Effects of corticosteroid on Henoch-Schönlein purpura: a systematic review

Abstract

Objective: No consensus exists among general pediatricians or pediatric rheumatologists regarding whether corticosteroid therapy ameliorates the acute manifestations of Henoch-Schönlein purpura or mitigates renal injury. Therefore, we sought to synthesize the reported experimental and observational data regarding corticosteroid use.

Methods: We performed a meta-analysis based on a comprehensive review of the literature in the Medline database (1956 to January 2007) and the Cochrane Controlled Trials Register. On the basis of reported outcomes among patients with Henoch-Schönlein purpura who were treated at diagnosis with corticosteroids compared with patients treated with supportive care only, we calculated odds ratios for the resolution of abdominal pain, the need for surgical intervention secondary to severe pain or intussusception, the likelihood of Henoch-Schönlein purpura recurrence, and the development of transient or persistent renal disease.

Results: Of 201 articles retrieved from the initial literature search, 15 were eligible for inclusion. Corticosteroid treatment did not reduce the median time to resolution of abdominal pain but did significantly reduce the mean resolution time and increased the odds of resolution within 24 hours. Early corticosteroid treatment significantly reduced the odds of developing persistent renal disease. In addition, although the results were not statistically significant, the prospective data suggest reduced odds of both surgical intervention and recurrence.

Conclusions: Corticosteroids, given early in the course of illness, seem to produce consistent benefits for several major clinically relevant Henoch-Schönlein purpura outcomes.

FIGURE 1

Corticosteroid (CS) treatment of HSP and resolution of abdominal pain. A, Prospective: time to resolution of abdominal pain (days) reported in means and medians. B, Retrospective: ORs (95% CIs) of abdominal pain resolution within 24 hours of corticosteroid administration. The box size is proportional to the inverse of the magnitude of the variance.

FIGURE 2

Corticosteroid treatment and odds of surgery. Shown are the ORs (95% CIs) of subsequent surgical intervention for severe abdominal pain and/or intussusception. A, Prospective; B, retrospective. The box size in B is proportional to the inverse of the magnitude of the variance.

FIGURE 3

Corticosteroid treatment of HSP and odds of recurrence. Shown are the ORs (95% CIs) of HSP recurrence. A, Prospective; B, retrospective. The box sizes are proportional to the inverse of the magnitude of the variance. No overall OR is displayed in B because of the heterogeneity of the studies.

FIGURE 4

Corticosteroid treatment and odds of cumulative incidence of renal disease. Shown are the ORs (95% CIs) of patients with HSP with cumulative (transient or persistent) renal involvement if treated early with corticosteroids. A, Prospective; B, retrospective. The box sizes are proportional to the inverse of the magnitudeof the variance. No overall OR is displayed because of the heterogeneity of the studies.

FIGURE 5

Corticosteroid treatment and odds of persistent renal disease. Shown are the ORs (95% CIs) of persistent renal involvement after HSP diagnosis. A, Prospective; B, retrospective. An end point of 1 year was used for the Huber et al and Mollica et al studies and 6 months for the Ronkainen et al study. The box size in A is proportional to the inverse of the magnitude of the variance.

FIGURE 6

Sensitivity analysis of effect size of future hypothetical studies for likelihood of persistent renal involvement. Shown are the new combined pooled OR versus OR of a hypothetical new study with sample sizes of 200 and 400. The prevalence of persistent renal involvement in the control group was calculated at either 5% (A) or 20% (B).