Oral budesonide is an effective alternative to prednisone for treatment of autoimmune hepatitis

A clinical decision report using: Manns MP, Woynarowski M, Kreisel W, et al. Budesonide induces remission more effectively than prednisone in a controlled trial of patients with autoimmune hepatitis. Gastroenterology. 2010;139(4):1198-1206. https://doi.org/10.1053/j.gastro.2010.06.046 for a patient with autoimmune hepatitis developing septic arthritis secondary to prednisone therapy.

95 Baseline body-mass-index and risk for obesity in children with rheumatic disease starting high-dose prednisone therapy

Primary Subject area Rheumatology Background Prednisone is a glucocorticoid (GC) medication commonly used in moderate (>7.5 mg/day) to high doses (≥ 1 mg/kg/day to maximum 60 mg/day) for children with moderate to severe presentations of rheumatic disease, including systemic lupus erythematosus (SLE), juvenile idiopathic arthritis (JIA), and juvenile dermatomyositis (JDM). Adverse effects (AE) to GCs impose a significant burden on health and quality of life including frequent development of weight gain, mood changes, sleep difficulties, osteoporosis, and Cushingoid features, amongst others. Objectives We sought to evaluate a possible relationship between baseline patient body-mass-index (BMI) measure and development of select GC-mediated toxicity within the first 12 months of starting moderate or high-dose prednisone therapy using conventional weight-based dosing of prednisone. Secondary outcomes were to examine rates of GC-mediated hypertension, osteopenia, and osteoporosis. Design/Methods We performed a retrospective chart review on children with rheumatic disease aged ≤ 17 years treated with moderate and high-dose prednisone therapy at a single Canadian academic hospital between January 1, 2010 and December 31, 2019. Demographic variables collected included diagnosis, age, sex, ethnicity. Clinical variables collected include weight, height, and body-mass-index (BMI), hepatitis (AST>41 U/L, ALT>40 U/L, or GGT>60 U/L), proteinuria (>0.1 g/L), and presence of hypoalbuminemia (<38g/L) at baseline. We collected weight, height, and body-mass-index (BMI), at 6 and 12 months, the maximum BMI, and transformed them to z-scores according to the World Health Organization's Child Growth standards. Cumulative prednisone dose (mg/kg/12 months), total days on prednisone in the first 12 months of therapy were also obtained, in addition to bone-mineral-density cores after 12 months of prednisone therapy. Baseline characteristics, which were significant for the subsequent development of obesity during the first 12 months at the bivariate level (p < 0 .05), were included as predictors of obesity in separate logistic regression analyses. In each regression analysis, we also adjusted for baseline BMI, and for confounding variables of hepatitis, hypoalbuminemia (albumin less than 38 grams per litre), proteinuria and prednisone dose. We conducted a complete case analysis, and all analyses were performed using SPSS v.26 (IBM Corp., Armonk, NY, USA), and p-values < 0 .05 were considered statistically significant. Results Seventy-four charts were reviewed, and 72 patients met criteria for analysis. The median prednisone dose was 35 mg per day (IQR 20 to 60 mg), and median duration of therapy was 302 days (IQR 126.75 to 581.25). Thirty-five (48.6%) patients developed obesity, 33 (45.8%) hypertension, five (7.0%) osteopenia, and three (4.2%) osteoporosis. Greater BMI at baseline was associated with greater total weight gain (OR 4.04, 95% CI = [1.98-8.33], p < 0 .001). Conclusion Greater baseline patient BMI may be a predictor of weight gain on high-dose prednisone therapy in children with rheumatic disease requiring high-dose therapy. Further work is required to determine methods for individualized prednisone dosing and counseling and behavioral interventions to mitigate risk for weight gain.

Low-Dose Prednisone Therapy is Efficacious in Treating Painful Subacute Thyroiditis

Subacute thyroiditis (SAT) usually presents with neck pain, radiating to ears and is often associated with hyperthyroidism. Currently the available treatment involves administration of NSAID or in more symptomatic patients prednisone 40mg daily tapered over 6 weeks or longer. We report successful treatment of 3 patients (Pts) with SAT with low-dose prednisone therapy (20mg/day) (LDP20) initially and tapered over 4 weeks. Patient 1: A 32-year-old female presented with severe neck pain radiating to both ears and low- grade fever of 2-weeks duration. Two weeks prior, patient had cold-like symptoms lasting for 3 days. Physical examination: HR 110bpm, tremors of fingers noted, tenderness of the anterior neck present, thyroid 30-gms in size. Labs: ESR 92 mm/hr, CRP 3.2 mg/dL, TSH <0.005 uIU/mL, free T4 2.71 ng/dL, total T3 168 ng/mL. Thyroid scan and uptake showed a 24-hrs uptake <1%, thyroid gland not visualized, consistent with SAT. Patient was treated with atenolol and LDP20 tapered over 4 weeks. Pain significantly improved after 2 days of treatment. Six weeks later TSH was 0.9 uIU/mL with a free T4 1.4 ng/dL and ESR 8 mm/hr. Patient 2: A 19-year-old female presented with left-ear pain, anterior neck pain, fever, and extreme fatigue. PE: HR 111bpm, heat shield present, tender-to-palpation thyroid, brisk DTR. Lab: CBC normal, ESR 98 mm/hr, CRP 9.9 mg/dL, TSH <0.01 uIU/mL, free T4 3.8 ng/dL, total T3 210 ng/mL. Thyroid scan and uptake: uptake <1%, no thyroid gland visualized and SAT was diagnosed. Patient was started on LDP20 and atenolol. Four days following prednisone therapy her symptoms completely resolved and prednisone was tapered off over 4 weeks. Thyroid functions were normal by the seventh week. Patient 3: A 38-year-old male presented with fever, fatigue, severe neck pain, palpitation and a weight loss of 8 pounds. PE: HR 120 bpm, thyroid severely tender on palpation, brisk DTR. Lab: normal CBC, ESR 128 mm/hr, CRP 11.9 mg/dL, TSH <0.001 uIU/mL, free T4 4.2 ng/dL, total T3 201 ng/mL. Thyroid scan: thyroid gland not visualized and uptake was < 1%. SAT was diagnosed and patient was treated with propranolol and LDP20. After 5 days the dose of prednisone was reduced to 15mg/day and the prednisone was tapered over five weeks. Patient had resolution of symptoms in 70 hours and remained asymptomatic for the next 12 months of follow-up. Thyroid function normalized by the eighth week. Conclusion: SAT is a painful disabling thyroid disorder apparently caused by a viral infection; and NSAID or high-dose steroid treatment remains the standard of care. We have treated 3 Pts with relatively lower doses of prednisone than previously recommended and attained remission successfully. Thus side effects can be avoided with lower prednisone dose.

Insulin Autoimmune Syndrome After Exposure to Clopidogrel: A Case Report

Background: Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia that is characterized by hyperinsulinemia, hypoglycemia, and a high autoantibody titer. About 50% of patients with IAS have taken a medication containing sulfhydryl (-SH) groups. We present a case of IAS that developed after taking clopidogrel, a drug with an active metabolite that contains an SH-group. Case report: IAS was suspected in a 63-year-old Chinese man because of high concentrations of insulin and C-peptide during hypoglycemic episodes, and positivity for anti-insulin autoantibody (IAA). During his first episode of hypoglycemia, no trigger medication was identified and prednisone therapy was effective. However, imaging examination revealed a colonic carcinoma and the patient was discharged to undergo surgery. He had no episodes of hypoglycemia for 10 weeks after discontinuation of the prednisone, but then hypoglycemia recurred. A review of his medication revealed that he had taken a 10-day course of clopidogrel just before the recurrence. Therefore, a specialized multidisciplinary team consisting of endocrinologists, dieticians, and clinical pharmacists took charge of his management. Prednisone therapy was restarted and tapered off over 16 weeks. The patient also consumed small, frequent, low-carbohydrate meals and was instructed to avoid trigger medications. No further episodes of hypoglycemia were detected. His insulin and C-peptide concentrations and his anti-IAA index normalized during the follow-up period. Conclusion: SH-group-containing drugs might induce or exacerbate hypoglycemia in patients with a history of IAS. Furthermore, patients with IAS can benefit from multidisciplinary team management. We suggest herein an evaluation process for patients suspected of IAS.

Treatment with Intravenous Methylprednisolone in Patients with Graves’ Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

SUN-201 Adrenal Insufficiency After Treatment for Vaping Associated Pulmonary Injury

Background: In 2019 a record number of patients were admitted to our children’s hospital with e-cigarette or vaping-associated lung injury (EVALI). The majority of patients were treated with high-dose prednisone therapy including 3 days of 1000 mg daily followed by a 4 week wean. Because of the concern for iatrogenic adrenal insufficiency, all patients were then placed on a 3-4 weak hydrocortisone taper followed by ACTH stimulation testing. The purpose of this study is to document the incidence of iatrogenic adrenal insufficiency following a 2 months glucocorticoid wean. Methods: All patients seen by the Pulmonary team for EVALI who also received high dose prednisone therapy were referred to Pediatric Endocrinology for ACTH testing. A low dose (1 mcg) ACTH stimulation test was performed with cortisol measurements at baseline, 30 minutes, and 60 minutes. A passing result was any cortisol over 18 ug/dl. Results: An anticipated 20-25 patients will have had ACTH stimulation testing by the time of abstract presentation. Of those that have already completed testing, three of four patients failed the first time. Discussion: High-dose prednisone therapy for EVALI is associated with significant rates of iatrogenic adrenal insufficiency, even after slow hydrocortisone wean. Structures need to be implemented to teach patients about adrenal insufficiency prior to hospital discharge and organize adequate post-discharge follow-up until HPA function returns.