Treatment of Henoch-Schonlein Purpura With Steroids
Treatment of Henoch-Schonlein Purpura With Steroids
Weiss PF, Feinstein JA, Luan X, Burnham JM, and Feudtner C
Pediatrics. 2007;120:1079-1087
The authors note that many of the previous studies (including 3 prospective clinical trials and other observational studies) evaluating use of steroids in Henoch-Schönlein purpura (HSP) had very small sample sizes and had differing conclusions as to whether use of steroids was beneficial.
This meta-analysis included both randomized trials and large observational studies in order to try to answer several questions about whether use of steroids in HSP was associated with shorter duration of abdominal symptoms, decreased odds of needing surgical intervention (for intussusception, for example), decreased risk for recurrent HSP, decreased odds of any renal disease, or persistent renal disease.
After an extensive literature search, the authors identified 15 articles that explicitly examined the use of steroids in HSP. Where possible, the authors pooled data to determine pooled odds ratios for the various outcomes. For some of the questions, the studies demonstrated so much heterogeneity that pooling data was not possible.
The authors found that treatment with steroids was associated with reduced duration of abdominal symptoms for patients with HSP (odds ratio [OR], 5.42; 95% confidence interval [CI], 1.60-18.29). Use of steroids was associated with reduced risk of requiring surgical intervention, but the 95% CI crossed 1, making the association nonsignificant (OR 0.16; 95% CI, 0.01-3.62).
Two prospective studies demonstrated a reduced recurrence rate if treated with steroids, but again the 95% CI included 1.0 (OR, 0.32). In regard to developing "any" renal dysfunction, the studies were too heterogeneous to pool data for OR calculation. Of those studies, 3 were prospective and demonstrated mixed results.
Of retrospective studies, 2 demonstrated reduced risk, 1 no difference, and 1 increased risk for renal dysfunction if treated with steroids. Finally, the authors were able to pool prospective data for the question of whether steroid use reduces risk for LONG-TERM renal disease; steroid treatment demonstrated a protective effect (OR, 0.43; 95% CI, 0.19-0.96).
Although the authors were not able to pool data for all questions, and several of the outcomes had nonsignificant outcomes, the general direction of all estimates favored steroid use. The authors estimated that 200-400 patients would be needed and that steroid use would have to raise the odds of renal disease by an OR of 2-3 to reverse these general protective effects seen with the existing data.
The authors concluded that early treatment of HSP with steroids reduces abdominal pain duration and reduces the long-term risk for renal disease.
The authors point out several of the limitations of existing data and small studies, with the majority of them being nonrandomized. However, reviews such as this one, with a strong suggestion of beneficial effects, are the groundwork for larger, multicenter trials. Therefore, one cannot take this article as a strong recommendation to use steroids universally in HSP, but the findings suggest that existing data do not clearly contraindicate their use. It also shows how badly we need large-sample, experimental data to refer to in treating patients with HSP.
Abstract
Weiss PF, Feinstein JA, Luan X, Burnham JM, and Feudtner C
Pediatrics. 2007;120:1079-1087
The authors note that many of the previous studies (including 3 prospective clinical trials and other observational studies) evaluating use of steroids in Henoch-Schönlein purpura (HSP) had very small sample sizes and had differing conclusions as to whether use of steroids was beneficial.
This meta-analysis included both randomized trials and large observational studies in order to try to answer several questions about whether use of steroids in HSP was associated with shorter duration of abdominal symptoms, decreased odds of needing surgical intervention (for intussusception, for example), decreased risk for recurrent HSP, decreased odds of any renal disease, or persistent renal disease.
After an extensive literature search, the authors identified 15 articles that explicitly examined the use of steroids in HSP. Where possible, the authors pooled data to determine pooled odds ratios for the various outcomes. For some of the questions, the studies demonstrated so much heterogeneity that pooling data was not possible.
The authors found that treatment with steroids was associated with reduced duration of abdominal symptoms for patients with HSP (odds ratio [OR], 5.42; 95% confidence interval [CI], 1.60-18.29). Use of steroids was associated with reduced risk of requiring surgical intervention, but the 95% CI crossed 1, making the association nonsignificant (OR 0.16; 95% CI, 0.01-3.62).
Two prospective studies demonstrated a reduced recurrence rate if treated with steroids, but again the 95% CI included 1.0 (OR, 0.32). In regard to developing "any" renal dysfunction, the studies were too heterogeneous to pool data for OR calculation. Of those studies, 3 were prospective and demonstrated mixed results.
Of retrospective studies, 2 demonstrated reduced risk, 1 no difference, and 1 increased risk for renal dysfunction if treated with steroids. Finally, the authors were able to pool prospective data for the question of whether steroid use reduces risk for LONG-TERM renal disease; steroid treatment demonstrated a protective effect (OR, 0.43; 95% CI, 0.19-0.96).
Although the authors were not able to pool data for all questions, and several of the outcomes had nonsignificant outcomes, the general direction of all estimates favored steroid use. The authors estimated that 200-400 patients would be needed and that steroid use would have to raise the odds of renal disease by an OR of 2-3 to reverse these general protective effects seen with the existing data.
The authors concluded that early treatment of HSP with steroids reduces abdominal pain duration and reduces the long-term risk for renal disease.
The authors point out several of the limitations of existing data and small studies, with the majority of them being nonrandomized. However, reviews such as this one, with a strong suggestion of beneficial effects, are the groundwork for larger, multicenter trials. Therefore, one cannot take this article as a strong recommendation to use steroids universally in HSP, but the findings suggest that existing data do not clearly contraindicate their use. It also shows how badly we need large-sample, experimental data to refer to in treating patients with HSP.
Abstract
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