Alternate-day therapy with

Nephrotic syndrome. Patients with minimal change disease respond well to daily or alternate day therapy. With a total of prednisolone 60 mg/d, 90% of those who will lose their proteinuria will have done so within 4-6 weeks, and the dose is tapered off over 3-4 months. Longer courses only induce adverse effects. Relapses are common (50%) and it is then necessary to find a minimum dose of steroid that will keep the patient well. If a steroid is for any reason undesirable, cyclophosphamide or chlorambucil may be substituted. Membranous nephropathy may respond to high dose corticosteroid with or without chlorambucil. 

What is the advantage of alternate-day therapy with corticosteroids Which steroids are unsuitable for alternate-day therapy ... 

Oral corticosteroids may be required in asthmatics not adequately controlled with bronchodilators, cromolyn and/or beclomethasone therapy. When indicated, alternate-day therapy with a prednisone-like steroid should be used. Reduction of either the oral or inhaled corticosteroid dose should be frequently attempted. Although less frequent with alternate-day dosing, monitoring for the undesirable effects of oral corticosteroids should be routine. 

Daily oral doses are generally given before 9 00 am to minimize adrenal suppression and to coincide with normal adrenal function. However, alternate-day therapy may be prescribed for patients receiving long-term therapy (see below). Fludrocortisone is given orally and is well tolerated in the GI tract. 

Betamethasone is hardly ever used orally. It has a long duration of activity and can therefore also be used for alternate-day therapy. The parenteral formulation is also the sodium phosphate salt which when given IV or IM has a rapid onset of action. There are many similarities with dexamethasone such as their metabolic pathways and the indications for which both steroids are used, like the prevention of neonatal RDS and reduction of raised intracranial pressure. Combinations of betamethasone acetate and sodium phosphate have, when used for intra-articular and intra-lesional injections, the dual advantage of a rapid onset of action together with the long duration of action of a depot preparation. 

Blair GP, Light RW. Treatment of chronic obstructive pulmonary disease with corticosteroids. Comparison of daily vs alternate-day therapy. Chest 1984 86(4) 524-8. 

Alternate-day therapy can prove useful for such conditions as chronic uveitis that require long-term systemic administration. This approach has also been advocated for treatment of chronic conditions in children because it minimizes growth suppression.The alternate-day regimen has not been widely accepted, and modifications have been suggested. Clinical experience also indicates that this treatment method is not as effective as divided daily doses, particularly in severe ocular inflammatory conditions. Adrenal gland suppression and other side effects associated with systemic therapy can still occur with the alternate-day regimen. 

Most patients show improvement with corticosteroids. Steroids may be of optimum benefit when added to another therapeutic regimen such as anticholinesterase therapy or immunosuppressants such as azathioprine. Moderate-dose daily prednisone for 4 to 6 weeks, followed by low-dose alternate-day therapy as needed, has been foimd to improve ocular motility and decrease the development of generalized myasthenia. Steroid therapy must be used cautiously in these patients because of the worrisome character and incidence of unwanted effects of these drugs. It is possible for patients to develop immunosuppression such that tapering of... 

If oral corticosteroids must be used, alternate-day therapy is preferred because it interferes less with normal growth in children. The answer is (D). 

For the long-term treatment of polymyositis with single-dose alternative-day prednisolone therapy, previous studies reported no difference in the efficacies of high-dose alternate-day therapy (ADT) and daily-dose therapy (DDT) with prednisolone in myositis patients, and also that the incidence of side effects was lower in the former. Currently, a newer study compares tixe long-term outcomes of both treatments [bl ]. 

In patients without contraindications, spironolactone is initiated at a dose of 12.5 to 25 mg daily, or occasionally on alternate days for patients with baseline renal insufficiency. Eplerenone is used at a dose of 25 mg daily, with the option to titrate up to 50 mg daily. Doses should be halved or switched to alternate-day dosing if creatinine clearance falls below 50 mL/minute. Potassium supplementation is often decreased or stopped after aldosterone antagonists are initiated, and patients should be counseled to avoid high-potassium foods. At anytime after initiation of therapy, if potassium concentrations exceed... 

Most patients require standard doses to prevent relapses. H2RAs may be an effective maintenance therapy in patients with mild disease. The PPIs are the drugs of choice for maintenance treatment of moderate to severe esophagitis. Usual once-daily doses are omeprazole 20 mg, lansoprazole 30 mg, rabeprazole 20 mg, or esomeprazole 20 mg. Lower doses of a PPI or alternate-day regimens may be effective in some patients with less severe disease. 

The combination of amphotericin B with flucytosine for 6 weeks is often used for treatment of cryptococcal meningitis. An alternative is amphotericin B for 2 weeks followed by fluconazole for an additional 8 to 10 weeks. Suppressive therapy with fluconazole 200 mg/day for 6 to 12 months is optional. 

Addisonian pernicious anemia - Parenteral therapy is required for life oral therapy is not dependable. Administer 100 meg daily for 6 or 7 days by IM or deep subcutaneous injection. If there is clinical improvement and a reticulocyte response, give the same amount on alternate days for 7 doses, then every 3 to 4 days for another 2 to 3 weeks. By this time, hematologic values should have become normal. Follow this regimen with 100 meg monthly for life. Administer folic acid concomitantly if needed. 

Edema - Initiate therapy with 50 to 100 mg Thalitone, 30 to 60 mg) daily, or 100 mg Thalitone, 60 mg) on alternate days. Some patients may require 150 or 200 mg Thalitone, 90 to 120 mg) at these intervals, or 120 mg Thalitone daily. However, dosages above this level do not usually create a greater response. 

Broad spectrum therapy is started on an empirical basis. Intra-abdominal infections can be treated by ampicillin (or amoxycillin) or clindamycin combined with aminoglycosides, penicillin-beta-lacta-mase inhibitors such as amoxycillin-clavulanic acid or a second or third generation cephalosporin combined with metronidazole are good alternatives. In patients with impaired immunity and/or prior use of antibiotics, i.e. when it is reasonable to expect resistant pathogens, a broad spectrum penicillin plus beta-lactamase inhibitor or a carbapenem can be used empirically in monotherapy. In septic patients, the rapidly bactericidal action of aminoglycosides is useful. Aminoglycosides should preferentially not be given for more than 3-5 days. 

Parenteral ganciclovir 5 mg/kg i.v. 12-hourly for 14-21 days arrests retinochoroiditis and enteritis caused by CMV in HIV-infected patients. Maintenance therapy with ganciclovir 10 mg/kg i.v. 3 times weekly should be given to prevent relapse of retinitis. Alternative therapy with intravenous foscarnet can be used if necessary. 

The treatment of choice for extraintestinal infections is metronidazole plus a luminal amebicide. A 10-day course of metronidazole cures over 95% of uncomplicated liver abscesses. For unusual cases in which initial therapy with metronidazole has failed, aspiration of the abscess and the addition of chloroquine to a repeat course of metronidazole should be considered. Dehydroemetine and emetine are toxic alternative drugs. 

Pentamidine is an alternative to sodium stibogluconate in the treatment of visceral leishmaniasis, with similar efficacy, although resistance has been reported. The drug has been successful in some cases that have failed therapy with antimonials. The dosage is 2-4 mg/kg intramuscularly daily or every other day for up to 15 doses, and a second course may be necessary. Pentamidine has also shown success against cutaneous leishmaniasis, but it is not routinely used for this purpose. 

Fluconazole is well absorbed following oral administration, with a plasma half-life of 30 hours. In view of this long half-life, daily doses of 100 mg are sufficient to treat mucocutaneous candidiasis alternate-day doses are sufficient for dermatophyte infections. The plasma half-life of itraconazole is similar to that of fluconazole, and detectable therapeutic concentrations remain in the stratum corneum for up to 28 days following termination of therapy. Itraconazole is effective for the treatment of onychomycosis in a dosage of 200 mg daily taken with food to ensure maximum absorption for 3 consecutive months. Recent reports of heart failure in patients receiving itraconazole for onychomycosis have resulted in recommendations that it not be given for treatment of onychomycosis in patients with ventricular dysfunction. 

---