Can a patient with idiopathic intracranial hypertension take prednisone?

Prednisone Use in Idiopathic Intracranial Hypertension

Prednisone is not recommended for patients with idiopathic intracranial hypertension (IIH) as it is not part of standard treatment protocols and may potentially exacerbate the condition. 1

Rationale for Avoiding Prednisone in IIH

• Steroids, including prednisone, are listed as potential causes of secondary pseudotumor cerebri syndrome (PTCS), suggesting they could worsen rather than improve IIH 2
• Current consensus guidelines do not include prednisone or other corticosteroids as recommended treatments for IIH 1
• The 2018 consensus guidelines specifically recommend against using medications that may exacerbate the condition 1

Recommended First-Line Treatments for IIH

• Weight loss should be encouraged as a primary intervention for obese patients with IIH 3
• Acetazolamide is the first-line pharmacological treatment for symptomatic IIH patients or those with visual field/acuity loss 1
  • Starting dose typically 250-500 mg twice daily, with titration as needed 1
  • Maximum dose used in clinical trials was 4g daily, though many patients cannot tolerate doses above 1-1.5g due to side effects 1
• Topiramate may be considered as an alternative due to its dual benefits:
  • Carbonic anhydrase inhibition (reducing intracranial pressure) 1
  • Appetite suppression (aiding weight loss) 1
  • Weekly dose escalation from 25mg to 50mg twice daily is recommended 1

Management of Headaches in IIH

• NSAIDs or paracetamol are recommended for acute headache management 1
• Indomethacin may be particularly beneficial due to its effect on reducing intracranial pressure 1
• Migraine prophylactic agents may be used for headaches with migrainous features 1
• Opioids should be avoided for headache management in IIH 1
• Medication overuse should be monitored and addressed, as it is a common issue in IIH patients 1

Special Considerations

• Pregnant patients require special consideration:
  • Acetazolamide is not recommended during pregnancy due to potential teratogenic effects in animal studies 1
  • Topiramate is contraindicated during pregnancy due to clear evidence of higher rates of fetal abnormalities 1
• For patients with progressive visual loss despite maximal medical therapy, surgical interventions may be necessary:
  • Optic nerve sheath fenestration 3
  • CSF shunting procedures 1

Monitoring and Follow-up

• Follow-up intervals should be based on papilledema grade and visual field status 1
• More frequent monitoring is needed for severe or worsening cases 1, 2
• Visual acuity, visual fields, and fundus appearance should be closely monitored 3

By avoiding prednisone and following evidence-based treatment approaches, patients with IIH can receive appropriate care that addresses both symptom management and the underlying condition while minimizing potential complications.