Effect of Different Corticosteroid Dosing Regimens on Clinical Outcomes in Boys With Duchenne Muscular Dystrophy: A Randomized Clinical Trial.

Abstract

Importance:

Corticosteroids improve strength and function in boys with Duchenne muscular dystrophy. However, there is uncertainty regarding the optimum regimen and dosage.

Objective:

To compare efficacy and adverse effects of the 3 most frequently prescribed corticosteroid regimens in boys with Duchenne muscular dystrophy.

Design, Setting, and Participants:

Double-blind, parallel-group randomized clinical trial including 196 boys aged 4 to 7 years with Duchenne muscular dystrophy who had not previously been treated with corticosteroids; enrollment occurred between January 30, 2013, and September 17, 2016, at 32 clinic sites in 5 countries. The boys were assessed for 3 years (last participant visit on October 16, 2019).

Interventions:

Participants were randomized to daily prednisone (0.75 mg/kg) (n = 65), daily deflazacort (0.90 mg/kg) (n = 65), or intermittent prednisone (0.75 mg/kg for 10 days on and then 10 days off) (n = 66).

Main Outcomes and Measures:

The global primary outcome comprised 3 end points: rise from the floor velocity (in rise/seconds), forced vital capacity (in liters), and participant or parent global satisfaction with treatment measured by the Treatment Satisfaction Questionnaire for Medication (TSQM; score range, 0 to 100), each averaged across all study visits after baseline. Pairwise group comparisons used a Bonferroni-adjusted significance level of .017.

Results:

Among the 196 boys randomized (mean age, 5.8 years [SD, 1.0 years]), 164 (84%) completed the trial. Both daily prednisone and daily deflazacort were more effective than intermittent prednisone for the primary outcome (P < .001 for daily prednisone vs intermittent prednisone using a global test; P = .017 for daily deflazacort vs intermittent prednisone using a global test) and the daily regimens did not differ significantly (P = .38 for daily prednisone vs daily deflazacort using a global test). The between-group differences were principally attributable to rise from the floor velocity (0.06 rise/s [98.3% CI, 0.03 to 0.08 rise/s] for daily prednisone vs intermittent prednisone [P = .003]; 0.06 rise/s [98.3% CI, 0.03 to 0.09 rise/s] for daily deflazacort vs intermittent prednisone [P = .017]; and -0.004 rise/s [98.3% CI, -0.03 to 0.02 rise/s] for daily prednisone vs daily deflazacort [P = .75]). The pairwise comparisons for forced vital capacity and TSQM global satisfaction subscale score were not statistically significant. The most common adverse events were abnormal behavior (22 [34%] in the daily prednisone group, 25 [38%] in the daily deflazacort group, and 24 [36%] in the intermittent prednisone group), upper respiratory tract infection (24 [37%], 19 [29%], and 24 [36%], respectively), and vomiting (19 [29%], 17 [26%], and 15 [23%]).

Conclusions and Relevance:

Among patients with Duchenne muscular dystrophy, treatment with daily prednisone or daily deflazacort, compared with intermittent prednisone alternating 10 days on and 10 days off, resulted in significant improvement over 3 years in a composite outcome comprising measures of motor function, pulmonary function, and satisfaction with treatment; there was no significant difference between the 2 daily corticosteroid regimens. The findings support the use of a daily corticosteroid regimen over the intermittent prednisone regimen tested in this study as initial treatment for boys with Duchenne muscular dystrophy.

Trial Registration:

ClinicalTrials.gov Identifier: NCT01603407.

• Authors: Michela Guglieri, Kate Bushby, Michael P McDermott, Kimberly A Hart, Rabi Tawil, William B Martens, Barbara E Herr, Elaine McColl, Chris Speed, Jennifer Wilkinson, Janbernd Kirschner, Wendy M King, Michelle Eagle, Mary W Brown, Tracey Willis, Robert C Griggs, FOR-DMD Investigators of the Muscle Study Group, Volker Straub, Henriette van Ruiten, Anne-Marie Childs, Emma Ciafaloni, Perry B Shieh, Stefan Spinty, Lorenzo Maggi, Giovanni Baranello, Russell J Butterfield, I A Horrocks, Helen Roper, Zoya Alhaswani, Kevin M Flanigan, Nancy L Kuntz, Adnan Manzur, Basil T Darras, Peter B Kang, Leslie Morrison, Monika Krzesniak-Swinarska, Jean K Mah, Tiziana E Mongini, Federica Ricci, Maja von der Hagen, Richard S Finkel, Kathleen O'Reardon, Matthew Wicklund, Ashutosh Kumar, Craig M McDonald, Jay J Han, Nanette Joyce, Erik K Henricson, Ulrike Schara-Schmidt, Andrea Gangfuss, Ekkehard Wilichowski, Richard J Barohn, Jeffrey M Statland, Craig Campbell, Giuseppe Vita, Gian Luca Vita, James F Howard Jr, Imelda Hughes, Hugh J McMillan, Elena Pegoraro, Luca Bello, W Bryan Burnette, Mathula Thangarajh, Taeun Chang
• Journal: JAMA (JAMA) Vol. 327 Issue 15 Pg. 1456-1468 (04 19 2022) ISSN: 1538-3598 [Electronic] United States
• PMID: 35381069 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial)

Chemical References

• Glucocorticoids
• Pregnenediones
• Prednisone

Topics

• Child
• Child, Preschool
• Female
• Glucocorticoids (administration & dosage, adverse effects, therapeutic use)
• Humans
• Male
• Muscular Dystrophy, Duchenne (drug therapy)
• Prednisone (administration & dosage, adverse effects, therapeutic use)
• Pregnenediones (adverse effects)