intravenouse methylprednisolone used in sle with infection
TRANSCRIPT
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Case Reports :The Use of Intravenous
Methylprednisolone in the Treatment of Systemic Lupus Erythematosus
(SLE) with Infection and TB
dr. Khoirul Anwar
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Pendahuluan
• Cornerstone Tx• Severe SLE IVMP (pulse dose) • Double-edged sword • Risk vs benefit• Komplikasi IVMP detection, risk factor, prevention and
treatment
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KASUS
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Kasus
•Wanita 27 tahun• Bengkak badan• SLE• Susp nefritis lupus CKD stage V• Susp NPSLE• AIHA• Serositis (efusi pericard, efusi pleura)• Hematologi (trombositopenia, limfopenia)
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Kasus
• Pleuropneumonia ec TB• ISK ec ESBL• Riwayat TB paru
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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 (+)
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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 (+)
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Rontgen torax• Edema pulmo• Cardiomegali
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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
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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
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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 ?
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PEMBAHASAN
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Hubungan infeksi dengan SLE
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Infection, 44%
SLE flare, 24%
Others, 18%
Surgical Cause, 14%
Penyebab Rehospitalisasi
Infection SLE flare Others Surgical Cause
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Lata S Bichile, Vaibhav C Chewoolkar Lupus Flare: How to Diagnose and Treat, Medicine update 2011
Faktor-faktor yang menyebabkan SLE flare
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Lingkaran setan hubungan infeksi dengan autoimunitas (SLE)
Inadequately of
immune response
Using
immunosupressant
agent
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Molecular mimicry theory
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Molecular mimicry theory
• SLE dan terapi SLE• penurunan innate dan
adaptive immune• infeksi ⬆
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Flare vs infection
Procal ⬆ in SLE infection
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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).
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Flare vs infection
• serum PCT increased significantly in patients with SLE with non-viral infection compared with patients with lupus flare
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Flare vs infection
Flare vs infection• Proteinuria • Fever • SLEDAI
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Apa resiko/komplikasi penggunaan IVMP pada
SLE
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Genomic and non genomic action of glucorticoids
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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
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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
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Glucocorticoids effects
Genomic effect
NonGenomic effect
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Glucocorticoids effects on SLE flare
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Corticosteroid... antiinflamation
SLE Flare• > High dose• Antiinflamasi• Infeksi ⬆ tapi
tidak seberat penggunaan low dose (genomic effect)
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THEORY
EVIDENCE
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
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MP pulse dose
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MP pulse dose
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RiskPreventabl
eTherapy
Detection
Tx Flare
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
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HASIL
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Tx Flare
Apakah penggunaan corticosteroid aman pada SLE flare dengan infeksi ?
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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
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Terapi • Inj. Methylprednisolone 125 mg/ 12 jam• Cellcept 2x1000mg• Kloroquin 1x150mg• Inj. Meropenem 500mg/12jam• Inj. Moxifloxacin 400mg/12jam• Transfusi albumin• HD sesuai jadwal
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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 (-)
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Kesimpulan• Infeksi membaik dengan pengobatan antibiotik• Aktivitas SLE membaik setelah pemberian IVMP
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TB pada SLE
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• Prevalence ± 5%• Pulmonary TB > extra
pulmonary
Tuberculosis in SLE
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Immunodeficiency in SLE
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Immune respone in TB
Melibatkan sel T (CD4 CD8), sitokin, sel B, complemen
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Complement in TB
C3-dependent entry pathwayinto resident alveolar macrophages
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Problems... (1)
SLE Complement
deficiency
Risk for TB
infection
SLE is Risk factor for TB infection
Pada Pasien ini• Penderita SLE • Kadar complement rendah
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TB in SLE
Rontgen thorax :• Milier• Konsolidasi diffuse• TB klasik (konsolidasi
apex)
Pada Pasien iniGambaran parenkim paru normalTB ditegakan dari gambaran USG
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TB in SLE
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TB in SLE
Perjalanan penyakit TB pada SLE:• Akut • progresif
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Pirazinamide in liver
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SLE pathophysiology
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SLE in drug induced hepatitis
Tissue inflamation and necrosis (liver injury)
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SLE in drug induced hepatitis EVIDENCE...??
• Incidence 12,9% overall
• SLE increase risk for Anti TB liver injury
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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
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Terapi • INH 1x300mg• Rifampisin 1x450mg• Pirazinamide 1250mg 3x/minggu• Etambutol 750mg 3x/minggu
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Evaluasi
SGOT 15 23 15 SGPT 80 9 4Tbil NA 0,55 0,21Dbil NA 0,16 0,12
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Kesimpulan • Pasien mendapat OAT • Monitoring tidak didapatkan efeksamping DILI
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TAKE HOME MESSAGE • Risk and benefit• Judgment klinis (referensi, evidence, experience)•Monitoring• Edukasi
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THANK YOU....