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Ann Indian Acad Neurol. 2010 Apr-Jun; 13(2): 152.
PMCID: PMC2924519

Immunoglobulins as steroid sparing agents in chronic relapsing inflammatory optic neuropathy

Sir,

I read with great interest the case reported by Drs Saini and Khurana titled "Chronic relapsing inflammatory optic neuropathy".[1] I do really appreciate their contribution to the knowledge of chronic relapsing inflammatory optic neuropathy. However, after reading the case I have one main concern: long-term management. It is well known that steroids can prevent reactivation of chronic relapsing inflammatory optic neuropathy. Nonetheless, we should be aware of the severe adverse effects that long-term steroids can induce in these patients. Therefore, there is an increasing interest in the use of intravenous immunoglobulins as steroid-sparing agents, as they have been demonstrated to be effective in the treatment of idiopathic inflammatory neuropathies including Guillain-Barré syndrome, chronic inflammatory demyelinating neuropathy and multifocal motor neuropathy (MMN; in this case represents the gold standard for treatment).[2,3] In the past, other steroid-sparing agents have been used with mild to severe side effects (methotrexate, cyclophosphamide, azathioprine – the most used drug within this group – and mycophenylate).[4,5] The authors could argue that deflazacort was administered on alternate days. Nevertheless, the anti-inflammatory effect is 30% higher compared with prednisolone and a better risk/benefit ratio has only been demonstrated for the bone-sparing effect.[6]

This is why steroid sparing agents should be strongly considered (especially i.v. immunoglobulins) for the management of this condition.

References

1. Saini M, Khurana D. Chronic relapsing inflammatory optic neuropathy. Ann Indian Acad Neurol. 2010;13:61–3. [PMC free article] [PubMed]
2. Stiebel-Kalish H, Hammel N, van Everdingen J, Huna-Baron R, Lee AG. Intravenous immunoglobulin in recurrent-relapsing inflammatory optic neuropathy. Can J Ophthalmol. 2010;45:71–5. [PubMed]
3. Nobile-Orazio E, Terenghi F. IVIg in idiopathic autoimmune neuropathies: analysis in the light of the latest results. J Neurol. 2005;252:I7–13. [PubMed]
4. Myers TD, Smith JR, Wertheim MS, Egan RA, Shults WT, Rosenbaum JT. Use of corticosteroid sparing systemic immunosuppression for treatment of corticosteroid dependent optic neuritis not associated with demyelinating disease. Br J Ophthalmol. 2004;88:673–80. [PMC free article] [PubMed]
5. Smith JR, Rosenbaum JT. A role for methotrexate in the management of non-infectious orbital inflammatory disease. Br J Ophthalmol. 2001;85:1220–4. [PMC free article] [PubMed]
6. Gennari C. Differential effect of glucocorticoids on calcium absorption and bone mass. Br J Rheumatol. 1993;32:11–4. [PubMed]

Articles from Annals of Indian Academy of Neurology are provided here courtesy of Medknow Publications