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LETTER TO EDITOR
Year : 2004  |  Volume : 70  |  Issue : 4  |  Page : 244-246

Dexamethasone cyclophosphamide pulse therapy for pemphigus


Consultant Dermatologist, Dombivali, Thane, Maharashtra, India

Correspondence Address:
A-230, Kasturi Plaza, Dombivali, Thane, India
modidr_100@yahoo.co.in



How to cite this article:
Modi N. Dexamethasone cyclophosphamide pulse therapy for pemphigus. Indian J Dermatol Venereol Leprol 2004;70:244-6


How to cite this URL:
Modi N. Dexamethasone cyclophosphamide pulse therapy for pemphigus. Indian J Dermatol Venereol Leprol [serial online] 2004 [cited 2019 Oct 22];70:244-6. Available from: http://www.ijdvl.com/text.asp?2004/70/4/244/12367


Sir,
The IJDVL September-October 2003 issue covered various aspects of dexamethasone-cyclophosphamide pulse) DCP pulse therapy.[1],[2],[3]
I would like to make the following important points related to DCP therapy:
(1) The duration of infusion of cyclophosphamide pulse:
While the editorial[1] has not discussed this aspect of therapy, Dr. Pasricha[2] has categorically stated that the intravenous drip of dexamethasone and cyclophosphamide should be given over 2 hours. Others have administered this drip over 2 hours[3] or 1 hour.[4] Dr. Balachandran recommends a slower infusion, over 3 to 4 hours.[5],[6] These give a false sense of non-standardization of therapy.
As per the manufacturer's package insert, cyclophosphamide should be infused as soon as possible after reconstitution since there is a possibility of loss of pharmacologic activity. Also its half life is only 7 hours. Hence, it should be given over 1 to 1.5 hours (maximum 2 hours) in order to maintain the maximum blood concentration uniformly over a short time.[7]
(2) Prevention of cyclophosphamide induced sterile hemorrhagic cystitis:
The modification of pulse therapy[3] which advocates an infusion of 500 ml of 5% dextrose on the day of intravenous cyclophosphamide administration needs to be reevaluated. Since patients are frequently diabetic or anemic, and hence in a hyperdynamic circulatory stage, is giving intravenous fluids justified? As a routine ample oral fluid intake is recommended[8] and might suffice.
Administration of the drug should be interrupted at the first indication of dysuria or hematuria.[8] On the day of cyclophosphamide infusion I ask my patients to empty their bladder as frequently as possible, may be half hourly, during the infusion and preferably till 2 hours later.
Cystitis can be reduced in intensity or prevented by the parenteral administration of MESNA, a sulfhydryl compound that reacts readily with acrolein in the acid environment of the urinary tract.[8]
(3) Supportive management for prevention of steroid induced osteoporosis:[3]
This should not be called a modification of Dr. Pasricha's DCP therapy since it is a totally different aspect of comprehensive patient management. If glucocorticoid associated osteoporosis is the main concern, then the bisphosphonate group of drugs (e.g. alendronate), which have emerged as the most efficacious drugs for the prevention of osteoporosis, should be given.[9] Most authorities also advocate a calcium intake of 1500 mg/day in the diet and calcium supplementation and vitamin D intake of 400 IU/day for the prevention of osteoporosis.[10]
(4) Steroids are normally given in a single early morning dose.
While none of the authors have commented on this aspect of DCP therapy, shouldn't DCP therapy infusions be given in the early morning only? 

   References Top

1.Ramam M. Dexamethasone pulse therapy in dermatology. Indian J Dermatol Venereol Leprol 2003;69:319-22.  Back to cited text no. 1    
2.Pasricha JS. Pulse therapy as a cure for autoimmune diseases. Indian J Dermatol Venereol Leprol 2003;69:323-8.  Back to cited text no. 2    
3.Rao NP, Lakshmi TS. Pulse therapy and its modifications in pemphigus: A six year study. Indian J Dermatol Venereol Leprol 2003;69:329-33.  Back to cited text no. 3    
4.Gokhale NR, Mahajan PM, Sule RR, Belgaumkar VA, Jain SM. Treatment of pemphigus with intravenous pulse cyclophosphamide. Indian J Dermatol Venereol Leprol 2003;69:334-7.  Back to cited text no. 4    
5.Balachandran C. Treatment of pemphigus. Indian J Dermatol Venereol Leprol 2003;69:3-5.  Back to cited text no. 5    
6.Balachandran C. Letter to editor: Response. Indian J Dermatol Venereol Leprol 2003;69:314-5.  Back to cited text no. 6    
7.Gupta R, Gupta S. Treatment of pemphigus (Letter). Indian J Dermatol Venereol Leprol 2003;69:314.  Back to cited text no. 7    
8.Chabner BA, Ryan DP, Paz-Ares L, Garcia-Carbonero R, Calabresi P. Chemotherapy of neoplastic diseases. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1391-6.  Back to cited text no. 8    
9.Robert M. Agents affecting calcification and bone turnover. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1738-43.  Back to cited text no. 9    
10.Shimmer BP, Parker KL. Adrenocorticotropic hormone, adrenocortical sterioids and their synthetic analogs, Inhibitors of the synthesis and actions of adrenocortical hormones. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1649-77.  Back to cited text no. 10    

 

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