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Corticosteroid Induced Myopathy - StatPearls - NCBI Bookshelf - Continuing Education Activity |
Weekly Steroids Strengthen and Repair Muscles - News Center.
Myopathy in patients being treated with corticosteroids is known primarily among chronically treated patients or in critically ill and mechanically ventilated patients receiving corticosteroids, often in high doses. To highlight the entity of acute, early onset corticosteroid-treatment-associated myopathy and its characteristics.
Acute corticosteroid myopathy ASM exists, though the syndrome appears to be rare. Proximal limb muscle weakness is the most common form, but distal limb, bulbar and respiratory muscles may be involved. A high index of suspicion for the possibility of ASM is necessary to ensure drug discontinuation and recovery. This is particularly true since the entity is not widely recognized and its symptoms are often erroneously interpreted as due to the patient's underlying disease. Iatrogenic steroid-induced myopathy, first described by Dubois inis well recognized in its chronic form but considerably less in the acute, early onset variant.
The prevailing thought is that chronic steroid myopathy evolves over a course of months of treatment with oral corticosteroids, presents with gradually increasing weakness of the proximal limb muscles and may or may not be accompanied by myalgia, increased muscle enzymes or electromyographic changes. We present in brief, four cases demonstrating that acute, early onset steroid myopathy can develop shortly after initiation of treatment, involve varied muscle groups and should be considered even in patients treated with moderate doses of oral glucocorticoids started in the ambulatory setting.
Patients were diagnosed and treated by the authors at a single academic medical center over a period of 8 years. All gave their signed informed consent for publication, specifying their wish to facilitate recognition in time to allow reversibility of muscle weakness.
The reference lists of publications meeting criteria for ASM were scanned and additional relevant reports were retrieved. After the first course, he complained of being unable to lift weights as before instead of 60 he could hardly lift 40 Kg. This was ascribed to his illness. Only a few months later, when more severe myopathic features developed and he was unable to climb stairs, steroid myopathy was recognized. Changing to a non-steroid containing treatment regimen led to significant improvement in his muscle strength within weeks but not to full resolution.
He had been using voice analysis software regularly and decided to apply it to monitor changes associated with his steroid treatment. Significant differences in all measured parameters were recorded within an hour of taking the prednisone, compared with pretreatment tracings available upon request.
Gradual significant improvement occurred 2 weeks after stopping steroids, until the next course. Only months after completely stopping steroid treatment did he recover his pretreatment singing ability, voice tracings returning to near-normal.
Case 3: A year-old physician with muscle-specific tyrosine kinase MuSK myasthenia developed severe limb weakness after a single dose of 60 mg prednisone, followed by respiratory crisis. Steroid discontinuation and emergent plasmapheresis led to gradual improvement.
Three years later 10 mg prednisone every other day was started. Within a few days significant worsening was noted, particularly on the days of treatment and with increased doses she became bedridden, developed significant swallowing difficulties and required continuous non-invasive ventilatory support.
Gradually decreasing steroid dose until they could be stopped led to significant improvement, yet residual weakness remained and she required a wheel chair and assistance in activities of daily living ADL. Steroids were discontinued with complete resolution of this acute exacerbation within a few days.
An alternative desensitization protocol instead of premedication with steroids was given during subsequent rituximab infusions. Case 4: An year-old man with a 6 year history of mostly ocular myasthenia treated with pyridostigmine developed gradual worsening of his symptoms. After the second dexamethasone dose, he developed severe generalized weakness and new-onset breathing and swallowing difficulties. He was discharged wheelchair-bound and dependent on intermittent respiratory support and assistance in ADL.
Diagnosed as refractory myasthenia, treatment with steroids was continued. In retrospect, he described worsening of his symptoms after each dose of the steroids. Steroid-induced myopathy was considered only after he had been treated with relatively high doses of steroids for over a year, too late to benefit when treatment was tapered. Glucocorticoid-induced myopathy is well-known in chronically treated patients. Some reports involve mechanically ventilated patients whose myopathy developed with concurrent use of neuromuscular blocking agents, prolonged muscle disuse, critical-care nutritional deficiencies and very high doses of corticosteroids.
The true extent of the problem is hard to estimate. Nevertheless, ASM can be considered a rare occurrence. Our cases and literature review demonstrate the great clinical diversity of ASM Table 1 2—12already noted by Askari et al. In contrast with early reports which involved very high doses of steroids, often given to ventilated patients with severe status asthmaticus, 2—5 and suggestions that patients treated with fluorinated corticosteroids are more susceptible, 7 our experience and the scant existing literature reveal that ASM is unpredictable and should be considered when patients treated with steroids regardless of dose, route of administration or length of treatment develop muscle weakness at any site Table 1.
The fact that no single test is diagnostic for this condition 910 adds to the difficulty in its timely recognition. Yet, even the relatively indolent course can be later followed by a more severe, chronic and possibly irreversible form if steroids are continued cases 3 and 4. Thus, when ASM is suspected, corticosteroid-dose should probably be reduced or omitted altogether if an alternative treatment is feasible.
The clinical characteristics of ASM, based on our four patients and the comprehensive review of additional patients reported in the literature is summarised in Table 2.
Table 1. Acute, early onset myopathy associated with glucocorticoid treatment: cases from our clinic and the literature. Old age, malnutrition, immobilization, sedentary lifestyle and a prior muscle disease may all increase the risk of steroid myopathy. Chronic steroid myopathy is mediated mainly through muscle fibre atrophy, affecting glycolytic more than oxidative fibres 15 and takes months to develop.
The exact mechanism of ASM is unclear, but a direct effect on muscle contraction and energy production is likely.
Steroids have numerous non-genomic effects. Thus, a high index of suspicion for steroid myopathy is warranted in any patient who develops new-onset fatigable or constant muscle weakness of any muscle group, independent of the dose or time frame following corticosteroid treatment.
This is even more important in patients with underlying neuromuscular diseases, in which the symptoms of steroid myopathy can be easily attributed to their pre-existing disease. In such cases, timely dose reduction, or preferably, drug discontinuation if possible, are likely to be followed by a significant improvement in muscle strength. Currently, the great diversity in the presentation of early steroid myopathy; the frequent ascribing of symptoms to the primary disease; and poor awareness of this entity, all contribute to delayed recognition and belated treatment.
Steroid myopathy. Clinical, histologic and cytologic observation. Johns Hopkins Med J ; : — Google Scholar. Acute hydrocortisone myopathy. Acute hydrocortisone myopathy in acute severe asthma. Thorax ; 41 : — 2. Acute myopathy in severe acute asthma treated with intravenously administered corticosteroids.
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❿Evidence that prednisone-induced myopathy is reversed by physical training
Weekly doses of glucocorticoid steroids, such as prednisone, help speed recovery in muscle injuries, reports a new Northwestern Medicine study published in the Journal of Clinical Investigation.
The weekly steroids also repaired muscles damaged by muscular dystrophy. One of the major problems of using steroids such as prednisone is they cause muscle wasting and weakness when taken long term. This is a significant problem for people who take steroids for many chronic conditions, and can often result in patients having to stop steroid treatments.
The study showed prednisone directs the production of annexins, proteins that stimulate muscle healing. Giving weekly doses of prednisone also stimulated a molecule called KLF15, which is associated with improved muscle performance. Daily doses of prednisone, however, reduced KLF15, leading to muscle wasting.
In the study, normal mice with a muscle injury received steroids just before injury and for two weeks after the injury. Mice receiving two weekly doses of steroids after the injury performed better on treadmill testing and had stronger muscle than mice receiving a placebo.
Mice that received daily steroids for two weeks after the muscle injury performed poorly on the treadmill and in muscle strength studies, compared to placebo-treated mice.
Scientists also tested the drug in a mouse model of muscular dystrophy, since prednisone is normally given for this disease. Mice with muscular dystrophy that received weekly prednisone were stronger and performed better on the treadmill than those that received a placebo. When prednisone was given every day, the muscles atrophied and wasted. While years of being on the steroids cause growth suppression, osteoporosis and other bad side effects, boys with Duchenne Muscular Dystrophy walk two to three years longer if they take steroids.
Only boys get Duchenne Muscular Dystrophy because it is on the X chromosome, and males have only one X chromosome. This technique uses a laser to poke a hole in muscle cells. Then the muscle cell is observed in real time as it reseals the hole, a natural repair process. For the second part of the study, scientists tested steroids in mice. They damaged the leg muscles in mice and noticed the mice receiving the steroids recovered more rapidly from injury.
Her work also implies normal muscle injury would improve more quickly by taking a weekly dose of steroids such as prednisone. In the future, McNally would like to test steroids in humans and is considering studying it in forms of muscular dystrophy in which steroids would not normally be given, like Becker Muscular Dystrophy or Limb Girdle Muscular Dystrophy.
Steroid treatment is not usually offered for these diseases since the side effects are thought to outweigh any potential benefit. Type above and press Enter to search. Press Esc to cancel. News Center. Disease Discoveries. By Marla Paul May 17, Share Facebook Twitter Email. Steroids thought to waste muscles surprisingly turn out to be beneficial in weekly doses Weekly doses of glucocorticoid steroids, such as prednisone, help speed recovery in muscle injuries, reports a new Northwestern Medicine study published in the Journal of Clinical Investigation.
Images of mouse muscle repair with and without prednisone. The red images indicate the area of muscle injury, which is reduced by prednisone. The green images show the repair cap scab forming over the site of injury. The repair complex forms more quickly with prednisone.
The studies were conducted in mice, with implications for humans. But the new study showed weekly doses — rather than daily ones — promote muscle repair. Next, the scientists tested to see if steroids could boost the repair process. Rehabilitation Research.
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Federal government websites often end in. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. NCBI Bookshelf. Natalya Surmachevska ; Vivekanand Tiwari. Authors Natalya Surmachevska 1 ; Vivekanand Tiwari 2. Corticosteroid-induced myopathy is an iatrogenic myopathy caused by chronic high to moderate systemic corticosteroid use. This is a common condition that must be differentiated from other iatrogenic and organic causes of myopathy.
Diagnosis is based on a high degree of clinical suspicion in patients on chronic steroids; prompt initiation of treatment in the form of corticosteroid withdrawal, if possible, should be initiated to avoid the morbidity associated with the condition.
This activity reviews the characteristics, evaluation, and management of corticosteroid-induced myopathy and highlights the role of the interprofessional team in the care of patients with this condition. Objectives: Outline the epidemiology of corticosteroid-induced myopathy. Explain the pathophysiology of corticosteroid-induced myopathy. Describe the evaluation of corticosteroid-induced myopathy. Identify opportunities for improving care coordination within the interprofessional team to improve outcomes for patients affected by corticosteroid-induced myopathy.
Access free multiple choice questions on this topic. Corticosteroid-induced myopathy is a highly prevalent toxic noninflammatory myopathy, which occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. It was first described in by Harvey Cushing, as part of a constellation of symptoms seen in Cushing syndrome. With the broader use of corticosteroids as therapeutic tools in the s, corticosteroid-induced myopathy became a more well-known entity.
Acute steroid-induced myopathy in the critical care setting is another presentation. Workup typically reveals normal creatine kinase and no other signs of inflammatory disease, with EMG studies unremarkable and biopsy showing atrophy of type 2b fast-twitch muscle fibers. The diagnosis requires a high index of suspicion and is confirmed when muscle weakness improves after 3 to 4 weeks of tapering steroids, although improvement may take months to a year. Other than steroid withdrawal, other options include switching from fluorinated to nonfluorinated glucocorticoids, or alternate day dosing.
Additionally, physical therapy in the form of resistance and aerobic exercise has shown in some studies to prevent and treat steroid-induced myopathy. Corticosteroid-induced myopathy is a toxic noninflammatory myopathy caused by exogenous corticosteroid administration.
Oral and intravenous formulations are most associated with corticosteroid myopathy, although case reports exist regarding steroid myopathy following inhaled corticosteroids and epidural, intramuscular, or intra-articular injection.
Additional risk factors for corticosteroid-induced myopathy include patients with prior muscle disease or spinal cord injury, chronic respiratory illness, poor nutritional status, and sedentary lifestyle. Corticosteroid-induced myopathy is believed to occur through both catabolic and anti-anabolic mechanisms. In terms of catabolic mechanisms, corticosteroids upregulate proteolytic systems such as the ubiquitin-proteasome system, cathepsins lysosomesand calpains calcium-dependent systems.
This increases the proteolysis of myofibrillar proteins by dissociating actin from myosin. Additionally, corticosteroids with high mineralocorticoid activity lower serum potassium and phosphate, which may contribute to muscle weakness.
Muscle biopsy, if performed, reveals atrophy of type 2b or fast-twitch muscle fibers, with less impact on type 1 or slow-twitch muscle fibers, with variability in fiber size and centralization of nuclei, without evidence of inflammation or necrosis. Symptoms of corticosteroid-induced myopathy consist of muscle weakness, typically in a symmetric distribution involving the proximal extremity muscles, with the hip girdle affected more and earlier than the shoulders.
It is associated with long-term muscle atrophy, notably with very minimal or no associated pain. Patients often complain of difficulty rising from a seated position, climbing stairs, and trouble with overhead activities. It is important to observe that the higher doses are more likely to induce clinical myopathy. They may have metabolic complications, including obesity, diabetes, adrenal insufficiency, hyperlipidemia, hypertension, skin, and bone disorders, including osteoporosis and avascular necrosis.
Corticosteroid-induced myopathy is a clinical diagnosis that requires a high index of suspicion. Labwork including creatine kinase CKaspartate aminotransferase ASTlactate dehydrogenase LDHand aldolase are typically normal, although these may be elevated very early in the disease process or acute steroid myopathy of critically ill patients.
EMG findings are typically normal, with an occasional slight reduction in the amplitude of the motor unit potentials. This occurs as EMG measures both type 1 and type 2 fiber activity, and does not differentiate in the preferential atrophy of type 2b muscle fibers. Determination of corticosteroid-induced myopathy is ultimately tested and confirmed when symptoms improve with tapering or discontinuing corticosteroids.
Corticosteroid-induced myopathy is an often overlooked diagnosis, as symptoms are occasionally attributed to the primary illness that the corticosteroid is treating. This prolongs time to diagnosis and increases morbidity. Thus, a high index of suspicion must be maintained when patients present with muscle weakness in any muscle group with particular emphasis on pelvic girdle with any dose, route, or duration of steroids.
For patients unable to taper off steroids, replacement of fluorinated glucocorticoids with non-fluorinated glucocorticoids, such as dexamethasone with prednisone or hydrocortisone should be considered. Although the mechanism is not clear, fluorinated glucocorticoids are known to be much more potent than non-fluorinated glucocorticoids, and this may contribute to their higher toxicity.
Diagnosis is confirmed when muscle strength improves within 3 to 4 weeks of tapering steroids, although recovery may take months to a year. Physical therapy with aerobic and resistance exercises is effective at modulating muscle atrophy in patients who have corticosteroid-induced myopathy.
However, they have not been conclusively evaluated in humans and are not currently recommended. Other medications known to cause drug-induced myopathy include colchicine, antimalarials, and antiretrovirals. Drug-induced myopathy should be considered mainly for patients taking two myopathic agents such as hydroxychloroquine and glucocorticoids for inflammatory disorders.
In contrast to corticosteroid-induced myopathy, these present with elevated muscle enzymes, worsening muscle weakness with discontinuation of steroids, systemic signs of muscle breakdown and inflammation, and characteristic "early recruitment" findings on EMG. Metabolic myopathies related to carbohydrate, lipid, and purine metabolism, and congenital myopathies are more rare causes of muscle weakness and have distinct patterns of presentation.
Corticosteroid-induced myopathy is reversible, with improvement in myopathy within 3 to 4 weeks of tapering corticosteroids, although recovery can take months to a year. Switching from fluorinated glucocorticoids like dexamethasone to nonfluorinated glucocorticoids such as prednisone can sometimes help. It should be recognized that many of the patients on the chronic steroid therapy would need to be weaned off slowly from their steroid regimen to avoid adrenal insufficiency or exacerbation of the disease process for which they have been on long-term steroids.
Physical therapy, with both resistance and endurance exercise, taking into account baseline functional status, is recommended to help prevent and treat glucocorticoid-induced myopathy. Complications of corticosteroid-induced myopathy include the morbidity and subsequent mortality associated with chronic muscle weakness.
Patients experience decreased quality of life through the inability to perform activities of daily living and are at increased risk for falls and injury. Patients should routinely be educated on the risk versus benefit profile of corticosteroids, including the risk of corticosteroid-induced myopathy. Patients should be advised to contact their provider if they notice weakness developing. Patients should be informed that physical activity can help prevent and mitigate the effects of corticosteroid-induced myopathy, and should be prescribed physical therapy as part of a preventive and treatment regimen.
Given the high incidence of corticosteroid-induced myopathy in patients receiving glucocorticoid therapy for a wide range of clinical indications, an interprofessional team should implement systematic clinical screening for corticosteroid-induced myopathy in the appropriate patient populations. Since primary care clinicians are the most frequently and consistently involved specialty in taking care of such patients, they should maintain a high degree of suspicion for this diagnosis.
Additionally, providers and team members should systematically recommend and prescribe physical therapy to prevent and treat corticosteroid-induced myopathy.
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StatPearls [Internet]. Search term. Continuing Education Activity Corticosteroid-induced myopathy is an iatrogenic myopathy caused by chronic high to moderate systemic corticosteroid use. Introduction Corticosteroid-induced myopathy is a highly prevalent toxic noninflammatory myopathy, which occurs as an adverse effect of prolonged oral or intravenous glucocorticoid use. Etiology Corticosteroid-induced myopathy is a toxic noninflammatory myopathy caused by exogenous corticosteroid administration.
Pathophysiology Corticosteroid-induced myopathy is believed to occur through both catabolic and anti-anabolic mechanisms. Histopathology Muscle biopsy, if performed, reveals atrophy of type 2b or fast-twitch muscle fibers, with less impact on type 1 or slow-twitch muscle fibers, with variability in fiber size and centralization of nuclei, without evidence of inflammation or necrosis.
History and Physical Symptoms of corticosteroid-induced myopathy consist of muscle weakness, typically in a symmetric distribution involving the proximal extremity muscles, with the hip girdle affected more and earlier than the shoulders.
Evaluation Corticosteroid-induced myopathy is a clinical diagnosis that requires a high index of suspicion. Differential Diagnosis Other medications known to cause drug-induced myopathy include colchicine, antimalarials, and antiretrovirals.
Prognosis Corticosteroid-induced myopathy is reversible, with improvement in myopathy within 3 to 4 weeks of tapering corticosteroids, although recovery can take months to a year. Complications Complications of corticosteroid-induced myopathy include the morbidity and subsequent mortality associated with chronic muscle weakness.
Deterrence and Patient Education Patients should routinely be educated on the risk versus benefit profile of corticosteroids, including the risk of corticosteroid-induced myopathy. Enhancing Healthcare Team Outcomes Given the high incidence of corticosteroid-induced myopathy in patients receiving glucocorticoid therapy for a wide range of clinical indications, an interprofessional team should implement systematic clinical screening for corticosteroid-induced myopathy in the appropriate patient populations.
Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Glucocorticoid-induced myopathy. Joint Bone Spine. Resistance exercise prevents glucocorticoid-induced myopathy in heart transplant recipients. Med Sci Sports Exerc. Evidence that prednisone-induced myopathy is reversed by physical training. J Clin Endocrinol Metab. Corticosteroid-induced adverse events in adults: frequency, screening and prevention.
Drug Saf. Gupta A, Gupta Y. Glucocorticoid-induced myopathy: Pathophysiology, diagnosis, and treatment. Indian J Endocrinol Metab. Glucocorticoid-induced apoptosis and cellular mechanisms of myopathy. J Steroid Biochem Mol Biol. Steroid myopathy: some unresolved issues.
The muscle weakness usually begins insidiously after chronic use of high-dose steroids, although some patients may develop an acute onset of severe generalized. One of the major problems of using steroids such as prednisone is they cause muscle wasting and weakness when taken long term. Myopathy in patients being treated with corticosteroids is known primarily among ASM was arbitrarily defined as acute-onset muscle weakness with no. Acute, generalized weakness, including weakness of the respiratory muscles, typically occurs days after the onset of treatment with high-. Methylprednisolone is often given in doses of g and theoretically even 2 days treatment (equivalent to g hydrocortisone) might be enough to cause. Steroid-induced myopathy was considered only after he had been treated with relatively high doses of steroids for over a year, too late to benefit when treatment was tapered. Chronic steroid myopathy is mediated mainly through muscle fibre atrophy, affecting glycolytic more than oxidative fibres 15 and takes months to develop. The weekly steroids also repaired muscles damaged by muscular dystrophy. Steroid myopathy: some unresolved issues. In the study, normal mice with a muscle injury received steroids just before injury and for two weeks after the injury. Type above and press Enter to search.Before using this product to practice acne for the first time, pay if you are allergic to it. To fatty, put a small amount on one or two different areas of acne for three days. If you have an allergic reaction, stop using this product and get latest help right away (see the symptoms of an electronic reaction in the Side Warranties section). If you don't have an electronic reaction, you can use the product.
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