Intravenouse Methylprednisolone used in SLE with infection
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Transcript of Intravenouse Methylprednisolone used in SLE with infection
Case Reports :The Use of Intravenous
Methylprednisolone in the Treatment of Systemic Lupus Erythematosus
(SLE) with Infection and TB
dr. Khoirul Anwar
Pendahuluan
• Cornerstone Tx• Severe SLE IVMP (pulse dose) • Double-edged sword • Risk vs benefit• Komplikasi IVMP detection, risk factor, prevention and
treatment
KASUS
Kasus
•Wanita 27 tahun• Bengkak badan• SLE• Susp nefritis lupus CKD stage V• Susp NPSLE• AIHA• Serositis (efusi pericard, efusi pleura)• Hematologi (trombositopenia, limfopenia)
Kasus
• Pleuropneumonia ec TB• ISK ec ESBL• Riwayat TB paru
Kasus
• TD 140/90 N 100 RR 26 T 37,3•Malar rash (-) • Edem anasarka• Paru : redup di aspek inferior paru dextra, roncho (-) • Jantung : cardiomegali (+), muffled sound (-), bising (-) • Abdomen : ascites (+)
Kasus
Hb 8,8 AL 15,4 S 92,7 L 4,3 AT 94Procal 4,9
Bun 77,7 creat 6,4 Na 133 K 4,2 Cl 93
UR : protein +4 Nit - LE +3 bakt 30.020 Leu 45.444
SGOT 15 SGPT 80 alb 1,6
ANA IF (+) titer 1:100Pola homogendsDNA 1173 (N=<100)C3 48 (N=90-180)C4 26,2 (N=10-90)Coomb (+)
K/S urin
Klebseilla pneumonie
ESBL (+)
Rontgen torax• Edema pulmo• Cardiomegali
USG torax• Hemitorax sinistra didapatkan hasil pleuropneumonia (penebalan dan irreguleritas pleura viseralis sinistra,
B line (+), didapatkan efusi pleura minimal• Hemithorax dextra didapatkan efusi pleura minimal• Curiga efusi pericard
USG ginjal• Ren dextra : ukuran 10,09 x 5,2 cm, echostruktur meningkat, batas kortek medula mengabur, SPC tidak melebar, tak tampak massa/batu• Ren sinistra : ukuran 8,04 x4,42 cm, echostruktur meningkat, batas kortek medula mengabur, SPC tidak melebar, tak tampak massa/batu• Kesan : inflamasi renal bilateral terutama sinistra
Problem• Severe SLE• Infection • CKD V• TB paru
Apakah penggunakan IVMP aman pada kondisi infeksi ? Komplikasi IVMP dan faktor yang mempengaruhi munculnya komplikasi IVMP
Apakah yang harus diketahui dengan TB pada SLE ?
PEMBAHASAN
Hubungan infeksi dengan SLE
Infection, 44%
SLE flare, 24%
Others, 18%
Surgical Cause, 14%
Penyebab Rehospitalisasi
Infection SLE flare Others Surgical Cause
Lata S Bichile, Vaibhav C Chewoolkar Lupus Flare: How to Diagnose and Treat, Medicine update 2011
Faktor-faktor yang menyebabkan SLE flare
Lingkaran setan hubungan infeksi dengan autoimunitas (SLE)
Inadequately of
immune response
Using
immunosupressant
agent
Molecular mimicry theory
Molecular mimicry theory
• SLE dan terapi SLE• penurunan innate dan
adaptive immune• infeksi ⬆
Flare vs infection
Procal ⬆ in SLE infection
Flare vs infection
• CRP increased in 92% of the group with infection
• 89% of the group with lupus flare• CRP tended to be higher in the group with
non-viral • but this did not reach significance (p=0.98).
Flare vs infection
• serum PCT increased significantly in patients with SLE with non-viral infection compared with patients with lupus flare
Flare vs infection
Flare vs infection• Proteinuria • Fever • SLEDAI
Apa resiko/komplikasi penggunaan IVMP pada
SLE
Genomic and non genomic action of glucorticoids
Genomic action of glucorticoidsTransactivation
the synthesis of anti-inflammatory proteins (such as, for example, annexin (lipocortin)
1, IκB, interleukin (IL)-10)
Transrepressionsuch as nuclear factor-κB, activator
protein-1 and nuclear factor for activated T cells, as a consequence
reducing the expression of proinflammatory proteins such as IL-1,
IL-6 or tumor necrosis factor (TNF) alpha
Genomic and non genomic action of glucorticoids
optimization of the genomic action• by low-dose administration• modified-release prednisone
optimization of the nongenomic action• high doses• any time of the day
genomic
Glucocorticoids effects
Genomic effect
NonGenomic effect
Glucocorticoids effects on SLE flare
Corticosteroid... antiinflamation
SLE Flare• > High dose• Antiinflamasi• Infeksi ⬆ tapi
tidak seberat penggunaan low dose (genomic effect)
THEORY
EVIDENCE
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
MP pulse dose
MP pulse dose
RiskPreventabl
eTherapy
Detection
Tx Flare
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
HASIL
Tx Flare
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
Infection
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
• Infeksi harus diatasi (molecular mimicry)
• Tx optimal sesuai KS• Faktor resiko prediktor harus
dioptimalkan terapinya• Albumin• Limfositopenia• Trombositopenia • Fungsi ginjal
Terapi • Inj. Methylprednisolone 125 mg/ 12 jam• Cellcept 2x1000mg• Kloroquin 1x150mg• Inj. Meropenem 500mg/12jam• Inj. Moxifloxacin 400mg/12jam• Transfusi albumin• HD sesuai jadwal
Evaluasi
Hb 8,8 10,7 8,2AL 15,4 19 9,7S 92,7 93,3 93,5L 4,3 3,6 3,7AT 94 137 138Procal 4,9 N/AAlb 1,6 2,2 2,6
UR : Prot +4 +4Nit - -LE +3 +3bakt 30.020 1274Leu 45.444 8841
Klinis :
Demam (-)
Sesak (+) ⬇
Bengkak (+) ⬇
Nyeri perut (-)
Kejang (-)
Penkes (-)
Nyeri kepala (-)
Kesimpulan• Infeksi membaik dengan pengobatan antibiotik• Aktivitas SLE membaik setelah pemberian IVMP
TB pada SLE
• Prevalence ± 5%• Pulmonary TB > extra
pulmonary
Tuberculosis in SLE
Immunodeficiency in SLE
Immune respone in TB
Melibatkan sel T (CD4 CD8), sitokin, sel B, complemen
Complement in TB
C3-dependent entry pathwayinto resident alveolar macrophages
Problems... (1)
SLE Complement
deficiency
Risk for TB
infection
SLE is Risk factor for TB infection
Pada Pasien ini• Penderita SLE • Kadar complement rendah
TB in SLE
Rontgen thorax :• Milier• Konsolidasi diffuse• TB klasik (konsolidasi
apex)
Pada Pasien iniGambaran parenkim paru normalTB ditegakan dari gambaran USG
TB in SLE
TB in SLE
Perjalanan penyakit TB pada SLE:• Akut • progresif
Pirazinamide in liver
SLE pathophysiology
SLE in drug induced hepatitis
Tissue inflamation and necrosis (liver injury)
SLE in drug induced hepatitis EVIDENCE...??
• Incidence 12,9% overall
• SLE increase risk for Anti TB liver injury
SLE in drug induced hepatitis EVIDENCE...??
• 237 pts SLE 3 pts TB
• 3 pts TB Anti TB liver injury
• SLE ⬆ risk anti TB liver injury
Terapi • INH 1x300mg• Rifampisin 1x450mg• Pirazinamide 1250mg 3x/minggu• Etambutol 750mg 3x/minggu
Evaluasi
SGOT 15 23 15 SGPT 80 9 4Tbil NA 0,55 0,21Dbil NA 0,16 0,12
Kesimpulan • Pasien mendapat OAT • Monitoring tidak didapatkan efeksamping DILI
TAKE HOME MESSAGE • Risk and benefit• Judgment klinis (referensi, evidence, experience)•Monitoring• Edukasi
THANK YOU....