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Thread: Wise ? about Decadron vs Solumderol

  1. #1

    Wise ? about Decadron vs Solumderol

    After a recent discussion we had a bout the availability of Solumedrol on ambulances I became curious about when the county I used to work for began carrying it on their trucks. It wasn't unitl 2003.

    They told me that last year they switched to Decadron bc it was cheaper and safer. I am wondering how effective this is for SCI compared to solumedrol. Obviously it is not methylprednisolone but what are the components? I admit I have not done my research on the decadron, just came straight to you. They said they will put solumedrol back on if I give them some data.

  2. #2
    Quote Originally Posted by addisue

    addiesue's Avatar

    Join Date: Jan 2006
    Location: Tennessee
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    Wise ? about Decadron vs Solumderol
    After a recent discussion we had a bout the availability of Solumedrol on ambulances I became curious about when the county I used to work for began carrying it on their trucks. It wasn't unitl 2003.

    They told me that last year they switched to Decadron bc it was cheaper and safer. I am wondering how effective this is for SCI compared to solumedrol. Obviously it is not methylprednisolone but what are the components? I admit I have not done my research on the decadron, just came straight to you. They said they will put solumedrol back on if I give them some data.
    addiesue,

    Decadron is dexamethasone and is a more potent steroid than Solumedrol, which is methylprednisolone sodium succinate. Dexamethasone is approximately 5 times more potent as a steroid and therefore less drug dose is used. I am not sure that Decadron is cheaper than Solumedrol in the United States. We had chosen to study methylprednisolone in the beginning because at doses of 30 mg/kg, the drug also has significant antioxidant effects that may be beneficial when combined with its anti-inflammatory effects. Please note that there has never been a prospective randomized study of dexamethansone for spinal cord injury and this needs to be done.

    It is not clear to me that Solumedrol and Decadron would be interchangeable. To my knowledge, there was only clinical study of dexamethasone treatment of acute spinal cord injury in patients. In 1993, Kiwerski from Konstancin Poland reported 290 patients given dexamethasone compared to 330 controls not treated with corticosteroids. Patients with complete and incomplete injuries showed better recovery than controls.

    Methylprednisolone is used to treat optic neuritis. Although this is not a spinal cord injury study, there is one study that suggest that dexamethasone is effective for optic neuritis, a conditions for which methylprednisolone is a standard therapy. Menon, et al. (2007) randomized 21 patients to either i.v. megadose methylprednisolone (250 mg q6h for 3 days) or dexamethasone (200 mg qd for 3 days), followed by 11 days of oral prednisone. At 3 months, there was no statistically significant difference between the two groups. Dexamethasone has long been used as a therapy for malignant spinal cord edema associated with tumors (LobLaw, et al. 2007; Higdon, et al., 2006; Sorenson, et al., 1994). Graham, et al., (2006) compared 96 vs. 16 mg/day for patients with malignant tumor induced spinal cord edema, suggesting that both may be effective. There is higher ambulation rates in patients that received dexamethasone before radiation therapy (Loblaw, et al. 2005).

    Several animal studies suggest that dexamethasone may be effective in animals. Genovese, et al. (2007) has reported that dexamethasone is effective in a mouse spinal cord injury model. Genovese and Mazzon (2007) found that dexamethasone and melatonin combined is beneficial in a mouse slip compression model of spinal cord injury. Wang, et al. (2007) found the dexamethasone restored central spinal cannabinoid-1 receptor changes after peripheral nerve injury. Only one animal study has directly compared methylprednisolone and dexamethasone treatment of acute spinal cord injury in rats. Sharma, et al. (2004) found that methylprednisolone is more effective than dexamethasone in reducing pathological changes and edema, when it is given within a hour after injury.

    Please note the importance of adhering to the NASCIS recommended protocols. Osebold & Kody (1994) described case of bilateral humeral head osteonecrosis following spinal cord injury, in a man who received 797 mg of dexamethasone over 26 days following spinal cord injury. Even though his total steroid dose was significantly less than that given in the NASCIS recommended protocol, the fact that it was given over a 26 day period resulted in a significant and well-known complication. Heimdal, et al. (1992) had similar reported a high incidence of serious side-effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression.

    Wise.

    References Cited
    1. Kiwerski JE (1993). Application of dexamethasone in the treatment of acute spinal cord injury. Injury. 24: 457-60. Metropolitan/Rehabilitation Centre, Konstancin, Poland. This communication evaluates the clinical efficacy of dexamethasone in acute spinal cord injury. The results of treatment in 290 patients given dexamethasone were compared with those of the control group of 330 patients not treated with corticosteroids. Patients with complete injuries and those with incomplete injuries showed greater improvement both quantitatively and qualitatively after treatment with dexamethasone than those without corticosteroids. The slightly increased risk of complications such as gastrointestinal bleeding and delayed wound healing was noted. It is recommended that corticosteroids should be used within the first hours after spinal cord injury.
    2. Menon V, Mehrotra A, Saxena R and Jaffery NF (2007). Comparative evaluation of megadose methylprednisolone with dexamethasone for treatment of primary typical optic neuritis. Indian J Ophthalmol. 55: 355-9. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. drabhasmehrotra@hotmail.com. Aim: To compare the efficacy of intravenous methylprednisolone and intravenous dexamethasone on visual recovery and evaluate their side-effects for the treatment of optic neuritis. Materials and Methods: Prospective, randomized case-controlled study including 21 patients of acute optic neuritis presenting within eight days of onset and with visual acuity less then 20/60 in the affected eye who were randomly divided into two groups. Group I received intravenous dexamethasone 200 mg once daily for three days and Group II received intravenous methylprednisolone 250 mg/six-hourly for three days followed by oral prednisolone for 11 days. Parameters tested were pupillary reactions, visual acuity, fundus findings, color vision, contrast sensitivity, Goldmann visual fields and biochemical investigations for all patients at presentation and follow-up. Results: Both groups were age and sex-matched. LOGMAR visual acuity at presentation was 1.10 +/- 0.52 in Group I and 1.52 +/- 0.43 in Group II. On day 90 of steroid therapy, visual acuity improved to 0.28 +/- 0.33 in Group I and 0.36 +/- 0.41 in Group II ( P =0.59). At three months there was no statistically significant difference in the color vision, contrast sensitivity, stereoacuity, Goldman fields and the amplitude and latency of visually evoked response between the two groups. The concentration of vitamin C, glucose, sodium, potassium, urea and creatinine were within the reported normal limits. Conclusion: Intravenous dexamethasone is an effective treatment for optic neuritis. However, larger studies are required to establish it as a safe, inexpensive and effective modality for the treatment of optic neuritis.
    3. Genovese T, Mazzon E, Esposito E, Muia C, Di Paola R, Bramanti P and Cuzzocrea S (2007). Beneficial effects of FeTSPP, a peroxynitrite decomposition catalyst, in a mouse model of spinal cord injury. Free Radic Biol Med. 43: 763-80. Department of Clinical and Experimental Medicine and Pharmacology, School of Medicine, University of Messina, 98100 Messina, Italy. The aim of the present study was to assess the contribution of peroxynitrite formation in the pathophysiology of spinal cord injury (SCI) in mice. To this purpose, we used a peroxynitrite decomposition catalyst, 5,10,15,20-tetrakis(4-sulfonatophenyl)porphyrinato iron III chloride (FeTSPP). Spinal cord trauma was induced by the application of vascular clips (force of 24g) to the dura via a four-level T5-T8 laminectomy. SCI in mice resulted in severe trauma characterized by edema, neutrophil infiltration, production of inflammatory mediators, tissue damage, and apoptosis. FeTSPP treatment (10-100 mg/kg, i.p.) significantly reduced in dose-dependent manner 1 and 4 h after the SCI (1) the degree of spinal cord inflammation and tissue injury (histological score), (2) neutrophil infiltration (myeloperoxidase activity), (3) nitrotyrosine formation and poly-(ADP-ribose) polymerase activation, (4) proinflammmaory cytokines expression, (5) NF-kappaB activation, and (6) apoptosis (TUNEL staining, Bax and Bcl-2 expression). Moreover, FeTSPP significantly ameliorated the recovery of limb function (evaluated by motor recovery score) in a dose-dependent manner. Taken together, our results clearly demonstrate that FeTSPP treatment reduces the development of inflammation and tissue injury associated with spinal cord trauma similarly to dexamethasone, a well-known antiinflammatory agent which we have used as positive control.
    4. Genovese T, Mazzon E, Crisafulli C, Esposito E, Di Paola R, Muia C, Di Bella P, Bramanti P and Cuzzocrea S (2007). Effects of combination of melatonin and dexamethasone on secondary injury in an experimental mice model of spinal cord trauma. J Pineal Res. 43: 140-53. Department of Clinical and Experimental Medicine and Pharmacology, School of Medicine, University of Messina, Messina, Italy. This study investigates the effects of combination therapy with melatonin and dexamethasone on the degree of spinal cord injury caused by the application of vascular clip in mice. Spinal cord injury in mice resulted in severe trauma, characterized by edema, neutrophil infiltration, and apoptosis (measured by terminal deoxynucleotidyltransferase-mediated UTP end labeling staining, and immunoreaction of Bax, Bcl-2, and Fas Ligand). Infiltration of the spinal cord tissue with neutrophils (measured as increase in myeloperoxidase activity) was associated with enhanced immuno- histochemical and functional alterations revealed, respectively, by an increased of tumor necrosis factor (TNF)-alpha immunoreactivity, NOS as well as nitrotyrosine and loss of hind leg movement in spinal cord injury (SCI)-operated mice. In contrast, the degree of neutrophil infiltration at different time points, cytokine expression, histologic damage iNOS expression, apoptosis, was markedly reduced in the tissues obtained from SCI-treated mice with the combination therapy, and the motor recovery was also ameliorated. No anti-inflammatory effect was observed in animals treated with melatonin (10 mg/kg) or with dexamethasone (0.025 mg/kg) alone. This study shows that the combination therapy with melatonin and dexamethasone reduces the degree of secondary damage associated with spinal cord injury in mice, and supports the possible use of melatonin in combination with steroids to reduce the dose and the side effects related with the use of steroids for the management of inflammatory disease.
    5. Loblaw DA, Holden L, Xenocostas A, Chen E, Chander S, Cooper P, Chan PC and Wong CS (2007). Functional and pharmacokinetic outcomes after a single intravenous infusion of recombinant human erythropoietin in patients with malignant extradural spinal cord compression. Clin Oncol (R Coll Radiol). 19: 63-70. Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. andrew.loblaw@sunnybrook.ca. AIMS: To determine the cerebrospinal fluid concentrations and the functional and pain outcomes after a single intravenous infusion of erythropoietin at the start of a standard radiotherapy and steroid protocol. MATERIALS AND METHODS: Ten paraparetic patients with malignant extradural spinal cord compression who were eligible for radiotherapy, lumbar puncture and intravenous epoetin alpha were enrolled. The patients received epoetin alpha 1500 IU/kg intravenously over 30 min followed by a standardised dexamethasone and radiotherapy protocol. A lumbar puncture and venipuncture were carried out 24-30 h after the epoetin alpha infusion. The patients were followed closely at defined intervals. RESULTS: Erythropoietin was detectable in the cerebrospinal fluid in all eight patients sampled (median 92.5 mIU/ml, range 17.8-214.0 mIU/ml). Before treatment, eight patients were non-ambulatory and two patients were ambulatory with assistance. After treatment, eight (80%, 95% confidence interval [CI] 44-97%) improved at least one functional class and recovered or maintained ambulation. Five of seven patients (71%; 95% CI 29-96%) with objective sensory deficits and one of seven (14%; 95% CI 0-58%) catheter-dependent patients recovered. Overall, 78% (95% CI 40-97%) had a pain response. CONCLUSIONS: After an intravenous infusion of epoetin alpha, radiotherapy and steroids, high concentrations of erythropoietin were detectable in the cerebrospinal fluid. Patients with malignant extradural spinal cord compression showed encouraging improvements in neurological function and pain.
    6. Menon V, Mehrotra A, Saxena R and Jaffery NF (2007). Comparative evaluation of megadose methylprednisolone with dexamethasone for treatment of primary typical optic neuritis. Indian J Ophthalmol. 55: 355-9. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. drabhasmehrotra@hotmail.com. Aim: To compare the efficacy of intravenous methylprednisolone and intravenous dexamethasone on visual recovery and evaluate their side-effects for the treatment of optic neuritis. Materials and Methods: Prospective, randomized case-controlled study including 21 patients of acute optic neuritis presenting within eight days of onset and with visual acuity less then 20/60 in the affected eye who were randomly divided into two groups. Group I received intravenous dexamethasone 200 mg once daily for three days and Group II received intravenous methylprednisolone 250 mg/six-hourly for three days followed by oral prednisolone for 11 days. Parameters tested were pupillary reactions, visual acuity, fundus findings, color vision, contrast sensitivity, Goldmann visual fields and biochemical investigations for all patients at presentation and follow-up. Results: Both groups were age and sex-matched. LOGMAR visual acuity at presentation was 1.10 +/- 0.52 in Group I and 1.52 +/- 0.43 in Group II. On day 90 of steroid therapy, visual acuity improved to 0.28 +/- 0.33 in Group I and 0.36 +/- 0.41 in Group II ( P =0.59). At three months there was no statistically significant difference in the color vision, contrast sensitivity, stereoacuity, Goldman fields and the amplitude and latency of visually evoked response between the two groups. The concentration of vitamin C, glucose, sodium, potassium, urea and creatinine were within the reported normal limits. Conclusion: Intravenous dexamethasone is an effective treatment for optic neuritis. However, larger studies are required to establish it as a safe, inexpensive and effective modality for the treatment of optic neuritis.
    7. Higdon ML and Higdon JA (2006). Treatment of oncologic emergencies. Am Fam Physician. 74: 1873-80. Martin Army Community Hospital Family Medicine Residency Program, Fort Benning, Georgia, USA. higdon@mac.com. Most oncologic emergencies can be classified as metabolic, hematologic, structural, or side effects from chemotherapy agents. Tumor lysis syndrome is a metabolic emergency that presents as severe electrolyte abnormalities. The condition is treated with allopurinol or urate oxidase to lower uric acid levels. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. Syndrome of inappropriate antidiuretic hormone should be suspected if a patient with cancer presents with normovolemic hyponatremia. This metabolic condition usually is treated with fluid restriction and furosemide. Febrile neutropenia is a hematologic emergency that usually requires inpatient therapy with broad-spectrum antibiotics, although outpatient therapy may be appropriate for low-risk patients. Hyperviscosity syndrome usually is associated with Waldenstrom's macroglobulinemia, which is treated with plasmapheresis and chemotherapy. Structural oncologic emergencies are caused by direct compression of nontumor structures or by metastatic disease. Superior vena cava syndrome presents as neck or facial swelling and development of collateral venous circulation. Treatment options include chemotherapy, radiation, and intravenous stenting. Epidural spinal cord compression can be treated with dexamethasone, radiation, or surgery. Malignant pericardial effusion, which often is undiagnosed in cancer patients, can be treated with pericardiocentesis or a pericardial window procedure.
    8. Sorensen S, Helweg-Larsen S, Mouridsen H and Hansen HH (1994). Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer. 30A: 22-7. Department of Neurology, National University Hospital, Rigshospitalet, Copenhagen, Denmark. We performed a randomised single blind trial of high-dose dexamethasone as an adjunct to radiotherapy in patients with metastatic spinal cord compression from solid tumours. After stratification for primary tumour and gait function, 57 patients were allocated randomly to treatment with either high-dose dexamethasone or no steroidal treatment. Dexamethasone was administered as a bolus of 96 mg intravenously, followed by 96 mg orally for 3 days and then tapered in 10 days. A successful treatment result defined as gait function after treatment was obtained in 81% of the patients treated with dexamethasone compared to 63% of the patients receiving no dexamethasone therapy. Six months after treatment, 59% of the patients in the dexamethasone group were still ambulatory compared to 33% in the no dexamethasone group. Life table analysis of patients surviving with gait function showed a significantly better course in patients treated with dexamethasone (P < 0.05). Median survival was identical in the two treatment groups. Similar results were found in subgroup analysis of 34 patients with breast cancer as the primary malignancy. Significant side-effects were reported in 3 (11%) of the patients receiving glucocorticoids, 2 of whom discontinued the treatment. We conclude that high-dose glucocorticoid therapy should be given as adjunct treatment in patients with metastatic epidural spinal cord compression.
    9. Graham PH, Capp A, Delaney G, Goozee G, Hickey B, Turner S, Browne L, Milross C and Wirth A (2006). A pilot randomised comparison of dexamethasone 96 mg vs 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study. Clin Oncol (R Coll Radiol). 18: 70-6. St George Hospital Cancer Care Centre, Kogarah, Sydney, Australia. grahamp@sesahs.nsw.gov.au. AIM: To test the viability of a full-scale randomised comparison of two steroid doses given with radiotherapy for malignant spinal-cord compression (MSCC), to test Internet randomisation and to compare different functional outcome measures. MATERIALS AND METHODS: A log of screened patients at eight recruiting centres was maintained. Patients were randomised via the Superdex website to either 96 mg or 16 mg daily of dexamethasone. Radiotherapy treatment was 30 Gy in 10 fractions. Outcomes assessed used ambulation, Barthel Index ambulation, Functional Independence Measure (FIM) ambulation and Functional Improvement Score (FIS) at 1 month. RESULTS: One hundred and thirty-one patients were screened. Ninety-three (71%) were ineligible, 65% of these were because duration of prior steroid use was greater than 12 h, failure to meet strict definition of magnetic resonance imaging, defined MSCC, multi-level disease or previous spinal-cord compression treatment. Twenty of the 38 eligible patients were randomised, including seven outside standard office hours. There was a high rate of serious adverse events (n = 9), but only one was considered likely to be related to study medication. At baseline, 75% were ambulant, 70% had FIM ambulation scores greater than 5 and 50% had Barthel Index ambulation scores greater than 2. At day 28, including all randomised patients (by scoring four dead patients as non-ambulant), ambulation scores by the various definitions were 60%, 45% and 40%, respectively. For the 16 patients evaluable at day 28, the mean FIS was -1.4. Median survival was 69 days and 1-year survival 13%. CONCLUSION: Web randomisation was successful; however, the high ineligibility rate precludes a full-scale dexamethasone dose trial in Australia. Choice of measure of ambulation has potentially significant effects on outcomes and implications for the design of any future MSCC trials. Referral delays are of concern.
    10. Loblaw DA, Perry J, Chambers A and Laperriere NJ (2005). Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. J Clin Oncol. 23: 2028-37. Departments of Radiation Oncology and Medicine, Sunnybrook and Women's College Health Science Centre, University of Toronto, Ontario, Canada. andrew.loblaw@sw.ca. PURPOSE: This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MSCC). METHODS: MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to January 2004 using the following terms: spinal cord compression, nerve compression syndromes, spinal cord neoplasms, clinical trial, meta-analysis, and systematic review. RESULTS: Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC. The sensitivity and specificity for magnetic resonance imaging (MRI) range from 0.44 to 0.93 and 0.90 to 0.98, respectively, in the diagnosis of MSCC. The sensitivity and specificity for myelography range from 0.71 to 0.97 and 0.88 to 1.00, respectively. A randomized study detected higher ambulation rates in patients with MSCC who received high-dose dexamethasone before radiotherapy (RT) compared with patients who did not receive corticosteroids before RT (81% v 63% at 3 months, respectively; P = .046). There is no direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted if patient is progressing on or shortly after RT, and whether patients with spinal instability should be treated with surgery. CONCLUSION: Patients with symptoms of MSCC should be managed to minimize treatment delay. MRI is the preferred imaging technique. Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.
    11. Sharma A, Tiwari R, Badhe P and Sharma G (2004). Comparison of methylprednisolone with dexamethasone in treatment of acute spinal injury in rats. Indian J Exp Biol. 42: 476-80. Department of Neurosurgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai 400 022, India. alok276@hotmail.com. Effect of methylprednisolone sodium succinate (MPSS) and its comparison with dexamethasone in experimentally induced acute spinal cord compression in adult rats was studied. The rats were divided into group A (control) and group B, which was subdivided into B1, B2, B3 where MPSS was given after 1, 8 and 24 hr and B4 where dexamethasone was given after 1 hr of cord injury respectively. Proper neurological evaluation was done with mobility, running and climbing score. Recovery index was evaluated for 7 days. After sacrificing the rats, spinal cord was observed histopathologically. Mean recovery index and microscopic findings based on hemorrhage in gray and white matter, neuronal degeneration, hematomyelia and edema in white matter were recorded. The results suggested that MPSS was effective in promoting post-traumatic clinical and histological recovery and to a greater extent, when given 1 hr after trauma. MPSS is more effective than dexamethasone in reducing edema when both are given after interval of 1 hr.
    12. Osebold WR and Kody MH (1994). Bilateral humeral head osteonecrosis following spinal cord injury: a case report illustrating the importance of adhering to the recommendations of the Second National Acute Spinal Cord Injury Study. Iowa Orthop J. 14: 120-4. Specialty Orthopaedics, P.C., Spokane, Washington, USA. Five years prior to the 1990 publication of the Second National Acute Spinal Cord Injury Study (SNASCIS), a 24-year-old man sustained traumatic paraplegia, and was treated with 797 mg of dexamethasone over the ensuing 26 days. Within three years he developed symptomatic bilateral humeral head osteonecrosis. Although his total steroid dose was less than one-third of the comparable dose recommended by the SNASCIS, the duration of administration of the steroid was much longer. This case illustrates the importance of adhering to the guidelines established by the SNASCIS, especially regarding the 24-hour administration period.
    13. Heimdal K, Hirschberg H, Slettebo H, Watne K and Nome O (1992). High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression. J Neurooncol. 12: 141-4. Department of Medical Oncology, Norwegian Radium Hospital, Oslo. Twenty-eight consecutive patients were given high-dose dexamethasone (96 mg i.v. loading dose, decreasing doses to zero in 14 days) and radiotherapy for epidural spinal cord compression due to malignant disease. There were eight events classified as side effects of the dexamethasone treatment. Four of these were considered as serious (one fatal ulcer with haemorrhage, one rectal bleeding and one gastrointestinal perforation from undetermined origins, and one perforation of the sigmoid colon) giving a total rate of serious side effects of 14.3 percent. Due to the high incidence of serious side effects of the high dexamethasone dose, the regimen was abandoned in favor of a standard dexamethasone dose of 16 mg daily reduced to zero in 14 days. There were three events classified as side effects, but none were considered as serious in 38 consecutive patients receiving this dose. The differences both in total number of side effects and number of serious side effects are statistically significant. There was no significant difference in the number of ambulant patients in the group that received the high dexamethasone dose. We conclude that the high dexamethasone dose in our experience gives an unacceptably high incidence of serious side effects and we have therefore abandoned the regimen in favour of a more standard dexamethasone dose.

  3. #3
    Thanks Dr.Wise you are wonderful.

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