High-dose corticosteroids improve the prognosis of Bell’s

palsy compared with low-dose corticosteroids: A

propensity score analysis
Takashi Fujiwara *, Yasuharu Haku, Takuya Miyazaki, Atsuhiro Yoshida,
Shin-ich Sato, Hisanobu Tamaki

Dewi Sri Fitriani

405172091
Pembimbing :
dr. Sunaryo, M. Kes, Sp. S
KEPANITERAAN ILMU PENYAKIT SARAF
RSUD RAA SOEWONDO PATI
PERIODE 23 APRIL 2018 – 27 MEI 2018
FAKULTAS KEDOKTERAN UNIVERSITAS TARUMANAGARA
JAKARTA
 Abstract
• Objective: Evaluate the effectiveness of high-dose
corticosteroid (120 mg prednisolone equivalent daily) in
Bell’s palsy compared with low-dose corticosteroid (60 mg PSL
equivalent).
• Methods: A single-center retrospective observational study
was performed.We compared high- and low-dose
corticosteroid for the non-recovery rate at 6 months after
disease onset using inverse probability-weighted propensity
score analysis (IPW-PS).
• Results:
Abstract
• A total of 368 Bell’s palsy patients (281 in the high-dose and 87 in the low-dose
group) were included.
• The non-recovery rate without IPW-PS was 13.8% in the low-dose and 8.2% in the
high-dose group.
• IPW-PS adjustment, the non-recovery rate was 13.1% in the low-dose and 7.8%.
• High-dose corticosteroid decreased the non-recovery rate in severe Bell’s palsy
patients with a Yanagihara score of 0–10, but did not decrease in moderate Bell’s
palsy patients with a Yanagihara score of 12–18.
• The efficacy of high-dose corticosteroids was higher when patients were treated
within 3 days after disease onset
• Conclusions:
• Physicians would be better to treat severe Bell’s palsy patients with high-dose
corticosteroids when the patients are treated within 3 days after disease onset.
 1. Introduction
• Bell’s palsy, defined as an acute facial nerve paralysis of unknown origin, is the
most common cause of peripheral facial palsy
• The etiology of Bell’s palsy remains unclear, but reactivation of latent herpes
simplex type 1 infection in the geniculate ganglion is considered a major cause [5].
• The reactivation of herpes simplex type 1 introduces edematous changes in the
facial nerve [6], causing compression of the nerve in the facial canal.
• Corticosteroids are anti-inflammatory agents, reducing edema and inflammation
of the facial nerve in the acute presentation of Bell’s palsy.
• Several clinical practice guidelines recommend the use of steroids during the acute
phase of Bell’s palsy [7–9], but the optimal dosage of corticosteroids remains
unclear.
 2. Methods
2.1. Study design and setting
Retrospective observational study at Kurashiki Central Hospital
from October 2009 to September 2016.
 2. Methods
2.2. Treatment of Bell’s palsy in our hospital
Bell’s palsy was treated using the following strategy:
1. 30 mg (0.5 mg/kg) PSL equivalent daily for 3 days with a 6-day
taper.
2. 60 mg (1.0 mg/kg) PSL equivalent for 3 days with a 6-day taper
3. 120 mg (2.0 mg/kg) PSL equivalent for 3 days with a 6-day taper.
Corticosteroids were administered orally at an initial dose of 0.5 or 1.0
mg/kg, and intravenously at an initial dose of 2.0 mg/kg.
 2. Methods
2.3. Outcome measures
• The primary outcome was non-recovery at 6
months after onset.
• Recovery was defined as an improvement in the
Yanagihara facial nerve grading system score to
36 or more without sequelae, according to the
facial paralysis guidelines of the Japan Society of
Facial Nerve Research.
 2. Methods
2.4. Statistical analysis
• Data are presented as frequencies and percentages for categorical variables and
continuous variables are expressed as mean and standard deviation.
• The non-recovery rate was compared using the unpaired t-test.
• Calculate the average treatment effects of high-dose corticosteroid using IPW-PS
• We included the following factors in the logistic regression: age, sex, time from
disease onset to start of treatment, side of palsy, initial Yanagihara facial grading
system score, diabetes mellitus, hypertension, and use of antiviral medication.
• Number of patients who had new prescriptions for adverse effects was compared
using odds ratio.
• Data were analyzed using Stata for Mac software (ver. 14.0; Stata Corp., College
Station, TX, USA).
 3. Results
3.1. Patient characteristics
 3. Results
3.2. Comparison of non-recovery rate between low- and high- dose
corticosteroid
 4. Discussion
• IPW-PS analysis revealed that a high-dose of corticosteroid
improved prognosis in Bell’s palsy.
• The effectiveness of high-dose corticosteroid was greater in
patients with a Yanagihara score of 0–10.
• High-dose corticosteroid tended to decrease the non-recovery rate
in patients with a Yanagihara score of 12–18, but no significant
difference was observed based on IPW-PS analysis.
• Thus, 60 mg PSL equivalent daily would be sufficient for Bell’s palsy
with a Yanagihara score of 12–18, and the treatment strategy in the
clinical practice guidelines of the Japan Society of Facial Nerve
Research is adequate.
4. Discussion
4. Discussion
 4. Discussion
This study has some limitations:
• First, 39 patients were excluded because they were lost to follow-up.
• Second, we did not collect data on body mass index (BMI), hematologic
parameters (e.g., neutrophil-to-lymphocyte ratio), or stapedial muscle reflex.
• Third, the mean initial dose of prednisolone in the high-dose group was 120mg PSL
equivalent daily. We did not evaluate the initial PSL dose of 200 mg daily for the
prognosis of Bell’s palsy.
• Fourth, we could not select non-recovery at 12 months as an endpoint instead of
non-recovery at 6 months because the number of patients lost to follow-up would
increase between 6 and 12 months.
• Fifth, we could not avoid a bias due to differences in the administration route and
where the administration route impacts on the effectiveness of high- dose
corticosteroids.
 5. Conclusions
• This study showed that high-dose (120 mg PSL
equivalent) corticosteroid improved prognosis
in Bell’s palsy compared with low-dose
corticosteroid (60 mg PSL equivalent).
• High efficacy could be obtained only if
patients were treated within 3 days after
disease onset.
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