Recovery of hypothalamic-pituitary-adrenal function after intermittent high-dose prednisolone and cytotoxic chemotherapy

Chemotherapy-induced neurotoxicity in pediatric solid non-CNS tumor patients: An update on current state of research and recommended future directions

Neurocognitive sequelae are known to be induced by cranial radiotherapy and central-nervous-system-directed chemotherapy in childhood Acute Lymphoblastic Leukemia (ALL) and brain tumor patients. However, less evidence exists for solid non-CNS-tumor patients. To get a better understanding of the potential neurotoxic mechanisms of non-CNS-directed chemotherapy during childhood, we performed a comprehensive literature review of this topic. Here, we provide an overview of preclinical and clinical studies investigating neurotoxicity associated with chemotherapy in the treatment of pediatric solid non-CNS tumors. Research to date suggests that chemotherapy has deleterious biological and psychological effects, with animal studies demonstrating histological evidence for neurotoxic effects of specific agents and human studies demonstrating acute neurotoxicity. Although the existing literature suggests potential neurotoxicity throughout neurodevelopment, research into the long-term neurocognitive sequelae in survivors of non-CNS cancers remains limited. Therefore, we stress the critical need for neurodevelopmental focused research in children who are treated for solid non-CNS tumors, since they are at risk for potential neurocognitive impairment.

Immediate and Delayed Complications of Dexamethasone Cyclophosphamide Pulse (DCP) Therapy

Dexamethasone-cyclophosphamide pulse (DCP) is the prefered mode of therapy in pemphigus in India because it is relatively free from the side effects seen with heavy doses of daily oral steroids. One hundred forty-six pemphigus patients treated with DCP were observed for side effects of this regimen. One hundred forty mg of dexamethasone was administered IV in 200 ml of 5% dextrose over a period of 60-90 minutes on 3 consecutive days. Five hundred mg of cyclophosphamide was added on first day of the pulse and 50 mg given orally daily in the intervening period. DCP was repeated every 4 weeks and continued for 6 months after subsidence of the disease (no new lesions). Flushing over the face was the most common event recorded during the adiministration in 78 subjects followed by palpitations in 11, hiccups in 9, and numbness of feet in 6. Fourteen patients had polyurea, and 3 developed skin rash. Shivering, shooting pains along thighs, breathlessness, seizure and unilateral limb edema were observed in one patient each. Generalized weakness/malaise was the most troublesome delayed side effect in 81 (55.4%) patients; it lasted for 8-15 days after the pulse. Thirty-six (24.6%) had inadequate sleep syndrome, 23 (15.7%) had headache, 21 (14.3%) complained of arthralgias, 19 (13%) experienced alteration in taste, and 13 (9%) had diffuse hair loss. 28 females developed menstrual disturbances, and 14 (9.5%) had blurring of vision (glaucoma in 3 and posterior subcapsular cataract in 1). Thirteen of eighteen diabetics had an increase in blood sugar requiring higher doses of insulin. Five NIDDM patients needed insulin. Four (2.7%) developed hypertension. Pulse therapy is not absolutely free from side effects. Hypertension and diabetes occur less frequently as compared to conventional steroid therapy. Generalized weakness, flushing, headache and taste alteration occur exclusively with pulse therapy.

Intravenous pulses of methylprednisolone for systemic lupus erythematosus

BACKGROUND

Intravenous (IV) pulses of methylprednisolone (MEP) commonly are used to treat severe manifestations of systemic lupus erythematosus (SLE). However, despite wide use of this treatment the best dose, timing, and the situations in which this treatment should be used remain largely anecdotal.

AIM

To review the mechanisms of action and evidence for clinical use of IV MEP in the treatment of SLE.

METHOD

The literature on MEP use in SLE from 1966 to 2002, using PubMed from the National Library of Medicine, was reviewed.

RESULTS

As with other modes of corticosteroid administration, IV MEP has significant anti-inflammatory and immunosuppressive actions. These actions have been shown to be effective in treating SLE in clinical trials, for lupus nephritis. The studies are mainly uncontrolled and retrospective. Long-term observations from a few double-blind prospective trials suggest that monthly pulses of MEP, in addition to IV cyclophosphamide, may be useful. Pulse MEP is beneficial for several serious manifestations of SLE, such as neuro-psychiatric lupus, pulmonary hemorrhage, severe blood dyscrasias, cardiomyopathy, and vasculitis. However, significant side effects may occur, mostly infections, which are worse in patients with hypoalbuminemia.

CONCLUSION

IV pulses of MEP rapidly immunosuppress patients with organ and/or life-threatening manifestations of SLE. However, the gold standard 1 g/day for 3 consecutive days is associated with significant infectious complications and lower doses may be just as useful.

Glucocorticosteroid replacement therapy: a literature review and suggested replacement therapy

Administration of exogenous glucocorticosteroids will cause adrenal suppression lasting for up to 12 months; however, the patient's stress response will return within 14 to 30 days. This difference occurs as a result of the effects of corticotropin-releasing factor on the autonomic nervous system and on visceral systems. A new protocol for glucocorticosteroid replacement therapy is proposed that is based on the patient's ability to respond to dental stress.

Pharmacological aspects of corticosteroid pulse therapy

Pulse corticosteroid therapy involves intravenous administration of "suprapharmacological" doses (0.5-2 g) of prednisolone or its equivalents. This dose is usually given on three consecutive days and possibly once a month thereafter. The pharmacological effects of the single pulse dose lasted for about two days. Whether these effects differ quantitatively or qualitatively from the effects of the smaller, conventional doses is unclear at present. The usual side-effects of glucocorticoid therapy may occur with pulse therapy but evidently less frequently than with conventional modes of steroid therapy.