Mirtazapine Is Effective in Steroid Withdrawal Syndrome Related Depression: A Case Report

Steroid withdrawal syndrome (SWS) following steroid dependence is becoming a common clinical condition. It may be associated with body image disorder. Though selective serotonin reuptake inhibitors (SSRIs) are found to be effective SWS associated depression, data for this clinical condition is limited. We present a case of SWS associated with body image disorder which improved with mirtazapine. Mirtazapine might be better option than SSRIs in this subgroup of patients for its noradrenergic property and better gastrointestinal profile. More research should explore its efficacy in this clinical condition.

Prospective Controlled Protocol for Three Months Steroid Withdrawal with Tacrolimus, Basiliximab, and Mycophenolate Mofetil in Renal Transplant Recipients

During the past few years, new immunosuppressants, such as tacrolimus, mycophenolate mofetil (MMF) and basiliximab, have been shown to successfully decrease the incidence of acute rejection, possibly acting as potent substrates for safe steroid withdrawal. Therefore, clinical outcome of 3 months steroid withdrawal, while using the above immunosuppressants, was analyzed. Clinical trial registry No. was NCT 01550445. Thirty de novo renal transplant recipients were enrolled, and prednisolone was slowly withdrawn 3 months post-transplantation by 2.5 mg at every two weeks, until 8 weeks. During steroid withdrawal, 10 patients (30.0%) discontinued the protocol and they were maintained on steroid treatment. Among 20 steroid free patients, 8 patients (40.0%) re-started the steroid within 12 months post-transplantation. By the study endpoint, 12 (40%) recipients did not take steroid and survival of patients and grafts was 100%. In conclusion, in kidney transplant patients, 3 months steroid withdrawal while taking tacrolimus, basiliximab and mycophenolate mofetil was not associated with increased mortality or graft loss. Despite various causes of failure of steroid withdrawal during the follow-up period, it is a strategy well advised for kidney transplant recipients with regard to long-term steroid-related complications.

Prospective Controlled Protocol for Three Months Steroid Withdrawal with Tacrolimus, Basiliximab, and Mycophenolate Mofetil in Renal Transplant Recipients

During the past few years, new immunosuppressants, such as tacrolimus, mycophenolate mofetil (MMF) and basiliximab, have been shown to successfully decrease the incidence of acute rejection, possibly acting as potent substrates for safe steroid withdrawal. Therefore, clinical outcome of 3 months steroid withdrawal, while using the above immunosuppressants, was analyzed. Clinical trial registry No. was NCT 01550445. Thirty de novo renal transplant recipients were enrolled, and prednisolone was slowly withdrawn 3 months post-transplantation by 2.5 mg at every two weeks, until 8 weeks. During steroid withdrawal, 10 patients (30.0%) discontinued the protocol and they were maintained on steroid treatment. Among 20 steroid free patients, 8 patients (40.0%) re-started the steroid within 12 months post-transplantation. By the study endpoint, 12 (40%) recipients did not take steroid and survival of patients and grafts was 100%. In conclusion, in kidney transplant patients, 3 months steroid withdrawal while taking tacrolimus, basiliximab and mycophenolate mofetil was not associated with increased mortality or graft loss. Despite various causes of failure of steroid withdrawal during the follow-up period, it is a strategy well advised for kidney transplant recipients with regard to long-term steroid-related complications.

Retirada da corticoterapia: recomendações para a prática clínica: [revisão] / Withdrawal from glucocorticosteroid therapy: clinical practice recommendations: [review]

OBJETIVO: Apresentar uma revisão atualizada e prática sobre como efetuar de forma segura a retirada da corticoterapia. FONTES DOS DADOS: Revisão da literatura utilizando os bancos de dados MEDLINE e LILACS (1997-2007), selecionando os artigos mais atuais e representativos do tema. SÍNTESE DOS DADOS: Três situações clínicas podem ocorrer durante a retirada da corticoterapia prolongada: insuficiência adrenal secundária à supressão do eixo hipotálamo-hipófise-adrenal, síndrome de retirada ou deprivação dos corticóides e reativação da doença de base. Embora não exista consenso sobre o melhor esquema para descontinuar a terapia prolongada com corticóides, existe concordância quanto ao fato desta retirada ser gradual. Este artigo atualiza o pediatra quanto ao reconhecimento desses problemas e fornece orientações para a suspensão do tratamento prolongado com corticóide. Uma breve revisão da farmacologia dos corticóides também é descrita. CONCLUSÃO: Não existe teste com bom valor preditivo para antecipar o risco de insuficiência adrenal nos pacientes que receberam terapia crônica com corticóide. São necessários estudos prospectivos para avaliar a real incidência desse problema e assim propor estratégias racionais para sua prevenção. No momento, a menos que a integridade do eixo hipotálamo-hipófise-adrenal esteja estabelecida por testes dinâmicos, recomenda-se a administração de corticóide em situações de estresse nos pacientes que fizeram uso de corticoterapia crônica e/ou em doses elevadas.

OBJECTIVE: To present an up-to-date and practical review of how to safely withdraw glucocorticosteroid therapy. SOURCES: A review of the published literature identified by searching the MEDLINE and LILACS databases (1997-2007), selecting the most representative articles on the subject. SUMMARY OF THE FINDINGS: Three clinical situations may occur during glucocorticoid withdrawal: adrenal insufficiency secondary to negative feedback on the hypothalamic-pituitary adrenal (HPA) axis, steroid withdrawal syndrome and relapse of the disease for which the glucocorticoids were prescribed. Although there is no consensus on how to best discontinue prolonged glucocorticosteroid therapy, there is agreement that this withdrawal should be gradual. This article updates pediatricians on how to recognize these problems and provides recommendations on how to safely suspend glucocorticosteroid therapy. A brief review of the pharmacology of glucocorticoids is also presented. CONCLUSION: There is no good predictive test for predicting the risk of adrenal insufficiency in patients who have been on corticosteroid therapy chronically. There is a need for prospective studies to assess the true incidence of this problem and to propose rational strategies for preventing it. The current recommendation is that patients who have been on chronic and/or high dose glucocorticoids should be administered glucocorticoids during stress situations unless the integrity of the HPA axis has been established by dynamic tests.

Steroid Withdrawal in Renal Transplantation / 대한이식학회지

Steroid is a critical component of immunosuppressive regimen. Unfortunately, steroid is associated with numerous adverse effects including diabetes, hypertension, hyperlipidemia, osteoporosis, sodium retention, and avascular necrosis. These adverse effects have prompted trials of steroid withdrawal with introduction of potent immunosuppressive agents in renal transplantation. Although late steroid withdrawal raised acute rejection rate compared with early steroid withdrawal, results of recent trials that used diverse steroid withdrawal protocols suggest good short and long term graft outcomes. But, in patients survival, patients with steroid withdrawal is similar to patients administered steroid. This review summarizes usefulness according to timing of steroid withdrawal and re-exams benefits of steroid withdrawal in renal transplantation.

Randomized Trial of Tacrolimus Versus Cyclosporine in Steroid Withdrawal in Living Donor Renal Transplant Recipients / 대한신장학회잡지

BACKGROUND: The introduction of new immunosuppressants has prompted several trials of steroid withdrawal immunosuppression. However, several groups have reported a higher incidence of rejection. METHODS: We conducted a randomized two-arm, parallel group, open label, prospective study to compare steroid withdrawal (at 6 months post-transplant) regimens: tacrolimus+mycophenolate mofetil (MMF) (FK group) vs cyclosporine+MMF (CyA group). Entry criteria were: first living donor transplant recipient, no diabetes mellitus (DM), no congestive heart failure, no chronic liver disease, and no acute rejection by 6 months post-transplant. The primary endpoint was a biopsy-proven acute rejection episode or treatment failure within 1 year post- transplant. RESULTS: While eighty-seven recipients were assigned to FK (n=43) and CyA group (n=44) before transplantation, seventy-six recipients (FK 39, CyA 37) could taper off steroid at 6 months post-transplant since eleven were excluded due to acute rejection within 6 months post-transplant (FK 2, CyA 3), protocol violation (FK 2, CyA 1), drug change due to side effect (CyA 2) and follow-up loss (CyA 1). After steroid withdrawal, acute rejection episode was 0% in FK group and 13.5% in CyA group (p0.05 in every variable). CONCLUSION: These data suggest that steroid withdrawal are successful in first living donor renal transplant recipients and tacrolimus may be more effective than cyclosporine significantly in preventing acute rejection after steroid withdrawal.

Steroid Withdrawal(SW) with Simultaneous Administration of Mycophenolate Mofetil(MMF) in Renal Recipients / 대한신장학회잡지

Long term use of steroid induces multiple side effects and morbidity. However, SW has been reported to be associated with increased incidence of acute and chronic rejection, and subsequently reduced graft outcome. MMF inhibits the proliferation and functions of lymphocytes, decreases the incidence of acute rejection in organ transplants, and therefore may decrease the graft rejection associated with SW. We tried to withdraw steroid from 21 renal transplants treated with prednisolone and cyclosporine, who had clinically significant steroid induced side effects. Reasons for SW were diabetes in 15 patients (pre-transplant DM 4 and post-transplant 11), moon face 4 and avascular necrosis of femur 2. Prednisolone was tapered at a rate of 2.5mg every 2 weeks and was discontinued. MMF, 1.0-2.0g/day, was initiated at the beginning of SW. The time interval between transplantation and SW was 26+/-5 (1.5-67) months. Mean age was 48(28-61). Two patients developed MMF-induced GI side effects, and were returned to previous immuno- suppressants. In 1 patient, serum creatinine increased during SW, and steroid was re-administered with the restoration of renal function. In 18(86%) of 21 patients, therefore, steroid was successfully with-drawn. At the follow up of 17+/-1(13-24) months after SW, 1 patient with drug incompliance developed chronic rejection. The rest showed stable renal function. Steroid can be safely withdrawn from renal transplants by simultaneous administration of MMF. The long-term safety, however, needs to be evaluated by prolonged follow up studies.