prednisone pre tx?

[viaduk]

The doc want to put me on prednisone for two weeks prior to starting treatment, in order to deal with Cryoglobulinemia and associated vasculitis.  Does it make sense to take the prednisone? I thought that tx is a way to get rid of the cryoglobulins.  I was also under the impression that prednisone may lead to increased viral load, and that is the last thing that I would want before starting tx.  I'm on vacation right now, and won't have to  deal with this until I return, but I've been obsessing a bit and would appreciate advice.

Thanks.

[spectda]

Treatment depends on the type of cryoglobulin, underlying disease, and severity of symptoms. Cryoglobulinemia with severe hyperviscosity syndrome requires plasmapheresis and chemotherapy of the underlying malignancy. Some patients with cryoglobulinemia suffer from mild, recurrent crops of lower extremity purpura that require no specific therapy. More extensive vasculitis associated with autoimmune diseases or essential cryoglobulinemia may respond to prednisone, cyclophosphamide, or both. The most effective treatment for cryoglobulinemia associated with hepatitis C has not yet been determined. Brief use of prednisone followed by 6 months of interferon alfa has produced clinical and liver function test improvement, but relapse of liver disease and vasculitis often occurs when interferon alfa is stopped.

[spectda]

http://www.hcvadvocate.org/hcsp/articles/Bonkovsky-2.html

The skin, kidney, nerves and joints can be affected by cryoglobulins. Cutaneous leukocytoclastic vasculitis is a skin lesion that appears as palpable purpura (hemorrhages in the skin that result in the appearance of purplish spots or patches) that usually affects the lower extremities over the shins (Fig 1). These lesions are caused by plugging of the dermal capillaries (very small blood vessels in the skin). Successful treatment of the hepatitis C infection with interferon (+ ribavirin) usually results in resolution of the skin lesions.

[spectda]

My understanding is that tx with interferon will sometimes repress or destroy the cryoglobulins if the underlying cause is HCV. For some people who successfully treat the HCV the cryoglobulinemia is resolved also. It is important to see a doctor who has a lot of experience with cryoglobulinemia especially symptomatic with vasculitis.

The problem in getting help with this is finding a hepatologist with experience treating cryo, or having the hepatologist consult with a rheumatologist who has experience with cryo and hep c. Unfortunately there are no truly clear answers.

I don't know a lot about using prednisone pre tx, Is your vasculitis currently active? Do you know your percentage of cryoglobulins in your blood?


Here is some info that may be helpful:

http://emedicine.medscape.com/article/329255-treatment

"Treatment

Medical Care

The goal of therapy is to treat underlying conditions, as well as to limit the precipitant cryoglobulin and the resultant inflammatory effects. Thus, HCV testing is required. HCV-antibody or HCV-RNA testing may be diagnostic. If HCV test results are negative and clinical suspicion remains high, these tests may be performed on the cryoprecipitate. Asymptomatic cryoglobulinemia does not require treatment. Some authors recommend intervening as little as possible except when faced with severe deterioration of renal or neurologic function. Secondary cryoglobulinemia is best managed with treatment of the underlying malignancy or associated disease. Otherwise, cryoglobulinemia is treated simply with suppression of the immune response. A paucity of controlled studies evaluating the relative efficacy of various therapies limits the use of existing data.


Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used in patients with arthralgia and fatigue.
Immunosuppressive medications (eg, corticosteroid therapy and/or cyclophosphamide or azathioprine) are indicated upon evidence of organ involvement such as vasculitis, renal disease, progressive neurologic findings, or disabling skin manifestations.
Plasmapheresis is indicated for severe or life-threatening complications related to in vivo cryoprecipitation or serum hyperviscosity. Concomitant use of high-dose corticosteroids and cytotoxic agents is recommended for reduction of immunoglobulin production. Some authors recommend using concomitant cytotoxic medications or corticosteroids to reduce a rebound phenomenon that may develop after plasmapheresis.
Pegylated interferon alfa (IFN-alfa) combined with ribavirin has demonstrated efficacy in patients with cryoglobulinemia associated with hepatitis C, and efficacy in patients with chronic myelogenous leukemias and low-grade lymphomas has been reported. The details of therapy and the recommended approach vary based on the clinical setting, and expert opinion should be sought.
Case reports have detailed the remission of hepatitis B–related cryoglobulinemic vasculitis with entecavir therapy.38
Small and uncontrolled studies suggest the anti-CD20 chimeric monoclonal antibody rituximab is effective in controlling disease manifestations such as vasculitis, peripheral neuropathy, arthralgias, low-grade B-cell lymphomas, renal disease, and fever.39,40 Rituximab therapy has been used predominately in HCV-related mixed cryoglobulinemia refractory to or unsuitable for corticosteroids and antiviral (IFN-alfa) therapy. Rituximab therapy is reportedly well tolerated in this patient population; however, treatment results in increased titers of HCV-RNA of undetermined significance. The National Institutes of Health has launched a large trial of rituximab in the treatment of mixed cryoglobulinemia."