Prednisone and Infections

Hi all, wishing you all the best.
I am posting about acute infections.
I was diagnosed with ITP about 7 months ago. I also have several auto-immune related illnesses.
A big part of my life is dedicated to the battle of not just the auto-immune illnesses and co-morbitities (sp?) but the acute things that my body has a hard time hiding from.
I was put on the high dose prednisone as many of you have been to get my platelets back from 13 to a safer range. Prednisone is not fun for sure. hardest thing I have ever dealt with in all my years. But what I find even more difficult is the acute infections that I catch because of the pred. I have problems with my sinus, and respiratory. Also bladder infections. I always end up with something on top of everything else. Funny thing is though that it is the "on top" thing, the acute infections, that knock me to the floor. I am right in bed unable to fight period.
No more walks, no more eating healthy, no more life! No keeping going. That's not good.

I learned about metabolic syndrome today, and insulin resistance. Rob told me about it and the affect of prednisone tapers which I have had such a struggle with, the fatigue is relentless. I read that pred aids in all kinds of problems when taken long enough at high enough doses and the tapers are very difficult. Lupus also has all kinds of challenges and adds to all kinds of serious co-morbidities. That's why one has to keep going, moving, eating well, keeping weight down, being happy and stress free and living. And for ever I have felt that it is my determination to get myself up anyway no matter what is why I do pretty darn good. Just keep going. But when I am so sick with acute infections always popping up I can no longer do anything. No more fight.
I ask, does anyone else have problems with constant acute infection while doing the high dose Prednisone blasts? Do you find the doctors are helpful? I can't say they have been for me, often I go for weeks before I finally get so sick they cannot ignore that there is a need for antibiotic. They have such an aversion to antibiotics, but for me, I think the lack of them in time like these is ssoooo much more detrimental. All I do is lay around sick for weeks!
thanks, Sandy Too

Sandy - You should speak to your doctor about these things. I have the same problem with constant infections and I don't know what to do about it either. All you can do is tackle one at a time and do the best you can.

Interesting because prednisone is given for bad asthma - I've had it for sinus infections that won't go away, doctor wanted to give it to me for an ear infection that made me go deaf in one ear but I refused (hearing did eventually come back).

Have your immunoglobulins (IgA, IgG, IgM) been tested? Problem is a low IgG treatment is IVIg and if I remember right you can't have that.

Are you happy with your doctors? If not can you change?

I'm sorry you are so down - and getting sick so often.

Sandy Too, Prednisone raises blood glucose, and elevated blood glucose can cause UTIs from bacteria or from yeast. I wonder if Metformin would lower the risk of infection by reducing blood glucose. You might ask your doctor.

Melinda, The thinking behind using prednisone for ear and sinus infections is that by relieving inflammation it allows sinuses/ear canal to drain so that the infection can clear up. My father-in-law just had a treatment of antibiotics + meclizine + prednisone for a stubborn ear infection, and it worked like a charm.

Yep, knew that Rob as I've had to take it a number of times for sinus infections that wouldn't go away - a couple years ago figured I was deaf in that ear thanks to the infection and taking pred wasn't a guarantee (I asked) so I refused - but thanks.

I'm not sure Metformin should be taken lightly - a couple of big red boxes here and a long "before you take Metformin tell your doctor or pharmacist....":
medlineplus.gov/druginfo/meds/a696005.html

Agreed, metformin should not be taken lightly, especially for those with kidney or liver problems.
Elevated glucose should not be taken lightly, either. It has many deleterious effects.
One must always weigh the risk against the benefit.

I don't recall elevated glucose being talked about until you mentioned metformin. Of course elevated glucose shouldn't be taken lightly but that is something that would be discussed with doctor by the patient and then a decision made. You had suggested asking a doctor about taking a medication, with lots of side effects & 2 red boxes, just in case bladder infections were being caused by prednisone raising glucose levels - it would have probably been wiser to suggest a test to see if prednisone had caused elevated glucose. If the person's glucose is elevated then I apologize.

Interesting stuff and informative. I will have three visits two this week and one nexy with specialists. GI, rheumatology and then hemo. I am certainly going to discuss this problem and they are going to hear me.
I can't be trying any second line drug, suggested rituximab, if I can end up with even more infections. It all has to be sorted out and a plan of attack before I would ever agree. No more of this wait and see and laying around sick. It's so unfair and unhealthy.
I did get a yeast issue right after the first bad UTI. The doctor last night wondered if that is the issue. So I have nystatin and yogurt pills to help with the new antibiotic. You have heard of high maintenance women, yep that's me! LOL! Kind of gives it a whole new meaning!
Sorry you deal with infections too Sandi, it just really take it out of you.
I am warned continually of diabetes because of the long term prednisone, but so far so good. I am very careful and do my best with diet and exercise. But who knows maybe with all this extra pred the past months something could have changed? It would account for the fatigue, blurred vision and terrible sweating even when I just think of doing something.....but so would an infection. I will talk to them this week. thanks, Sandy Too

You'd need to have your A1C tested for diabetes. I am pre-diabetic. I just lost about 20 pounds though (down to 133!) so that may have helped. That's another thing I have to follow up on.

Your symptoms are also Prednisone-related...sweating, blurred vision, fatigue....

Sandy Too are your doctors [GI, rheumatologist and hematologist] communicating with each other about you? I would want that to be happening.

Sandy Too wrote: I can't be trying any second line drug, suggested rituximab, if I can end up with even more infections.

Does Rituximab give one increased susceptibility to infections?
Just off hand I would think they are unrelated. Rituximab affecting Lymphocytes (B and T cells) and infections attacked by Neutrophils.

Any immunosuppressant can raise the risk of infections (and cancers). However, I didn't get sick at all after having Rituxan and it hasn't been a common complaint here. Rituxan has been used since 2002 by the members on the PDSA. A few people have reported getting sick but that could have happened anyway.

B cells and T cells produce antibodies that fight germs. They are an important part of the immune system, but there are many other components to the immune system as well. I would be more concerned about Rituxan and infections if I had other impaired immune functions as well, such as prior splenectomy or CVID.

Maybe not but then?? But why then in the Provan study and other studies I have read about Rutixamab does it state that often patients die more often from infection and cancer over bleeds from ITP? So that sometimes it's better just to wait and be watchful? Also that it would compromise one's immune system for up to a year after treatment?
The paper about Rutixamab, I was given by my Hemo said that I couldn't even be around people that had the flu shot?? It gives all kinds of just crazy warnings...many about infections...and then on the very bottom it says " ....because adverse reactions are listed, does not mean that the drug can't or won't cause death?"...
I thought a big part of the issue with the drug was all about compromising your immune response and therefor the potential for serious infection and a compromised immune system to deal with them???...Sandy Too

Sandy:

I said, "Any immunosuppressant can raise the risk of infections". That is true. A lot depends on the general health of the person and any other risks they might have. If someone who is otherwise healthy gets Rituxan, they probably won't have problems unless they are directly exposed to germs, of course. People who have other health issues that result in immunosuppression may have to be more careful. Their immune systems can't fight germs as well. Years ago, we had a woman here that died from sepsis. She'd had a splenectomy, was on Prednisone and had just had Rituxan. She got sick and within 24 hours, had passed away. Chances are, if she'd only had Rituxan, she would not have died.

It all depends on the risk factors of the individual. This is the time of year when illnesses get passed around, so of course anyone can get sick. Back when I had Rituxan (2003), I was relatively healthy. I didn't get sick. I'd definitely be more concerned about having it now, for the exact same reasons I avoid CellCept and Imuran.

Yes, more people die from infection than bleeding and I blame that on over-treating. People with other underlying problems need to be careful about treatment options and space them out.

Lupus qualifies as one of those underlying problems:

Lupus affects the immune system, thus reducing the body’s ability to prevent and fight infection. In addition, many of the drugs used to treat SLE also suppress the function of the immune system, thereby further depressing the ability to fight infection. The risk of infection parallels medication dosages and duration of treatment.

Patients with SLE who show signs and symptoms of infection need prompt therapy to prevent it from becoming life threatening. The most common infections involve the respiratory tract, urinary tract, and skin and do not require hospitalization if they are treated promptly. Other opportunistic infections, particularly Salmonella, herpes zoster, and Candida infections, are more common in patients with SLE because of altered immune status.

www.lupus.us.com/lupus-infection.html

I am agreeing with Sandi, and adding that most infections with Rituxan occur where:

• old infections, especially hepatitis B, are reactivated, or,
• Rituxan is used in combination with other immunosuppressants

www.iwmf.com/sites/default/files/docs/Rituximab-Associated_Infections-Seminars_in_Hematology.pdf
Rituximab-Associated Infections
After more than 10 years of use, rituximab has proven to be remarkably safe. However,
accumulated evidence now suggests that under some circumstances it may significantly
increase the risk of infections. This risk is difficult to quantify because of confounding factors
(namely, concomitant use of immunosuppressive or chemotherapeutic agents and underlying
conditions), as well as under-reporting. Increased number of infections has been documented
in patients treated with maintenance rituximab for low-grade lymphoma and in patients with
concomitant severe immunodeficiency, whether caused by human immunodeficiency virus
(HIV) infection or immunosuppressive agents like fludarabine. From the practical standpoint,
the most important infection is hepatitis B reactivation, which may be delayed and result in
fulminant liver failure and death. Special care should be placed on screening for hepatitis B
virus (HBV) and preemptive antiviral treatment. Some investigators have reported an increase
in Pneumocystis pneumonia. Finally, there is increasing evidence of a possible association with
progressive multifocal leukoencephalopathy (PML), a lethal encephalitis caused by the polyomavirus
JC. This review enumerates the described infectious complications, summarizes the
possible underlying mechanisms of the increased risk, and makes recommendations regarding
prevention, diagnosis and management.
Semin Hematol 47:187–198. © 2010 Published by Elsevier Inc.

So I saw my rheumatologist today. She is great. The only doctor I can say I truly trust.
I told her everything I have found out from my hemo and all the stuff I have learned here.
She agreed to everything. She knows like I know that I am not like most people....although I would very much like to be, so would she as it would make things a whole lot easier for both of us. I am complicated and years of experience has taught us both that neither her or I are at the wheel with regard to what my body will do at anytime or when it will do it and how bad and how long.
She agreed about not having the spleen removed, I might need it. As far as the Rituximab, she said there are no guarantees for any part of it. No guarantees that it won't harm me, that it won't make me sick, or I won't have a bad reaction or I won't end up with infections or worse. Also that it will work and for how long if it does, or even how often I will have to have it. She did agree about the low dose for me though, which is good, as she knows my track record with most any medication. But there is one other thing she did make clear and that is that "they" (her and my hemo) cannot allow me to walk around with platelets at 13. It's too dangerous.
So I feel better that we talked, and that I know I can still trust her. Trust her to give me enough credit to be listened too when I feel something needs considered or addressed.
Still though, I don't think I am any further ahead. The only thing I learned that is new is that she will not allow me to do nothing and go on with my life.
We had a good talk about my concerns for getting any kind of decent after care in my small town ER in the event I needed it or even my access to antibiotics if I end up needing them. Doctors don't like giving antibiotics. It's a problem for me.
Neither my rheumy or hemo run my local healthcare network. The healthcare here is not good for me at any given time. Also that I think it unfair to give me this kind of treatment, send me home and expect our local ER doctor and staff to even know what to do in the event of a serious problem.
Soooo, I am tired, and I worked hard again, and now it's time to rest. My rheumy did tell me that considering the infections, and high dose pred and the taper I am supposed to feel this crappy. So now I can stop feeling bad about it and lay around some more....
thanks for everything, Sandy Too.