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Three Part Question

In[patients with temporal arteritis] is [methylprednisolone better than oral steroids] at [reducing the symptoms and complications of therapy]?

Clinical Scenario

An 85 year old man presents to the emergency department with headache and sudden loss of vision. He has signs of an acute retinal arterial occlusion. He has a moderate headache and some mild tenderness along his scalp arteries. His ESR is 110 and his CRP is 150. You diagnose temporal arteritis and decide to give him steroids. The Ophthalmic nurse practitioner suggests Methylprednisolone, but your departmental handbook says that oral steroids will suffice. You wonder which to give.

Search Strategy

Medline 1966- August 2005.
Medline
[exp METHYLPREDNISOLONE HEMISUCCINATE/ or exp METHYLPREDNISOLONE/ or methylprednisolone.mp.] and [temporal arteritis.mp. or exp Temporal Arteritis/] limit to therapy (sensitivity).

Search Outcome

Medline 77 papers of which one was directly relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chevalet P 2000 France	164 patients with a diagnosis of TA. Patients received a 240 mg i.v. pulse of MP followed by 0.7 mg/kg/day oral prednisone (Group 1) or 0.7 mg/kg/day prednisone without an i.v. pulse (Group 2, controls), or a 240 mg i.v. pulse of MP followed by 0.5 mg/kg/day prednisone (Group 3). Corticosteroid dosage was reduced after normalization of 2 biological inflammatory variables to obtain half-dosage after 4 weeks in Groups 1 and 2 and 20 mg/day after 2 weeks in Group 3. Tapering was systematically attempted from the 6th month of treatment.	PRCT	Cumulative doses of steroids	No difference p=0.39	Study took 4 years to complete. Full paper awaited
			Incidence of AF	OPCAB group 4/80 (5%). CABG group 7/80 (8.7%). P=0.53
			Time required for normalisation of CRP	No difference
			Incidence of corticosteroid resistance	No difference between groups. Overall 13.5%
			Incidence if corticosteroid related side-effects	No difference p=0.37. Overall 39%.

Comment(s)

Temporal arteritis is a sight threatening condition predominantly affecting the elderly. There is widely heald belief that prompt therapy with steroids reduces morbidity greatly and can prevent sight loss. Many physicians hold the belief that intravenous steroids are more effective than oral medications, though in conditions like asthma, there is a definate trend away from this. This PRCT demonstrates no additional benefit to IV steroids and in particular no additional benefit to pulsed MethyPrednisolone.

Clinical Bottom Line

Temporal Arteritis can be treated with oral steroids.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Chevalet P. Barrier JH. Pottier P. Magadur-Joly G. Pottier MA. Hamidou M. Planchon B. El Kouri D. Connan L. Dupond JL. De Wazieres B. Dien G. Duhamel E. Grosbois B. Jego P. Le Strat A. Capdeville J. L A randomized, multicenter, controlled trial using intravenous pulses of methylprednisolone in the initial treatment of simple forms of giant cell arteritis: a one year followup study of 164 patients. Journal of Rheumatology. 27(6):1484-91, 2000 Jun.