High Dose Glucocorticoids Potentiate the Reponse to Erythropoietin.

Introduction: The role of steroids in mammalian erythropoiesis has remained not well defined.

At our institution, we have observed cases in which it appears that there is a synergism between Erythropoietin factor and glucocorticoids. In three cases, the patients were being treated for anemia that was slow to respond to erythropoietin, but then had a sudden quick rise in Hemoglobin following concomitant therapy with Glucocorticoids.

Case #1 is a 32 year-old black female, with SLE for more than 20 years, lupus nephropathy, end-stage renal disease on maintenance Hemodialysis, for the last 5 years, chronic anemia secondary to renal failure, and thrombocytopenia due to lupus. The patient was treated with prednisone 20 mg daily as a maintenance therapy for her SLE and erythropoietin (procrit) 10,000 units injection three times a week, during each session of hemodialysis.

On April 27^th patient was switched over from prednisone 20mg daily to dexamethasone 6mg orally every 12 hours for 4 does followed by prednisone 40 mg orally every day for worsening thrombocytopenia.

A robust rise in hemoglobin level was noticed, from 7.5gm/dl to 17.5 gm/dl within a month from the date started on high dose glucocorticoids a long with procrit.

Complete work up for secondary polycythemia was all negative.

Procrit was discontinued while prednisone 40mg/day was continued, hemoglobin level decreased to 14.8 g/dl, and platelet count remain stable above 150/CMM.

Case #2. A 52 years old female who was diagnosed with stage 111B NSCLC treated with chemo radiation.

During the period of chemo radiation hemoglobin level remained between 9–10gm/dl on procrit 40,000 units once per week.

Before completion of the Chemotherapy patient developed brain metastasis treated with whole brain irradiation, Dexamethasone 4mg every 6 hours and Dilantin 100mg orally daily for seizure prophylaxis.

Three weeks after starting dexamethasone hemoglobin level increased to 17 gm/dl without any obvious reason.

Complete work up for secondary polycythemia was all negative.

Case #3. is a 42 year old female, with HIV/AIDS (CD4<20) not on any HAART medications, Chronic anemia treated with procrit 10,000 units three times a week for six months and Feso4 325 mg tablets three times a day with hemoglobin base line around 8.00 gm/dl and Seizure.

Was admitted on 12/28/05 with odynophagia, cough and shortness of breath was treated for oropharyngeal candidiasis and PCP pneumonia with Bactrim IV, Nystatin, Diflucan and Methylprednisolone 125 IV daily on 12/28/06 changed later to Prednisone 20mg orally once daily from 12/30/06 until 1/27/06.

While the patient on both Glucocorticoids and procrit we notice the increased of hemoglobin from 7.7 gm/dl on 12/29/05 to 12gm/dl on 1/27/06.

All other causes of secondary polycythemia have been ruled out.

Conclusion:

The reason for the inordinate rise in hemoglobin after starting corticosteriods could be explained by the action of corticosteriods on an immune component of the anemia, to a synergistic effect with erythropoietin on erythropoiesis through a shared mechanism or to a coincidental factor(s) unrelated to either drugs. Whatever the mechanism,

1. When corticosteriods are prescribed for patient on erythropoietin they should be closely monitored for the development of erythrocytosis.

2. Cautious use of glucocorticoids should be considered in patients who are refractory to erythropoietin.