SJS Prevention And Cure
SJS Prevention and Cure

        Taiwan Drug Relief Foundation (2011.9.16) has been advocating the public that patients have to fully open to the doctors about their drug allergy history. Before taking any medicine, patients should consult the pharmacist about the use, side effect and instructions of the medicine. Don’t hesitate to ask if there is anything unclear. If symptoms such as cough, aching, headaches, and feverishness happen after taking the medicine, consult a doctor immediately and stop offending medicine immediately to prevent complications. Early treatment of SJS affords an opportunity to better recovery. Since the cases are rare and serious, SJS/TEN treatments are not easy to be performed a double-blind experiment to verify its effect. Yet, the medical field has confirmed that ADR is the main cause of SJS. Some treatments have been listed here for the references,

A. Regular Care and Supportive Therapy
1. Stop offending medicine immediately.
        Stop offending medicine right away and remove the residues in the blood.
2. Retrieve the medicine.
       Look up the patient’s medical records, onset time and drugs taken to make sure if there is any drug that is causing the SJS.
3. Good Supportive Care.
       Transfer to isolation ward, experienced ICU or burn unit to have a better cure and prevent from complications. What consists Good Supportive Care are,
a. Pain medications are administered to make the patient as comfortable as possible.
b. Treat with better nutrition for the wounds to heal.
c. Protect the wound and refrain from debridement and hurt the epidermal tissue.
d. Keep any possible infections under control
e. Keep electrolyte balanced
f. Fluid balance in the body
g. Good respiratory care
h. Water and body temperature regulation

B. Eye Lesions Treatments
When diagnosing, dermatologist and ophthalmologist often consult together, especially about the following parts (Thong, B. Y., 2013; Foster, 2013, August 12b),
1. Eyelids
        Trichiasis, distichiasis, xerophthalmia and blepharitis.
2. Conjunctiva
       Papillae, follicles, keratinization, subepithelial fibrosis, conjunctival shrinkage, foreshortening of fornices, symblepharon and ankyloblepharon.
3. Cornea
        Superficial punctate keratitis, epithelial defect, stromal ulcer, neovascularization, keratinization, limbitis, conjunctivalization, stromal opacity and perforation.
        The majority of affected patients develop conjunctival inflammation during the acute phase of the disease. If intense, this inflammation yields permanent destruction of the normal mucosal tissue of the ocular surface and eyelids. Loss of the normal glandular structures leads to severe dry eye problems and vision loss. Cyclosporine is efficient on curing inflammation and dry eyes.
        Recent reports have shown improved ocular outcomes with early pulse corticosteroid therapy. The use of amniotic membrane transplantation (AMT) for SJS/TEN was first reported in 2002 with subsequent studies supporting its effectiveness in minimizing long-term visual sequelae. Frequent lubrication, autologous serum, soft bandage contact lenses, moisture chamber goggles and Transplantation of cultivated LSCs can also be applied on serious dry eyes.

C. Specific Treatment
1. Plasma exchange can remove reactive drug metabolites or antibodies and can be considered.
2. Immune Suppression Drugs
A. corticosteroids
        Systemic corticosteroid use in the treatment of erythema multiforme major (EMM) and Stevens-Johnson syndrome (SJS) has been debated in the medical literature for many decades. Short courses of high-dose corticosteroids in early SJS/TEN have a good rationale, as immune mechanisms are directly responsible for the cascade of events leading to apoptosis
B. cyclosporine
       Cyclosporine is the one of the most commonly use immune suppression drugs to cure SJS/TEN. Many researches have indicated that cyclosporine is probably one of the most effective drugs on SJS/TEN.
C. Others
         Other immune suppression drugs, such as cyclophosphamide, are not as common since the reports and reviews are still scarce.
3. Anti-apoptotic drug
A. IVIG
        Early high-dose IVIG 2.7 g/kg over 3 days blocks antibodies and Fas ligand. However, despite some remarkable initial results using high-dose IVIG for TEN, further clinical trials involving small cohorts have reported conflicting results, and a retrospective analysis has suggested no improvement or even higher than expected mortality. Although there is controversy over the use of intravenous immunoglobulin (IVIG) in the treatment of SJS or TEN, IVIG is still the most common way, more than 50%, to treat SJS (Thong, B. Y., 2013).
B. Other anti-apoptotic drug
       Other anti-apoptotic drugs include, thalidomide, pentoxifylline, infliximab, insulin, N-acetylcysteine and zinc. However, thalidomide has been approved that it will increase mortality rate. These anti-apoptotic drugs are not commonly used since the reports and reviews are still scarce.  

4. Other treatments
        Other treatments include *G-CSF, Hyperbaric oxygen therapy ulinastatin and etc., but those related research are still very few though.
*G-CSF (granulocyte colony-stimulating factor) stimulates myeloid cell proliferation.

Reference
  1. 史麗珠(2005)。提升用藥安全。病人安全手冊。第二版。13-15。
  2. 朱家瑜(民100年2月21日)。史蒂芬強生症候群(Stevens-Johnson syndrome，SJS)【網站文字資料】。取自  http://derm.ntuh.gov.tw/Article.asp?BlockName=ArtView&AT_ID=115
  3. 陳立材、吳叔明(民97年12月20日)。疑似使用Carbamazepine引起Stevens-Johnson Syndrome案例報告【電子 報】。取自http://www.taiwan-pharma.org.tw/JTP/097/082-089.html
  4. 藥害救濟基金會(民100年9月16日)。吃藥前必看！服用卡巴氮平先讀用藥須知【網站文字資料】。取自 http://www.tdrf.org.tw/ch/02_affair/aff_01_main.asp?bull_id=4435
  5. Foster, C. S. (2013, August 12b). Stevens-Johnson Syndrome Clinical Presentation [Web message]. Retrieved from http://emedicine.medscape.com/article/1197450-clinical
  6. Thong, B. Y.(2013), Stevens-Johnson syndrome / toxic epidermal necrolysis: an Asia-Pacific perspective. Asia Pacific allergy 2013, 3:215-223
 
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