|LETTER TO EDITOR
|Year : 1995 | Volume
| Issue : 1 | Page : 59-61
Pulse steroid therapy in pemphigus
J Amrinder Kanwar, Sandipan Dhar, Goutam Dawn
J Amrinder Kanwar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kanwar J A, Dhar S, Dawn G. Pulse steroid therapy in pemphigus. Indian J Dermatol Venereol Leprol 1995;61:59-61
| To the Editor,|| |
Recently adverse effects of pulse steroid therapy (PST) were highlighted by White et al (J Am Acad Dermatol 1994; 30:768-73). While reviewing the literature, the authors found that severe adverse cardiovascular effects of PST were rare and mostly restricted to patients suffering from non-dermatological disorders particularly with cardiac or renal diseases. In contrast, PST was found to be relatively safe in 188 patients with various dermatologic disorders. We earlier reported the efficacy and safety of dexamethasone cyclophosphamide (DCP) pulse therapy in 50 patients with pemphigus. Over the last 4 years, we have fathered more experience in treating another 133 patients with pemphigus with DCP pulse therapy. However, we are not among the dermatologists who recommend continuous cardiac monitoring during PST administration.
At our centre, before administration of DCP, the following investigations are carried out : Hemogram, serum electrolytes, blood urea, serum creatinine, blood sugar, serum amylase, serum transaminases, electrocardiogram (ECG), skiagram of chest, routine urine and stool examination and stool for occult blood. Any abnormality detected is investigated in more detail. While on DCP for 3 consecutive days, careful monitoring is done of pulse, respiration and temperature. The ECG and serum electrolytes are done every day after completion of the pulse. The chest skiagram is however, repeated once in 3 months.
Each DCP pulse consists of 136 mg dexamethasone dissolved in 5% dextrose given by a slow intravenous drip over 1-2 hours and repeated on 3 consecutive days. In addition, on the first day, 50mg of cyclophosphamide is added to the drip. The pulses are repeated at intervals of 4 weeks. During the intervening period, the patient is only on 500 mg cyclophosphamide orally and occasionally a small oral dose of corticosteroids depending upon the clinical activity of the disease. DCP has now become the first line of therapy in pemphigus at our centre. Elderly patients (above 60 years) and those with compromised cardiac or renal functions are not taken up for pulses. We have successfully treated children (upto 16 years) with pemphigus with dexamethasone pulses without any adverse effects.,
Till date we have observed cardiac arrhythmias in only 2 patients while on DCP. Of these 2 patients, one was a female aged 36 years and the other, a 54-year-old male. Initial cardiological examination in both these patients was normal and the arrhythmias developed during 3rd and 6th pulses. The arrhythmias were transitory in nature and disappeared on stopping the pulses. However, neither ECG changes nor electrolyte imbalances were detected. These patients were subsequently switched over to conventional corticosteroid therapy. One patient (58 years male) developed chest pain while on DCP; the ECG confirmed the ischaemic changes. In addition to other mionr insignificant side effects reported by us earlier, two other side effects which have been observed are hiccups (4 patients) and facial flusing (4 patients).
Our experience with methylprednisolone pulses is limited to 10 patients only. High cost and non-availability limits its use. We have not observed any anaphylaxis due to methyl prednisolone. Apart from pemphigus, we have treated successfully 2 patients of pyoderma gangrenosum and 1 of Reiter's disease with PST without any adverse effect.
Inspite of finding it to be quite safe, we have so far not used DCP on an out patient basis as we want to have still more experience with it. It is also not possible to carry out all the investigations in patients without admission in hospital. However, experience with a larger number of patients would indicate if all these investigations are really required. Perhaps an ECG and evaluation of serum electrolytes would suffice. It would then be possible to recommend the DCP as an out patient procedure.
In conclusion, we would once again like to emphasize that in our opinion (based on experience), continuous cardiac monitoring is not essential during DCP administration in patients with pemphigus. The selection of patients for DCP however, should be careful and those with cardiac or renal diseases should be excluded as they are more likely to have serious adverse effects.
| References|| |
|1.||Kaur S, Kanwar AJ. Dexamethasone-cyclophosphamide pulse therapy in pemphigus. Int J Dermatol 1990; 29:371-5. [PUBMED] |
|2.||Kanwar AJ, Kaur S. Pemphigus in children. Int J Dermatol 1991; 30:343-6. [PUBMED] |
|3.||Kanwar AJ, Dhar S, Kaur S. Further experience with pemphigus in children. Pediatr Dermatol 1994;11:107-11. [PUBMED] |
|4.||Kanwar AJ, Kaur S, Dhar S, et al. Hiccup-A side effect of pulse therapy. Dermatology 1993; 187:279. [PUBMED] |
|5.||Dhar S, Kanwar AJ. Facial flushing-A side effect of pulse therapy. Dermatology 1993; 188:332. |
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