|LETTER TO EDITOR
|Year : 2004 | Volume
| Issue : 4 | Page : 244-246
Dexamethasone cyclophosphamide pulse therapy for pemphigus
Consultant Dermatologist, Dombivali, Thane, Maharashtra, India
A-230, Kasturi Plaza, Dombivali, Thane, India
|How to cite this article:|
Modi N. Dexamethasone cyclophosphamide pulse therapy for pemphigus. Indian J Dermatol Venereol Leprol 2004;70:244-6
The IJDVL September-October 2003 issue covered various aspects of dexamethasone-cyclophosphamide pulse) DCP pulse therapy.,,
I would like to make the following important points related to DCP therapy:
(1) The duration of infusion of cyclophosphamide pulse:
While the editorial has not discussed this aspect of therapy, Dr. Pasricha 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 or 1 hour. Dr. Balachandran recommends a slower infusion, over 3 to 4 hours., 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.
(2) Prevention of cyclophosphamide induced sterile hemorrhagic cystitis:
The modification of pulse therapy 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 and might suffice.
Administration of the drug should be interrupted at the first indication of dysuria or hematuria. 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.
(3) Supportive management for prevention of steroid induced osteoporosis:
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. 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.
(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|| |
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