短期大剂量糖皮质激素致皮肤副作用2例

糖皮质激素类药物主要用于抗炎、抗病毒、抗休克和免疫抑制治疗,在临床各科多种疾病的诊治上应用广泛,但是临床上不合理的应用非常突出。长期大剂量应用糖皮质激素类药物所致副反应普遍而严重,已引起医务人员的重视。但短期大剂量使用糖皮质激素类药物亦可引起严重副作用,容易被临床医护人员忽视。现我们报道两例短期大剂量使用糖皮质激素所致严重皮肤副反应病例,希望医护人员能从中吸     

雷公藤多苷联合小剂量泼尼松治疗肾病综合征临床观察

肾病综合征发病率近年来有所提高，对于原发性肾病综合征传统的治疗方案是糖皮质激素治疗。我国多采用泼尼松中长程疗法，激素使用时间长，可以出现很多不良反应；长期使用泼尼松可抑制下丘脑-垂体-肾上腺轴（HPA轴），诱发或加重感染、胃溃疡、出血、高血压动脉粥样硬化、骨质疏松等。由于大剂量长期服用糖皮质激素泼尼松副作用大，尤其对于老年患者，常有动脉硬化、高血压、冠心病等。治疗上如采用大剂量肾上腺糖皮质激素或细胞毒药物，对老年人的危害性很大，常可产生严重不良反应，不易为患者所接受，雷公藤多苷作为治疗肾小球肾炎的有效药物，临床已有十余年历史。我院近12年来以雷公藤多苷联合小剂量泼尼松治疗肾病综合征，与单纯应用糖皮质激素泼尼松治疗进行对比，副作用远比单纯使用糖皮质激素要小，结果如下。     

糖皮质激素性骨质疏松症的研究进展

糖皮质激素应用范围广泛且往往长期使用,它的主要副作用就是导致骨质疏松症并增加骨折风险.并非大剂量应用糖皮质激素才会导致骨质疏松.老年人及开始糖皮质激素治疗之前即存在骨矿密度低的患者,骨量丢失更加明显,更易导致骨折的发生.除了应用糖皮质激素以外,还有很多因素会导致骨量丢失,如:基础疾病、营养不良、维生素D缺乏、性腺发育不全及低体重等.本综述说明了糖皮质激素性骨质疏松症的发病率、高危人群、发病机制以及如何对其进行预防和治疗.目前预防糖皮质激素性骨质疏松症主要依赖于钙剂和维生素D的补充,充足的蛋白质摄取,定期的体育锻炼.一些新的治疗方法 如双膦酸盐和甲状旁腺素的应用给糖皮质激素性骨质疏松症的治疗带来了希望.尽管我们的治疗和预防策略已有长足进步,我们还需要对它进行进一步的补充.     

41例老年原发性肾病综合征的治疗探讨

原发性肾病综合征的治疗目前仍以大剂量糖皮质激素诱导治疗为主 ,除部分病理类型如膜性病变、膜增生性病变外 ,多能取得满意的临床疗效。但同时却又出现较多的激素相关副作用 ,如高血糖、骨质疏松等 ,且副作用与其用量相关。而这些副作用在老年肾病综合征患者则表现得尤为突出 ,有时往往成为激素治疗的障碍。为此 ,我们通过采取中等剂量激素结合雷公藤多甙治疗老年原发性肾病综合征 ,取得了一定的成效 ,兹报道如下。资料与方法1　一般资料　收集我科 1990年～ 2 0 0 0年住院的老年原发性肾病综合征患者 4 1例。排除各种继发性肾病综合征如糖…     

地黄丸类方在肾病综合征激素治疗不同阶段的运用

原发性肾病综合征(PNS)以大量蛋白尿和低蛋白血症为主要临床特点,西医主要是采用糖皮质激素及免疫抑制剂治疗,但仅用西药治疗常常出现很多副作用并且肾病复发率较高,笔者多年来选用地黄丸类方联合糖皮质激素治疗肾病综合征,取得了加快病情缓解、减少激素副作用、防止疾病复发等疗效。现介绍如下。     

联合护理对糖皮质激素冲击治疗药疹并发症的影响

目的:讨论大剂量糖皮质激素冲击治疗重症药疹时联合多种护理措施对其副作用及并发症的影响.方法:回顾性地分析2007～2009年间在我科接受糖皮质激素冲击治疗68例重症药疹患者的临床资料,分别对常规护理及联合护理病例进行归纳总结.结果:在治疗3周后,联合护理组出现:肌无力10例,睡眠精神障碍18例,低血钾3例,消化道溃疡1例.常规护理组出现肌无力16例,睡眠精神障碍25例,低血钾6例,消化道溃疡3例.结论:多种措施联合护理方法可以减少药疹患者大剂量糖皮质激素冲击治疗后肌无力、睡眠精神障碍、低血钾、消化道溃疡的发生率.     

淫羊藿及其复方制剂治疗糖皮质激素性骨质疏松症的 研究进展

淫羊藿具有补肾壮阳、祛风除湿和强筋健骨的功效,主治腰酸腿痛、四肢拘挛、筋骨痿软等症。古人常用淫羊藿医治骨痿、骨痹、腰痛等疾病。现代医学也常将淫羊藿作为治疗各种类型骨质疏松症的中药之一。糖皮质激素常被用于治疗各种炎症、风湿及免疫相关疾病,随着临床医疗的普遍应用,其副作用也日益凸显,其中最严重的副作用之一就是会导致骨质疏松,即糖皮质激素性骨质疏松症。糖皮质激素性骨质疏松症是最常见的继发性骨质疏松症之一,仅居于老年性骨质疏松症和绝经后骨质疏松症之后,位于第三位。近年来对淫羊藿治疗骨质疏松症方面的研究日渐增多,大量医学研究表明淫羊藿在糖皮质激素性骨质疏松症的医治方面具有广阔的发展空间。本文通过查阅国内外相关文献,对目前淫羊藿治疗糖皮质激素性骨质疏松症作一文献综述,旨在为临床研究及实验研究奠定理论基础。     

不同剂量糖皮质激素预防患者冠状动脉旁路移植术后并发症的效果:meta分析

目的 采用meta分析评价不同剂量糖皮质激素预防患者冠状动脉旁路移植术后并发症的效果.方法 检索PubMed、EMbase、Highwire、CENTREN及其下属各临床注册试验数据中心、中国生物医学文献数据库和中国期刊全文数据库,检索时间限定2000年至2010年.收集冠状动脉旁路移植术患者给予不同剂量糖皮质激素预防术后并发症的随机对照研究.采用Cochrane协作网系统评价文献质量,并分析有关资料,主要包括术后房颤的发生情况、术后因高血糖需胰岛素治疗的情况、术后感染发生情况、术后死亡情况(住院期间或出院30 d内)和机械通气时间.采用RevMan 5.1软件进行meta分析.结果 纳入21项研究,共1737例患者.冠状动脉旁路移植术患者给予不同剂量糖皮质激素可降低术后房颤发生的风险,不增加各种原因感染及死亡的风险；中、大剂量增加因高血糖需要胰岛素治疗的风险；大剂量糖皮质激素患者机械通气时间延长.结论 冠状动脉旁路移植术患者给予不同剂量糖皮质激素可降低术后房颤的发生风险,且不增加感染和死亡的风险；中、大剂量可增加因高血糖需胰岛素治疗的风险；大剂量可增加机械通气时间延长的风险.     

糖皮质激素与骨质疏松

糖皮质激素是由肾上腺皮质束状带合成和分泌的，其基本结构为甾核，糖皮质激素的药理作用广泛而复杂，在生理剂量下所分泌的糖皮质激素主要影响基本生命物质的代谢过程，超生理剂量的糖皮质激素则还有抗炎、抗免疫、抗休克等作用。因此，糖皮质激素在临床上应用极为广泛，如用作内分泌     

糖皮质激素性骨质疏松症

糖皮质激素(GC)有抗炎、免疫抑制、抗休克等作用，临床上应用广泛，是治疗许多风湿性疾病、肾病综合征、哮喘、器官移植排异等疾病的基础药物。其长程大剂量使用导致的副作用是医源性疾病的主要原因之一，其中GC诱发的骨质疏松(GIO)的发病率仅次于绝经后及老年性骨质疏松而居第3位，使用GC疗程6个月以上的患者中50％以上病例，可引起明显的骨量丢失，导致骨折     

Glucocorticoids in rheumatoid arthritis: Balancing benefits and harm by leveraging the therapeutic window of opportunity

Glucocorticoids have been available since the early 1950s and have since become an integral part of the management of rheumatoid arthritis (RA). Due to their rapid effect, glucocorticoids have an appealing profile for treating flares or as “bridging” agents in early RA. The efficacy of glucocorticoids to treat RA has been well established, both to control disease activity and to delay the progression of joint damage. However, despite their benefits, glucocorticoids have equally well-known adverse effects. It is generally accepted that long-term use of glucocorticoids, particularly at higher doses, is not advisable, and recent guidelines for the management of RA therefore either recommend against the use of glucocorticoids or suggest using them only as bridging therapy. Perceptions on the harmful effects of glucocorticoids remain, although mainly based on observational studies. Prolonged glucocorticoid therapy at low doses is still highly prevalent in clinical practice, but recent data suggest a rather favourable risk-benefit balance for this strategy, even in senior patients. Balancing the benefits and risks of treating RA with glucocorticoids thus remains a somewhat controversial topic. This narrative review outlines the historical and current position of glucocorticoids in the management of RA, while summarising recent evidence on their beneficial and detrimental effects. Furthermore, practical strategies for the current use and tapering of glucocorticoids in RA are formulated.     

Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis

Glucocorticoids are widely used anti-inflammatory and immunosuppressive drugs for rheumatoid arthritis (RA). The disease-modifying potential of low to medium doses of glucocorticoids has been reconfirmed in the past decade, and co-administration of DMARDs and glucocorticoids has become standard in many treatment protocols, especially those for early disease stages but also for long-standing RA. The glucocorticoid regimens used range from continuous low doses to intermittent high doses. Studies of the rationale for and clinical use of glucocorticoids as co-therapy with DMARDs in RA have shown that this approach has a place in modern (tight control) treatment strategies, and that glucocorticoid co-therapy has disease-modifying effects during the first 2 years of treatment in patients with early RA. Furthermore, medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect. Intra-articular glucocorticoids give good local control and have been used in tight control strategies. New glucocorticoid compounds are becoming available for clinical use that might have an enhanced risk:benefit ratio. Better monitoring of glucocorticoid use will also improve this ratio, and help to allay both patient and rheumatologist concerns about treatment-related adverse effects.     

Nebennierenrinde und Steroide

Since the publication of two case reports that are considered to represent the first clinical demonstration of iatrogenic adrenal insufficiency, it has been the generally accepted practice to cover steroid-treated patients undergoing surgery with glucocorticoids in the perioperative period. Both the inclusion criteria for the patients and the extent of the substitution pattern have been selected on an empirical rather than on a rational basis. Scientific advances over the past 50 years in the knowledge of the hypothalamic-pituitary-adrenal system's physiology and the molecular mechanism of action of its biologically active components are, for the most part, not reflected in current clinical practice and instead seem to be ignored. Clinical and experimental evidence suggests, however, that even glucocorticoid-treated patients undergoing surgery do not require maximum stress doses of hydrocortisone, which should be reserved for the treatment of sepsis. With regard to the broad spectrum of efficacy of glucocorticoids and their side effects, revision and modification of the historical regimen appear prudent.     

激素抵抗肾病综合征的中西医结合治疗

糖皮质激素(激素)抵抗型肾病综合征(SRNS)是肾脏病临床常见的疑难病症之一,属难治性肾病综合征。已有越来越多的学者探索中西医结合治疗方法,以提高临床疗效及缓解长期大剂量免疫抑制剂所带来的副反应。笔者在本文中系统阐述了产生激素抵抗的机制和影响激素疗效的因素,提出应注重规范化治疗,将中医辨"病"治疗的雷公藤制剂联合个体化的辨"证"治疗、传统辨证与微观辨证相结合,组方选药结合中药现代研究结果,是中西医结合治疗SRNS可借鉴的方法。     

The Role of Wnt Signaling and Sclerostin in the Pathogenesis of Glucocorticoid-Induced Osteoporosis

Bone formation is suppressed in glucocorticoid-induced osteoporosis. One of the mechanisms by which glucocorticoids depress bone formation is through their effects on the Wnt/β-catenin signaling pathway, a critical regulator of osteoblastogenesis. Thus, Wnt signaling induces the differentiation of osteoblast precursors toward mature osteoblasts and prevents osteoblast and osteocyte apoptosis. Glucocorticoids increase the expression of Wnt signaling antagonists (sclerostin and Dkk-1) in experimental studies in rodents and cell cultures. However, the scarce data of their effects in humans are somewhat contradictory, probably due to the dose and duration of treatment as well as the characteristics of the patients. A progressive decrease in Dkk-1 serum levels and an increase in circulating sclerostin levels at long-term follow-up have recently been reported in patients treated with high doses of glucocorticoids. This review describes the most recent data on the effects of glucocorticoids on the Wnt signaling pathway, especially on their antagonists, sclerostin and Dkk-1.     

Glucocorticoid-induced osteopenia in the mouse as assessed by histomorphometry,microcomputed tomography,and biochemical markers

Glucocorticoids are potent anti-inflammatory molecules used in the treatment of asthma, rheumatoid arthritis, inflammatory bowel disease, and other inflammatory and dermatological diseases, as well as in posttransplantation immunotherapy. Although glucocorticoids have been prescribed for many years, their potential side effects, when administered orally, can prevent their long-term use. The most serious side effect observed in the clinic is glucocorticoid-induced osteoporosis (GIOP). To develop a small animal model to characterize glucocorticoid-induced bone loss, we carried out a series of experiments using BALB/c mice given daily intraperitoneal doses of the synthetic glucocorticoid, dexamethasone. Following dexamethasone treatment, the mice became osteopenic, with highly significant decreases in bone formation rate and mineral apposition rate, as assessed by standard histomorphometry. Moreover, 3 week treatment with dexamethasone resulted in a decrease in trabecular thickness and trabecular number with an increase in surface-to-volume ratio of trabeculae in the distal femur, as measured using microcomputed tomography (micro-CT). The serum bone formation marker, osteocalcin, was dose-dependently decreased in all mice treated with dexamethasone and showed a parallel extent of regulation to the bone formation rate changes. In addition, serum levels of leptin, recently identified as playing a role in the regulation of bone mass, increased following dexamethasone treatment. BALB/c mice therefore represent a useful model system in which the detrimental effects of glucocorticoids on bone can be studied.     

Adrenal suppression and steroid supplementation in renal transplant recipients.

The use of increased dosages of glucocorticoids during periods of physiologic stress in allograft recipients represents a clinical dilemma in that the short-term exogenous therapy required may significantly impair wound healing and immunocompetence. To investigate whether "stress steroids" are actually necessary, a prospective study was conducted in 40 renal allograft recipients admitted with significant physiologic stress. Stress categories included sepsis, metabolic abnormalities, and surgery. These patients received only their baseline prednisone immunosuppression (5-10 mg/day) and no supraphysiologic or stress doses of glucocorticoids. The clinical course of the patients revealed no evidence of adrenal insufficiency. There was no mortality, increase in hospital stay, or eosinophilia. Five episodes of hyponatremia and seven instances of hypotension were attributed to primary disease processes and responded promptly to specific treatment without steroid supplementation. Biochemical evaluation during stress revealed suppression of ACTH levels in 74.5% of episodes, elevation of urinary free cortisol levels in 79.1% of episodes, and elevation of isolated serum cortisol levels in 55.9% of episodes. This suggested that these patients had physiologically adequate adrenal function. The cosyntropin stimulation test overestimated the incidence and degree of clinically significant adrenal dysfunction (63% of patients) and was not a useful indication of a requirement for additional glucocorticoids. We conclude that functional adrenal suppression is uncommon in renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) and that the demands of physiologic stress are met by a combination of endogenous adrenal function plus exogenous, baseline, immunosuppressive doses of glucocorticoids. Supra-physiologic or high doses of so-called "stress steroids" are not required. The cosyntropin stimulation test has significant clinical limitations and did not serve to alter clinical care.     

Adult-onset Still's disease as a mask of Hodgkin lymphoma

Adult-onset Still''s disease is a rare disorder, which creates difficulties in making a proper diagnosis. Ambiguous symptoms and results of auxiliary tests, lack of unequivocal diagnostic tests and the need to exclude other causes of the disease are major problems in clinical practice.A case of a 22-year-old woman with dominated recurrent fever, significantly elevated inflammation markers and arthritis is presented. Based on clinical signs after exclusion of infection, hematological and other reasons, the patient was diagnosed with adult-onset Still''s disease. Standard treatment, with high doses of glucocorticoids and a disease-modifying drug, was applied, without the anticipated effects. The diagnostic tests were conducted again due to the lack of clinical improvement, increase of inflammatory markers and unusual response to treatment. A new symptom of significance, i.e. mediastinal lymphadenopathy, was found. After the histopathological examination of lymph nodes, Hodgkin''s disease was diagnosed and targeted therapy for hematological malignancy was applied.     

The Skeletal Effects of Inhaled Glucocorticoids

The skeletal effects of inhaled glucocorticoids are poorly understood. Children with asthma treated with inhaled glucocorticoids have lower growth velocity, bone density, and adult height. Studies of adults with asthma have reported variable effects on BMD, although prospective studies have demonstrated bone loss after initiation of inhaled glucocorticoids in premenopausal women. There is a dose-response relationship between inhaled glucocorticoids and fracture risk in asthmatics; the risk of vertebral and non-vertebral fractures is greater in subjects treated with the highest doses in the majority of studies. Patients with COPD have lower BMD and higher fracture rates compared to controls, however, the majority of studies have not found an additional detrimental effect of inhaled glucocorticoids on bone. While the evidence is not conclusive, it supports using the lowest possible dose of inhaled glucocorticoids to treat patients with asthma and COPD and highlights the need for further research on this topic.