Prednisolone withdrawal

The interaction of ciclosporin with mycophenolate mofetil was investigated in 52 renal transplant patients taking triple therapy (ciclosporin, mycophenolate mofetil, and prednisone), who continued taking the same treatment (n = 19) or underwent elective ciclosporin withdrawal (n = 19) or prednisolone withdrawal (n = 14) 6 months after transplantation (275). Median mycophenolate mofetil trough concentrations 3 months later were about two-fold higher in patients who had discontinued ciclosporin compared with patients who continued to take triple therapy and patients who had discontinued prednisone. No clear mechanism readily explains these changes. 

Krogsgaard K, Marcellin P, Trepo C, Berthelot P, Sanchez-Tapias JM, Bassendine M, Tran A, Ouzan D, Ring-Larsen H, Lindberg J, Enriquez J, Benhamou JP, Bindslev N. Prednisolone withdrawal therapy enhances the effect of human lymphoblastoid interferon in chronic hepatitis B. INTERPRED Trial Group. J Hepatol 1996 25(6) 803-13. 

Krogsgaard K, Marcellin P, Trepo C, et al. Prednisolone withdrawal ther- 77. 

Anorexia nervosa has been precipitated by withdrawal of oral prednisolone for asthma (SEDA-21, 414 356). 

Prednisolone - The stress of surgery causes an increase in plasma adrenocorticotrophic hormone and cortisol concentrations. Cortisol secretion can rise from 30 mg/day to 50 mg/day following minor surgery and 150 mg/day following major surgery. However, an abrupt withdrawal after a prolonged period may lead to acute adrenal insufficiency, hypotension or shock. Thus it is important to continue SC s corticosteroid therapy and additional intravenous hydrocortisone may be administered peri-operatively. 

A 68-year-old man, who had been taking lorazepam, perphenazine, and amitriptyline for many years, developed acute thrombocytopenic purpura after combination therapy of chlordiazepoxide 5 mg and clidinium 2.5 mg tds for irritable bowel syndrome (2). His disease improved after withdrawal of chlordiazepoxide and clidinium and treatment with intravenous prednisolone. 

An alternative scheme is to try halving the dose weekly until 25 mg prednisolone or equivalent is reached, after which it may be reduced by about 1 mg every third to seventh day. Paediatric tablets (1 mg) can be useful during withdrawal. 

A 34-year-old woman with colitis developed pancreatitis 1 week after starting mesalazine 1 g tds she recovered after drug withdrawal (70). She was admitted 15 months later with a relapse of colitis and was given oral prednisolone 50 mg/day and mesalazine enemas (2 g bd). Although the colitis regressed, 10 days later she again developed acute pancreatitis. She recovered 3 days after prednisolone and mesalazine enemas were withdrawn. Symptoms of pancreatitis did not recur when prednisolone was restarted. 

A 59-year-old man, who had taken amiodarone 200 mg/day for 2 years, developed fever, pleuritic chest pain, dyspnea at rest, a non-productive cough, malaise, and joint pains (211). He had a verrucous endocarditis and a pleuropericardial effusion. He had raised titers of antinuclear antibodies (1 320) with anti-Ro specificity. Serum complement was normal and there were no circulating immune complexes, no cryoglobulins, and no anti-dsDNA, anti-La, anti-Ul ribonucleoprotein, anti-Sm, anti-Scl, 70, anti-Jo 1, antihistone, antiphosphohpid, anticentromere, anticardioli-pin, or anticytoplasmic antibodies. Within 7 days of withdrawal of amiodarone the signs and symptoms started to resolve, and he recovered fuUy with the addition of prednisolone. 

Over a year after renal transplantation, a 48-year-old man, who took azathioprine, ciclosporin, and prednisolone, developed acute necrotizing pancreatitis (38). Improvement was obtained after azathioprine withdrawal, but he again took azathioprine and had similar symptoms within 30 hours after a single dose. 

A 62-year-old woman, who had applied DoloPosterine N ointment topically to the perianal skin and rectal mucosa for several days, developed erythematous vesicular lesions in the perianal area and an erythematous edematous rash of the face, axillae, elbow flexures, and inner thighs (7). This abated on withdrawal of the drug and the administration of oral prednisolone for 10 days. Patch testing was positive with cinchocaine. 

After a kidney transplant for end-stage renal insnffi-ciency a 58-year-old man was given ciclosporin, azathioprine, and prednisolone (29). Fonr years later he started to take St. John s wort (300 mg bd) for depression, and 2 weeks later his previonsly stable ciclosporin concentrations had halved. Withdrawal of the St. John s wort resnlted in normalization of his ciclosporin concentrations. 

The incomplete resolution of anemia in this case suggests that factors other than the speculated enalapril-related inhibition of erythropoietin may have contributed to the initial anemia (worsening renal function, frequent blood sampling, withdrawal of prednisolone). 

Two patients, one of whom also received ribavirin, had facial nerve palsy after 5 and 8 months of interferon alfa therapy (59). The palsy resolved completely in one patient after withdrawal and the administration of prednisolone however, in the other case, the palsy resolved without drug withdrawal, suggesting coincidence. 

X 10 / , with 40% eosinophils on bone marrow aspiration and a markedly high IgE concentration. Radiological examination showed diffuse jejunal and ileal wall thickening and gross ascites with numerous eosinophils. Complete resolution was obtained after interferon alfa withdrawal and prednisolone treatment. There was no recurrence after prednisolone was withdrawn. 

A 64-year-old man with no history of allergy had progressive fatigue, loss of appetite, and facial edema after 6 months of interferon alfa-2b treatment for chronic hepatitis C (319). Angioedema was diagnosed and it resolved after withdrawal of interferon alfa and a short course of prednisolone. Serum immunoglobuhn E and plasma bradykinin concentrations were raised, but the Cl esterase inhibitor and serum complement concentrations were normal. 

A 50-year-old woman was given interferon alfa for chronic hepatitis C and primary biliary cirrhosis, and within 2 months became febrile and developed a diffuse nodular erythematous rash. The skin biopsy showed typical features of necrotizing angiitis, and cutaneous periarteritis nodosa was diagnosed. Full recovery was obtained after interferon alfa withdrawal and prednisolone treatment. 

Liver damage due to lidocaine has rarely been reported. However, severe liver damage has been reported shortly after the withdrawal of mexiletine 300 mg/day and the introduction of lidocaine 1000 mg/day, although lidocaine in the same dose had been used during the previous week (40). The lidocaine was withdrawn and the liver enzymes normalized after treatment with prednisolone. 

A 62-year-old woman with severe asthma took oral pranlukast 450 mg/day and oral prednisolone 80 mg/day for a severe asthmatic attack. After oral prednisolone was tapered and subsequently withdrawn by day 35, she was maintained on pranlukast only and 5 days later had fever, deteriorating pulmonary symptoms, hypoxemia, and bibasal reticulonodular pulmonary infiltrates on chest CT. A transbronchial biopsy was consistent with drug-related interstitial pneumonitis. A lymphocyte stimulation test was positive for pranlukast. Her fever abated and her pulmonary symptoms markedly improved 3 days after withdrawal of pranlukast, and 5 months later the pulmonary infiltrates had completely resolved. 

A 26-year-old asthmatic woman had severe acute necrotizing eosinophilic endomyocarditis while taking pranlukast, inhaled beclomethasone, and oral theophylline (4). Oral prednisolone had been replaced by pranlukast 9 months before the event. Cardiac injury was accompanied by peripheral eosinophilia, cardiogenic shock, and pulmonary infiltrates, suggesting atypical Churg-Strauss syndrome. She recovered after intensive treatment, steroid pulse therapy, and withdrawal of pranlukast. 

A 51-year-old woman developed erythema and swelling on sun-exposed areas and complained of a local burning sensation and pruritus 10 days after she started to take rilmenidine 1 mg/day for mild hypertension. She recovered fully 1 week after rilmenidine withdrawal and treatment with prednisolone. The chronology and the results of patch and photopatch tests suggested a phototoxic reaction to rilmenidine. 

Vasculitic rashes have been described rarely. Two case reports have suggested that there may be cross-reactivity between vancomycin and teicoplanin with respect to biopsy-proven leukocytoclastic vasculitis (91). In both cases, vancomycin-induced vasculitis improved after drug withdrawal. Teicoplanin was started and the rash reappeared several days later. In one case the rash faded after teicoplanin had been withdrawn. In the other, teicoplanin was continued, but the rash improved after prednisolone was given. 

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