Pseudotumor cerebri medical therapy: Difference between revisions
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==== 1.Carbonic anhydrase inhibitors ==== | ==== 1.Carbonic anhydrase inhibitors ==== | ||
Carbonic anhydrase inhibitors like acetazolamide reduce cerebrospinal fluid production and reduce the CSF pressure, papilledema and visual field loss. | Carbonic anhydrase inhibitors like acetazolamide reduce cerebrospinal fluid production and reduce the CSF pressure, papilledema and visual field loss.<ref name="pmid22423118">{{cite journal |vauthors=Biousse V, Bruce BB, Newman NJ |title=Update on the pathophysiology and management of idiopathic intracranial hypertension |journal=J. Neurol. Neurosurg. Psychiatry |volume=83 |issue=5 |pages=488–94 |date=May 2012 |pmid=22423118 |pmc=3544160 |doi=10.1136/jnnp-2011-302029 |url=}}</ref><ref name="pmid24756514">{{cite journal |vauthors=Wall M, McDermott MP, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL, Schron EB, Kupersmith MJ |title=Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension treatment trial |journal=JAMA |volume=311 |issue=16 |pages=1641–51 |date=2014 |pmid=24756514 |pmc=4362615 |doi=10.1001/jama.2014.3312 |url=}}</ref> The starting dose is 500 mg twice a day for adults which we can increase to 2-4 gr a day. In young children we start with 25mg/kg and increase it to 100 mg/kg or 2 gr a day.<ref name="pmid18208981">{{cite journal |vauthors=Matthews YY |title=Drugs used in childhood idiopathic or benign intracranial hypertension |journal=Arch Dis Child Educ Pract Ed |volume=93 |issue=1 |pages=19–25 |date=February 2008 |pmid=18208981 |doi=10.1136/adc.2006.107326 |url=}}</ref> Another drug in this group is topiramate which is an antizeizure drug but can inhibit carbonic anhydrase activity too. Case reports suggest that topiramate can reduce symptoms and visual field loss in IIH patients.<ref name="pmid17922725">{{cite journal |vauthors=Celebisoy N, Gökçay F, Sirin H, Akyürekli O |title=Treatment of idiopathic intracranial hypertension: topiramate vs acetazolamide, an open-label study |journal=Acta Neurol. Scand. |volume=116 |issue=5 |pages=322–7 |date=November 2007 |pmid=17922725 |doi=10.1111/j.1600-0404.2007.00905.x |url=}}</ref><ref name="pmid12482228">{{cite journal |vauthors=Pagan FL, Restrepo L, Balish M, Patwa HS, Houff S |title=A new drug for an old condition? |journal=Headache |volume=42 |issue=7 |pages=695–6 |date=2002 |pmid=12482228 |doi= |url=}}</ref><ref name="pmid17324704">{{cite journal |vauthors=Shah VA, Fung S, Shahbaz R, Taktakishvili O, Wall M, Lee AG |title=Idiopathic intracranial hypertension |journal=Ophthalmology |volume=114 |issue=3 |pages=617 |date=March 2007 |pmid=17324704 |doi=10.1016/j.ophtha.2006.08.034 |url=}}</ref><ref name="pmid17085265">{{cite journal |vauthors=Finsterer J, Földy D, Fertl E |title=Topiramate resolves headache from pseudotumor cerebri |journal=J Pain Symptom Manage |volume=32 |issue=5 |pages=401–2 |date=November 2006 |pmid=17085265 |doi=10.1016/j.jpainsymman.2006.07.009 |url=}}</ref> | ||
==== 2.Loop diuretics ==== | ==== 2.Loop diuretics ==== | ||
In addition to acetazolamide we can use loop diuretics like furosemide with the start dose of 20 to 40 mg per day for adults and 1 to 2 mg/kg per day in children. Studies suggest that treatment with both acetazolamide and furosemide can rapidly reduce CSF pressure and papilledema | In addition to acetazolamide we can use loop diuretics like furosemide with the start dose of 20 to 40 mg per day for adults and 1 to 2 mg/kg per day in children. Studies suggest that treatment with both acetazolamide and furosemide can rapidly reduce CSF pressure and papilledema.<ref name="pmid18208981">{{cite journal |vauthors=Matthews YY |title=Drugs used in childhood idiopathic or benign intracranial hypertension |journal=Arch Dis Child Educ Pract Ed |volume=93 |issue=1 |pages=19–25 |date=February 2008 |pmid=18208981 |doi=10.1136/adc.2006.107326 |url=}}</ref><ref name="pmid18208981">{{cite journal |vauthors=Matthews YY |title=Drugs used in childhood idiopathic or benign intracranial hypertension |journal=Arch Dis Child Educ Pract Ed |volume=93 |issue=1 |pages=19–25 |date=February 2008 |pmid=18208981 |doi=10.1136/adc.2006.107326 |url=}}</ref> | ||
==== 3.Corticosteroids ==== | ==== 3.Corticosteroids ==== | ||
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* Weight gain and worsening of symptoms | * Weight gain and worsening of symptoms | ||
* Steroid withdrawal which is one of the IIH risk factors | * Steroid withdrawal which is one of the IIH risk factors | ||
* Systemic side effects | * Systemic side effects<ref name="pmid2679506">{{cite journal |vauthors=Corbett JJ, Thompson HS |title=The rational management of idiopathic intracranial hypertension |journal=Arch. Neurol. |volume=46 |issue=10 |pages=1049–51 |date=October 1989 |pmid=2679506 |doi= |url=}}</ref> | ||
==== 4.Indomethacin ==== | ==== 4.Indomethacin ==== | ||
This drug is believed to reduce the CSF pressure by cerebral vasoconstriction and reducing blood flow | This drug is believed to reduce the CSF pressure by cerebral vasoconstriction and reducing blood flow<ref name="pmid15752400">{{cite journal |vauthors=Rasmussen M |title=Treatment of elevated intracranial pressure with indomethacin: friend or foe? |journal=Acta Anaesthesiol Scand |volume=49 |issue=3 |pages=341–50 |date=March 2005 |pmid=15752400 |doi=10.1111/j.1399-6576.2005.00647.x |url=}}</ref> | ||
==== 5.Iron ==== | ==== 5.Iron ==== | ||
Treatment of iron deficiency anemia can improve IIH patients symptoms | Treatment of iron deficiency anemia can improve IIH patients symptoms<ref name="pmid12654358">{{cite journal |vauthors=Biousse V, Rucker JC, Vignal C, Crassard I, Katz BJ, Newman NJ |title=Anemia and papilledema |journal=Am. J. Ophthalmol. |volume=135 |issue=4 |pages=437–46 |date=April 2003 |pmid=12654358 |doi= |url=}}</ref> | ||
==== 6.analgesics ==== | ==== 6.analgesics ==== | ||
We can use analgesics to control headaches. Overusing of analgesics can cause rebound headaches which should be avoided. | We can use analgesics to control headaches. Overusing of analgesics can cause rebound headaches which should be avoided.<ref name="pmid12034799">{{cite journal |vauthors=Friedman DI, Rausch EA |title=Headache diagnoses in patients with treated idiopathic intracranial hypertension |journal=Neurology |volume=58 |issue=10 |pages=1551–3 |date=May 2002 |pmid=12034799 |doi= |url=}}</ref> | ||
=== Non medical treatment === | === Non medical treatment === | ||
Weight loss with low soduim diet is helpful in IIH patients and can reduce CSF pressure, papilledema and disease symptoms.( | Weight loss with low soduim diet is helpful in IIH patients and can reduce CSF pressure, papilledema and disease symptoms.<ref name="pmid22423118">{{cite journal |vauthors=Biousse V, Bruce BB, Newman NJ |title=Update on the pathophysiology and management of idiopathic intracranial hypertension |journal=J. Neurol. Neurosurg. Psychiatry |volume=83 |issue=5 |pages=488–94 |date=May 2012 |pmid=22423118 |pmc=3544160 |doi=10.1136/jnnp-2011-302029 |url=}}</ref><ref name="pmid20610512">{{cite journal |vauthors=Sinclair AJ, Burdon MA, Nightingale PG, Ball AK, Good P, Matthews TD, Jacks A, Lawden M, Clarke CE, Stewart PM, Walker EA, Tomlinson JW, Rauz S |title=Low energy diet and intracranial pressure in women with idiopathic intracranial hypertension: prospective cohort study |journal=BMJ |volume=341 |issue= |pages=c2701 |date=July 2010 |pmid=20610512 |pmc=2898925 |doi= |url=}}</ref><ref name="pmid9855165">{{cite journal |vauthors=Johnson LN, Krohel GB, Madsen RW, March GA |title=The role of weight loss and acetazolamide in the treatment of idiopathic intracranial hypertension (pseudotumor cerebri) |journal=Ophthalmology |volume=105 |issue=12 |pages=2313–7 |date=December 1998 |pmid=9855165 |doi=10.1016/S0161-6420(98)91234-9 |url=}}</ref> | ||
==References== | ==References== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
Medical treatment
Pharmacologic medical therapies for pseudotumor cerebri include:
1.Carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors like acetazolamide reduce cerebrospinal fluid production and reduce the CSF pressure, papilledema and visual field loss.[1][2] The starting dose is 500 mg twice a day for adults which we can increase to 2-4 gr a day. In young children we start with 25mg/kg and increase it to 100 mg/kg or 2 gr a day.[3] Another drug in this group is topiramate which is an antizeizure drug but can inhibit carbonic anhydrase activity too. Case reports suggest that topiramate can reduce symptoms and visual field loss in IIH patients.[4][5][6][7]
2.Loop diuretics
In addition to acetazolamide we can use loop diuretics like furosemide with the start dose of 20 to 40 mg per day for adults and 1 to 2 mg/kg per day in children. Studies suggest that treatment with both acetazolamide and furosemide can rapidly reduce CSF pressure and papilledema.[3][3]
3.Corticosteroids
In the past, prednisone was suggested for IIH patients but nowadays we avoid using them for long term treatment because of following reasons:
- Weight gain and worsening of symptoms
- Steroid withdrawal which is one of the IIH risk factors
- Systemic side effects[8]
4.Indomethacin
This drug is believed to reduce the CSF pressure by cerebral vasoconstriction and reducing blood flow[9]
5.Iron
Treatment of iron deficiency anemia can improve IIH patients symptoms[10]
6.analgesics
We can use analgesics to control headaches. Overusing of analgesics can cause rebound headaches which should be avoided.[11]
Non medical treatment
Weight loss with low soduim diet is helpful in IIH patients and can reduce CSF pressure, papilledema and disease symptoms.[1][12][13]
References
- ↑ 1.0 1.1 Biousse V, Bruce BB, Newman NJ (May 2012). "Update on the pathophysiology and management of idiopathic intracranial hypertension". J. Neurol. Neurosurg. Psychiatry. 83 (5): 488–94. doi:10.1136/jnnp-2011-302029. PMC 3544160. PMID 22423118.
- ↑ Wall M, McDermott MP, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL, Schron EB, Kupersmith MJ (2014). "Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension treatment trial". JAMA. 311 (16): 1641–51. doi:10.1001/jama.2014.3312. PMC 4362615. PMID 24756514.
- ↑ 3.0 3.1 3.2 Matthews YY (February 2008). "Drugs used in childhood idiopathic or benign intracranial hypertension". Arch Dis Child Educ Pract Ed. 93 (1): 19–25. doi:10.1136/adc.2006.107326. PMID 18208981.
- ↑ Celebisoy N, Gökçay F, Sirin H, Akyürekli O (November 2007). "Treatment of idiopathic intracranial hypertension: topiramate vs acetazolamide, an open-label study". Acta Neurol. Scand. 116 (5): 322–7. doi:10.1111/j.1600-0404.2007.00905.x. PMID 17922725.
- ↑ Pagan FL, Restrepo L, Balish M, Patwa HS, Houff S (2002). "A new drug for an old condition?". Headache. 42 (7): 695–6. PMID 12482228.
- ↑ Shah VA, Fung S, Shahbaz R, Taktakishvili O, Wall M, Lee AG (March 2007). "Idiopathic intracranial hypertension". Ophthalmology. 114 (3): 617. doi:10.1016/j.ophtha.2006.08.034. PMID 17324704.
- ↑ Finsterer J, Földy D, Fertl E (November 2006). "Topiramate resolves headache from pseudotumor cerebri". J Pain Symptom Manage. 32 (5): 401–2. doi:10.1016/j.jpainsymman.2006.07.009. PMID 17085265.
- ↑ Corbett JJ, Thompson HS (October 1989). "The rational management of idiopathic intracranial hypertension". Arch. Neurol. 46 (10): 1049–51. PMID 2679506.
- ↑ Rasmussen M (March 2005). "Treatment of elevated intracranial pressure with indomethacin: friend or foe?". Acta Anaesthesiol Scand. 49 (3): 341–50. doi:10.1111/j.1399-6576.2005.00647.x. PMID 15752400.
- ↑ Biousse V, Rucker JC, Vignal C, Crassard I, Katz BJ, Newman NJ (April 2003). "Anemia and papilledema". Am. J. Ophthalmol. 135 (4): 437–46. PMID 12654358.
- ↑ Friedman DI, Rausch EA (May 2002). "Headache diagnoses in patients with treated idiopathic intracranial hypertension". Neurology. 58 (10): 1551–3. PMID 12034799.
- ↑ Sinclair AJ, Burdon MA, Nightingale PG, Ball AK, Good P, Matthews TD, Jacks A, Lawden M, Clarke CE, Stewart PM, Walker EA, Tomlinson JW, Rauz S (July 2010). "Low energy diet and intracranial pressure in women with idiopathic intracranial hypertension: prospective cohort study". BMJ. 341: c2701. PMC 2898925. PMID 20610512.
- ↑ Johnson LN, Krohel GB, Madsen RW, March GA (December 1998). "The role of weight loss and acetazolamide in the treatment of idiopathic intracranial hypertension (pseudotumor cerebri)". Ophthalmology. 105 (12): 2313–7. doi:10.1016/S0161-6420(98)91234-9. PMID 9855165.