Triamcinolone acetonide: a new management of noncompliance in nephrotic children

Noncompliance is frequent in children and adolescents with nephrotic syndrome. Once suspected, noncompliance is difficult to confirm and often impossible to avoid. The standard oral glucocorticoid treatment for children has been shown to be efficient and safe. However, a small number of children/parents are noncompliant to the steroid treatment, resulting in multiple relapses. For these patients the use of steroids with prolonged half-life such as triamcinolone acetonide (TA) can be helpful. We studied seven children (six boys, one girl; median age at diagnosis 8.6 years, range 1.8-10.7) receiving conventional steroid treatment for a median of 30 months (8-74) before starting intramuscular (IM) TA treatment. The standard prednisone treatment was replaced by 1 monthly IM injection of TA (1 mg/kg per day oral prednisone replaced by 1 mg/kg per month IM TA). The treatment was tapered off by a reduction of 10-20% of the initial dose per month over 6-8 months. After a mean observation period of 14 months (3-36) the results were evaluated in terms of number of relapses and treatment tolerance. Four children showed a clear decrease in number of relapses (1.8 to 0 per year); in the other three the number of relapses remained stable. Tolerance was excellent (no cataract, no arterial hypertension), and the cushingoid syndrome did not exceed the level experienced under conventional oral steroid therapy. However, growth velocity decreased during the TA treatment and returned to normal after discontinuation of TA. These preliminary results demonstrate that TA may be used in patients of suspected noncompliance in steroid-sensitive patients who respond with a complete remission during TA treatment over the observation period. Patients who do not benefit from the TA can be classified as very probably steroid-dependent. TA seems to be a useful therapeutic strategy in those patients for whom noncompliance is strongly suspected.