Oral Medicine, Diagnosis and Radiology Journal Discussion

1. Pulse therapy as a cure for autoimmune diseases
Indian J Dermatol Venereol Leprol September-October 2003 Vol 69
Issue 5
J. S. Pasricha
PRESENTED BY
A.PRIYADHARSHINI
II YEAR MDS
DEPT OF ORAL MEDICINE AND RADIOLOGY

2. PULSE THERAPY
Pulse therapy means the administration of large
(suprapharmacologic) doses of drugs in an intermittent
manner to enhance the therapeutic effect and reduce the side
effects

3. FIRST REPORTED USE OF PULSE THERAPY
Kountz and Cohn – renal graft rejection
Lupus nephritis, rheumatoid arthritis and pyoderma
gangrenosum
Author use pulse therapy for reiter’s disease, pemphigus,
systemic sclerosis, pyoderma gangrenosum

4. THE REGIMEN
Dosage
I phase - 100mg of dexamethasone in 500ml of 5%glucose for 3
consecutive days along with cyclophosphamide – 500 mg in the
same drip
II phase – 9 DCP at exactly 28 day cycles along with 50mg CP
orally per day
III phase – Only 50mg CP orally per day for the next 9 months
IV phase – follow up for the next 10 years

5. INDICATIONS AND CONTRAINDICATIONS
Indications
 Clinical remission
 Have to take maintenance dose of steroids
Contraindication
 Unmarried and those who want to have more children
 Pregnancy, lactating mother
 Have to be given only dexamethasone pulses
 Cyclophosphamide - amenorrhea or azoospermia

6. The AIIMS experience
Relapse rate
53.8%
18.2%
8%
23.5%
Condition
Incomplete treatment
Irregular intervals
Regular intervals
Only cyclophosphamide

7. Conditions Total no of
patients
Sex Age No of
patients
P.Vulgaris 444 Male – 251 <20 44
P.Foliaceus 33 Female - 249 20-40 246
P.Erythematosus 18 40-60 190
P.Vegetans 5 >60 20
1982 and 1998
Not complete – 97
Died due to variety of causes – 19
Completely recovered - 384

8. CLINIC EXPERIENCE
Rx in all patients with active disease
 Betamethasone 2-3 mg/day
 Ketoconazole 200mg/day
 Ciprofloxacin – 500mg bid, in addition to DCPs and daily
dose of 50mg cyclophosphamide
Skin lesions – 1- 2 months
Oral lesion – 2-3 months

9. SIDE EFFECTS
 Leukopenia,thrombocytopenia,anemia – rare
 Generalized hyperpigmentation – 5 patients
 Hemorrhagic cystitis – 5 patients
 Hair loss – reversible
 Amenorrhea, azoospermia
 Weakness, tiredness, bad taste, diarrheaa
 Recurrent hiccup
 Bone pains

10. IMMUNOFLUORESCENCE TESTS
 Positive in almost all patients
 Autoantibodies was higher even when patient had recovered
completely
 Amount of treatment to be given should depend upon the
clinical state and not IF tests

11. Other regimens and drugs
Azathioprine
Methotrexate
Cyclosporine
Mycophenolate mofetil

12. MERITS
Indication
Contra- indication
Regimen
DEMERITS
Mechanism of action of drug

13. DISCUSSION

14. CYCLOPHOSPHAMIDE
 Alkylating agent of nitrogen mustard
 Prodrug
 Activated in liver

15. Alkylating agents
Form highly reactive ion
Transfer of alkyl group to DNA bases
Results in
 Cross linkage
 Abnormal base pairing
 DNA strand breakage
 Apoptosis
MECHANISM OF ACTION

16. CYCLOPHOSPHAMIDE
Aldophosphamide
Phosphoramide mustard Acrolein
Hemorrhagic cystitis
Mesna

17. Dosage Route of
administration
Uses Adverse
effects
Drug
interaction
Tab- 50mg Oral Autoimmune Pancytopenia No drug
interactions
IV 100,
200, 500,
1000 mg
vial
Intravenous Cancer Hemorrhagic
cystitis
Graft rejection

18. DEXAMETHASONE
Glucocorticoid agonist
Dexamethasone
Binds with specific cytoplasmic glucocorticoid receptors
Complex binds with DNA elements
Modify transcription
Inhibit leukocyte infiltration
Suppress humoral immune response

19. Dosage Route of
administration
Uses Adverse
effects
Drug
interaction
Tab –
0.75mg to
9mg
Oral Infections Adrenal crisis Barbiturates
8mg to
16mg
Intramuscular Autoimmune
diseases
Thrush,
muscle
weakness
Phenytoin
10mg vial Intravenous Malignancy Rifampicin

20. REFERENCES
Dexamethasone - The American Society of Health-System Pharmacists.
Retrieved Jul 29, 2015
Pulse therapy in autoimmune diseases - Indian J Dermatol Venereol Leprol
September-October 2003 Vol 69 Issue 5
Tripati pharmacology textbooks
Schmelzeisen R; Frölich Janice C. (1993). "Prevention of postoperative
swelling and pain by dexamethasone after operative removal of impacted third
molar teeth". Eur. J. Clin. Pharmacology. 44 (3): 275–7.