Corticosteroid-induced clinical adverse events: frequency, risk factors and patient's opinion

Dentin hypersensitivity-like tooth pain seen in patients receiving steroid therapy: An exploratory study

To ascertain whether steroid therapy evokes dentin hypersensitivity (DH)-like tooth pain, we performed a study based on compelling evidence from patients receiving steroid therapy. An exploratory study was conducted using a questionnaire for 220 patients prescribed steroids who attended the Department of Hematology and Rheumatology of Tohoku University Hospital. Group comparisons between patients with and without steroid pulse therapy were analysed by statistical means. In this study, any DH-like tooth pain that commenced subsequent to steroid treatment was defined as steroid-derived (SD) tooth pain. The prevalence of SD tooth pain was 17.7% (39/220 patients). SD tooth pain was triggered in many vital teeth by cold and/or hot water (84.2% and 23.7%, respectively) with the pain characterised as continuous, in contrast to typical DH tooth pain. SD tooth pain was significantly more frequent in pulse therapy patients than in non-pulse therapy patients (p < 0.05). Logistic regression analysis adjusted for age and sex showed similar results (odds ratio = 3.74, p = 0.013). Moreover, a positive correlation was observed between the steroid dose and pain score (ρ = 0.642). Dose reduction or discontinuation of steroid therapy relieved SD tooth pain in all cases. Thus, steroid therapy can evoke DH-like tooth pain during treatment.

Health-related quality of life associated with systemic corticosteroids

BACKGROUND

Systemic corticosteroids (SCS) are commonly used but are associated with adverse effects. Given their prevalent use, the potential impact of SCS use on health-related quality of life (HRQoL) is important to characterize.

OBJECTIVE

To assess the HRQoL of patients taking SCS.

METHODS

The 2000-2003 Medical Expenditure Panel Survey was used to examine EQ-5D and SF-6D scores associated with SCS use in adults. The study sample was restricted to those with a condition for which SCS are prescribed. SCS use was categorized into three levels: none; 1-3; and ≥4 prescriptions per year. HRQoL scores were regressed on SCS use (1-3 or ≥4 annual prescriptions) controlling for age, gender, race, ethnicity, education, income category, geographic region, number of ER visits, number of outpatient visits, total number of chronic conditions (for which SCS are not used) and conditions for which SCS are clinically indicated.

RESULTS

There were 54,856 individuals with no SCS exposure, 2245 with 1-3 and 624 with ≥4 annual SCS prescriptions. In adjusted analyses, use of ≥4 annual SCS prescriptions appeared to be associated with significantly lower EQ-5D (US), EQ-5D (UK), SF-6D and EQ-5D VAS scores compared to no exposure: -0.032, -0.047, -0.036, and -7.58.

CONCLUSION

While SCS are efficacious and widely used for numerous conditions, results suggest that their use may be associated with a substantial deleterious impact on HRQoL. This potential negative effect should be considered in balance with the cost and efficacy of comparable treatments.

Impact of omalizumab on treatment of severe allergic asthma in UK clinical practice: a UK multicentre observational study (the APEX II study)

OBJECTIVE

To describe the impact of omalizumab on asthma management in patients treated as part of normal clinical practice in the UK National Health Service (NHS).

DESIGN

A non-interventional, mixed methodology study, combining retrospective and prospective data collection for 12 months pre-omalizumab and post-omalizumab initiation, respectively.

SETTING

Data were collected in 22 UK NHS centres, including specialist centres and district general hospitals in the UK.

PARTICIPANTS

258 adult patients (aged ≥16 years; 65% women) with severe persistent allergic asthma treated with omalizumab were recruited, of whom 218 (84.5%) completed the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was change in mean daily dose of oral corticosteroids (OCS) between the 12-month pre-omalizumab and post-omalizumab initiation periods. A priori secondary outcome measures included response to treatment, changes in OCS dosing, asthma exacerbations, lung function, employment/education, patient-reported outcomes and hospital resource utilisation.

RESULTS

The response rate to omalizumab at 16 weeks was 82.4%. Comparing pre-omalizumab and post-omalizumab periods, the mean (95% CIs) daily dose of OCS decreased by 1.61 (-2.41 to -0.80) mg/patient/day (p<0.001) and hospital exacerbations decreased by 0.97 (-1.19 to -0.75) exacerbations/patient (p<0.001). Compared with baseline, lung function, assessed by percentage of forced expiratory volume in 1 s, improved by 4.5 (2.7 to 6.3)% at 16 weeks (p<0.001; maintained at 12 months) and patient quality of life (Asthma Quality of Life Questionnaire) improved by 1.38 (1.18 to 1.58) points at 16 weeks (p<0.001, maintained at 12 months). 21/162 patients with complete employment data gained employment and 6 patients lost employment in the 12-month post-omalizumab period. The mean number of A&E visits, inpatient hospitalisations, outpatient visits (excluding for omalizumab) and number of bed days/patient decreased significantly (p<0.001) in the 12-month post-omalizumab period.

CONCLUSIONS

These data support the beneficial effects of omalizumab on asthma-related outcomes, quality of life and resource utilisation in unselected patients treated in 'real-world' clinical practice.

MECHANISMS IN ENDOCRINOLOGY: Tissue-specific activation of cortisol in Cushing's syndrome

Glucocorticoids are widely prescribed for their anti-inflammatory properties, but have 'Cushingoid' side effects including visceral obesity, muscle myopathy, hypertension, insulin resistance, type 2 diabetes mellitus, osteoporosis, and hepatic steatosis. These features are replicated in patients with much rarer endogenous glucocorticoid (GC) excess (Cushing's syndrome), which has devastating consequences if left untreated. Current medical therapeutic options that reverse the tissue-specific consequences of hypercortisolism are limited. In this article, we review the current evidence that local GC metabolism via the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) plays a central role in mediating the adverse metabolic complications associated with circulatory GC excess - challenging our current view that simple delivery of active GCs from the circulation represents the most important mode of GC action. Furthermore, we explore the potential for targeting this enzyme as a novel therapeutic strategy for the treatment of both endogenous and exogenous Cushing's syndrome.

Use of Glucocorticoids and Risk of Community-Acquired Staphylococcus aureus Bacteremia: A Population-Based Case-Control Study

OBJECTIVE

To investigate whether the use of systemic glucocorticoids is a risk factor for community-acquired Staphylococcus aureus bacteremia (CA-SAB).

PATIENTS AND METHODS

We used population-based medical registries in Northern Denmark to conduct a case-control study including all adults with first-time CA-SAB and matched population controls from January 1, 2000, through December 31, 2011. Glucocorticoid users were categorized as current users (new or long-term use), former users, and nonusers. Using conditional logistic regression, we computed odds ratios (ORs) of CA-SAB according to glucocorticoid exposure, overall and by 90-day prednisolone-equivalent cumulative dose.

RESULTS

We identified 2638 patients with first-time CA-SAB and 26,379 matched population controls. Current glucocorticoid users experienced considerably increased risk of CA-SAB compared with nonusers (adjusted OR=2.48; 95% CI, 2.12-2.90). The adjusted OR was 2.73 (95% CI, 2.17-3.45) in new users, 2.31 (95% CI, 1.90-2.82) in long-term users, and much lower at 1.33 (95% CI, 0.98-1.81) in former users of glucocorticoids compared with nonusers. The risk of CA-SAB increased with higher 90-day cumulative doses. Compared with nonusers of glucocorticoids, the adjusted OR was 1.32 (95% CI, 1.01-1.72) for persons with a cumulative dose of 150 mg or less, 2.42 (95% CI, 1.76-3.33) for persons whose cumulative dose was greater than 500 to 1000 mg, and 6.25 (95% CI, 4.74-8.23) for persons with a cumulative dose greater than 1000 mg.

CONCLUSION

Glucocorticoid use was associated with a substantially increased risk of CA-SAB. The risk increased with higher cumulative dose, revealing a distinct dose-response relation.

Prednisolone increases neural reactivity to negative socio-emotional stimuli in healthy young men

Exogenous glucocorticoids are known to trigger affective changes, but these are highly variable across individuals. A better understanding of how synthetic glucocorticoids impact the processing of negative emotions in the human brain might help to predict such changes. In the present functional magnetic resonance imaging (fMRI) study, we sought to uncover the slow effects of a synthetic glucocorticoid infusion on the neural response to socio-emotional scenes using a within-participant, double-blind, placebo-controlled design. In two separate sessions, 20 young males were given either an intravenous prednisolone dose (250mg) or placebo in a cross-over, randomized order. Four hours later, they were scanned while viewing drawings of persons in a neutral or negative emotional situation. On the next morning participants provided a blood sample for serum cortisol measurement, which served as a manipulation check. Prednisolone strongly suppressed morning cortisol, and heightened brain reactivity to emotional stimuli in left amygdala, left caudate head, right inferior frontal gyrus, bilateral supplementary motor area, and right somatosensory cortex. Amygdala reactivity was related to lower self-reported fatigue and higher irritability in the prednisolone condition. Moreover, prednisolone blunted inferior frontal and amygdala connectivity with other regions of the emotion-processing neural circuitry. Our results suggest specific brain pathways through which exogenous glucocorticoids may labilize affect.

Patient-reported adverse effects of high-dose intravenous methylprednisolone treatment: a prospective web-based multi-center study in multiple sclerosis patients with a relapse

In a prospective multi-center observational study, we evaluated the frequency, severity, and impact on activities of daily living (ADL) of adverse effects (AEs) of high-dose intravenous methylprednisolone (IVMP) in relapsing remitting multiple sclerosis (MS) patients with a relapse. Online self-report questionnaires stating IVMP’s most common AEs were completed at baseline, the 2nd day of treatment, and 1 day and 1 week after treatment. Eighty-five patients were included, 66 completed the baseline questionnaire, and 59 completed at least one post-baseline questionnaire. Patients reported on average 4 (median) AEs; two (3.4 %) reported no AE. Most frequent was change in taste (61 %), facial flushing (61 %), sick/stomach pain (53 %), sleep disturbance (44 %), appetite change (37 %), agitation (36 %), and behavioral changes (36 %). Of all AEs, 34.3 % were severe and 37.9 % impacted on ADL. A 3-day course resulted in 4 (median) AEs and a 5-day course in 7. All patients with high disease impact had two or more AEs, compared with 79 % of those with low impact (p < 0.01). Of patients with high disability, 45 % had severe AEs, compared with 16 % of those with low disability. Severe central nervous system (CNS)-related AEs occurred two times more frequently in patients with high disease impact, and two-and-a-half times more frequently in patients with high disability. Therefore, in virtually all patients, high-dose IVMP leads to AEs, with about one of three AEs being severe with impact on ADL. Patients with high disease impact or high disability may experience more (severe) AEs, due to a higher occurrence of severe CNS-related AEs.

Outcome of a glucocorticoid discontinuation regimen in patients with inactive systemic sclerosis

Glucocorticoids (GC) are widely used to treat systemic sclerosis (SSc). The lack of efficacy data and patient/physician concerns may prompt therapy discontinuation. The aim of this study is to identify factors hampering GC discontinuation in patients with stable disease on oral GC for longer than 12 months. Consecutive patients fulfilling the 2013 ACR/EULAR criteria for SSc and with stable disease were prescribed a slow tapering GC regimen to achieve discontinuation. At study entry and 6 months later (T6), patients were assessed for disease activity and severity. Moreover, the Short-Form-36; the Health Assessment Questionnaire Disability Index (HAQ-DI); and visual analog scales for fatigue, pain, and general health were completed. Reasons for stopping the discontinuation regimen were recorded. Forty-eight patients (46 females, 9 diffuse SSc), with a mean ± SD age of 56±14 years and a median disease duration of 10 years (range 2-22), were enrolled. The median daily GC dose was 5 mg (range 5-10; all patients treated with prednisone). At T6, 33 (68.7 %) patients had discontinued GC. The remaining 15 patients could not discontinue GC because of arthralgia in eight, arthritis in two, puffy fingers in two, increased creatine-kinase in two, and bursitis in one patient. At multiple logistic analysis, a higher baseline HAQ-DI was the only independent factor associated with GC need (OR 2.98, 95 % CI 1.20-7.41; p = 0.01). About one third of SSc patients did not achieve a GC-free regimen. Disability as assessed by HAQ-DI was the leading factor hindering GC discontinuation. A low HAQ-DI score can identify candidates for GC discontinuation.

Head-to-Head Comparison of Anti-Inflammatory Performance of Known Natural Products In Vitro

Inflammation is an important therapeutic target. Due to their potency, steroidal drugs dominate the current treatment of inflammatory disorders. However, steroidal drugs can also exert a broad range of side effects and appear not always effective. This calls for the development of alternative drugs with a different mechanism of action, which are likely to be found in the field of natural products (NPs). For many NPs strong anti-inflammatory effects have been described, but usually investigating a single compound in a single assay. In this study, eight promising NPs were selected and tested against the strong anti-inflammatory drug prednisolone. For this head-to-head comparison, in vitro assays were used which represent different pathways of the inflammatory response: TNF-α and IL-6 expression by macrophages, IL-8 expression by colon epithelial cells, ROS production in polymorphonuclear leukocytes and platelet activation in whole blood. Performance profiles were established which allowed us to identify curcumin, berberine chloride and epigallocatechin gallate as potential alternatives for prednisolone or other glucocorticoids in inflammation.

Chitosan nanoparticles in drug therapy of infectious and inflammatory diseases

INTRODUCTION

Chitosan, a polymer from the chitin family has diverse pharmaceutical and bio-medical utility because of its easy widespread availability, non-toxicity, biocompatibility, biodegradability, rich functionalities and high drug-loading capacity. Recent pharmaceutical research has examined the use of chitosan-based systems for drug delivery applications in various diseases. The availability of functional groups permits the conjugation of specific ligands and thus helps to target loaded drugs to the site of infection/inflammation. Slow biodegradation of chitosan permits controlled and sustained release of loaded moieties; reduces the dosing frequency and is useful for improving patient compliance in infectious drug therapy. The muco-adhesion offered by chitosan makes it an attractive candidate for anti-inflammatory drug delivery, where rapid clearance of the active moiety due to the increased tissue permeability is the major problem. The pH-dependent swelling and drug release properties of chitosan present a means of passive targeting of active drug moieties to inflammatory sites.

AREAS COVERED

Development of chitosan-based nanoparticulate systems for drug delivery applications is reviewed. The current state of chitosan-based nanosystems; with particular emphasis on drug therapy in inflammatory and infectious diseases is also covered.

EXPERT OPINION

The authors believe that chitosan-based nanosystems, due to the special and specific advantages, will have a promising role in the management of infectious and inflammatory diseases.

Long-term side effects of glucocorticoids

INTRODUCTION

Glucocorticoids represent the standard therapy for reducing inflammation and immune activation in various diseases. However, as with any potent medication, they are not without side effects. Glucocorticoid-associated side effects may involve most major organ systems. Musculoskeletal, gastrointestinal, cardiovascular, endocrine, neuropsychiatric, dermatologic, ocular, and immunologic side effects are all possible.

AREAS COVERED

This article analyzes English-language literature and provides an update on the most recent literature regarding side effects of systemic glucocorticoid treatment.

EXPERT OPINION

The risk/benefit ratio of glucocorticoid therapy can be improved by proper use. Careful monitoring and using appropriate preventive strategies can potentially minimize side effects.

Comorbidity in severe asthma requiring systemic corticosteroid therapy: cross-sectional data from the Optimum Patient Care Research Database and the British Thoracic Difficult Asthma Registry

OBJECTIVE

To determine the prevalence of systemic corticosteroid-induced morbidity in severe asthma.

DESIGN

Cross-sectional observational study.

SETTING

The primary care Optimum Patient Care Research Database and the British Thoracic Society Difficult Asthma Registry.

PARTICIPANTS

Optimum Patient Care Research Database (7195 subjects in three age- and gender-matched groups)-severe asthma (Global Initiative for Asthma (GINA) treatment step 5 with four or more prescriptions/year of oral corticosteroids, n=808), mild/moderate asthma (GINA treatment step 2/3, n=3975) and non-asthma controls (n=2412). 770 subjects with severe asthma from the British Thoracic Society Difficult Asthma Registry (442 receiving daily oral corticosteroids to maintain disease control).

MAIN OUTCOME MEASURES

Prevalence rates of morbidities associated with systemic steroid exposure were evaluated and reported separately for each group.

RESULTS

748/808 (93%) subjects with severe asthma had one or more condition linked to systemic corticosteroid exposure (mild/moderate asthma 3109/3975 (78%), non-asthma controls 1548/2412 (64%); p<0.001 for severe asthma versus non-asthma controls). Compared with mild/moderate asthma, morbidity rates for severe asthma were significantly higher for conditions associated with systemic steroid exposure (type II diabetes 10% vs 7%, OR=1.46 (95% CI 1.11 to 1.91), p<0.01; osteoporosis 16% vs 4%, OR=5.23, (95% CI 3.97 to 6.89), p<0.001; dyspeptic disorders (including gastric/duodenal ulceration) 65% vs 34%, OR=3.99, (95% CI 3.37 to 4.72), p<0.001; cataracts 9% vs 5%, OR=1.89, (95% CI 1.39 to 2.56), p<0.001). In the British Thoracic Society Difficult Asthma Registry similar prevalence rates were found, although, additionally, high rates of osteopenia (35%) and obstructive sleep apnoea (11%) were identified.

CONCLUSIONS

Oral corticosteroid-related adverse events are common in severe asthma. New treatments which reduce exposure to oral corticosteroids may reduce the prevalence of these conditions and this should be considered in cost-effectiveness analyses of these new treatments.

Hypercalcemia of Malignancy: An Update on Pathogenesis and Management

Hypercalcemia of malignancy is a common finding typically found in patients with advanced stage cancers. We aimed to provide an updated review on the etiology, pathogenesis, clinical presentation, and management of malignancy-related hypercalcemia. We searched PubMed/Medline, Scopus, Embase, and Web of Science for original articles, case reports, and case series articles focused on hypercalcemia of malignancy published from 1950 to December 2014. Hypercalcemia of malignancy usually presents with markedly elevated calcium levels and therefore, usually severely symptomatic. Several major mechanisms are responsible for the development of hypercalcemia of malignancy including parathyroid hormone-related peptide-mediated humoral hypercalcemia, osteolytic metastases-related hypercalcemia, 1,25 Vitamin D-mediated hypercalcemia, and parathyroid hormone-mediated hypercalcemia in patients with parathyroid carcinoma and extra parathyroid cancers. Diagnosis should include the history and physical examination as well as measurement of the above mediators of hypercalcemia. Management includes hydration, calcitonin, bisphosphonates, denosumab, and in certain patients, prednisone and cinacalcet. Patients with advanced underlying kidney disease and refractory severe hypercalcemia should be considered for hemodialysis. Hematology or oncology and palliative care specialists should be involved early to guide the options of cancer targeted therapies and help the patients and their closed ones with the discussion of comfort-oriented care.

Robust Association Between Inflammatory Bowel Disease and Generalized Anxiety Disorder: Findings from a Nationally Representative Canadian Study

BACKGROUND

Although the link between inflammatory bowel diseases (IBD) and depression is well accepted, less is known about the relationship between IBD and anxiety disorders and factors associated with anxiety among those with IBD.

METHODS

Data were derived from the nationally representative 2012 Canadian Community Health Survey-Mental Health. The survey response rate was 68.9%. Two sets of analyses were undertaken. First, a series of logistic regression analyses were used to estimate the odd ratios of generalized anxiety disorder among those with IBD compared with those without (n = 22,522). The fully adjusted model controlled for sociodemographics, depression, substance abuse/dependence, pain, and adverse childhood experiences. Second, among those with IBD (n = 269), significant correlates of generalized anxiety disorder were identified using logistic regression. The presence of generalized anxiety disorder was determined using the WHO-CIDI lifetime criteria, and IBD was assessed by a self-reported health professional diagnosis.

RESULTS

Individuals with IBD had over twice the odds of anxiety compared with those without IBD, even when controlling for a range of potential explanatory factors (odds ratio = 2.18; 95% confidence interval, 1.50-3.16). Controlling for chronic pain and childhood adversities attenuate the relationship the most. Among those with IBD, a history of childhood sexual abuse, female gender, and chronic pain are the strongest correlates of anxiety. Those with Crohn's and ulcerative colitis were equally vulnerable to generalized anxiety disorder.

CONCLUSIONS

Our findings show that IBD is robustly related to generalized anxiety disorder. Health care professionals should be aware of the increased prevalence of generalized anxiety disorder among their patients with IBD, particularly women, those in chronic pain, and those with a history of childhood sexual abuse.

A review of suicidality in nonpsychotropic medications

Introduction

The term suicidality describes the multitude of behaviors related to suicide: suicidal ideation, self-injurious behavior, suicide attempt, and completed suicide. Risk factors associated with increased suicidality in individuals include specific demographics, medical and psychologic conditions, socioeconomic status, family history, and major life events. In addition to baseline risk factors, there have been reports of numerous medications associated with increased suicidality in patients. Most of these medications are antiepileptics and antidepressants. Because of the contradictory risk posed by the exact medications prescribed to treat depression and psychologic conditions, the nonpsychotropic medications with reports of suicidality are often overshadowed.

Methods

Medications with FDA-issued warnings were reviewed for inclusion. Further medications were identified through PubMed literature review.

Results

Eight medications with various indications were identified and evidence is assessed regarding risk of suicidality.

Discussion

This review evaluates the current literature for nonpsychotropic medications that have been implicated in treatment-emergent suicidality.

Decisional support to prevent adverse drug reactions of long latency: pilot randomized controlled intervention for glucocorticoid-induced diabetes

RATIONALE, AIMS, AND OBJECTIVES

Long-term exposure to glucocorticoids can cause adverse drug reactions of long latency (ADRLLs), including glucocorticoid-induced diabetes mellitus (GID). Providers can monitor for GID using the glycosylated haemoglobin blood (HbA1C) test. This study examined the utility of decisional support to improve HbA1C-based screening for GID. US veterans were identified as chronic users of oral glucocorticoids (>120 days of oral glucocorticoids in the last 2 years). The primary care providers caring for these patients were the target of the intervention. Providers were randomized to receive automatic HbA1C orders for their patients receiving chronic glucocorticoid or usual care.

METHODS

This study was a pilot two-arm, group-randomized, controlled trial (n = 12 providers, n = 38 patients). Data collection occurred from 5 May 2013 until 10 January 2014. A pharmacist generated the order for an HbA1C through the electronic medical record. The time between the intervention start date and the date on which an HbA1C order was signed were compared using Cox proportional and hierarchical linear regression.

RESULTS

The time to sign HbA1C orders (mean 12.0 days for the intervention arm; 104.0 days for control arm) was associated with significant differences favouring the intervention [HR (Hazard Ratio) 50.2, P < 0.001, confidence interval (CI) 6.3 to 398.7]. For the intervention group, 95% of orders were signed, whereas only 12% of control providers signed orders (odds ratio 150, P < 0.001, CI 12.4 to 1812.9).

CONCLUSIONS

The results of this study strongly suggest that the clinical pharmacist-triggered order intervention is effective. This method of computerized decisional support may be useful in improving screening for GID and ADRLLs.

Monitoring of patients on long-term glucocorticoid therapy: a population-based cohort study

About 1% of the general population receives long-term systemic glucocorticoids. The monitoring provided to these patients is unknown. We conducted a population-based cohort study using The Health Improvement Network database. A total of 100,944 adult patients prescribed systemic glucocorticoids for >3 months between January 2000 and December 2012 were studied. The monitoring done before prescribing glucocorticoid therapy and during exposure to the drug was examined. This included measurement of body weight, blood pressure, lipids, glucose and potassium levels, referrals for dual-energy X-ray absorptiometry (DEXA-scan) or to an ophthalmologist/optician, and vaccinations. We assessed factors associated with the odds of being monitored before and during exposure. Before glucocorticoid initiation, weight and blood pressure were monitored in < 20% and < 50% of patients, respectively. Glucose and lipid levels were monitored in less than one-third of the patients, while DEXA-scan and eye monitoring were offered to <15% of them. Vaccination against flu and pneumococcus was given to 57% and 46% of the patients, respectively. During exposure to the drug, <60% of patients who were prescribed the drug for more than a year had their weight, glucose, or lipid levels recorded at least once and <25% of patients were referred at least once for DEXA-scan or screening for eye diseases. Overall, the odds of being monitored were higher in older patients and in those with comorbidities. There were variations in the level of monitoring provided across the UK, but the monitoring has improved over the last 12 years. Although the extent of monitoring of people on long-term glucocorticoids has improved over time, the overall monitoring provided is not satisfactory, particularly in young patients and those without comorbidities.

Glucocorticoids in systemic sclerosis: patients' beliefs and treatment adherence

OBJECTIVES

To investigate how chronic intake of glucocorticoids (GCs) is perceived by patients with systemic sclerosis (SSc) in terms of necessity and concerns, and whether such beliefs influence treatment adherence.

METHOD

Ninety-eight consecutive SSc patients who they had been taking oral GCs for > 3 months prior to the study were enrolled. All patients underwent a clinical evaluation and laboratory investigations, and were asked to complete four self-administered questionnaires: the Beliefs about Medicines Questionnaire (Specific-BMQ), the four-item Morisky Medication Adherence Scale (MMAS-4), the 36-item Short Form Health Survey (SF-36), and the Health Assessment Questionnaire Disability Index (HAQ-DI). Moreover, patients answered two additional questions investigating their knowledge about GC-related adverse events (AEs).

RESULTS

Seventy-seven patients (83.6%) believed in the necessity of GCs for maintaining health but 72.8% also reported concerns about potential AEs to GCs. A high adherence rate was recorded in 64.1% of patients. Only about 20% of patients reported knowing that a daily GC dose and treatment duration influence the burden of GC-related AEs. Patients who believed that GC-related AEs were influenced by the dose scored lower concerns (p = 0.043) and were more frequently labelled as accepting (perceiving high necessity and low concerns) (p = 0.009).

CONCLUSIONS

The majority of patients taking GCs perceived them as necessary, but high concerns about chronic GC use exist. Patients with a poorer knowledge of the factors associated with GC-related AEs and those with a poorer quality of life were the most worried about these compounds. Experimental studies assessing the efficacy of educational programmes aiming to increase the adherence to GC therapy should be planned in these patients.

Acute effect of topical menthol on chronic pain in slaughterhouse workers with carpal tunnel syndrome: triple-blind, randomized placebo-controlled trial

Topical menthol gels are classified “topical analgesics” and are claimed to relieve minor aches and pains of the musculoskeletal system. In this study we investigate the acute effect of topical menthol on carpal tunnel syndrome (CTS). We screened 645 slaughterhouse workers and recruited 10 participants with CTS and chronic pain of the arm/hand who were randomly distributed into two groups to receive topical menthol (Biofreeze) or placebo (gel with a menthol scent) during the working day and 48 hours later the other treatment (crossover design). Participants rated arm/hand pain intensity during the last hour of work (scale 0–10) immediately before 1, 2, and 3 hours after application. Furthermore, global rating of change (GROC) in arm/hand pain was assessed 3 hours after application. Compared with placebo, pain intensity and GROC improved more following application of topical menthol (P = 0.026 and P = 0.044, resp.). Pain intensity of the arm/hand decreased by −1.2 (CI 95%: −1.7 to −0.6) following topical menthol compared with placebo, corresponding to a moderate effect size of 0.63. In conclusion, topical menthol acutely reduces pain intensity during the working day in slaughterhouse workers with CTS and should be considered as an effective nonsystemic alternative to regular analgesics in the workplace management of chronic and neuropathic pain.

A qualitative study of the impact of severe asthma and its treatment showing that treatment burden is neglected in existing asthma assessment scales

BACKGROUND

People with severe asthma experience significant respiratory symptoms and suffer adverse effects of oral corticosteroids (OCS), including disturbed mood and physical symptoms. OCS impacts on health-related quality of life (HRQoL) have not been quantified. Asthma HRQoL scales are valid as outcome measures for patients requiring OCS only if they assess the deficits imposed by OCS.

AIMS

The aim of this study was to compare the burden of disease and treatment in patients with severe asthma with items in eight asthma-specific HRQoL scales.

METHODS

Twenty-three patients with severe asthma recruited from a severe asthma clinic were interviewed about the impact of their respiratory symptoms and the burden of their treatment. The domains from a thematic analysis of these interviews were compared with the items of eight asthma-specific HRQoL scales.

RESULTS

In addition to the burden caused by symptoms, ten domains of OCS impact on HRQoL were identified: depression, irritability, sleep, hunger, weight, skin, gastric, pain, disease anxiety, and medication anxiety. Some patients experienced substantial HRQoL deficits attributed to OCS. Although all HRQoL scales include some OCS-relevant items, all eight scales fail to adequately assess the several types of burden experienced by some patients while on OCS.

CONCLUSION

The burden of OCS in severe asthma is neglected in policy and practice because it is not assessed in outcome studies. Existing asthma HRQoL scales provide an overly positive estimation of HRQoL in patients with frequent exposure to OCS and underestimate the benefit of interventions that reduce OCS exposure. Changes to existing measurement procedures are needed.

Systemic therapy of Cushing's syndrome

Cushing’s disease (CD) in a stricter sense derives from pathologic adrenocorticotropic hormone (ACTH) secretion usually triggered by micro- or macroadenoma of the pituitary gland. It is, thus, a form of secondary hypercortisolism. In contrast, Cushing’s syndrome (CS) describes the complexity of clinical consequences triggered by excessive cortisol blood levels over extended periods of time irrespective of their origin. CS is a rare disease according to the European orphan regulation affecting not more than 5/10,000 persons in Europe. CD most commonly affects adults aged 20–50 years with a marked female preponderance (1:5 ratio of male vs. female). Patient presentation and clinical symptoms substantially vary depending on duration and plasma levels of cortisol. In 80% of cases CS is ACTH-dependent and in 20% of cases it is ACTH-independent, respectively. Endogenous CS usually is a result of a pituitary tumor. Clinical manifestation of CS, apart from corticotropin-releasing hormone (CRH-), ACTH-, and cortisol-producing (malign and benign) tumors may also be by exogenous glucocorticoid intake. Diagnosis of hypercortisolism (irrespective of its origin) comprises the following: Complete blood count including serum electrolytes, blood sugar etc., urinary free cortisol (UFC) from 24 h-urine sampling and circadian profile of plasma cortisol, plasma ACTH, dehydroepiandrosterone, testosterone itself, and urine steroid profile, Low-Dose-Dexamethasone-Test, High-Dose-Dexamethasone-Test, after endocrine diagnostic tests: magnetic resonance imaging (MRI), ultra-sound, computer tomography (CT) and other localization diagnostics. First-line therapy is trans-sphenoidal surgery (TSS) of the pituitary adenoma (in case of ACTH-producing tumors). In patients not amenable for surgery radiotherapy remains an option. Pharmacological therapy applies when these two options are not amenable or refused. In cases when pharmacological therapy becomes necessary, Pasireotide should be used in first-line in CD. CS patients are at an overall 4-fold higher mortality rate than age- and gender-matched subjects in the general population. The following article describes the most prominent substances used for clinical management of CS and gives a systematic overview of safety profiles, pharmacokinetic (PK)-parameters, and regulatory framework.

11β-HSD1 is the major regulator of the tissue-specific effects of circulating glucocorticoid excess

The adverse metabolic effects of prescribed and endogenous glucocorticoid (GC) excess, Cushing syndrome, create a significant health burden. We found that tissue regeneration of GCs by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), rather than circulating delivery, is critical to developing the phenotype of GC excess; 11β-HSD1 KO mice with circulating GC excess are protected from the glucose intolerance, hyperinsulinemia, hepatic steatosis, adiposity, hypertension, myopathy, and dermal atrophy of Cushing syndrome. Whereas liver-specific 11β-HSD1 KO mice developed a full Cushingoid phenotype, adipose-specific 11β-HSD1 KO mice were protected from hepatic steatosis and circulating fatty acid excess. These data challenge our current view of GC action, demonstrating 11β-HSD1, particularly in adipose tissue, is key to the development of the adverse metabolic profile associated with circulating GC excess, offering 11β-HSD1 inhibition as a previously unidentified approach to treat Cushing syndrome.

Corticosteroids and transition to delirium in patients with acute lung injury

OBJECTIVE

Delirium is common in mechanically ventilated patients in the ICU and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury.

DESIGN

Prospective cohort study.

SETTING

Thirteen ICUs in four hospitals in Baltimore, MD.

PATIENTS

Five hundred twenty mechanically ventilated adult patients with acute lung injury.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Delirium evaluation was performed by trained research staff using the validated Confusion Assessment Method for the ICU screening tool. A total of 330 of the 520 patients (64%) had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was noncomatose), with a total of 2,286 days of observation and a median (interquartile range) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior nondelirious, noncomatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio; 95% CI) were independently associated with transition to delirium: older age (compared to < 40 years old, 40-60 yr [1.81; 1.26-2.62], and ≥ 60 yr [2.52; 1.65-3.87]) and administration of any systemic corticosteroid in the prior 24 hours (1.52; 1.05-2.21).

CONCLUSIONS

After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a nondelirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with acute lung injury.

Benefits and risks of low-dose glucocorticoid treatment in the patient with rheumatoid arthritis

Glucocorticosteroids (GCs) have been employed extensively for the treatment of rheumatoid arthritis (RA) and other autoimmune and systemic inflammatory disorders. Their use is supported by extensive literature and their utility is reflected in their incorporation into current treatment guidelines for RA and other conditions. Nevertheless, there is still some concern regarding the long-term use of GCs because of their potential for clinically important adverse events, particularly with an extended duration of treatment and the use of high doses. This article systematically reviews the efficacy for radiological and clinical outcomes for low-dose GCs (defined as ≤10 mg/day prednisone equivalent) in the treatment of RA. Results reviewed indicated that low-dose GCs, usually administered in combination with synthetic DMARDs, most often MTX, significantly improve structural outcomes and decrease symptom severity in patients with RA. Safety data indicate that GC-associated adverse events are dose related, but still occur in patients receiving low doses of these agents. Concerns about side effects associated with GCs have prompted the development of new strategies aimed at improving safety without compromising efficacy. These include altering the structure of existing GCs and the development of delayed-release GC formulations so that drug delivery is timed to match greatest symptom severity. Optimal use of low-dose GCs has the potential to improve long-term outcomes for patients with RA.

Glucocorticoid-induced diabetes mellitus in patients with lymphoma treated with CHOP chemotherapy

PURPOSE

Glucocorticoid-induced diabetes mellitus (GDM) is a major complication arising from corticosteroid administration, but there is lack of studies on GDM attributing to CHOP chemotherapy. We studied the incidence and risk factors for GDM development in patients with lymphoma during CHOP chemotherapy.

METHODS

We analyzed 80 patients with lymphoma treated with a CHOP regimen with or without rituximab between 2004 and 2012 at the University of Tsukuba hospital. Patients with a known history of DM were excluded. Diagnosis of DM was performed according to the American Diabetes Association's criteria.

RESULTS

Among the 80 patients, 26 (32.5 %) developed GDM. We found that age ≥ 60 years, glycated hemoglobin (HbA1c) levels >6.1 %, body mass index (BMI) >30 kg/m(2), prednisolone administration prior to chemotherapy, history of hypertension or hypertension at admission, and the presence of metabolic syndrome were significant (p ≤ 0.05) factors associated with GDM development by univariate analysis. Multivariate analysis revealed that age ≥ 60 years [p<0.05; hazard ratio (HR)=3.59; 95 % confidence interval (CI), 1.22-10.51], HbA1c levels >6.1 % (p<0.05; HR=9.35; 95%CI, 1.45-60.34), and BMI >30 kg/m(2) (p=0.052; HR=6.27; 95%CI, 0.98-40.00) were independently significant association factors.

CONCLUSION

The results suggest a guideline for plasma glucose monitoring during CHOP chemotherapy in patients with no history of DM.

Reduction in oral corticosteroid use in patients receiving omalizumab for allergic asthma in the real-world setting

Background

Oral corticosteroids (OCS) are commonly administered in patients with severe persistent allergic asthma. Despite their efficacy, they are associated with a wide variety of adverse events. The eXpeRience registry was set up to investigate real-world outcomes among patients receiving omalizumab for the treatment of uncontrolled allergic asthma. Here, we present the effect of omalizumab treatment on OCS use.

Methods

eXpeRience was a 2-year, multinational, non-interventional, observational registry of patients receiving omalizumab for uncontrolled allergic asthma. OCS use (proportion of patients on maintenance OCS, mean total daily OCS dose and change in status of OCS therapy) was assessed at baseline, 16 weeks, and 8, 12, 18, and 24 months after the initiation of omalizumab. Response to omalizumab was assessed using the physician’s Global Evaluation of Treatment Effectiveness (GETE) at approximately Week 16. Safety data were also recorded.

Results

A total of 943 patients (mean age, 45 years; female, 64.9%) were enrolled in the registry, 263 of whom were receiving maintenance OCS at baseline. The proportion of patients taking maintenance OCS was markedly lower at Months 12 (16.1%) and 24 (14.2%) than at baseline (28.6%; intent-to-treat population). GETE status was determined in 915 patients receiving omalizumab: 64.2% were responders (excellent or good response), 30.7% were non-responders (moderate, poor or worsening response); 5.1% had no assessment. The frequency of serious adverse events was comparable to that seen in controlled trials of omalizumab.

Conclusions

Omalizumab use is associated with an OCS-sparing effect in patients with uncontrolled persistent allergic asthma in the real-world setting.

[Oral glucocorticoid-induced psychiatric side-effects: focus on clinical specificities, incidence, risk factors and treatment]

Oral glucocorticoids have been used for several decades and psychiatric side-effects may occur. This review will discuss relevant data of the clinical specificities, the incidence, the risk factors for the occurrence of these episodes and the preventive and curative medications of these episodes. We performed a literature review by using PubMed database. We selected and discussed articles and studies with high standard of evidence. The occurrence of psychiatric symptoms is quite frequent. The varying intensity of clinical features ranges from minor signs (impregnation) to acute psychotic episodes which may occur from 5 to 30% of patients. Affective symptoms or disorders are the most prominent clinical features. Delirium may occur and suicidal risk could be increased. The significant predictive factors are prednisone dosage more than 40 mg/day, particularly weight-based dosage, and a history of psychiatric disorders. When a reduced dosage of glucocorticoids is not sufficient to control the symptomatology, curative medication is mainly based on atypical antipsychotics such as olanzapine. Studies about neuropsychiatric complications of glucocorticoids present various and heterogeneous results. Further prospective clinical studies should be based on a close cooperation between physicians and consultation liaison psychiatrists. This collaboration is required for an optimized management of the patient who receive glucocorticoids.

[Corticosteroid therapy and therapeutic education: experience of an internal medicine department]

In 2003, we sought to determine what were the needs of patients prescribed with long-term glucocorticoid therapy in our internal medicine department. Following this inventory, we decided to homogenize the medical practices regarding glucocorticoid prescriptions in our institution. We also set up a therapeutic educational program focused on these prescriptions. This program is based both on individual and collective sessions. Its aims are to improve patients' autonomy regarding the glucocorticoid therapy and to improve the quality of care. This program has widely favored discussions within the medical team and has contributed to enrich experience and expertise of each of its member. We believe it has improved both the satisfaction of the patients and the medical staff.

[Systemic glucocorticoid therapy: associated measures]

Long-term treatment with glucocorticoids results in many adverse effects. Prevention of osteoporosis is well codified, but prevention of other adverse effects is not. If there is some consensus on the prevention of glucocorticoid-induced adverse events, there are also many habits since interventional studies are lacking. A low caloric and low carbohydrate diet as well as a regular physical training are certainly necessary to avoid lipodystrophy, weight gain and diabetes mellitus. Some patients benefit from the repeated intervention of a dietetic or nutrition specialist. Physical training is often neglected though it is efficacious to limit severity of glucocorticoid-induced myopathy and probably to reduce vascular risk. Low sodium intake has no effect on lipodystrophy and its efficacy to prevent hypertension is doubtful. Benzodiazepines may be useful against anxiety, insomnia and nervousness when these symptoms are cumbersome. Anti-ulcer drugs are generally not indicated because glucocorticoids are not ulcerogenic. Hypokaliemia rarely occurs, so we prefer controlling serum potassium level 1 and 3 months after glucocorticoid initiation rather than systematically prescribe potassium supplementation. Patients on glucocorticoids are at increased risk for cardiovascular events. Due to the lack of studies specific to patients on long-term glucocorticoid therapy, the rules for the prescription of statins are the same as in the general population. There is no known prevention for cutaneous atrophy. However, use of adhesive tape should be strictly avoided when skin atrophy is severe. Prevention of infections is developed elsewhere.

[Lipodystrophies]

Human lipodystrophies represent a group of diseases characterized by altered body fat amount and/or repartition. Most forms of lipodystrophies are associated with metabolic alterations such as insulin resistance, diabetes and dyslipemia, leading to diabetic complications, increased cardiovascular risk or liver steatosis. Lipodystrophies can be classified as genetic or acquired, generalized or partial. Genetic forms such as Berardinelli-Seip syndrome or partial familial lipodystrophies are uncommon and acquired forms are much more frequent. Beside the rare Lawrence or Barraquer-Simons syndromes, the main forms of acquired lipodystrophies are those observed in HIV-infected people treated with antiretroviral therapies or in people exposed to an endogenous or an exogenous hypercortisolism. The treatment of lipodystrophies is difficult. Lifestyle modifications (e.g., specific diet, physical training) may be helpful but are usually insufficient. Associated metabolic disorders should be treated as soon as possible with insulin sensitizers, insulin and lipid lowering drugs. New therapies such as leptin have been proven to be helpful in some genetic or acquired forms of lipodystrophy.

[Evaluation of the prescription of long-term systemic steroid-therapy associated measures]

INTRODUCTION

To prevent the occurrence of corticosteroid's side effects, adjuvant measures are prescribed in a very different way depending on the practitioner's experience. The aim of this study was to assess the physicians' practices regarding the prescription of long-term corticosteroid therapy.

METHODS

In May 2010, we realized a cross-sectional study among physicians in Ibn Sina University Hospital in Rabat. With a data collection form, we assessed the principal indications for prescribing steroids and the frequency of prescription of measures sometimes associated with systemic corticosteroid.

RESULTS

Fifty-nine out of eighty physicians completed the data collection form (response rate: 69.4%). Calcium-vitamin D supplementation was recommended by most of the physicians. Half of them were prescribing biphosphonate therapy. Most of them propose a low-sodium, a low-fat and a low-carbohydrate dietary regimen. Regular physical exercise was recommended by 35% of physicians. Gastric protection was indicating by 54.4% of practicians and potassium supplementation by 42.1% of them. Finally, the recommendation for influenza vaccination, hydrocortisone prescription and Synacthen(®) test, varied between physicians.

CONCLUSION

The prescription of adjuvant measures with a long-term corticosteroid therapy was very heterogeneous. There is no consensus regarding most of the measures.

Risk of cardiovascular events in people prescribed glucocorticoids with iatrogenic Cushing's syndrome: cohort study

OBJECTIVE

To investigate whether there is an increased risk of cardiovascular events in people who exhibit iatrogenic Cushing's syndrome during treatment with glucocorticoids.

DESIGN

Cohort study.

SETTING

424 UK general practices contributing to The Health Improvement Network database.

PARTICIPANTS

People prescribed systemic glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome (n = 547) and two comparison groups: those prescribed glucocorticoids and with no diagnosis of iatrogenic Cushing's syndrome (n = 3231) and those not prescribed systemic glucocorticoids (n = 3282).

MAIN OUTCOME MEASURES

Incidence of cardiovascular events within a year after diagnosis of iatrogenic Cushing's syndrome or after a randomly selected date, and association between iatrogenic Cushing's syndrome and risk of cardiovascular events.

RESULTS

417 cardiovascular events occurred in 341 patients. Taking into account only the first event by patient (coronary heart disease n = 177, heart failure n = 101, ischaemic stroke n = 63), the incidence rates of cardiovascular events per 100 person years at risk were 15.1 (95% confidence interval 11.8 to 18.4) in those prescribed glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome, 6.4 (5.5 to 7.3) in those prescribed glucocorticoids without a diagnosis of iatrogenic Cushing's syndrome, and 4.1 (3.4 to 4.8) in those not prescribed glucocorticoids. In multivariate analyses adjusted for sex, age, intensity of glucocorticoid use, underlying disease, smoking status, and use of aspirin, diabetes drugs, antihypertensive drugs, lipid lowering drugs, or oral anticoagulant drugs, the relation between iatrogenic Cushing's syndrome and cardiovascular events was strong (adjusted hazard ratios 2.27 (95% confidence interval 1.48 to 3.47) for coronary heart disease, 3.77 (2.41 to 5.90) for heart failure, and 2.23 (0.96 to 5.17) for ischaemic cerebrovascular events). The adjusted hazard ratio for any cardiovascular event was 4.16 (2.98 to 5.82) when the group prescribed glucocorticoids and with iatrogenic Cushing's syndrome was compared with the group not prescribed glucocorticoids.

CONCLUSION

People who use glucocorticoids and exhibit iatrogenic Cushing's syndrome should be aggressively targeted for early screening and management of cardiovascular risk factors.

[Functional manifestations associated to corticosteroid therapy among the elderly]

PURPOSE

Corticosteroid therapy is frequently prescribed in the elderly with potentially significant consequences in this frail population. The objective of this study was to describe the functional manifestations associated and the preventive measures prescribed with corticosteroid therapy among patients over 75 years old.

PATIENTS AND METHODS

We conducted an exposed/non-exposed, prospective, multi-centre, observational study. Each exposed patient was sex and age (± 2 years) matched to two unexposed subjects. The sample included patients aged over 75 years treated with long-term corticosteroid therapy and hospitalized in an acute geriatric unit between June 2006 and November 2009. Sociodemographic and geriatric characteristics, history of corticosteroid therapy, clinical manifestations and preventive measures prescribed were collected.

RESULTS

Fifty exposed and 100 unexposed patients were included. Mean age was 85±6 years. Prevalence of falls, osteoarticular complications, amyotrophy, vertebral fractures, lipodystrophy, purpura, hematomas and cataracts, and the number of medications were higher among patients taking corticosteroid therapy than in controls. Preventive measures were more often prescribed to patients under taking corticosteroid therapy (calcium and vitamin supplementation, potassium supplementation, anti-osteoporosis medication and gastroprotective agents).

CONCLUSION

Functional manifestations associated with corticosteroid therapy are frequent among the elderly and may have serious consequences in this frail population. Attention should be paid to the prescription of preventive measures through comprehensive care.

Characteristics and outcome of immune thrombocytopenia in elderly: results from a single center case-controlled study

The management of ITP in elderly raises several questions that have not been fully addressed in the literature. To assess the impact of ITP in elderly, a case-control study was performed. The main characteristics at onset and the outcome of ITP in 55 patients aged of 70 years and above (cases) were compared with those of 97 younger adults (controls) seen at the same tertiary referral institution. The mean age at diagnosis was respectively 77.8±6.1 years (cases) and 40.3±14.9 years (controls). While the median platelet count at time of diagnosis was not significantly different in cases and controls (6×10(9) /L, range: 2-26 versus 12×10(9) /L: 5-21.5), bleeding symptoms were more frequent in cases (82%) than in the controls (68%, p=0.07), and the median bleeding score was significantly higher in elderly (p=0.001). The rate of treatment-related adverse events was more than twofold higher in elderly patients and the mean cumulative duration of hospital stay for ITP during the follow-up period was much longer when compared to the controls (p<0.0001). Three ITP-related deaths (5.4%) including 1 from intracranial hemorrhage occurred in the cases but none in the controls. In conclusion, this study confirms that at equivalent platelet count, ITP has a greater impact in elderly.