Re: A new prednisone risk -- AVN/ post from Hobb

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In a message dated 11/7/02 12:29:47 PM Pacific Standard Time, Hob writes:

RCColloran

,

There has been some discussion on Avascular Necrosis (AVN) in Polyarteritis patients why have been taking prednisone for a while on the PAN (PolyArteritis Nodosa) list. AVN occurs when the blood supply to bone ends is cut off and the bones begin to die. This can happen from trauma or from disease and many doctors believe it is also a side effect of long term high dose prednisone in about 10% of patients who are on prednisone.

Since RP patients also take prednisone this may be something the RP list would like to know.

Most of the patients with eventual diagnosis of AVN complain of pain in their hip or hips but some will have the pain in their knees or shoulders or ankles. In some cases AVN can be caused by trauma and when there has been trauma (like a broken shoulder) a lot of docs will just blow it off with a comment about it being caused by a "bone callous" in the area of the break that is causing friction in the joint. If you complain enough they may refer you to an orthopedic surgeon to have an evaluation of whether the "callous" should be cleaned out.

I saw my doc today and asked about AVN because I have a tender spot on both of my hips and I have been taking pred. for four years. The right hip is just "a little sore" in the joint and when I press on it with my fingers it is tender in an area all around the joint.

If this is something that RP or Polyarteritis can cause in the normal course of the disease is not apparent in the research I have read. I do know that Polyarteritis causes some blood vessels to die and if they happen to be the ones that feed bones I can see where AVN might result with or without prednisone. The inflammation of joint cartilage by RP may also cause a stricture of blood vessels and cut off adequate blood supply to the bone. Of course, all of that is speculation.

The important thing is for RP patients to be aware of the symptoms of AVN. AVN has several stages. In the early stages there may just be apparent erosion of the tips of bones in the joints but there can also be bone chips that start floating around the joint adding to the pain. As AVN progresses the entire knob on the end of a bone can disappear and in the third stage the straight part of the bone can become involved (not just the end). The usual treatment is blood supply cannot be restored in some way is to replace the joint with an artificial one.

My pain is at the hip and it is not very bad as yet - just always there. The doctor said that the pain from AVN usually is at the hip joint but also goes across the front of the groin. Since I could not report groin pain he said he doubted there would be any evidence of AVN.

He ordered an xray which I had right after the appointment.

All of the PAN list members who have been diagnosed with AVN and those whose histories are at the AVN support site say that a regular x-ray is generally not sufficient to diagnose AVN - it requires an MRI in most cases but sometimes a CT

Scan will show it.

I plan to get the x-ray film and report and take it with me on my next visit to my Rheumatologist (I saw an internist today). If it is negative I will discuss the pain I have with him a little more to get his opinion. Hopefully he will order the CT scan or MRI that would tell the tale if he feels it is necessary.

The AVN support site has a number of cases of AVN documented where the pain was in the shoulder, knees or ankle. Do not ignore any pain or tenderness at any joint if you have been on prednisone for a long time. If you suspect AVN, visit the AVN support site and read the case histories and the symptoms and diagnostic tests and treatments described there.

http://members.aol.com/AVNrie/OSmain.html

There is also some info about AVN at the NIH web site. Go to google.com and then type in: avascular necrosis The first two titles that come up are the ones I have looked at. AOL did not find anything except a book for sale. I had to go to google.

One of the patients at the AVN site said an orthopedic surgeon diagnosed AVN but he wanted a second opinion. He next went to a man who was a "bone and joint specialist" (wonder how that differs from an orthopedist) and there he got what he believed was a proper diagnosis -- it was not AVN but something else.

One of the other patients suffered with pain, fatigue and other problems for almost seven years while under the care of her "wrist patting" family physician. He just gave her "nerve and pain medicines." She did not take any steroids during that time. She finally went to a Rheumatologist and learned she has AVN, Lupus, Chronic Fatigue Syndrom and, if I recall, something else that is autoimmune. Since she has not taken any steroids until now and has AVN there is the question of whether the Lupus or other disorder is at fault.

I also wonder how a PAN or RP patient who is in a serious flare but who already has AVN would be treated if prednisone had to be taken off the table because of the AVN. Do any of the AVN patients on the PAN list still take prednisone when needed?

The Jewish Hospital web site said that high dose IV prednisone is not believed to have the side effects of oral prednisone -- that there is no record of AVN resulting from short term use of IV steroids.

The Jewish Hospital web sites on vasculitis and on AVN are both very good.