You see a kid that you’re pretty sure has Henoch Schonlein Purpura (HSP). OK, you’re certain ’cause they have the rash and EVERYTHING. They aren’t hypertensive, and their urine is normal. They have belly pain, but no currant jelly stools, and they don’t have intussusception because the ultrasound was normal. He is eating and drinking OK, and can walk to the bathroom , despite some pain. But the kid’s belly still hurts. And mom is wondering if there’s something that can be done. She tried acetaminophen and that didn’t work. After consulting Dr. Google she saw something about steroids – now she is asking whether or not they would help her son.
So watch’cha gonna do?
Take NSAIDs says you
Well first, let’s look at some treatment options. For most kids with HSP, the symptoms are relatively mild. Though no RCTs exist on the use of NSAIDs in HSP, they are the first line in therapy. There does not seem to be an increased risk of GI bleeding in gut vasculitis, and thus agents that modulate COX activity should be safe. If a patient with HSP has abdominal or joint pain, and does not have GI bleeding or glomerulonephritis, then I recommend NSAIDs. Namely Naproxen, 10-20 mg/kg/day divided into 2 doses. It is easier to do 2 doses as opposed to . The max of 1500mg per day is safe in older children. If you are going to need to use it for >5-7days I suggest dropping back to a max of 1000mg/day. Ibuprofen would be fine as well, but it requires more frequent dosing, and thus adherence may be an issue.
OK, so mom hasn’t tried that yet, but what about the therapy she is asking about?
Stering [sic] down the Corticosteroid option
Some investigator suggest that NSAIDs may fail to work in cases of HSP and belly pain because of bowel edema and compromised absorption. Their claims would not support the use of steroids either since they, you know, require the gut for absorption too. Nevertheless, there is some evidence to suggest that corticosteroids help with;
- Length of pain
- Decreased risk of intussusception
- Decreased risk of recurrence of pain
- Decreased risk of kidney involvement
- Decreased risk of invasive GI interventions (surgery)
This is all far from iron clad however. If you’re going to take a look at one paper check out Weiss et al, Pediatrics, 2007 – a meta-analysis that suggested that corticosteroids reduced the mean time to resolution of pain, and the odds of development of renal disease. On the other hand, a prospective study out of Finland showed no benefit in the risk of onset of renal disease or the subsequent clinical course over 6 months. If you are convinced that steroids would be of benefit the patients most likely to reap said benefits are those with pain severe enough to compromise PO intake, limit their ability to walk, and/or that necessitates admission. You can then give 1/2mg/kg per day up to 60mg/day max of PO prednisone, or 0.8 to 1.6mg/kg/day (max 64mg/day) methylprednisolone in patients that can’t tolerate PO. Depending on how long you continue dosing (there is no solid information on this of course) you may need a protracted taper.
So what about the patient in question?
Well, since he hadn’t received Naproxen that’s what I would try first. I would also spend extra time discussing the usual clinical course, and the expectations that mom has about her son’s symptoms and their eventual resolution. I would assure that PMD follow up is scheduled, and make a plan to discuss steroids if the trial of NSAIDs fails and/or his symptoms worsen. I would not give steroids ostensibly to prevent renal disease, since the evidence is lacking.