High dose steroid & adjuvant Rx

 Q: 28 years old female is admitted to ICU with exacerbation of Multiple Sclerosis (MS) and started on high dose steroid. What two adjuvant treatments may help to blunt the adverse effects?

Answer: MS patients usually require a short course of a gram of prednisolone per day. The two notable side effects can be gastritis and psychiatric symptoms. Psychiatric disturbances can be depressive, manic, or hypomanic. It may help to add 

• proton pump inhibitor (PPI), and 
• clonazepam

Other adverse effects to watch are hyperglycemia, particularly in diabetic or pre-diabetic patients, and increased susceptibility to infections. It would be prudent to treat infection, if present prior to pulse steroid treatment.

On a side note, clonazepam has also shown promise in patients who develop psychiatric symptoms from tacrolimus, hemodialysis, or SLE.

#neurology

#pharmacology

References:

1. Morrow SA, Barr J, Rosehart H, Ulch S. Depression and hypomania symptoms are associated with high dose corticosteroids treatment for MS relapses. J Affect Disord 2015; 187:142. 

2. Viswanathan R, Glickman L. Clonazepam in the treatment of steroid-induced mania in a patient after renal transplantation. N Engl J Med. 1989 Feb 2;320(5):319-20. doi: 10.1056/NEJM198902023200517. PMID: 2643052.

3. Ithman M, Malhotra K, Bordoloi M, Singh G. Treatment-Refractory Mania with Psychosis in a Post-Transplant Patient on Tacrolimus: A Case Report. Clin Med Res. 2018 Jun;16(1-2):47-49. doi: 10.3121/cmr.2018.1409. Epub 2018 May 18. PMID: 29776917; PMCID: PMC6108512. 

4. Jones BD, Chouinard G. Clonazepam in the treatment of recurrent symptoms of depression and anxiety in a patient with systemic lupus erythematosus. Am J Psychiatry. 1985 Mar;142(3):354-5. doi: 10.1176/ajp.142.3.354. PMID: 3970277. 

5. Jarecke CR, De Moya VF, Ware MR. A case of mania secondary to hemodialysis: successful treatment with clonazepam. J Clin Psychopharmacol. 1990 Aug;10(4):298-9. doi: 10.1097/00004714-199008000-00018. PMID: 2286703.