Inhaled corticosteroids and bone mineral density at school age: a follow-up study after early childhood wheezing

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Risk and management of osteoporosis due to inhaled, epidural, intra-articular or topical glucocorticoids

Glucocorticoids (GCs) are widely used by several specialties for the treatment of a variety of diseases and conditions. The unfavorable effect of oral GCs on bone health is well-documented. The ensuing from their use glucocorticoid-induced osteoporosis (GIOP) is the most common cause of medication-induced osteoporosis and fractures. It is uncertain, however, if, and in what extent, GCs administered by other routes affect the skeleton. In the present review, we quote current evidence on the effect of inhaled GCs, epidural and intra-articular steroid injections, and topical GCs on bone outcomes. Although evidence is limited and weak, it seems that a small proportion of the administered GCs may be absorbed, enter the systemic circulation, and adversely affect the skeleton. Potent GCs, higher doses, and longer treatment duration seem to infer the greater risk for bone loss and fractures. There are scarce data, and only for inhaled GCs, regarding the efficacy of antiosteoporotic medications in patients receiving GCs through routes other than oral. Further studies are needed to clarify the relationship between GC administration through these routes and bone outcomes and to help establishing guidelines for the optimal management of such patients.

[Osteoporosis in pneumological diseases : Joint guideline of the Austrian Society for Bone and Mineral Research (ÖGKM) and the Austrian Society for Pneumology (ÖGP)]

Chronic inflammation induces proinflammatory cytokine cascades. In addition to systemic inflammation, hypoxemia, hypercapnia, a catabolic metabolism, gonadal or thyroid dysfunction, musculoskeletal dysfunction and inactivity as well as vitamin D deficiency contribute to an increased risk of fragility fractures. Iatrogenic causes of osteoporosis are long-term use of inhaled or systemic glucocorticoids (GC). Inhalative GC application in asthma is often indicated in childhood and adolescence, but interstitial lung diseases such as chronic organizing pneumonia, COPD, sarcoid or rheumatic diseases with lung involvement are also treated with inhalative or oral GC. In patients with cystic fibrosis, malabsorption in the context of pancreatic insufficiency, hypogonadism and chronic inflammation with increased bone resorption lead to a decrease in bone structure. After lung transplantation, immunosuppression with GC is a risk factor.The underlying pneumological diseases lead to a change in the trabecular and cortical bone microarchitecture and to a reduction in osteological formation and resorption markers. Hypercapnia, acidosis and vitamin D deficiency can accelerate this process and thus increase the individual risk of osteoporotic fragility fractures.A bone mineral density measurement with a T‑Score < -2.5 is a threshold value for the diagnosis of osteoporosis; in contrast the vast majority of all osteoporotic fractures occur with a T‑Score > -2.5. A history of low-trauma fracture indicates osteological therapy.All antiresorptive or anabolic drugs approved in Austria for the treatment of osteoporosis are also indicated for pneumological patients with an increased fragility fracture risk of bone fractures in accordance with the national reimbursement criteria.

X-ray densitometric indices of proximal phalanx, medial phalanx and ungular pelvic limb bones as criteria for age diagnosis of cattle in forensic veterinary expertise

Morphological parameters of biological material are extremely informative in diagnostic studies, in particular, to determine the species, sex, time of death, the term of burial. The most informative object for these tasks is the skeleton, because changes in the bones are stored for a long time, while soft tissue is subjected to rotting. Bone tissue is the most durable, but at the same time, it is very labile and reacts to all metabolic processes in the body. The object of the study was proximal phalanx, medial phalanx and ungular bone of the pelvic limb of cattle ranging in age from newborn to 12 years old. Radiography of the proximal phalanx, medial phalanx and ungular bones of the pelvic limb was performed on the Arman apparatus. The bones were subjected to X-ray in the lateromedial projection. The inner and outer sections of the tubular bone were determined. The mathematical modeling of the interaction of X-rays and the cortical layer of bones of fingers (proximal phalanx, medial phalanx and ungular) of cattle was carried out in this work. It is established that this process is described by Bouger's law. The physico-mathematical model of proximal phalanx, medial phalanx and ungular bones has been calculated, on the basis of which it was possible to calculate the X-ray densitometric indices of these bones of cattle. The age features of dynamics of X-ray densitometric indices of the proximal phalanx, medial phalanx and ungular bones were established and a method of determining the age of cattle according to this criterion was proposed. A mathematical model for the proximal phalanx, medial phalanx and ungular bones of the pelvic limbs of cattle that can be applied in X-ray densitometry uses: for the average third proximal phalanx – section of heterogeneous tubular structure modeled by a semicircle; for a medial phalanx bone – a section of a triangular shape; for the ungular bone – a heterogeneous structure, the plantar surface is inscribed in a rectangle. The process of interaction of X-rays with the bone structure of the examined pelvic limb bones can be described by Bouguer's law. The developed mathematical modeling of this interaction and the algorithm for its analysis is the basis for determining the age of cattle for X-ray densitometric indices of the proximal phalanx, medial phalanx and ungular bones of pelvic limbs. By X-ray densitometry of the proximal phalanx and medial phalanx bones of the pelvic limbs extremities one can diagnose the age of bovine animals from birth to 5 years, but according to ungular bones – from birth to 10 years. X-ray densitometry of medial phalanx and ungular bones of pelvic limbs can be used for diagnosing bovine cattle in a complex with other morphological, chemical and physical methods of investigation.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Body fat mass, lean body mass and associated biomarkers as determinants of bone mineral density in children 6-8years of age - The Physical Activity and Nutrition in Children (PANIC) study

Lean body mass (LM) has been positively associated with bone mineral density (BMD) in children and adolescents, but the relationship between body fat mass (FM) and BMD remains controversial. Several biomarkers secreted by adipose tissue, skeletal muscle, or bone may affect bone metabolism and BMD. We investigated the associations of LM, FM, and such biomarkers with BMD in children. We studied a population sample of 472 prepubertal Finnish children (227 girls, 245 boys) aged 6-8years. We assessed BMD, LM, and FM using whole-body dual-energy x-ray absorptiometry and analysed several biomarkers from fasting blood samples. We studied the associations of LM, FM, and the biomarkers with BMD of the whole body excluding the head using linear regression analysis. LM (standardized regression coefficient β=0.708, p<0.001), FM (β=0.358, p<0.001), and irisin (β=0.079, p=0.048) were positive correlates for BMD adjusted for age, sex, and height in all children. These associations remained statistically significant after further adjustment for LM or FM. The positive associations of dehydroepiandrosterone sulphate (DHEAS), insulin, homeostatic model assessment for insulin resistance (HOMA-IR), leptin, free leptin index, and high-sensitivity C-reactive protein and the negative association of leptin receptor with BMD were explained by FM. The positive associations of DHEAS and HOMA-IR with BMD were also explained by LM. Serum 25-hydroxyvitamin D was a positive correlate for BMD adjusted for age, sex, and height and after further adjustment for FM but not for LM. LM and FM were positive correlates for BMD also in girls and boys separately. In girls, insulin, HOMA-IR, leptin, and free leptin index were positively and leptin receptor was negatively associated with BMD adjusted for age, height, and LM. After adjustment for age, height, and FM, none of the biomarkers was associated with BMD. In boys, leptin and free leptin index were positively and leptin receptor was negatively associated with BMD adjusted for age, height, and LM. After adjustment for age, height and FM, 25(OH)D was positively and IGF-1 and leptin were negatively associated with BMD. FM strongly modified the association between leptin and BMD. LM but also FM were strong, independent positive correlates for BMD in all children, girls, and boys. Irisin was positively and independently associated with BMD in all children. The associations of other biomarkers with BMD were explained by LM or FM.

Association Between Inhaled Corticosteroid Use and Bone Fracture in Children With Asthma

IMPORTANCE

Daily use of inhaled corticosteroids is a widely recommended treatment for mild persistent asthma in children. There is concern that, similar to systemic corticosteroids, inhaled corticosteroids may have adverse effects on bone health.

OBJECTIVE

To determine whether there is an increased risk of bone fracture associated with inhaled corticosteroid use in children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based nested case-control study, we used health administrative databases to identify a cohort of children aged 2 to 18 years with a physician diagnosis of asthma between April 1, 2003, and March 31, 2014, who were eligible for public drug coverage through the Ontario Drug Benefit Program (Ontario, Canada). We matched cases of first fracture after asthma diagnosis to fracture-free controls (ratio of 1 to 4) based on date of birth (within 1 year), sex, and age at asthma diagnosis (within 2 years). We used a 1-year lookback period to ascertain history of inhaled corticosteroid use. Multivariable conditional logistic regression was used to obtain an odds ratio (OR) with 95% confidence interval for fracture, comparing no inhaled corticosteroid use vs current, recent, and past use.

EXPOSURES

Inhaled corticosteroid use during the child's 1-year lookback period, measured as current user if the prescription was filled less than 90 days prior to the index date, recent user (91-180 days), past user (181-365 days), or no use.

MAIN OUTCOMES AND MEASURES

First emergency department visit for fracture after asthma diagnosis, identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes.

RESULTS

This study included 19 420 children (61.0% male; largest proportion of children, 31.5%, were aged 6-9 years at their index date). The multivariable regression results did not show a significant association between first fracture after asthma diagnosis and current use (OR, 1.07; 95% CI, 0.97-1.17), recent use (OR, 0.96; 95% CI, 0.86-1.07), or past use (OR, 1.00; 95% CI, 0.91-1.11) of inhaled corticosteroids, compared with no use, while adjusting for sociodemographic factors and other medication use. However, use of systemic corticosteroids in the 1-year lookback period resulted in greater odds of fracture (OR, 1.17; 95% CI, 1.04-1.33).

CONCLUSIONS AND RELEVANCE

Systemic corticosteroids, but not inhaled corticosteroids, were significantly associated with increased odds of fracture in the pediatric asthma population.

Treatment of allergic children - Where is the progress (for the practicing allergist)?

For any kind of therapeutic intervention in allergic diseases such as environmental control, pharmacological, or immunomodulating treatment including educational programs, children are addressed separately from adults. Health authorities like the Food and Drug Administration in the United States of America or the European Medicine Agency in Europe request a specific 'Pediatric investigational plan' with studies addressing dose-response relationship, safety, and efficacy for infants, children, and adolescents. During the last 2 years, promising advances have been reported for the treatment of a variety of allergic and immunologic disorders. This review summarizes the progress in the treatment of pediatric asthma and allergic diseases, based on publications of approximately the last 2.5 years (end of 2013 until May 2016) in and beyond this journal. Meanwhile, it highlights areas with promising novel therapeutic approaches, which are likely to change treatment for allergic children in the near future.

Pediatric pulmonology year in review 2015: Part 3

Our journal covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review (Part 3) covers articles on asthma, diagnostic testing/endoscopy, respiratory complications of neuromuscular disorders, and rare lung diseases. Pediatr Pulmonol. 2016;51:747-753. © 2016 Wiley Periodicals, Inc.

The Skeletal Effects of Inhaled Glucocorticoids

The skeletal effects of inhaled glucocorticoids are poorly understood. Children with asthma treated with inhaled glucocorticoids have lower growth velocity, bone density, and adult height. Studies of adults with asthma have reported variable effects on BMD, although prospective studies have demonstrated bone loss after initiation of inhaled glucocorticoids in premenopausal women. There is a dose-response relationship between inhaled glucocorticoids and fracture risk in asthmatics; the risk of vertebral and non-vertebral fractures is greater in subjects treated with the highest doses in the majority of studies. Patients with COPD have lower BMD and higher fracture rates compared to controls, however, the majority of studies have not found an additional detrimental effect of inhaled glucocorticoids on bone. While the evidence is not conclusive, it supports using the lowest possible dose of inhaled glucocorticoids to treat patients with asthma and COPD and highlights the need for further research on this topic.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Prescription patterns of inhaled corticosteroids for preschool children--A Norwegian register study

BACKGROUND

Although guidelines for treatment of wheeze and asthma in preschool children are available, symptoms are overlapping and it may be difficult to decide which children should be given inhaled corticosteroids (ICS). Previous studies suggest an inappropriate prescription pattern of ICS in this age group. We studied time trends of ICS use in preschool children in Norway during 2004-2013 by age, gender and physician specialty, and the persistence of ICS use during preschool years.

METHODS

Data were drawn from the Norwegian Prescription Database. The study population consisted of children ≤5 years who were prescribed ICS (alone or in combination) during 2004-2013.

RESULTS

The one-year prevalence of ICS use was generally high, and increased from 2004 to 2010, but decreased thereafter. The prevalence was highest in 2-year-olds (boys 12.9% and girls 9.3% in 2010) and declined by age, and higher among boys in all ages. 40-50% of ICS users received only one prescription per year. The share of children with persistent use of ICS over several preschool years was low, irrespective of the age at the first prescription. The majority of prescriptions were given by general practitioners, increasing during the study period.

CONCLUSIONS

The prevalence of ICS prescription for preschool children was high, but with low persistence, suggesting that ICS are frequently given for intermittent asthma-like symptoms. Asthma guidelines suggest a restrictive use of ICS during the first years of life, and the results may call for actions to better implement these guidelines.