Steroids in HSP—more fuel!

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Henoch-Schonlein purpura (HSP) is a common childhood vasculitis, which rarely requires referral beyond the primary care physician. The most bothersome feature of the disorder for many patients turns out to be the gastrointestinal manifestations. Significant abdominal pain can be disabling in some children, even to the point of requiring a period of parenteral nutrition.

Many pediatricians find that corticosteroids are efficacious in addressing the gastrointestinal complications of HSP, although until now they have had little in the way of evidence to support this. Some evidence is now available in a study by Ronkainen et al published in this issue of The Journal. These workers enrolled 171 children with HSP from several centers in Finland in a double-blind, placebo controlled trial of prednisone. Of note, the drug was given at the onset of HSP, regardless of the presence of gastrointestinal complaints at presentation. Treated children were less likely to develop significant abdominal pain, and, when they did, it tended to be of less severity and duration than in the placebo-treated children.

Strictly speaking, the study does not address the use of corticosteroid once gastrointestinal complaints have surfaced. Thus, purists may continue to claim, with some merit, that the study provides no support to the use of corticosteroids in established gastrointestinal disease in children with HSP. Believers, however, will probably use this study to support what is already widespread clinical practice.

This study also examined renal disease as an endpoint. Steroids had no apparent effect on the development of nephritis, although there was a tendency for renal disease to “resolve” more readily in the treated group. This observation, however, must be interpreted with caution. Serious renal complications of HSP are extremely rare in children, and, when they occur, may do so late in the course of the disease, even after the other manifestations have resolved.