibody was shown to have a directly inhibitory effect on hKv1.3 currents expressed in HEK 293 or Jurkat T cells and the inhibition showed a concentration-dependence. However, it exerted no significant difference on hKv1.1, hKv1.2, hKv1.4, hKv1.5, hKCa3.1, HERG, hKCNQ1/hKCNE1, L-type Ca(2+) or voltage-gated Na(+) currents. The present study demonstrates that the antibody targeting the E314 peptide of hKv1.3 pore region could be a novel, potent and specific hKv1.3 blocker without affecting a variety of closely related K(v)1 channels, KCa3.1 channels and functional cardiac ion channels underlying central nervous system (CNS) disorders or drug-acquired arrhythmias, which is required as a safe clinic-promising channel blocker.

Clinical outcomes of 174 nasopharyngeal carcinoma patients with radiation-induced temporal lobe necrosis

PURPOSE

To retrospectively study the clinical outcomes of nasopharyngeal carcinoma patients with radiation-induced temporal lobe necrosis (TLN) treated with steroids, surgery, or observation only.

METHODS AND PATIENTS

We performed a retrospective analysis of 174 consecutive patients diagnosed with TLN between 1990 and 2008. Before 1998, symptomatic patients were treated with oral steroids, while asymptomatic patients were treated conservatively. After 1998, most symptomatic and asymptomatic patients with a large volume of necrosis were treated by intravenously pulsed-steroid therapy with a standardized protocol. We examined factors affecting grade 4 complication-free survival and overall survival. Outcomes of the three treatment groups, those receiving conservative treatment, those receiving oral steroid, and those receiving intravenous pulse steroid, were compared.

RESULTS

The mean follow-up time was 115 months. Rates of grade 4 complication-free survival at 2 years and at 5 years after diagnosis of TLN were 72.2% and 54.1%, respectively. The 2-year and 5-year overall survival rates were 57.5% and 35.4%, respectively. Multivariate analysis revealed that being symptomatic at diagnosis (relative risk [RR], 4.5; p = 0.0001), re-irradiation of the nasopharynx (NP) (RR, 1.56; p = 0.008), salvage brachytherapy to the NP (RR, 1.75; p = 0.012), and a short latency period before the diagnosis of TLN (RR, 0.96, p < 0.0001) were independent prognosticators of poor grade 4 complication-free survival. Patients with all four factors had a 100% risk of developing grade 4 complications within 5 years; whereas if no factor was present, the risk was 12.5%. Intravenous pulse steroid therapy was associated with a higher clinical response rate compared with conventional steroid therapy (p < 0.0001); however, it did not affect complication-free survival in multivariate analysis.

CONCLUSIONS

TLN patients with good prognosticators could be observed without active treatment. Although treatment with intravenously pulsed steroid was associated with better clinical response than conventional steroid delivery, it did not affect the complication-free survival rate of TLN patients.

Plasma pharmacokinetics and tissue disposition of novel dextran-methylprednisolone conjugates with peptide linkers in rats

The plasma and tissue disposition of two novel dextran prodrugs of methylprednisolone (MP) containing one (DMP-1) or five (DMP-5) amino acids as linkers were studied in rats. Single 5-mg/kg doses (MP equivalent) of each prodrug or MP were administered intravenously, and blood and tissue samples were collected. Prodrug and drug concentrations were quantitated using HPLC, and noncompartmental pharmacokinetic parameters were estimated. Whereas conjugation of MP with dextran in both prodrugs substantially decreased the clearance of the drug by approximately 200-fold, the accumulations of the drug in the liver, spleen, and kidneys were significantly increased by conjugation. However, the extent of accumulation of DMP-1 in these tissues was substantially greater than that for DMP-5. Substantial amounts of MP were regenerated from both prodrugs in the liver and spleen, with the rate of release from DMP-5 being twice as fast as that from DMP-1. However, the AUCs of MP regenerated from DMP-1 in the liver and spleen were substantially higher than those after DMP-5. In contrast, in the kidneys, the AUC of MP regenerated from DMP-5 was higher than that after DMP-1 administration. These data suggest that DMP-1 may be more suitable than DMP-5 for targeting immunosuppression to the liver and spleen.

Attenuation of acute rejection in a rat liver transplantation model by a liver-targeted dextran prodrug of methylprednisolone

BACKGROUND

The use of methylprednisolone (MP) and other corticosteroids for the treatment of acute liver allograft rejection is associated with severe toxicities in nontarget tissues. Therefore, selective delivery of MP to the liver may improve its efficacy and alleviate its side effects. We investigated the effects of a novel liver-targeted dextran prodrug of MP (DMP) in an orthotopic rat liver transplantation (OLT) model.

METHODS

The model consisted of a high responder rejection strain combination (Dark Agouti donors and Lewis recipients). Liver recipients were intravenously administered saline or a single subtherapeutic dose of MP (5 mg/kg) as the parent drug (MP) or its prodrug (DMP). Different groups were then monitored for graft survival or euthanized 5 or 9 days posttransplantation. Plasma chemistry, including alkaline phosphatase and bilirubin, allograft histology, and survival duration were determined.

RESULTS

Untreated recipients exhibited elevated plasma levels of liver injury markers, progressive portal and venous inflammation and cellular infiltration in liver allografts, and a mean graft survival time (MST) of 10.5 days. MP treatment did not alter any of these parameters. In contrast, a single dose of DMP resulted in a decrease in plasma levels of liver injury markers, a decrease in histological grade of rejection on day 5, and a substantial increase in MST (27.5 days).

CONCLUSIONS

These results demonstrate attenuation of acute rejection following local (allograft) immunosuppression with a single subtherapeutic dose of MP delivered as a liver-targeted prodrug. Dextran prodrugs may be useful for selective delivery of immunosuppressants to the liver following liver transplantation.

Arteriitis temporalis (Riesenzellarteriitis)

Giant cell arteritis (arteritis temporalis) is the most common form of systemic vasculitis in the elderly. A series of symptoms such as new-onset headache, jaw claudication, proximal myalgia, weight loss, and fever may lead to the diagnosis. However, there is also a silent or occult presentation with minor or no systemic symptoms, especially no headache. A number of laboratory values (erythrocyte sedimentation rate, CRP, fibrinogen, thrombocytes, and cardiolipin antibodies) indicate giant cell arteritis, but none of this proves the diagnosis. Temporal artery biopsy is the gold standard for diagnosis of giant cell arteritis. Due to skip lesions, a negative result does not exclude the diagnosis. The most important complication of giant cell arteritis is visual loss in one or both eyes due to AION or retinal artery occlusion. Usually, visual loss is irreversible even with therapy. Corticosteroids are the drug of choice to treat giant cell arteritis. Therapy is required for a long time, monitored by parameters of inflammation (ESR, CRP).

Oral and intravenous steroids in giant cell arteritis

Giant cell arteritis can result in devastating visual loss. Treatment with steroids does result in visual recovery in some patients but the exact percentage is unknown. Intravenous megadose steroids appear to offer some advantage over oral steroids presumably through non-genomic effects, which manifest at doses of 500 mg or more. Side-effects are more likely in the elderly especially those with renal and cardiac co-morbidities. The authors' current recommendation is that intravenous steroids should be given to patients with established visual loss or amaurosis fugax.

Pulse glucocorticoids

High-dose intravenous (i.v.) methylprednisolone has been used therapeutically in a number of medical fields to avoid the complications and side effects of long-term glucocorticoid (GC) therapy and because of the perception that high-dose i.v. methylprednisolone may have "special" therapeutic effects. It is possible that aggressive early therapy with GCs allows for a more rapid taper of GCs and therefore prevents some of the dose-related side effects associated with long-term use. Some of the neurologic and rheumatologic literature related to multiple sclerosis and lupus nephritis suggest that i.v. methylprednisolone has therapeutic effects that are different from those of conventional doses of oral prednisone. There is still considerable debate about this in nondermatologic fields, and extrapolation of the role of pulse i.v. methylprednisolone to dermatologic disease, where trials are lacking, is difficult. Given this subset of possible candidates of this therapy as suggested by anecdotal reports, there is at least a rationale for considering the use of this modality in a subset of patients.

Progressive visual loss from giant cell arteritis despite high-dose intravenous methylprednisolone

BACKGROUND

Giant cell arteritis (GCA) often presents with devastating visual loss in the elderly, yet the ideal treatment is unknown. The disease most often has been treated with oral prednisone, although recently the use of the high-dose intravenous methylprednisolone (IVMP) has been reported to enhance visual recovery.

METHODS

The authors reviewed patient charts from two university-based neuroophthalmology services and reviewed all previously reported cases of GCA treated with IVMP.

RESULTS

Four patients with GCA exhibited severe, progressive visual loss after at least 48 hours of high-dose IVMP. A fifth patient had further visual loss in one eye and improvement in the other eye after 24 hours of IVMP. In previous reports of IVMP treatment in GCA, four patients lost vision and 14 patients recovered vision. The authors review the details of these reports.

CONCLUSIONS

The results of IVMP treatment of patients with visual loss from GCA are similar to the results of treatment with oral corticosteroids, with IVMP treatment being more costly and having a small risk of sudden death. The optimal dosage and route of corticosteroid treatment for GCA with visual loss remain elusive and warrant a treatment trial.

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.

Severe adverse cardiovascular effects of pulse steroid therapy: is continuous cardiac monitoring necessary?

Pulse steroid therapy (PST) has been used in dermatology to treat a variety of severe inflammatory disorders. Dermatologists have usually recommended that patients be hospitalized for continuous cardiac monitoring during PST administration, although specialists in other fields have administered PST in an outpatient setting. We reviewed the literature concerning serious adverse cardiovascular effects of PST. These were rare and have been mainly reported in nondermatologic patients, typically those with kidney or heart disease. Although outpatient administration of PST may be a safe practice for some dermatologic patients, we cannot make a firm recommendation without a prospective trial.

Are late potentials operative in arrhythmias following methylprednisolone pulse therapy

We have evaluated 11 patients for the presence of late potentials in an attempt to investigate whether pulse methylprednisolone exerted its arrhythmogenic effect via this mechanism. All patients received pulse steroid therapy for their glomerulopathies. One of the patients developed bradycardia, no electrocardiographic abnormalities were present in the rest of these patients. Late potentials were not detected in any of the patients. Thus, in this preliminary study we have not been able to demonstrate that pulse steroid therapy plays a role in the genesis of late potentials.

Treatable blindness in temporal arteritis

Temporal arteritis is a common cause of blindness. Prompt steroid treatment limits unilateral visual loss while protecting the contralateral eye. Established blindness is irreversible. We report a case of temporal arteritis in which an eye with no light perception secondary to an arteritic anterior ischaemic optic neuropathy regained 6/6 vision.