Advances in Steroid Sparing Agents for Children with Nephrotic Syndrome
Department of Child Health FKUNIBRAWDr Syaiful Anwar General Hospital
Immunosuppressive agents including cyclophosphamide, calcineurin inhibitors, and mycophenolate mofetil are often used to treat these are often used in children with resistant steroid, dependent steroid, frequently relapsing nephrotic syndrome as steroid sparing effects. Cyclophosphamide remains the most commonly used steroid sparing agent. Cyclophosphamide, chlorambucil and levamisole reduce the risk of relapse in children with new medications (mycophenolate mofetil, tacrolimus and rituximab) have become widely used in children with relapsing steroid sensitive nephrotic syndrome.
Oral cyclophosphamide and chlorambucil substantially reduced the risk of relapse compared with prednisone alone, there was no significant difference in efficacy between cyclophosphamide and chlorambucil. The intravenous of cyclophosphamide has significantly better efficiency, when compared with the oral cyclophosphamide. Chlorambucil treatment also reduced the risk for relapse at 12 months compared with placebo or prednisone alone.
Cyclosporin A appears to be as effective as alkylating agents during therapy. However, relapse commonly occurs when cyclosporin therapy is terminated. Complete remission significantly higher with tacrolimus than cyclophosphamide. The decision as to which medication should be used in a child with steroid resistant, frequently relapsing or steroid-dependent will largely depend on patient and physician preference following discussion of the need for prolonged courses of cyclosporin or levamisole compared with eight to 12 week courses of the alkylating agents to maintain remission, the possible side effects, and the costs of courses of alkylating agents, and those of prolonged courses of cyclosporin A or levamisole.