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LETTER TO EDITOR
  
Year : 2000  |  Volume : 66  |  Issue : 1  |  Page : 49-50

The pulse rate of pulse therapy

Anurag Tiwari, CR Srinivas, S Ramalingam 
 

Correspondence Address:
Anurag Tiwari





How to cite this article:
Tiwari A, Srinivas C R, Ramalingam S. The pulse rate of pulse therapy.Indian J Dermatol Venereol Leprol 2000;66:49-50


How to cite this URL:
Tiwari A, Srinivas C R, Ramalingam S. The pulse rate of pulse therapy. Indian J Dermatol Venereol Leprol [serial online] 2000 [cited 2019 Dec 6 ];66:49-50
Available from: http://www.ijdvl.com/text.asp?2000/66/1/49/4868


Full Text

To the Editor

Dexamethasone pulse therapy alone or in combination with cyclophosphamide is used for the treatment of pemphigus, systemic sclerosis, SLE and others. The minor side effects include transient symptoms of hypotension or hypertension,[1]metallic taste within hours after receiving first infusion and pitting oedema of ankles.[2] Other side effects reported include acute arthralgia, [3],[4],[5]a transient syndrome of joint pain, swelling or both. Baethge et al reported 4 patients who developed hiccups persisting longer than 24 hours after treatment with high-dose intravenous methylprednisolone.[6] Hiccups persisting longer than 48 hours are considered intractable.[7]

Several cases of sudden death after taking dexamethasone or methylprednisolone have been reported. [8],[9]Some, but not all, were associated with rapid infusions or pre-existing heart disease.[10] Studies in animals have suggested that intravenous steroids can be arrhythmogenic and speed of administration has been suggested as an important factor.[11] Intravenous bolus of steroids administered over a relatively short period (10 to 20 min) is associated with fatal events.[12] Concomitant use of furosemide also increases the incidence of death.[12] Rapid infusion of steroids associated with concomitant use of furosemide may lead to sudden potassium shifts and result in decreased total peripheral resistance and/ or cardiac arrhythmias.[3]lt has been suggested that increasing the infusion time to at least 30 minutes might prevent these events.[13]

To avoid these complications it is avocated that dexamethasone 100mg be added to 500ml of 5% dextrose and infused over three hours. More often than not we found the nursing staff and prescribing doctor are unaware of the drops per minute required to complete the therapy over the desired time and how much steroid is administered per ml of dextrose water. We have calculated the number of drops/ min. required to administer the medication for various times which are as follows. The algorithm has been arrived by taking into consideration that 15 drops of a fluid amount to Iml. Thus when giving 500ml/ in 3 hours (180min) we have to infuse 500 / 180 = 2.7 ml/min.

Since iml = 15 drops

2.7ml = 40.5 drops

Thus,

500m1 over 3 hours = 2.7m1 / min =41 drops/min Similarly, 500m1 over 31/2 hours = 2.3ml/min =35 drops/min

Also in 500m1 of solution we add 100mg of dexam­ethasone thus each ml contains 100/500 = 0.2mg.

We submit this write up not as on original finding but to reinforce what is already established.

References

1Liebling MR, Leib E, Me laughlin K, et al. Pulse methylprednisolone in rheumatoid arthritis. Ann Int. Med 1981;94:21-26.
2Fan PT, Yu DTY, Clenents PI, et al. Effects of corticosteroids on human immune response: Comparison of one and three daily 1 gm intravenous pulses of methyl prednisolone. 3 Lab Clin Invest, 1973; 53:2629 -2640.
3Newmark KJ et al: Acute arthralgia following high dose of intravenous methylprednisolone therapy. Lancet 1974; ii: 229.
4Bailey BR, Armour P. Acute arthralgia after high dose intravenous methylprednisolone. Lancet, 1974;ii:1014.
5Bennet WM, Strong D: Arthralgia after high dose steroids. Lancet 1:332,1975;1:332.
6Baethge BA, Lidsky MD. Intractable hiccups associated with high dose intravenous methylprednisolone therapy. Ann Intern Med. 1986;104:58-59.
7Souadijan 3V, Cain JC. Intractable hiccups-etiological factors in 220 cases. Postgrad Med J. 43:72-77, 1968; 43;72-77.
8Schmidt GB, Meier MA, Sadave MS. Sudden appearance of cardiac arrhythmias after dexamethasone. JAMA,221:1404,1972;221: 142­1404.
9Bocanegra TS, Castaneda Mo, Espinoza LR, et al. Sudden death after methylprednisolone pulse therapy. Ann Intern Med, 1981; 95:122.
10Gardiner PVG, Griffiths ID: Sudden death after treatment with pulsed methylprednisolone. Br Med J, 1990 ; 300: 125.
11Barry M. 'The use of high dose pulse methylprednisolone in rheumatoid arthritis. Arch Intern Med 1985;145:1483-1484.
12Stubbs SS, Morrell RN. Intravenous methylprednisolone sodium succinate: adverse reactions reported in association with immunosuppressive therapy. Transplant Proc.1973;5:1145-1146.
13Olds JW, Reed WP, Eberle B, et al. Corticosteroids, serum and phagocytosis: in vitro and vivo studies. Infect Immum 1974 ; 9 524-529.

 

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