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The impact of asthma and its treatment on growth: an evidence‐based review. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Katsaounou P, Buhl R, Brusselle G, Pfister P, Martínez R, Wahn U, Bousquet J. Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma. Respir Med 2019; 150:51-62. [PMID: 30961951 DOI: 10.1016/j.rmed.2019.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
Systemic/oral corticosteroids (OCS) have been used for decades in the management of acute asthma exacerbations and chronically in patients with uncontrolled severe asthma. However, while OCS are effective at treating acute exacerbations, there is only empirical evidence regarding the efficacy of OCS at reducing the rate of exacerbations. Evidence, although scarce, is suggestive of high exacerbation rates in severe asthma patients even when receiving maintenance treatment with OCS. In addition, use of OCS is associated with undesirable effects. Despite all this, physicians have continued to use OCS for managing severe asthma and acute exacerbation due to the lack of availability of effective alternatives. Fortunately, in the last decade several biologics have been proven safe and effective for patients with uncontrolled severe asthma. This has led to the Global Initiative for Asthma (GINA) recommending the use of biologics, instead of maintenance OCS, in patients with severe asthma (GINA Step 5). These include one biologic targeting immunoglobulin E (IgE) (omalizumab), and different biologics targeting interleukin-5 (IL-5), the IL-5 receptor (IL-5R) or IL-4 receptor α-unit (IL-4R α), including mepolizumab (subcutaneous), reslizumab (intravenous), benralizumab (subcutaneous) and dupilumab (subcutaneous). Omalizumab for the treatment of severe allergic asthma reduces exacerbations, irrespective of blood eosinophil levels. Anti-IL-5/IL-5R biologics are indicated in patients with severe eosinophilic asthma and repetitive exacerbations, irrespective of the presence or absence of allergy. Recently, an anti-IL4Rα biologic has been approved by the FDA for eosinophilic phenotype or oral corticosteroid-dependent asthma. Finally, physicians should consider using biologics as an alternative to chronic OCS therapy.
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Affiliation(s)
- Paraskevi Katsaounou
- School of Medicine, National and Kapodistrian University of Athens, 1st ICU Evangelismos Hospital, Athens, Greece.
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, De Pintelaan, Ghent, Belgium; Department of Epidemiology and Respiratory Medicine, Erasmus MC Rotterdam, Rotterdam, the Netherlands.
| | - Pascal Pfister
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland.
| | - Rafael Martínez
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland
| | - Ulrich Wahn
- Department of Paediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Jean Bousquet
- Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, Montpellier, France.
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Guilbert TW, Bacharier LB, Mauger DT, Phipatanakul W, Szefler SJ, Boehmer S, Beigelman A, Fitzpatrick AM, Jackson DJ, Baxi SN, Benson M, Burnham CAD, Cabana MD, Castro M, Chmiel JF, Covar R, Daines M, Gaffin JM, Gentile DA, Holguin F, Israel E, Kelly HW, Lazarus SC, Lemanske RF, Ly N, Meade K, Morgan W, Moy J, Olin JT, Peters SP, Pongracic JA, Raissy HH, Ross K, Sheehan WJ, Sorkness C, Teague WG, Thyne S, Martinez FD. Challenges in assessing the efficacy of systemic corticosteroids for severe wheezing episodes in preschool children. J Allergy Clin Immunol 2019; 143:1934-1937.e4. [PMID: 30660645 DOI: 10.1016/j.jaci.2018.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Wanda Phipatanakul
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - Susan Boehmer
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Avraham Beigelman
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | | | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sachin N Baxi
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Michael D Cabana
- Departments of Medicine and Pediatrics, University of California, San Francisco, San Francisco, Calif
| | - Mario Castro
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | | | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Michael Daines
- Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Mass
| | - Deborah A Gentile
- Department of Pediatrics, Allegheny General Hospital, Pittsburgh, Pa
| | | | | | - H William Kelly
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
| | - Stephen C Lazarus
- Departments of Medicine and Pediatrics, University of California, San Francisco, San Francisco, Calif
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ngoc Ly
- Airway Clinical Research Center, University of California, San Francisco, San Francisco, Calif
| | | | - Wayne Morgan
- Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - James Moy
- Stroger Hospital of Cook County Pediatric Services, Chicago, Ill
| | - J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | | | | | - Hengameh H Raissy
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
| | - Kristie Ross
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - William J Sheehan
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | - Shannon Thyne
- Department of Pediatrics, San Francisco General Hospital, San Francisco, Calif
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Haslund-Krog SS, Schmidt M, Mathot R, Kryger Jensen A, Jørgensen IM, Holst H. Pharmacokinetics of prednisolone in children: an open-label, randomised, two-treatment cross-over trial investigating the bioequivalence of different prednisolone formulations in children with airway disease. BMJ Paediatr Open 2019; 3:e000520. [PMID: 31646194 PMCID: PMC6782035 DOI: 10.1136/bmjpo-2019-000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/03/2019] [Accepted: 09/08/2019] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION One in three Danish children under 3 years of age experience asthma-like symptoms, and one-third will later be diagnosed with asthma. Oral prednisolone is used in various formulations to treat acute asthma. However, the potential differences in bioequivalence between these formulations have never been examined in children despite interchangeable use in clinical practice. METHODS AND ANALYSIS An open-label, randomised, two-treatment cross-over trial investigating the bioequivalence of different prednisolone formulations in children with airway disease.The included patients (6 months-11 years of age) are admitted to the Department of Paediatric and Adolescent Medicine Nordsjællands University Hospital, Hillerød, with asthma or asthma-like symptoms.The primary objective is to assess the bioequivalence between different prednisolone formulations herein area under the concentration time curve, Cmax and Tmax using saliva samples. The secondary objectives are to evaluate tolerability (five-point face scale), adverse events and severity of the disease. If the patient has an intravenous access for other purposes, the saliva samples will be validated with plasma samples.A total of 66 evaluable patients are needed according to European Medicines Agency Guideline on bioequivalence. ETHICS AND DISSEMINATION Traditional pharmacokinetic trials are burdensome due to the extent of blood samples necessary to capture the time-dependant drug profile. Saliva sampling is far more acceptable for paediatric patients. In addition, this trial adheres to standard dosing strategies. No additional venepunctures are performed, and no additional prednisolone doses are administered.Guidelines for paediatric bioequivalence trials are warranted. TRIAL REGISTRATION NUMBER The Danish Medicines Agency EudraCT: 2017-003590-33, The Ethics Committee case no: H-17027252, and the Danish Data Protection Agency: BFH-2017-103, I-Suite no.: 05935.
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Affiliation(s)
- Sissel Sundell Haslund-Krog
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Paediatric and Adolescent Medicine, Hillerød Hospital, Hillerød, Denmark
| | - Maria Schmidt
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Ron Mathot
- Department of Hospital Pharmacy - Clinical Pharmacology Unit, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Andreas Kryger Jensen
- Department of Biostatistics, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Research, Hillerød Hospital, Hillerød, Denmark
| | - Inger Merete Jørgensen
- Department of Paediatric and Adolescent Medicine, Hillerød Hospital, Hillerød, Denmark.,Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Helle Holst
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
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Elements Associated With Early Mortality in Children With B Cell Acute Lymphoblastic Leukemia in Chiapas, Mexico: A Case-control Study. J Pediatr Hematol Oncol 2019; 41:1-6. [PMID: 30339656 DOI: 10.1097/mph.0000000000001337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Childhood Lymphoblastic leukemia's (ALL) early mortality (EM) is an undesirable treatment outcome for a disease for which >90% long term success is achievable. In the Western world EM constitutes no >3%; yet, in Chiapas, Mexico, remains around 15%. With the objective of improving on EM, we determined associated elements in 28 ALL who died within 60 days of arriving at Hospital de Especialidades Pediátricas in Chiapas (HEP), by comparing them to those in 84 controls who lived beyond the first 90 days. χ, t test, and binary logistic regression (BLR) were used to determine significant individual and multiple variables associated to outcome. On arrival, fever, liver and spleen enlargement, active bleeding, lower albumin, less platelets, higher creatinine, and uric acid, more diploid and less hyperdiploid cases were associated with EM cases. Time to diagnosis, nutritional status, risk group and leukocyte count were not related. Antileukemic treatment approach was similar in both groups. The BLR model including fever, active bleeding, liver enlargement, <10,000 platelets/µL, and >2X upper normal lactic dehydrogenase, determined outcome in 66.7% EM and 90.2% controls. To improve on EM in ALL, patients with characteristics defined here ought to be treated differently at HEP.
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Delgado‐Noguera MF, Forero Delgadillo JM, Franco AA, Vazquez JC, Calvache JA. Corticosteroids for septic arthritis in children. Cochrane Database Syst Rev 2018; 11:CD012125. [PMID: 30480764 PMCID: PMC6517045 DOI: 10.1002/14651858.cd012125.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Septic arthritis is an acute infection of the joints characterised by erosive disruption of the articular space. It is the most common non-degenerative articular disease in developing countries. The most vulnerable population for septic arthritis includes infants and preschoolers, especially boys. Septic arthritis disproportionately affects populations of low socioeconomic status. Systemic corticosteroids and antibiotic therapy may be beneficial for treatment of septic arthritis. Even if the joint infection is eradicated by antibiotic treatment, the inflammatory process may produce residual joint damage and sequelae. OBJECTIVES To determine the benefits and harms of corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, Latin American Caribbean Health Sciences Literature (LILACS), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/), ClinicalTrials.gov (www.ClinicalTrials.gov), and Google Scholar. We searched all databases from their inception to 17 April 2018, with no restrictions on language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) with patients from two months to 18 years of age with a diagnosis of septic arthritis who were receiving corticosteroids in addition to antibiotic therapy or as an adjuvant to other therapies such as surgical drainage, intra-articular puncture, arthroscopic irrigation, or debridement. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, data extraction, and evaluation of risk of bias. We considered as major outcomes the presence of pain, activities of daily living, normal physical joint function, days of antibiotic treatment, length of hospital stay, and numbers of total and serious adverse events. We used standard methodological procedures expected by Cochrane. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table. MAIN RESULTS We included two RCTs involving a total of 149 children between three months and 18 years of age who were receiving antibiotics for septic arthritis. The most commonly affected joints were hips and knees. These studies were performed in Costa Rica and Israel. In both studies, dexamethasone administered intravenously (ranging from 0.15 to 0.2 mg/kg/dose every six to eight hours) during four days was the corticosteroid, and the comparator was placebo. Trials excluded patients with any degree of immunodeficiency or immunosuppression. The longest follow-up was one year. Trials did not report activities of daily living nor length of hospital stay. Both studies used adequate processes for randomisation, allocation concealment, and blinding, and review authors judged them to have low risk of selection and performance bias. Losses to follow-up were substantive in both studies, and we judged them to have high risk of attrition bias and of selective outcome reporting. We graded all outcomes as low quality due to concerns about study limitations and imprecision.The risk ratio (RR) for absence of pain at 12 months of follow-up was 1.33, favouring corticosteroids (95% confidence interval (CI) 1.03 to 1.72; P = 0.03; number needed to treat for an additional beneficial outcome (NNTB) = 13, 95% CI 6 to 139; absolute risk difference 24%, 95% CI 5% to 43%).The RR for normal function of the affected joint at 12 months of follow-up was 1.32, favouring corticosteroids (95% CI 1.12 to 1.57; P = 0.001; NNTB = 13, 95% CI 7 to 33; absolute risk difference 24%, 95% CI 11% to 37%).We found a reduction in the number of days of intravenous antibiotic treatment favouring corticosteroids (mean difference (MD) -2.77, 95% CI -4.16 to -1.39) based on two trials with 149 participants.Researchers did not report length of hospital stay. One trial (49 participants) reported that treatment with dexamethasone was associated with a shorter duration of IV antibiotic treatment, leading to a shorter hospital stay, and although duration of hospitalisation was a primary outcome of the study, study authors did not provide data on the duration of hospitalisation. We downgraded the quality by one level for concerns about study limitations (high risk of attrition bias and selective reporting), and by another level for imprecision.In one trial of 49 participants, researchers followed 29 children for 12 months, and parents reported that no children demonstrated adverse effects of the intervention. AUTHORS' CONCLUSIONS Evidence for corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis is of low quality and is derived from the findings of two trials (N = 149). Corticosteroids may increase the proportion of patients without pain and the proportion of patients with normal function of the affected joint at 12 months, and may also reduce the number of days of antibiotic treatment. However, we cannot draw strong conclusions based upon these trial results. Additional randomised clinical trials in children with relevant outcomes are needed.
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Affiliation(s)
- Mario F Delgado‐Noguera
- Facultad Ciencias de la Salud, Universidad del CaucaDepartamento de PediatriaHospital Universitario San JoseDepartamento de PediatríaPopayánColombiaNA
| | - Jessica M Forero Delgadillo
- Facultad Ciencias de la Salud, Universidad del CaucaDepartamento de PediatriaHospital Universitario San JoseDepartamento de PediatríaPopayánColombiaNA
| | - Alexis A Franco
- Facultad Ciencias de la Salud, Universidad del CaucaDepartamento de PediatriaHospital Universitario San JoseDepartamento de PediatríaPopayánColombiaNA
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
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Abrams EM, Becker AB, Szefler SJ. Use of Oral Corticosteroids in the Wheezy Toddler. J Pediatr 2018; 201:16-20. [PMID: 30251636 DOI: 10.1016/j.jpeds.2018.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/10/2018] [Accepted: 06/04/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Allan B Becker
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pulmonary Medicine, Breathing Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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Ranakusuma RW, McCullough AR, Safitri ED, Pitoyo Y, Widyaningsih, Del Mar CB, Beller EM. Oral prednisolone for acute otitis media in children: protocol of a pilot randomised, open-label, controlled study (OPAL study). Pilot Feasibility Stud 2018; 4:146. [PMID: 30214821 PMCID: PMC6130070 DOI: 10.1186/s40814-018-0337-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/29/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute otitis media (AOM) is an acute inflammation of the middle ear commonly found in children, for which antibiotics are frequently prescribed. However, antibiotics are beneficial for only one third of AOM cases, and then, with only modest benefit. Since antibiotic use leads to risk of side effects and resistance, effective alternative treatments are required. Corticosteroids are a candidate because of their anti-inflammatory effects, although evidence of their efficacy and harms is insufficient. Accordingly, we plan a large, rigorous clinical trial to test this. Initially, we will test pre-specified methods and procedures (including the overall process, resources, management, and scientific components) in a pilot study of corticosteroids for AOM, which will inform a future, definitive trial. METHODS This is a pilot pragmatic, randomised, open-label, single-blind, controlled study of corticosteroids as either monotherapy or an addition to antibiotics in 60 children aged 6 months to 12 years with AOM in two cities (Jakarta and Bekasi) in Indonesia. We will randomise eligible children to prednisolone or control. We will also stratify by disease severity and randomise those with mild AOM to expectant observation plus prednisolone or observation alone and those with severe AOM to prednisolone plus antibiotic or antibiotic alone. Our outcomes are to determine (1) recruitment rates, (2) the success of the study procedures, (3) the ability to measure planned outcomes of the proposed main study, (4) the compliance to study visits and study medication, and (5) verification of the sample size calculation for the main study. We will also assess middle ear effusion using tympanometry as part of a mechanistic sub-study. DISCUSSION This study will test all procedures in preparation for the main study, including several potential obstacles and challenges from the perspective of participating physicians, nurses, pharmacists, and the parents of eligible children. This information will be useful for developing strategies to overcome practical and procedural issues. This study may also provide information about the effects of corticosteroids on middle ear effusion in AOM. TRIAL REGISTRATION Study registry number: ACTRN12618000049279. Name of registry: the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of registration: 16 January 2018.
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Affiliation(s)
- Respati W. Ranakusuma
- Centre for Research in Evidence-Based Practice Faculty of Health Sciences and Medicine Bond University, 14 University Drive, Robina, 4226 Queensland Australia
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Amanda R. McCullough
- Centre for Research in Evidence-Based Practice Faculty of Health Sciences and Medicine Bond University, 14 University Drive, Robina, 4226 Queensland Australia
| | - Eka D. Safitri
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Yupitri Pitoyo
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Widyaningsih
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Christopher B. Del Mar
- Centre for Research in Evidence-Based Practice Faculty of Health Sciences and Medicine Bond University, 14 University Drive, Robina, 4226 Queensland Australia
| | - Elaine M. Beller
- Centre for Research in Evidence-Based Practice Faculty of Health Sciences and Medicine Bond University, 14 University Drive, Robina, 4226 Queensland Australia
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Abstract
PURPOSE OF REVIEW Despite currently available treatments, many asthma patients remain inadequately controlled, but identifying distinct patient populations (phenotypes/endotypes) may optimize their management. This review discusses some of the controversies and opportunities for improved disease control in severe asthma. RECENT FINDINGS Currently approved anti-immunoglobulin E and anti-interleukin 5 biologics, which target specific pathways instead of using a 'one size fits all' strategy, are efficacious and well tolerated therapies for severe asthma. The appropriate use of these biologics, and of those in development (e.g., benralizumab and dupilumab), should be aided by further understanding of asthma phenotypes and endotypes, utilizing appropriate biomarkers.Oral corticosteroids are often added as maintenance therapy for patients with severe uncontrolled asthma, but their use is associated with significant adverse effects and should be considered a last option. The true cost of this therapy, including the cost of morbidities associated with its use, remains to be determined.Severe asthma in pediatrics poses a unique opportunity for possible prevention strategies and the potential for primary prevention. Although several avenues for primary prevention are being explored and are out of the scope of this review, we focus our discussion on the use of omalizumab, which has been recently explored in clinical trials. SUMMARY Appropriate use of biologics in severe asthma should be supported by further understanding of biomarkers predicting response to targeted therapy. Because of their association with significant adverse effects, add-on oral corticosteroids should be considered a last treatment option for patients with uncontrolled severe asthma. Finally, severe asthma in pediatrics poses a unique opportunity for potential prevention strategies.
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Kirkland SW, Vandermeer B, Campbell S, Villa-Roel C, Newton A, Ducharme FM, Rowe BH. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018; 56:522-533. [PMID: 29693459 DOI: 10.1080/02770903.2018.1467444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this systematic review was to explore the effectiveness of various systemic corticosteroid (SCS) regimens to mitigate relapse in children with asthma discharged from an acute care setting. DATA SOURCES Medline, EMBASE, Global Health, International Pharmaceutical Abstracts, EMB ALL, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS were searched using controlled vocabulary and key words. Additional citations were searched via clinical trial registries, Google Scholar, bibliographies, a SCOPUS forward search of a sentinel paper, and hand searching conference abstracts. STUDY SELECTION No limitations based on language, publication status, or year of publication were applied. Two independent reviewers searched to identify randomized controlled trials comparing the effectiveness of SCS regimens to prevent relapse in children following treatment for acute asthma. RESULTS Fifteen studies were included. In 3 studies comparing SCS to placebo, asthma relapse was significantly reduced (RR = 0.10; 95% CI: 0.01, 0.77; I2 = 0%). A network analysis identified a significant reduction in relapse in children treated with intramuscular corticosteroids (OR = 0.038; 95% CrI: 0.001, 0.397), short-course oral prednisone (OR = 0.054; 95% CrI: 0.002, 0.451), and oral dexamethasone (OR = 0.071; 95% CrI: 0.002, 0.733) compared to placebo. CONCLUSION This review found evidence that SCS reduces relapse in children following treatment for acute asthma, albeit based on a limited number of studies. Additional studies are required to assess the differential effect of SCS doses and treatment duration to prevent relapse in children following discharge for acute asthma.
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Affiliation(s)
- Scott W Kirkland
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Ben Vandermeer
- b Department of Pediatrics, Alberta Research Centre for Health Evidence , University of Alberta, Edmonton Clinic Health Academy , Edmonton , AB , Canada
| | - Sandy Campbell
- c J.W. Scott Health Sciences Library , University of Alberta , Walter C. Mackenzie Health Sciences Centre, Edmonton , AB , Canada
| | - Cristina Villa-Roel
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Amanda Newton
- d Department of Pediatrics , University of Alberta , Edmonton , AB , Canada
| | - Francine M Ducharme
- e Departments of Pediatrics and of Social and Preventive Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Brian H Rowe
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada.,f School of Public Health, University of Alberta , Edmonton Clinic Health Academy , Edmonton , AB , Canada
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Abraham AS, Liu MY, Vinson DR. Image Diagnosis: Iliopsoas Abscess from Crohn Disease. Perm J 2018; 21:16-150. [PMID: 28609262 DOI: 10.7812/tpp/16-150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ashley S Abraham
- Research Intern with the CREST (Clinical Research on Emergency Services and Treatment) Network in Sacramento, CA.
| | - Michelle Y Liu
- Research Assistant with the CREST (Clinical Research on Emergency Services and Treatment) Network in Oakland, CA.
| | - David R Vinson
- Senior Emergency Physician at the Sacramento Medical Center and Co-Chair of the CREST (Clinical Research on Emergency Services and Treatment) Network. He is an Adjunct Investigator at the Division of Research in Oakland, CA, and an Assistant Clinical Professor, Volunteer Clinical Faculty, in the Department of Emergency Medicine at the University of California, Davis in Sacramento.
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Kuzik BA. The routine use of oral steroids in paediatric asthma is not routine. Paediatr Child Health 2018; 23:237-238. [PMID: 29769811 DOI: 10.1093/pch/pxy005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brian A Kuzik
- Director, Paediatric Asthma Clinic, Royal Victoria Regional Health Centre, Barrie, ON
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Barra CB, Fontes MJF, Cintra MTG, Cruz RC, Rocha JAG, Guimarães MCC, Silva IN. Oral corticosteroids for asthma exacerbations might be associated with adrenal suppression: Are physicians aware of that? ACTA ACUST UNITED AC 2018; 63:899-903. [PMID: 29267492 DOI: 10.1590/1806-9282.63.10.899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/05/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Oral corticosteroids (OCS) are a mainstay of treatment for asthma exacerbations, and short-term OCS courses were generally considered to be safe. Nevertheless, frequent short-term OCS courses could lead to hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Our study aimed at investigating the integrity of the HPA axis in children with persistent asthma or recurrent wheezing at the beginning of an inhaled corticosteroids (ICS) trial. METHOD Morning basal cortisol was assessed just before the beginning of ICS, and 30, 60, and 90 days later, using Immulite® Siemens Medical Solutions Diagnostic chemiluminescent enzyme immunoassay (Los Angeles, USA; 2006). RESULTS In all, 140 children (0.3-15 years old) with persistent asthma or recurrent wheezing have been evaluated and 40% of them reported short-term OCS courses for up to 30 days before evaluation. Out of these, 12.5% had biochemical adrenal suppression but showed adrenal recovery during a three-month ICS trial treatment. No significant differences were observed among children with or without adrenal suppression, neither in the number of days free of OCS treatment before cortisol evaluation (p=0.29) nor in the last OCS course duration (p=0.20). The number of short-term OCS courses reported in the year preceding the cortisol evaluation was also not different (p=0.89). CONCLUSION Short-term systemic courses of corticosteroids at conventional doses can put children at risk of HPA axis dysfunction. ICS treatment does not impair adrenal recovery from occurring. Health practitioners should be aware of the risk of a blunted cortisol response upon exposure to stress during the follow-up of patients with persistent asthma or recurrent wheezing.
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Affiliation(s)
- Cristina B Barra
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
| | - Maria Jussara F Fontes
- Professor of the Department of Pediatrics, Pediatric Pneumology Division, HC-FM-UFMG, Belo Horizonte, MG, Brazil
| | | | - Renata C Cruz
- Medical Student, FM-UFMG, Belo Horizonte, MG, Brazil
| | | | | | - Ivani Novato Silva
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
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Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY) 2018; 14:177-211. [PMID: 29735382 DOI: 10.1016/j.explore.2018.02.001] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/08/2018] [Indexed: 02/06/2023]
Abstract
Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.
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Affiliation(s)
- Heather Tick
- Departments of Family Medicine, Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Kenneth R Pelletier
- Department of Medicine, University of California School of Medicine, San Francisco, CA
| | - Robert Bonakdar
- Department of Pain Management, Scripps Center for Integrative Medicine, La Jolla, CA
| | | | - Ronald Glick
- Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Emily Ratner
- MedStar Health, Institute for Innovation, Integrative Medicine Initiatives, MedStar Montgomery Medical Center, Washington, DC
| | - Russell L Lemmon
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Peter Wayne
- Osher Center for Integrative Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Veronica Zador
- Beaumont Hospital Integrative Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI
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Aljebab F, Alanazi M, Choonara I, Conroy S. Observational study on the palatability and tolerability of oral prednisolone and oral dexamethasone in children in Saudi Arabia and the UK. Arch Dis Child 2018; 103:83-88. [PMID: 28735259 PMCID: PMC5754874 DOI: 10.1136/archdischild-2017-312697] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/01/2017] [Accepted: 04/15/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND Short-course oral corticosteroids are routinely used to treat acute asthma and croup. We evaluated their tolerability and palatability in Saudi Arabian (SA) and UK children. METHODS Prospective observational/interview study (3 months in each country). Palatability was evaluated using a 5-point facial Hedonicscale and tolerability by direct questioning of patient/parents. RESULTS In SA, of 122 patients (2-10 years) recruited, 52 received prednisolone base tablets, 37 prednisolone sodium phosphate syrup and 33 received dexamethasone elixir. In the UK, of 133 patients (2-16 years), 38 received prednisolone base tablets (mainly crushed and dispersed), 42 prednisolone sodium phosphate soluble tablets and 53 received dexamethasone sodium phosphate oral solution.In both countries, dexamethasone had the highest palatability scores (SA mean: 1.97; UK mean: 3) and prednisolone base tablets had the lowest (SA mean: 1.12; UK mean: 1.39). Palatability scores improved for all formulations of prednisolone with each subsequent daily dose.In SA, prednisolone base tablets were associated with more nausea (24vs7 patients) and vomiting (5vs0 patients) than sodium phosphate syrup (p=0.008 and p=0.073, respectively). In the UK, vomiting occurred more frequently with prednisolone base (8 patients) than sodium phosphate soluble tablets (2 patients) (p=0.041).In both centres, dexamethasone was associated with less side effects. Vomiting (1vs0 patients), nausea (7vs3 patients) and abdominal pain (10vs8 patients) occurred more with dexamethasone sodium phosphate solution than dexamethasone elixir. CONCLUSIONS Dexamethasone sodium phosphate solution was the most palatable preparation. Prednisolone base tablets were rated least palatable and were least well tolerated. Palatability scores improved with each dose taken.
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Affiliation(s)
- Fahad Aljebab
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Mofadhi Alanazi
- Gurayat General Hospital, Ministry of Health, Gurayat, Saudi Arabia
| | - Imti Choonara
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
| | - Sharon Conroy
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, UK
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Øymar K, Mikalsen IB, Nag T, Halvorsen T, Crowley S. [Systemic steroids for preschool children with lower respiratory tract symptoms]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:698-699. [PMID: 28551964 DOI: 10.4045/tidsskr.17.0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Edwards HB, Mallick AA, O'Callaghan FJK. Immunotherapy for arterial ischaemic stroke in childhood: a systematic review. Arch Dis Child 2017; 102:410-415. [PMID: 27864289 DOI: 10.1136/archdischild-2016-311034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 10/13/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is little evidence about either prevention or treatment of childhood arterial ischaemic stroke (AIS). However, drugs that regulate the immune and inflammatory response could theoretically prevent occurrence or recurrence of AIS. Additionally, as an acute treatment, they may limit the neurological damage caused by AIS. Here, we systematically review the evidence on the use of immunotherapy in childhood AIS. DESIGN A systematic review of publications in databases Embase and Medline from inception. All types of evidence were included from trials, cohorts, case-control and cross-sectional studies and case reports. RESULTS 34 reports were included: 32 observational studies and 2 trials. Immunotherapy was used in two key patient groups: arteriopathy and acute infection. The majority were cases of varicella and primary angiitis of the central nervous system. All three cohorts and 80% of the case studies were treated with steroids. Recurrence rates were low. Analytical studies weakly associated steroids with lower odds of new stroke and neurological deficits, and better cognitive outcomes in the context of Moyamoya disease and tuberculosis. CONCLUSIONS Immunotherapies are used in children with AIS, mainly as steroids for children with arteriopathy. However, there is currently little robust evidence to either encourage or discourage this practice. There is weak evidence consistent with the hypothesis that in certain children at risk, steroids may both reduce the risk of occurrent/recurrent stroke and enhance neurological outcomes. As the potential benefit is still uncertain, this indicates that a trial of steroids in childhood AIS may be justified.
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Affiliation(s)
- Hannah B Edwards
- School of Social and Community Medicine, University of Bristol and National Institute for Health Research (NIHR), Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West, Bristol, UK
| | - Andrew A Mallick
- Department of Paediatric Neurology, University Hospitals Bristol NHS Foundation Trust, Level 6, Education and Research Centre, Bristol, UK
| | - Finbar J K O'Callaghan
- Department of Clinical Neurosciences, University College London and Great Ormond Street Hospital for Children Institute of Child Health, University College London, London, UK
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Cutrera R, Baraldi E, Indinnimeo L, Miraglia Del Giudice M, Piacentini G, Scaglione F, Ullmann N, Moschino L, Galdo F, Duse M. Management of acute respiratory diseases in the pediatric population: the role of oral corticosteroids. Ital J Pediatr 2017; 43:31. [PMID: 28335827 PMCID: PMC5364577 DOI: 10.1186/s13052-017-0348-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/02/2017] [Indexed: 12/27/2022] Open
Abstract
Respiratory diseases account for about 25% of all pediatric consultations, and 10% of these are for asthma. The other main pediatric respiratory diseases, in terms of incidence, are bronchiolitis, acute bronchitis and respiratory infections. Oral corticosteroids, in particular prednisolone, are often used to treat acute respiratory diseases given their anti-inflammatory effects. However, the efficacy of treatment with oral corticosteroids differs among the various types of pediatric respiratory diseases. Notably, also the adverse effects of corticosteroid treatment can differ depending on dosage, duration of treatment and type of corticosteroid administered — a case in point being growth retardation in long-course treatment. A large body of data has accumulated on this topic. In this article, we have reviewed the data and guidelines related to the role of oral corticosteroids in the treatment and management of pediatric bronchiolitis, wheezing, asthma and croup in the attempt to provide guidance for physicians. Also included is a section on the management of acute respiratory failure in children.
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Affiliation(s)
- Renato Cutrera
- Pediatric Pulmonology and Sleep & Long Term Ventilation Unit, Academic Department Pediatric Hospital "Bambino Gesù", Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Eugenio Baraldi
- Women's and Children's Health Department, University of Padua, Via Giustiniani 3, 35128, Padova, Italy
| | - Luciana Indinnimeo
- Department of Maternal and Child Care and Urology, Gender Medicine Polyclinic, University of Rome "Sapienza", Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, Second University of Naples, Via Luigi De Crecchio 4, 80138, Naples, Italy
| | - Giorgio Piacentini
- Department of Surgery, Dentistry, Paediatrics and Gynecology, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Via Vanvitelli 32, 20129, Milan, Italy
| | - Nicola Ullmann
- Pediatric Pulmonology and Sleep & Long Term Ventilation Unit, Academic Department Pediatric Hospital "Bambino Gesù", Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Laura Moschino
- Women's and Children's Health Department, University of Padua, Via Giustiniani 3, 35128, Padova, Italy
| | - Francesca Galdo
- Department of Woman, Child and General and Specialized Surgery, Second University of Naples, Via Luigi De Crecchio 4, 80138, Naples, Italy
| | - Marzia Duse
- Department of Maternal and Child Care and Urology, Gender Medicine Polyclinic, University of Rome "Sapienza", Piazzale Aldo Moro 5, 00185, Rome, Italy
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Systematic Review of the Toxicity of Long-Course Oral Corticosteroids in Children. PLoS One 2017; 12:e0170259. [PMID: 28125632 PMCID: PMC5268779 DOI: 10.1371/journal.pone.0170259] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/01/2017] [Indexed: 02/05/2023] Open
Abstract
Background Long courses of oral corticosteroids are commonly used in children in the management of chronic conditions. Various adverse drug reactions (ADRs) are known to occur with their use. This systematic review aimed to identify the most common and serious ADRs and to determine their relative risk levels. Methods A literature search of Embase, Medline, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions in order to identify studies where oral corticosteroids were administered to patients aged 28 days to 18 years of age for at least 15 days of treatment. Each database was searched from their earliest dates to January 2016. All studies providing clear information on ADRs were included. Results One hundred and one studies including 33 prospective cohort studies; 21 randomised controlled trials; 21 case series and 26 case reports met the inclusion criteria. These involved 6817 children and reported 4321 ADRs. The three ADRs experienced by the highest number of patients were weight gain, growth retardation and Cushingoid features with respective incidence rates of 21.1%, 18.1% and 19.4% of patients assessed for these ADRs. 21.5% of patients measured showed decreased bone density and 0.8% of patients showed osteoporosis. Biochemical HPA axis suppression was detected in 269 of 487 patients where it was measured. Infection was the most serious ADR, with twenty one deaths. Varicella zoster was the most frequent infection (9 deaths). Conclusions Weight gain, growth retardation and Cushingoid features were the most frequent ADRs seen when long-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR.
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Weinberger M. Rebuttal From Dr Weinberger. Chest 2016; 150:494. [DOI: 10.1016/j.chest.2016.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/25/2022] Open
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Farber HJ. POINT: Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes. Chest 2016; 150:488-90. [PMID: 27426479 DOI: 10.1016/j.chest.2016.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Harold J Farber
- Pulmonary Section, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
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