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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 70, Num. 4, 2004, pp. 244-246
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Indian Journal of Dermatology, Venereology, Leprology, Vol. 70, No. 4, July-August, 2004, pp. 244-246
Letter To Editor
Dexamethasone cyclophosphamide pulse therapy for pemphigus
Modi Navin
Consultant Dermatologist, Dombivali, Thane, Maharashtra
Correspondence Address:A-230, Kasturi Plaza, Dombivali, Thane modidr_100@yahoo.co.in
Code Number: dv04082
Sir,
The IJDVL September-October 2003 issue covered various aspects of dexamethasone-cyclophosphamide
pulse) DCP pulse therapy.[1],[2],[3]
I would like to make the following important points related to DCP therapy:
(1) The duration of infusion of cyclophosphamide pulse:
While the editorial[1] has
not discussed this aspect of therapy, Dr. Pasricha[2] has
categorically stated that the intravenous drip of dexamethasone and cyclophosphamide
should be given over 2 hours. Others have administered this drip over 2
hours[3] or 1 hour.[4] Dr.
Balachandran recommends a slower infusion, over 3 to 4 hours.[5],[6] These
give a false sense of non-standardization of therapy.
As per the manufacturer′s package insert, cyclophosphamide should
be infused as soon as possible after reconstitution since there is a possibility
of loss of pharmacologic activity. Also its half life is only 7 hours.
Hence, it should be given over 1 to 1.5 hours (maximum 2 hours) in order
to maintain the maximum blood concentration uniformly over a short time.[7]
(2) Prevention of cyclophosphamide induced sterile hemorrhagic cystitis:
The modification of pulse therapy[3] which
advocates an infusion of 500 ml of 5% dextrose on the day of intravenous
cyclophosphamide administration needs to be reevaluated. Since patients
are frequently diabetic or anemic, and hence in a hyperdynamic circulatory
stage, is giving intravenous fluids justified? As a routine ample oral
fluid intake is recommended[8] and
might suffice.
Administration of the drug should be interrupted at the first indication
of dysuria or hematuria.[8] On
the day of cyclophosphamide infusion I ask my patients to empty their bladder
as frequently as possible, may be half hourly, during the infusion and
preferably till 2 hours later.
Cystitis can be reduced in intensity or prevented by the parenteral
administration of MESNA, a sulfhydryl compound that reacts readily with
acrolein in the
acid environment of the urinary tract.[8]
(3) Supportive management for prevention of steroid induced osteoporosis:[3]
This should not be called a modification of Dr. Pasricha′s DCP therapy
since it is a totally different aspect of comprehensive patient management.
If glucocorticoid associated osteoporosis is the main concern, then the
bisphosphonate group of drugs (e.g. alendronate), which have emerged as
the most efficacious drugs for the prevention of osteoporosis, should be
given.[9] Most
authorities also advocate a calcium intake of 1500 mg/day in the diet and
calcium supplementation and vitamin D intake of 400 IU/day for the prevention
of osteoporosis.[10]
(4) Steroids are normally given in a single early morning dose.
While none of the authors have commented on this aspect of DCP therapy,
shouldn′t DCP therapy infusions be given in the early morning only?
REFERENCES
| 1. | Ramam M. Dexamethasone pulse therapy in dermatology. Indian J Dermatol Venereol Leprol 2003;69:319-22. Back to cited text no. 1 |
| 2. | Pasricha JS. Pulse therapy as a cure for autoimmune diseases. Indian J Dermatol Venereol Leprol 2003;69:323-8. Back to cited text no. 2 |
| 3. | Rao NP, Lakshmi TS. Pulse therapy and its modifications in pemphigus: A six year study. Indian J Dermatol Venereol Leprol 2003;69:329-33. Back to cited text no. 3 |
| 4. | Gokhale NR, Mahajan PM, Sule RR, Belgaumkar VA, Jain SM. Treatment of pemphigus with intravenous pulse cyclophosphamide. Indian J Dermatol Venereol Leprol 2003;69:334-7. Back to cited text no. 4 |
| 5. | Balachandran C. Treatment of pemphigus. Indian J Dermatol Venereol Leprol 2003;69:3-5. Back to cited text no. 5 |
| 6. | Balachandran C. Letter to editor: Response. Indian J Dermatol Venereol Leprol 2003;69:314-5. Back to cited text no. 6 |
| 7. | Gupta R, Gupta S. Treatment of pemphigus (Letter). Indian J Dermatol Venereol Leprol 2003;69:314. Back to cited text no. 7 |
| 8. | Chabner BA, Ryan DP, Paz-Ares L, Garcia-Carbonero R, Calabresi P. Chemotherapy of neoplastic diseases. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1391-6. Back to cited text no. 8 |
| 9. | Robert M. Agents affecting calcification and bone turnover. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1738-43. Back to cited text no. 9 |
| 10. | Shimmer BP, Parker KL. Adrenocorticotropic hormone, adrenocortical sterioids and their synthetic analogs, Inhibitors of the synthesis and actions of adrenocortical hormones. In: Hardmon JG, Limbird LE, editors. Goodman and Gillman's Pharmacologic basis of therapeutics. 10th Ed. New York: McGraw-Hill; 2001. p. 1649-77. Back to cited text no. 10 |
Copyright 2004 - Indian Journal of Dermatology, Venereology, Leprology
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