Friday, September 27, 2013

ITP - Counter effects of Prednisolone


On the 10th June 2013 I noticed Purpura's on my chest and thigh region.  Bleeding Gums and bloody wounds inside the mouth region.  One small cut on my finger I ended up bleeding 30 minutes.  With no family history of any platelet disorder it was strange and scary.  Three days ago I had fully recovered from a viral fever later diagnosed to be a strand of Dengu.  On 11 June I underwent a simple platelet count followed by bleeding time / clotting time tests.  All tests failed with the platelet count of 6000.  The normal range is 1,50,000 - 4,50,000.  I was immediately admitted to a local hospital (Deepak Hospital).

Day 1:
Blood & Urine samples were again drawn and SDP(Single Donor Platelets) transfused. I was put on Dexamethasone 60mg IV (Very high Dose approximately equivalent to my Body weight).  The blood test reveled platelets count had further dropped to 3000 and Urine samples reveled RBC presence indicating internal bleeding.  By now purpuras had formed all over the body, while taking BP readings large purpuras formed over the bicep region.  It was a pretty tense moment.  Doctors feared Brain Hemorrhage but luckily I showed no symptoms of that.  I was soon later shifted to Fortis Hospital for further treatment.  The discharge summary mentioned 'ITP'.  A pretty unknown disease to this part of the world :).

Day 1 - 13:
I spent close to 13 days hospitalised, Doctors at Fortis did not treat me for ITP, their assumption was I had Dengu and treated me for Dengu, even though I had no fever nor symptoms of Dengu (Wrong diagnosis).  It was only after 10 days they decided to do a Bone Marrow Aspiration and rule out other blodd diseases/disorders.  During the initial 10 days, I was transfused 7 SDPs and 2 failed attempts of Pulse dose of Heavy Steroids (Dexamethazone 60 Mg).

Finally 1st line treatment for ITP began after one of the blood test revealed I had Antibodies against Platelets.  The Doctors decided I take Prednisolone 60 Mg to begin with and Platelet count check every 12 hours.  My response initially was very very slow, but positive.  

Goolge to find out more on this Immune Supressive Gluco Cortico Steroid, pay attention to the side effects.  Side Effects are what most doctors forget to tell you.  I will elaborate on the side effects and strict do's and don'ts....

Visible Side Effects: 
1. Moon face - This is temporal, jaw region swells up reminds me of 'Nutty Professor', this stays as long as you are on Predinsolone.  Once the medication is stopped, it goes away.  Note that it takes a pretty long time to get back to normal (few months after Perdnisolone has been stopped)

2. Swollen body (more prominent in the foot area)- Due to fluid retention - To prevent this stop taking sodium based salts, switch to Potassium Salts (Rock Salt/Black Salt).  There is noticeable difference when you switch to Potassium Salt (If you have Low BP DO NOT switch to Potassium salt).  However initially I had a mild headache due to drop in blood pressure, it took about a week to get used to.  Neck region swells up too, again this takes a long to get back to normal.

3. Aggression Levels - While on high doses of Predinsolone, you get very aggressive and short tempered.  Its hard to control emotions best thing to do is avoid conflict.

4. Pimples - You get pimples above abdomen  & above the low back region.  Includes, chest, high back, neck, face and head region.   This is preventable if you take any anti-pimple medication.  Make sure you change medication bi-weekly to prevent drug resistant bacterial growth.  I got best results with a combination of - Azithromycin, Clindamycin and Salicylic Acid based pimple treatment.  Since the area affected is too large it makes sense to use Anti-pimple Soap along with the cream.

5. Extreme Hunger - Predisolone increases metabolism which in-turn affects your appetite many fold, while taking 60 MG, my hunger exactly tripled.  Hungry every 1 hour :). Ended up gaining a lot of weight.  With dosage reduced the hunger reduces as well.  Refer Diet section to know more how to control weight gain and appetite.

6. Lack of Sleep - You tend to sleep less while taking predinsolone, but you feel normal next morning.

7. Frequent Urination - Fluid accumulates, belly swells and you pee 5 - 6 times all through the night.  That was the trend till the dose was reduced to 20 mg.  Most doctors find it weird, the doctor i consulted assumed I could have severe Kidney damage, however the tests proved all okay and normal.

1. Hyper Acidity - Taking Predinsolone increase body metabolism depending on the dosage prescribed.  This also increase acid secretion in the stomach.  Avoid all Spicy/Acidic food.  Taking Ant-acid is NOT Sufficient.  Refer Diet Section to know more on what to eat.

2. Severe Joint Pain - Predisolone reduces bone density, generally doctors forget to prescribe Calcium Supplements.

There are many Calcium supplements available the best Calcium supplement is Calcium Citrate 250mg.  It is to be taken on Empty stomach.  It can cause stomach irritation in some, after 30 minutes consume a glass of milk.  FYI : Under normal conditions your body cannot absorb more than 400 - 500 mg of calcium in 3 hours.  So it does not make sense to take 500 MG or a higher dose in 1 go.  Split your doses into 3 or 4  a day. Refer Diet Section to know what helps.

Calcium is one part, the other part is Joint Repair, which no Doctor prescribes - you need 'Glucosamine with MSM 750 Mg ' x 2 Per Day for joint repair, else you will be bed ridden pretty soon with Arthritis like symptoms.  The Joint pain gets worse when every Predinsolone dose taper - The pain is generally pretty severe and no pain killers help (the best remedy i found is Oil of winter Green (red oil)).  The pain is maximum at ->Knee Joint, Ankle and Groin Region initially, later it speads to neck region, low back,  Wrist and shoulder joints.  Do not mistake this pain for Arthritis- Note that Predinsolone is used to Treat Arthritis so there is nothing to worry.  Just take Glucosamine and MSM 1500 MG per day 1-0-1; 1 hour after meals as long as you are on Prednisolone.  Stop it once the Predinsolone dosage is reduced to 5 Mg a day.

1. Liver Damage - Prednisolone causes liver damage, higher the dose, more damage done.  In my case Serum Bilurubin was on the high side, indicating tissue damage.  There was minor pain in the liver area, but nothing significant.  Consuming a lot of raw Jeera, Sugarcane Juice should help.

2. Bed Ridden in just 2 weeks ! - Taking 60 mg of Prednisolone at a stretch without any supplements I was bed ridden by the end of 2nd week.  That's when I realised there is something called 'Side Effects' and you need to change your diet, lifestyle and take supplements.

3. Blood Sugar Levels - Prednisolone increases blood sugar levels, however in my case Blood Glucose was always within limits.

Diet is important in preventing weight gain, osteoporosis, multiple organ failures and joint pain.
Recommended diet (based on self study)

Breakfast -
Anything without OIL, No Potatoes, No legumes. Rich in Proteins, low on carbohydrates and sugar.
1 glass of milk.
1 hour post breakfast, if still hungry eat diabetic biscuits rich in Fibre.

Lunch -
Finger millet (Raagi Ball), Tur Daal as gravy, Curd one or 2 cups. <make sure not spicy>
2 or 3 hour post lunch, Ginger Tea with diabetic biscuits.

Snacks -
If hungry 1 fruit [preferably apples(to be consumed with the skin[rich in potassium]), sweet lime(rich in fibre)]

Dinner -
Finger millet (Raagi Ball) - Raagi is rich in fibre but takes a long time to digest, this helps control your appetite and reduce frequent urge to eat, it has good amount of calcium as well.
Tur Daal - Tur Daal is rich in proteins and it generally does not cause a stomach upset, easy to digest.  use this as gravy  along with the Raagi Ball<no spices>,
Curd one or 2 cups - Curd is rich in calcium.
A small walk and sleep.

1. Calcium 1-1-1 (30 minutes before any meal) 250 mg Calcium Citrate
2. Glucosamine with MSM 1-0-1 (1 hour post meal) 750 mg
3. Pantoprep 40 mg 1-0-0 (30 minutes before 1st meal for the day)
4. Oil of WinterGreen - for joint pain as required during steroid taper.

Patelet Count vs Date Plot:
Platelet Count vs Time

Series of Events shared in an Excel: Series of Events Documented