Objective: To study the efficacy of isoniazid prophylaxis (INHP) in patients with systemic lupus erythematosus (SLE) receiving long term glucocorticosteroid treatment. Patients and methods: Treatment with INHP (5 mg/kg/ day, max 300 mg/day) together with pyridoxine 10 mg/day for one year was started in all patients with SLE seen between January 1994 and December 1999 and followed up thereafter. Clinical examination and chest radiography were carried out in all patients before the start of INHP treatment. A liver profile was obtained only if liver toxicity was suspected owing to nausea, loss of appetite, and icterus. Only the data of those patients who completed the INHP treatment or who were withdrawn owing to toxicity have been analysed. This was compared with the results of an earlier study of the incidence of tuberculosis (TB) in patients with SLE not receiving INHP. Results: Ninety seven patients were included, of whom 95 completed one year's treatment with INHP. Treatment was discontinued in two owing to toxicity: hepatitis in one and peripheral neuropathy in one, at eight and 10 months, respectively. One patient developed TB within one month of starting INHP. Seventy patients were followed up further for at least one year (mean 26.4 months, range 12-60 months) after completion of the INHP treatment. During this period one patient developed TB after one month. No deaths due to TB or hepatitis occurred. In comparison with earlier series the incidence of TB decreased from 11% to 2%, a reduction of 82%. The cost of treatment for each case of TB prevented in the first year was 5800 rupees. Conclusion: INHP is safe and effective in SLE. P atients with systemic lupus erythematosus (SLE) are inherently susceptible to infections. This is aggravated by treatment with steroids and cytotoxic agents.1 In India, tuberculosis (TB) is the most important infection. We and others have reported a prevalence of TB ranging from 5% to 13.7% in patients with SLE receiving steroids.1 2 TB in SLE carries a higher mortality, 3 probably owing to the disseminated nature of the TB in these patients. 4 Treatment with isoniazid prophylaxis (INHP) has been advocated in immunocompromised subjects. In this paper we report our experience with INHP in SLE. PATIENTS AND METHODSSince 1994 we have adopted the policy of treatment with INHP (5 mg/kg/day isoniazid, maximum 300 mg/day and 10 mg/day pyridoxine) for one year of all patients with SLE requiring long term steroids. Patients who started treatment with INHP between January 1994 and December 1999 were studied. At the start all patients underwent a thorough clinical evaluation and chest radiograph to rule out active TB. Patients were evaluated at three to six monthly intervals. Liver function tests (LFT) were carried out during prophylaxis only if liver toxicity was suspected owing to nausea, loss of appetite, and icterus. Only data of those patients who completed the INHP treatment or in whom the drug was withdrawn owing to toxicity have been analysed. The results were compared with the re...
Although it is widely recognized that diagnosis plays a central role in clinical medicine, in recent years the primacy of diagnosis has come under attack from several sources. 1. “Billable terms” are replacing traditional medical diagnoses. The former are based on International Classification of Diseases lists, which include many non‐diagnoses such as symptoms and signs. 2. Diagnosis often gets short shrift because of the perceived urgency of discharge. 3. The problem oriented record, in practice, has frequently led to a shift in emphasis from synthesis of findings to fragmentation of problems. 4. Presumptive diagnoses frequently metamorphose into established diagnoses in medical records, even if incorrect. 5. A number of authors have apparently disparaged the importance of diagnosis. Nonetheless, it is clear that diagnosis must continue to play a central role in clinical medicine. We propose several ways by which we can resist these forces and assure that diagnosis retains its appropriate position of primacy. Journal of Hospital Medicine 2010;5:116–119. © 2010 Society of Hospital Medicine.
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