Steroid-induced myopathy in the ICU

Drug-Induced Myopathies: A Comprehensive Review and Update

Drug-induced myopathies are a common cause of muscle pain, and the range of drugs that can cause muscle side effects is constantly expanding. In this article, the authors comprehensively discuss the diagnostic and therapeutic process in patients with myalgia, and present the spectrum of drug-induced myopathies. The review provides a detailed analysis of the literature on the incidence of myopathy during treatment with hypolipemic drugs, beta-blockers, amiodarone, colchicine, glucocorticosteroids, antimalarials, cyclosporine, zidovudine, and checkpoint inhibitors, a group of drugs increasingly used in the treatment of malignancies. The article considers the clinical course of the different types of myopathies, their pathogenesis, histopathological features, and treatment methods of these disorders. The aim of this paper is to gather from the latest available literature up-to-date information on the course, pathophysiology, and therapeutic options of drug-induced myopathies, to systematize the knowledge of drug-induced myopathies and to draw the attention of internists to the fact that these clinical issues are an important therapeutic problem.

Medium-term impact of COVID-19 on pulmonary function, functional capacity and quality of life

Background

Coronavirus disease 2019 (COVID-19) has spread worldwide, having a dramatic impact on healthcare systems. The aim of this study is to evaluate mid-term clinical impact of COVID-19 on respiratory function.

Methods

379 patients were evaluated 4 months after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnosis. Patients were divided in two groups based on the presence of pneumonia during COVID-19. Clinical conditions, quality of life, symptomatology, 6-min walk test, pulmonary function test with spirometry and diffusing capacity of the lung for carbon monoxide were analysed. Data were compared to clinical evolution during COVID-19 (development of acute respiratory distress syndrome, need of invasive mechanical ventilation, partial oxygen saturation (S_pO2)/inspiratory oxygen fraction (F_IO2) ratio and pneumonia severity index (PSI)).

Results

After a median 135 days, 260 (68.6%) out of 379 patients referred at least one symptom. Patients who developed pneumonia during COVID-19 showed lower S_pO2 at rest (p<0.001), S_pO2 during 6-min walk test (p<0.001), total lung capacity (p<0.001), airway occlusion pressure after 0.1 s (P_0.1) (p=0.02), P_0.1/maximal inspiratory pressure ratio (p=0.005) and higher Borg category-ratio scale (p=0.006) and modified Medical Research Council breathlessness scale (p=0.003), compared to patients without pneumonia. S_pO2/F_IO2 ratio and PSI during SARS-CoV-2 pneumonia were directly associated with mid-term alteration of S_pO2 at rest (p<0.001) and during 6-min walk test (p<0.001), residual volume (p<0.001), total lung capacity (p<0.001 and p=0.003, respectively) and forced vital capacity (p=0.004 and p=0.03, respectively).

Conclusion

Lung damage during COVID-19 correlates to the reduction of pulmonary function 4 months after acute infection.

COVID-19 severe lung involvement can reduce respiratory performance in the medium- to long-term. Respiratory rehabilitation is recommended in COVID-19 survivors showing severe clinical and radiological signs of disease.https://bit.ly/3jCxN0s

Glucocorticoid-induced myopathy in people with asthma: a systematic review

OBJECTIVES

To review the current literature on the evidence and the underlying characteristics of glucocorticoids (type, dosage, and duration) associated with myopathy in asthma.

DATA SOURCES

Four electronic databases were searched to October 19, 2020.

STUDY SELECTION

Inclusion criteria: adults or adolescents with asthma, taking systemic glucocorticoids, and measures of muscle impairments.

RESULTS

Nine studies met the eligibility criteria. The methodologic quality of most studies was fair or good. Two studies reported significantly lower inspiratory muscle function in outpatients taking daily oral glucocorticoids (≥10 mg), but one study reported no such difference. No differences was found in limb muscle strength in one study. Only 11-36% patients with acute exacerbation taking glucocorticoids intravenously suffered from limb muscle weakness during/after critical care admissions. Two studies reported significant associations between dosage of oral glucocorticoid use and inspiratory and limb muscle function, whereas seven studies did not find any significant correlations among the characteristics of systemic glucocorticoids and myopathy. Two studies comparing people with non-glucocorticoid dependent asthma taking inhaled glucocorticoid and healthy people did not find any significant differences in their inspiratory muscle strength and endurance.

CONCLUSIONS

There were limited studies and inconsistent results on glucocorticoid-induced myopathy in people with asthma, and its association with the characteristics of glucocorticoids use. We recommended future studies should use a commonly accepted operational definition of myopathy, utilize a cohort study design, measure the cumulative dosage of glucocorticoids, and integrate possible confounding factors in the analysis.

Neurologic Complications in the Intensive Care Unit

Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.

Contemporary treatment of children with critical and near-fatal asthma

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

ICU-Acquired Weakness Is Associated With Differences in Clinical Outcomes in Critically Ill Children

OBJECTIVE

ICU-acquired weakness, comprised critical illness myopathy and critical illness neuropathy, occurs in a significant proportion of critically ill adults and is associated with high morbidity and mortality. Little is known about ICU-acquired weakness among critically ill children. We investigated the incidence of ICU-acquired weakness among PICUs participating in the Virtual PICU Systems database. We also sought to identify associated risk factors for ICU-acquired weakness and evaluate the hypothesis that ICU-acquired weakness is associated with poor clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

PICU.

MEASUREMENTS AND MAIN RESULTS

Virtual PICU System was queried for critical illness myopathy and critical illness neuropathy between January 2009 and November 2013. Demographic, admission, and clinical outcome variables including mechanical ventilation days, PICU length of stay, and discharge disposition were analyzed. The Pediatric Index of Mortality-2 was used to evaluate and control for illness severity and risk of mortality. Among 203,875 admissions, there were 55 cases of critical illness myopathy reported and no cases of critical illness neuropathy, resulting in an incidence of 0.02%. Mechanical ventilation days were higher among patients with ICU-acquired weakness versus those who did not develop ICU-acquired weakness (31.6 ± 28.9 vs 9.3 ± 20.6; p < 0.001). In our multivariable analysis, when controlling for Pediatric Index of Mortality-2, ICU-acquired weakness was more frequently reported in those with admission diagnoses of respiratory illness and infection and the need for mechanical ventilation, renal replacement therapy, extracorporeal life support, and tracheostomy. ICU-acquired weakness was associated with a longer PICU length of stay, episodes requiring mechanical ventilation, and discharge to an intermediate, chronic care, and rehabilitation care unit. ICU-acquired weakness was not independently associated with mortality.

CONCLUSIONS

ICU-acquired weakness is uncommonly diagnosed among PICU patients reported in Virtual PICU System. ICU-acquired weakness is associated with critical care therapies, invasive procedures, and resource utilization. Limitations of our retrospective study include underrecognition of ICU-acquired weakness and lack of standardized diagnostic criteria within Virtual PICU System. Prospective studies are needed to better understand the true incidence, risk factors, and clinical course for patients who develop ICU-acquired weakness.

Steroid myopathy in patients with chronic respiratory diseases

BACKGROUND

Corticosteroid-induced myopathy is a well known clinical entity, and experimental studies showed decreased rate of protein synthesis and increased rate of protein breakdown in muscles of chronically treated animals.

OBJECTIVE

The present observational study was aimed to evaluate skeletal muscle functions in asthmatics and patients with other chronic respiratory diseases treated by inhaled or oral corticosteroids.

METHODS

Thirty six patients with respiratory diseases were included into the study. The physician-rated peripheral motor deficits scale, stepper test and ankle/wrist index were used for assessment of muscle functions. The effects of length of glucocorticoids intake on muscle functions were evaluated.

RESULTS

Sixty five per cent of patients using corticosteroids daily during 1 year and longer reported weakness in legs, and 20% of these patients demonstrated objective signs of the muscle weakness. The performance on the stepper test was significantly worse in patients chronically using corticosteroids in comparison with the control group (10.9 ± 3.4 steps vs 16.1 ± 2.4 steps per 10s, respectively; F=21.6, p<0.001). In addition, a proportion of patients using corticosteroids for at least 18 months were characterized by muscle hypotrophy at a dominant leg.

CONCLUSION

Chronic intake of inhaled corticosteroids induces clinically significant decrease of muscle functions at least after 1-year of daily treatment.

[Congenital and endogenous endocrine myopathy]

Disorders in endocrinological pathways rarely lead to manifest acquired or endogenous myopathy so that an interdisciplinary evaluation between neurology and endocrinology is essential for these disorders. Asymptomatic or forme fruste variants may be more common and even underdiagnosed in these circumstances. Dysbalance disorders of protein synthesis, electrolytes and carbohydrates can lead to several rare forms of myopathy due to the dependence on hormonal metabolism. In general, the main neuromuscular symptom is proximal weakness, sometimes in addition to myalgia and muscle atrophy. Endocrine myopathies are usually reversible by treatment of the underlying disease. The severity of the endocrinopathy is of fundamental importance for the long-term clinical outcome.

Essential muscle pathology for the rheumatologist

This review introduces/refreshes some basic histopathologic methods and findings of skeletal muscle biopsies with emphasis on those diseases commonly encountered in a rheumatologist's practice. The 3 general areas of myopathology discussed are metabolic myopathies, toxic myopathies, and inflammatory myopathies. The authors, neuropathologists, hope to provide in this article what they think are some commonalities and disease-specific methods in their pathologic workup as well as a practical approach to the collaboration that pathologists undertake with their rheumatology colleagues to come to a working diagnosis.

Medication-related complications in the trauma patient

Trauma patients are twice as likely to have adverse reactions to medication as nontrauma patients. The need for medication in trauma patients is high. Surgery is often necessary, and immunosuppression and hypercoagulability may be present. Adverse drug events can be caused in part by altered pharmacokinetics, drug interactions, and polypharmacy. Medications may also have serious long-term adverse effects, which must be considered. It is not the purpose of this review article to discuss all adverse effects of all medications. This article will discuss the more common adverse effects of medications for trauma patients in the acute care setting, in the following categories: pain control, sedation, antibiotics, seizure prophylaxis in head trauma, atrial fibrillation, deep vein thrombosis and pulmonary embolism prophylaxis, hemodynamic support, adrenal insufficiency, factor VIIa.

Corticosteroid-induced myopathy mimicking therapy-resistant asthma

BACKGROUND

Therapy-resistant asthma is an important clinical problem. However, before considering asthma truly therapy resistant, it is essential to exclude diagnoses that may masquerade as therapy-resistant asthma, such as vocal cord dysfunction and recurrent aspiration, as well as factors related to loss of asthma control, including poor compliance, exposure to allergens, and sinusitis. Corticosteroid-induced myopathy may be an unrecognized but potentially important consideration in both settings.

OBJECTIVES

To describe a patient with corticosteroid-induced myopathy complicating recurrent exacerbations of asthma, which presented with persistently reduced airflow that mimicked therapy-resistant asthma.

METHODS

A 20-year-old Japanese woman with severe intractable asthma who had a history of near-fatal attacks was admitted with recurrent asthma exacerbations that required long-term systemic corticosteroids.

RESULTS

Wheezing episodes decreased but airflow limitation persisted, which was due to not only uncontrolled asthma but also corticosteroid-induced myopathy. Myopathy prevented the adequate use of inhalers, which in turn complicated the tapering of corticosteroids, leading to a vicious cycle. Careful and gradual reduction of corticosteroid dose, while continuing systemic administration of nonsteroidal antiasthma medications, resulted in a resolution of clinical and electromyographic signs of myopathy and pulmonary function abnormalities.

CONCLUSIONS

Corticosteroid-induced myopathy can masquerade as therapy-resistant asthma and can cause poor asthma control.

Steroid-induced ptosis: case studies and histopathologic analysis

PURPOSE

The purpose of this study was to review patients who developed ptosis after subtenon's steroid injection and to study the mechanism of steroid-induced ptosis in an animal model.

METHODS

Part 1. Twenty-two patients with uveitis who had received posterior subtenon's triamcinolone acetonide injections were retrospectively reviewed. Demographics, type of uveitis, type and number of surgeries, pre and postoperative marginal reflex distance (MRD1), and clinical outcomes were evaluated. Part 2. Study of rabbit levator muscle and aponeurosis histopathology after subtenon's triamcinolone injection was performed.

RESULTS

Part 1. The average age was 44.6 years (range: 14-85 years) with a mean follow-up of 14 months. The most common causes of uveitis included uveitis after cataract extraction (five), pars planitis (three), multifocal choroiditis (three), and juvenile rheumatoid arthritis (three). The average time to documented onset of ptosis was 13.9 months (range: 0-49 months). In patients who received only one steroid injection, the average time to ptosis recorded was 2.7 months (range: 0-6 months). Seventeen patients underwent ptosis repair. Part 2. No ptosis was noted in the experimental and control groups. Histopathologic analysis of levator tissues revealed no significant difference in atrophy or degree of inflammation between experimental and control groups.

CONCLUSIONS

Ptosis following subtenon's steroid injection ranged from mild to moderate and occurred a few months after steroid injection. Prior studies of muscles and periocular tissues exposed to corticosteroids demonstrated degenerative muscle changes; our studies revealed no histopathologic changes in the levator muscle or aponeurosis.

[Medically induced myopathia]

Muscular side effects of various anesthetics, analgetics, antibiotics, antihistaminic drugs, antiretrovirals, cardiotropics, immunosuppressants, lipid-lowering drugs, psychotropic drugs, anticancer drugs, and other substances are more frequent than assumed and are easily overlooked. Clinically, muscular side effects manifest as fatigue, myalgias, persistent or transient weakness, stiffness, intolerance to exercise, psychomotor slowing, muscle cramps, wasting, dyspnea, dysphagia, fasciculations, reduced tendon reflexes, impaired consciousness, myoglobinuria, renal failure, or hyperthermia. Diagnosis of these drug-induced myopathies is based on history, clinical neurologic examination, blood work, urine analysis, repetitive stimulation, electromyography, and muscle biopsy. A drug which induces muscular side effects should never be given again. Particularly in patients suffering from primary myopathy, myotoxic drugs should be applied with caution. The drugs which most frequently induce muscular side effects are steroids, statins, fibrates, antiretrovirals, immunosuppressants, colchicine, amiodarone, and anticancer drugs. Many drugs exhibit their myotoxic potential only in combination with other drugs or premorbid pathologic myogenic conditions.

Brief review: Nondepolarizing neuromuscular blocking drugs and critical illness myopathy

PURPOSE

Critically-ill patients who receive nondepolarizing neuromuscular blocking drugs (NMBDs) may be at risk of developing profound muscle weakness that may last for months after the NMBD is discontinued, especially when large cumulative doses of NMBDs and corticosteroids are co-administered to septic, mechanically ventilated patients. This review focuses on the etiology and clinical features of critical illness myopathy (CIM), summarizes specific risk factors for its development, and discusses strategies that might be used to attenuate or even prevent the development of this potentially devastating syndrome.

CLINICAL FEATURES

The etiology of CIM is unknown. Whether it can develop in at-risk patients who undergo lengthy operations during which they receive NMBDs is also unknown. In some patients following exposure to NMBDs their motor systems are impaired secondary to loss of thick (myosin) filaments that render the muscle unexcitable to direct electrical stimulation, while the sensory system is spared. Management of patients who develop NMBD myopathy is supportive, consisting of nutritional support, physical therapy, and daily trials of decreased ventilatory support.

CONCLUSION

Recent guidelines recommend that NMBDs be used in critically ill patients only when absolutely necessary, that the depth of muscle paralysis be monitored to avoid overdosing and metabolite accumulation, and that drug administration be curtailed periodically to allow interruption of sustained NMBD effect.

Thyrotoxic Periodic Paralysis in A Hispanic Man after the Administration Of Prednisone

OBJECTIVE

To present a case of thyrotoxic periodic paralysis (TPP) in a Hispanic man and to discuss the potential precipitating mechanisms.

METHODS

We review the clinical and laboratory findings relative to the occurrence of TPP in a 34-year-old Hispanic man, who had been diagnosed as having Graves' disease.

RESULTS

TPP is a rare complication of thyrotoxicosis. The two known triggers of TPP are high carbohydrate intake and rest after strenuous physical activity. Other precipitating factors include ingestion of alcohol, infection, trauma, emotional stress, and exposure to cold. Nonselective beta-adrenergic blocking agents are used as prophylaxis for the paralytic attacks. Glucocorticoids have been used to treat nonresponsive and recurrent episodes. Nevertheless, our patient, a 34-year-old Hispanic man, had received propranolol for 7 days and one single dose of prednisone 2 hours before the onset of the paralysis. In patients with TPP, the Na+/K+-adenosinetriphosphatase (ATPase) pump activity is considerably increased by excess thyroid hormones, resulting in an increased intracellular potassium shift. Insulin activates the Na+/K+-ATPase pump as well; thus, the precipitating effect of a high carbohydrate diet is explained. Glucocorticoids have been shown to increase the number of Na+/K+-ATPase molecules in skeletal muscle. They also increase insulin secretion in the basal state and the first-phase insulin release after a glucose load.

CONCLUSION

In our patient with TPP, the onset of the attack was not prevented by the use of propranolol and was likely triggered by the administration of prednisone.

Apoptosis of skeletal muscle on steroid-induced myopathy in rats

Apoptotic cell death of differentiated skeletal muscle has been reported in an experimental steroid-induced myopathy of rats. To investigate the underlying molecular changes in the apoptosis of skeletal muscle, in situ end labeling (ISEL), Fas expression, and Western blot analysis for apoptosis-related proteins in the soleus muscle of triamcinolone acetonide (TA)-induced myopathy of rats were studied. Proteins for Western blot analysis included Fas-associated death domain (FADD) and caspase 8 for extrinsic pathway, as well as Bcl-2, Bcl-XL, Bax, Bad, Bid, Akt, p-Akt, and caspase 9 for intrinsic pathway. ISEL-positive myonuclei in TA-treated rats were 1.8 +/- 1.2%, whereas Fas-positive muscle fibers were 4.5 +/- 2.0%. One-fourth of Fas-positive muscle fibers had ISEL-positive myonuclei. Levels of FADD, Bax, Bad, and Bid were substantially increased in the TA-induced myopathy group, whereas Bcl-2, Bcl-XL, Akt, p-Akt, and caspase 9 did not change between control and myopathy groups. Caspase 8 activity increased in the myopathy group. These findings indicate that apoptosis of skeletal muscle in TA-induced myopathy may be triggered by Fas-Fas ligand signals and promoted mainly by overexpression of the pro-apoptotic molecules of FADD and caspase 8 involving the extrinsic pathway. The apoptotic process presented in this study supports a direct, nongenomic effect of a glucocorticoid on cellular membranes leading to cellular apoptosis rather than genomic effector mechanism of steroid hormone mediated by cytosolic steroid receptors.

Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors

OBJECTIVE

To examine the impact of severe acute respiratory syndrome (SARS) on pulmonary function, exercise capacity, and health-related quality of life (HRQoL) among survivors.

METHODS

110 survivors with confirmed SARS were evaluated at the Prince of Wales Hospital, HK at the end of 3 and 6 months after symptom onset. The assessment included lung volumes (TLC, VC, RV, FRC), spirometry (FVC, FEV1), carbon monoxide transfer factor (TLCO adjusted for haemoglobin), inspiratory and expiratory respiratory muscle strength (Pimax and Pemax), 6 minute walk distance (6MWD), chest radiographs, and HRQoL by SF-36 questionnaire.

RESULTS

There were 44 men and 66 women with a mean (SD) age of 35.6 (9.8) years and body mass index of 23.1 (4.8) kg/m2. Seventy (64%) were healthcare workers. At 6 months 33 subjects (30%) had abnormal chest radiographs; four (3.6%), eight (7.4%), and 17 (15.5%) patients had FVC, TLC, and TLCO below 80% of predicted values; and 15 (13.9%) and 24 (22.2%) had Pimax and Pemax values below 80 cm H2O, respectively. The 6MWD increased from a mean (SD) of 464 (83) m at 3 months to 502 (95) m (95% CI 22 to 54 m, p<0.001), but the results were lower than normal controls in the same age groups. There was impairment of HRQoL at 6 months. Patients who required ICU admission (n = 31) had significantly lower FVC, TLC, and TLCO than those who did not.

CONCLUSION

The exercise capacity and health status of SARS survivors was considerably lower than that of a normal population at 6 months. Significant impairment in surface area for gas exchange was noted in 15.5% of survivors. The functional disability appears out of proportion to the degree of lung function impairment and may be related to additional factors such as muscle deconditioning and steroid myopathy.