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Debiazzi MS, Bonatto RC, Campos FJ, Martin JG, Fioretto JR, Hansen MLDN, Luz AMDA, de Carvalho HT. Inhaled magnesium versus inhaled salbutamol in rescue treatment for moderate and severe asthma exacerbations in pediatric patients. J Pediatr (Rio J) 2024; 100:539-543. [PMID: 38693043 DOI: 10.1016/j.jped.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVE To compare the effectiveness of inhaled Magnesium Sulfate associated with Salbutamol versus Inhaled Salbutamol alone in patients with moderate and severe asthma exacerbations. METHOD Clinical, prospective and randomized study with patients between 3 and 14 years of age divided into two groups: one to receive inhaled salbutamol associated with magnesium sulfate (GSM), the other to receive inhaled salbutamol alone (GS). The sample consisted of 40 patients, 20 patients in each group. Severity was classified using the modified Wood-Downes score, with values between 4 and 7 classified as moderate and 8 or more classified as severe. RESULTS Post-inhalation scores decreased both in patients who received salbutamol and magnesium and in those who received salbutamol alone, with no statistically significant difference between the groups. CONCLUSIONS Despite the benefits when administered intravenously, inhalation of the drug alone or in combination did not reduce the severity of the exacerbation.
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Affiliation(s)
- Michelle Siqueira Debiazzi
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Rossano César Bonatto
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Fábio Joly Campos
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Joelma Gonçalves Martin
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - José Roberto Fioretto
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Maria Letícia das Neves Hansen
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Arthur Martins de Araújo Luz
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil
| | - Haroldo Teófilo de Carvalho
- Faculdade de Medicina de Botucatu, Departamento de Pediatria, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), Botucatu, SP, Brazil.
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Bakakos A, Sotiropoulou Z, Vontetsianos A, Zaneli S, Papaioannou AI, Bakakos P. Epidemiology and Immunopathogenesis of Virus Associated Asthma Exacerbations. J Asthma Allergy 2023; 16:1025-1040. [PMID: 37791040 PMCID: PMC10543746 DOI: 10.2147/jaa.s277455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/16/2023] [Indexed: 10/05/2023] Open
Abstract
Asthma is a common airway disease, affecting millions of people worldwide. Although most asthma patients experience mild symptoms, it is characterized by variable airflow limitation, which can occasionally become life threatening in the case of a severe exacerbation. The commonest triggers of asthma exacerbations in both children and adults are viral infections. In this review article, we will try to investigate the most common viruses triggering asthma exacerbations and their role in asthma immunopathogenesis, since viral infections in young adults are thought to trigger the development of asthma either right away after the infection or at a later stage of their life. The commonest viral pathogens associated with asthma include the respiratory syncytial virus, rhinoviruses, influenza and parainfluenza virus, metapneumovirus and coronaviruses. All these viruses exploit different molecular pathways to infiltrate the host. Asthmatics are more prone to severe viral infections due to their unique inflammatory response, which is mostly characterized by T2 cytokines. Unlike the normal T1 high response to viral infection, asthmatics with T2 high inflammation are less potent in containing a viral infection. Inhaled and/or systematic corticosteroids and bronchodilators remain the cornerstone of asthma exacerbation treatment, and although many targeted therapies which block molecules that viruses use to infect the host have been used in a laboratory level, none has been yet approved for clinical use. Nevertheless, further understanding of the unique pathway that each virus follows to infect an individual may be crucial in the development of targeted therapies for the commonest viral pathogens to effectively prevent asthma exacerbations. Finally, biologic therapies resulted in a complete change of scenery in the treatment of severe asthma, especially with a T2 high phenotype. All available data suggest that monoclonal antibodies are safe and able to drastically reduce the rate of viral asthma exacerbations.
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Affiliation(s)
- Agamemnon Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Zoi Sotiropoulou
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Angelos Vontetsianos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Stavroula Zaneli
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Andriana I Papaioannou
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Petros Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
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3
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Islam MZ, Krajewska M, Hossain SI, Prochaska K, Anwar A, Deplazes E, Saha SC. Concentration-Dependent Effect of the Steroid Drug Prednisolone on a Lung Surfactant Monolayer. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2022; 38:4188-4199. [PMID: 35344368 DOI: 10.1021/acs.langmuir.1c02817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The lung surfactant monolayer (LSM) is the main barrier for particles entering the lung, including steroid drugs used to treat lung diseases. The present study combines Langmuir experiments and coarse-grained (CG) molecular dynamics simulations to investigate the concentration-dependent effect of steroid drug prednisolone on the structure and morphology of a model LSM. The surface pressure-area isotherms for the Langmuir monolayers reveal a concentration-dependent decrease in area per lipid (APL). Results from simulations at a fixed surface tension, representing inhalation and exhalation conditions, suggest that at high drug concentrations, prednisolone induces a collapse of the LSM, which is likely caused by the inability of the drug to diffuse into the bilayer. Overall, the monolayer is most susceptible to drug-induced collapse at surface tensions representing exhalation conditions. The presence of cholesterol also exacerbates the instability. The findings of this investigation might be helpful for better understanding the interaction between steroid drug prednisolone and lung surfactants in relation to off-target effects.
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Affiliation(s)
- Mohammad Zohurul Islam
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney, 15 Broadway, Ultimo, NSW 2007, Australia
| | - Martyna Krajewska
- Institute of Chemical Technology and Engineering, Poznan University of Technology, Berdychowo 4, 60-965 Poznań, Poland
| | - Sheikh I Hossain
- School of Life Sciences, University of Technology Sydney, 15 Broadway, Ultimo, NSW 2007, Australia
| | - Krystyna Prochaska
- Institute of Chemical Technology and Engineering, Poznan University of Technology, Berdychowo 4, 60-965 Poznań, Poland
| | - Azraf Anwar
- Independent Researcher, Dhaka 1000, Bangladesh
| | - Evelyne Deplazes
- School of Life Sciences, University of Technology Sydney, 15 Broadway, Ultimo, NSW 2007, Australia
| | - Suvash C Saha
- School of Mechanical and Mechatronic Engineering, University of Technology Sydney, 15 Broadway, Ultimo, NSW 2007, Australia
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4
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Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
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Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
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5
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Zhang XA, Yates A, Vasilevsky N, Gourdine JP, Callahan TJ, Carmody LC, Danis D, Joachimiak MP, Ravanmehr V, Pfaff ER, Champion J, Robasky K, Xu H, Fecho K, Walton NA, Zhu RL, Ramsdill J, Mungall CJ, Köhler S, Haendel MA, McDonald CJ, Vreeman DJ, Peden DB, Bennett TD, Feinstein JA, Martin B, Stefanski AL, Hunter LE, Chute CG, Robinson PN. Semantic integration of clinical laboratory tests from electronic health records for deep phenotyping and biomarker discovery. NPJ Digit Med 2019; 2:32. [PMID: 31119199 PMCID: PMC6527418 DOI: 10.1038/s41746-019-0110-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/18/2019] [Indexed: 12/22/2022] Open
Abstract
Electronic Health Record (EHR) systems typically define laboratory test results using the Laboratory Observation Identifier Names and Codes (LOINC) and can transmit them using Fast Healthcare Interoperability Resource (FHIR) standards. LOINC has not yet been semantically integrated with computational resources for phenotype analysis. Here, we provide a method for mapping LOINC-encoded laboratory test results transmitted in FHIR standards to Human Phenotype Ontology (HPO) terms. We annotated the medical implications of 2923 commonly used laboratory tests with HPO terms. Using these annotations, our software assesses laboratory test results and converts each result into an HPO term. We validated our approach with EHR data from 15,681 patients with respiratory complaints and identified known biomarkers for asthma. Finally, we provide a freely available SMART on FHIR application that can be used within EHR systems. Our approach allows readily available laboratory tests in EHR to be reused for deep phenotyping and exploits the hierarchical structure of HPO to integrate distinct tests that have comparable medical interpretations for association studies.
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Affiliation(s)
| | - Amy Yates
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, OR 97239 USA
| | - Nicole Vasilevsky
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, OR 97239 USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239 USA
| | - J. P. Gourdine
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, OR 97239 USA
- Library, Oregon Health and Science University, Portland, OR 97239 USA
| | - Tiffany J. Callahan
- Computational Bioscience Program, Department of Pharmacology, University of Colorado Anschutz School of Medicine, Aurora, CO 80045 USA
| | - Leigh C. Carmody
- The Jackson Laboratory for Genomic Medicine, Farmington CT, 06032 USA
| | - Daniel Danis
- The Jackson Laboratory for Genomic Medicine, Farmington CT, 06032 USA
| | - Marcin P. Joachimiak
- Environmental Genomics and Systems Biology Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720 USA
| | - Vida Ravanmehr
- The Jackson Laboratory for Genomic Medicine, Farmington CT, 06032 USA
| | - Emily R. Pfaff
- North Carolina Translational and Clinical Sciences Institute (NC TraCS), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - James Champion
- North Carolina Translational and Clinical Sciences Institute (NC TraCS), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Kimberly Robasky
- North Carolina Translational and Clinical Sciences Institute (NC TraCS), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Genetics Department, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- School of Information and Library Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Hao Xu
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Karamarie Fecho
- Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Nephi A. Walton
- Genomic Medicine Institute, Geisinger Health System, Danville, PA 17822 USA
| | - Richard L. Zhu
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD 21202 USA
| | - Justin Ramsdill
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, OR 97239 USA
| | - Christopher J. Mungall
- Environmental Genomics and Systems Biology Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720 USA
| | - Sebastian Köhler
- Charité Centrum für Therapieforschung, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, 10117 Germany
- Einstein Center Digital Future, Berlin, 10117 Germany
| | - Melissa A. Haendel
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, OR 97239 USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239 USA
- Linus Pauling Institute and Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR 97331 USA
| | - Clement J. McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894 USA
| | - Daniel J. Vreeman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, IN 46202 USA
| | - David B. Peden
- North Carolina Translational and Clinical Sciences Institute (NC TraCS), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599 USA
- University of North Carolina Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO 80045 USA
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO 80045 USA
| | - Blake Martin
- Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO 80045 USA
| | - Adrianne L. Stefanski
- Computational Bioscience Program, Department of Pharmacology, University of Colorado Anschutz School of Medicine, Aurora, CO 80045 USA
| | - Lawrence E. Hunter
- Computational Bioscience Program, Department of Pharmacology, University of Colorado Anschutz School of Medicine, Aurora, CO 80045 USA
| | - Christopher G. Chute
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, MD 21202 USA
| | - Peter N. Robinson
- The Jackson Laboratory for Genomic Medicine, Farmington CT, 06032 USA
- Institute for Systems Genomics, University of Connecticut, Farmington, CT 06032 USA
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6
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Abstract
Asthma is one of the commonest respiratory diseases in the United States, affecting approximately 8% of adults. This article reviews the epidemiology, diagnosis, and treatment of asthma, with integration of recommendations from professional societies, with special attention to differential diagnosis. A framework for outpatient management of patients with asthma is presented, including indications for subspecialist referral. With integration of objective diagnostic information, systematic approach through modification of disease triggers and adjustment of controller medications, and patient empowerment to respond to varying symptoms using an asthma action plan, most individuals with asthma are successfully managed in the primary care setting.
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Affiliation(s)
- Tianshi David Wu
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - Emily P Brigham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - Meredith C McCormack
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA.
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7
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Al Efraij K, Johnson KM, Wiebe D, Sadatsafavi M, FitzGerald JM. A systematic review of the adverse events and economic impact associated with oral corticosteroids in asthma. J Asthma 2018; 56:1334-1346. [PMID: 30513226 DOI: 10.1080/02770903.2018.1539100] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Oral corticosteroids (OCSs) are often used to achieve asthma control. OCS-related comorbidities increase the burden of disease for patients and healthcare providers. Most studies characterizing OCS use and risk of adverse events (AEs) are in non-asthma patients. We sought to systematically review the literature on the burden of OCS use among adults with asthma. Methods: We systematically reviewed the literature including MEDLINE (1946-May 2017), EMBASE (1974-May 2017), and the Cochrane Library (2005-May 2017) to identify studies that considered AEs due to OCS treatment of adults with asthma, their burden on healthcare utilization, and costs. Results: We retrieved 9,589 citations; and 15 studies were included. AEs were significantly higher among OCS-users compared with non-OCS users with pooled adjusted odds ratio (OR) 1.68 (95% CI 1.15-2.46) for diabetes mellitus and 1.34 (95% CI 1.23-1.46) for hypertension. Among high dose OCS-users (>10 mg) compared with non-OCS users, the pooled adjusted ORs for development of any complication was 3.35 (95% CI 2.94-3.82), and bone and muscle complications 2.30 (95% CI 2.18-2.42). The risk of any complication increased with higher doses of OCS, with pooled adjusted OR from 2 studies of 2.26 (95% CI 1.37-3.72), 2.94 (95% CI 2.62-3.29) and 3.35 (95% CI 2.94-3.82) for low dose (<6 mg), medium dose (5-12 mg) and high dose (>10 mg) respectively compared with no OCS use. Conclusions: The use of OCS in the management of asthma is associated with a higher risk of complications. This risk is higher as the OCS dose increases.
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Affiliation(s)
- Khalid Al Efraij
- Faculty of Medicine, Division of Respiratory Medicine, UBC , Vancouver , Canada
| | - Kate M Johnson
- Faculty of Pharmaceutical Sciences, UBC , Vancouver , Canada
| | - Darrin Wiebe
- Department of Internal Medicine, UBC , Vancouver , Canada
| | | | - J Mark FitzGerald
- Faculty of Medicine, Division of Respiratory Medicine, UBC , Vancouver , Canada
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8
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Kirkland SW, Cross E, Campbell S, Villa‐Roel C, Rowe BH. Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma. Cochrane Database Syst Rev 2018; 6:CD012629. [PMID: 29859017 PMCID: PMC6513614 DOI: 10.1002/14651858.cd012629.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute asthma is a common cause of presentations to acute care centres, such as the emergency department (ED), and while the majority of patients can be discharged, relapse requiring additional medical care is common. Systemic corticosteroids are a major part in the treatment of moderate to severe acute asthma; however, there is no clear evidence regarding the most effective route of administration for improving outcomes in patients discharged from acute care. OBJECTIVES To examine the effectiveness and safety of a single dose of intramuscular (IM) corticosteroids provided prior to discharge compared to a short course of oral corticosteroids in the treatment of acute asthma patients discharged from an ED or equivalent acute care setting. SEARCH METHODS The Cochrane Airways Group conducted searches of the Cochrane Airways Group Register of Trials, most recently on 14 March 2018. In addition in April 2017 we completed an extensive search of nine electronic databases including Medline, Embase, EBM ALL, Global Health, International Pharmaceutical Abstracts, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS. Furthermore, we searched the grey literature to identify any additional studies. SELECTION CRITERIA We included randomized controlled trials or controlled clinical trials if they compared the effectiveness of intramuscular (IM) versus oral corticosteroids to treat paediatric or adult patients presenting with acute asthma to an ED or equivalent acute care setting. Two independent reviewers assessed study eligibility and study quality. We resolved disagreements via a third party and assessed risk of bias using the Cochrane 'Risk of bias' tool. We assessed the quality of the evidence using GRADE. DATA COLLECTION AND ANALYSIS For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RRs) with 95% confidence intervals (CIs) using a random-effects model. We reported continuous outcomes using mean difference (MD) or standardised mean difference (SMD) with 95% CIs using a random-effects model. We reported heterogeneity using I² and Cochran Q statistics. We used standard procedures recommended by Cochrane. MAIN RESULTS Nine studies involving 804 participants (IM = 402 participants; oral = 402 participants) met our review inclusion criteria. Four studies enrolled children (n = 245 participants), while five studies enrolled adults (n = 559 participants). All of the studies recruited participants presenting to an ED, except one study which recruited participants attending a primary care clinic. All of the paediatric studies compared intramuscular (IM) dexamethasone to oral prednisone/prednisolone. In the adult studies, the IM corticosteroid provided ranged from methylprednisolone, betamethasone, dexamethasone, or triamcinolone, while the regimen of oral corticosteroids provided consisted of prednisone, methylprednisolone, or dexamethasone. Only five studies were placebo controlled. For the purposes of this review, we did not take corticosteroid dose equivalency into account in the analysis. The most common co-intervention provided to participants during the acute care visit included short-acting beta₂-agonists (SABA), methylxanthines, and ipratropium bromide. In some instances, some studies reported providing some participants with supplemental oral or IV corticosteroids during their stay in the ED. Co-interventions provided to participants at discharge consisted primarily of SABA, methylxanthine, long-acting beta₂-agonists (LABA), and ipratropium bromide. The risk of bias of the included studies ranged from unclear to high across various domains. The primary outcome of interest was relapse to additional care defined as an unscheduled visit to a health practitioner for worsening asthma symptoms, or requiring subsequent treatment with corticosteroids which may have occurred at any time point after discharge from the ED.We found intramuscular and oral corticosteroids to be similarly effective in reducing the risk for relapse (RR 0.94, 95% CI 0.72 to 1.24; 9 studies, 804 participants; I² = 0%; low-quality evidence). We found no subgroup differences in relapse rates between paediatric and adult participants (P = 0.71), relapse occurring within or after 10 days post-discharge (P = 0.22), or participants with mild/moderate or severe exacerbations (P = 0.35). While we found no statistical difference between participants receiving IM versus oral corticosteroids regarding the risk for adverse events (RR 0.83, 95% CI 0.64 to 1.07; 5 studies, 404 participants; I² = 0%; moderate-quality evidence), an estimated 50 fewer patients per 1000 receiving IM corticosteroids reported experiencing adverse events (95% from 106 fewer to 21 more). We found inconsistent reporting of specific adverse events across the studies. There were no differences in the frequency of specific adverse events including nausea and vomiting, pain, swelling, redness, insomnia, or personality changes. We did not seek additional adverse events data.Participants receiving IM corticosteroids or oral corticosteroids both reported decreases in peak expiratory flow (MD -7.78 L/min, 95% CI -38.83 L/min to 23.28 L/min; 4 studies, 272 participants; I² = 33%; moderate-quality evidence), similar symptom persistence (RR 0.41, 95% CI 0.14 to 1.20; 3 studies, 80 participants; I² = 44%; low-quality evidence), and 24-hour beta-agonist use (RR 0.54, 95% CI 0.21 to 1.37; 2 studies, 48 participants; I² = 0%; low-quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to identify whether IM corticosteroids are more effective in reducing relapse compared to oral corticosteroids among children or adults discharged from an ED or equivalent acute care setting for acute asthma. While we found no statistical differences, patients receiving IM corticosteroids reported fewer adverse events. Additional studies comparing the effectiveness of IM versus oral corticosteroids could provide further evidence clarity. Furthermore, there is a need for studies comparing different IM corticosteroids (e.g. IM dexamethasone versus IM methylprednisone) and different oral corticosteroids (e.g. oral dexamethasone versus oral prednisone), with consideration for dosing and pharmacokinetic properties, to better identify the optimal IM or oral corticosteroid regimens to improve patient outcomes. Other factors, such as patient preference and potential issues with adherence, may dictate practitioner prescribing.
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Affiliation(s)
- Scott W Kirkland
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Elfriede Cross
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Sandra Campbell
- University of AlbertaJohn W. Scott Health Sciences LibraryEdmontonABCanada
| | | | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
- University of AlbertaSchool of Public HeathEdmontonCanada
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9
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Castillo JR, Peters SP, Busse WW. Asthma Exacerbations: Pathogenesis, Prevention, and Treatment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:918-927. [PMID: 28689842 PMCID: PMC5950727 DOI: 10.1016/j.jaip.2017.05.001] [Citation(s) in RCA: 257] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Abstract
Guideline-based management of asthma focuses on disease severity and choosing the appropriate medical therapy to control symptoms and reduce the risk of exacerbations. However, irrespective of asthma severity and often despite optimal medical therapy, patients may experience acute exacerbations of symptoms and a loss of disease control. Asthma exacerbations are most commonly triggered by viral respiratory infections, particularly with human rhinovirus. Given the importance of these events to asthma morbidity and health care costs, we will review common inciting factors for asthma exacerbations and approaches to prevent and treat these events.
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Affiliation(s)
- Jamee R Castillo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stephen P Peters
- Wake Forest School of Medicine, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Winston-Salem, NC
| | - William W Busse
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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10
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Sun L, Ren X, Wang IC, Pradhan A, Zhang Y, Flood HM, Han B, Whitsett JA, Kalin TV, Kalinichenko VV. The FOXM1 inhibitor RCM-1 suppresses goblet cell metaplasia and prevents IL-13 and STAT6 signaling in allergen-exposed mice. Sci Signal 2017; 10:10/475/eaai8583. [PMID: 28420758 DOI: 10.1126/scisignal.aai8583] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Goblet cell metaplasia and excessive mucus secretion associated with asthma, cystic fibrosis, and chronic obstructive pulmonary disease contribute to morbidity and mortality worldwide. We performed a high-throughput screen to identify small molecules targeting a transcriptional network critical for the differentiation of goblet cells in response to allergens. We identified RCM-1, a nontoxic small molecule that inhibited goblet cell metaplasia and excessive mucus production in mice after exposure to allergens. RCM-1 blocked the nuclear localization and increased the proteasomal degradation of Forkhead box M1 (FOXM1), a transcription factor critical for the differentiation of goblet cells from airway progenitor cells. RCM-1 reduced airway resistance, increased lung compliance, and decreased proinflammatory cytokine production in mice exposed to the house dust mite and interleukin-13 (IL-13), which triggers goblet cell metaplasia. In cultured airway epithelial cells and in mice, RCM-1 reduced IL-13 and STAT6 (signal transducer and activator of transcription 6) signaling and prevented the expression of the STAT6 target genes Spdef and Foxa3, which are key transcriptional regulators of goblet cell differentiation. These results suggest that RCM-1 is an inhibitor of goblet cell metaplasia and IL-13 signaling, providing a new therapeutic candidate to treat patients with asthma and other chronic airway diseases.
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Affiliation(s)
- Lifeng Sun
- Department of Pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China.,Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Xiaomeng Ren
- Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - I-Ching Wang
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Life Sciences, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Arun Pradhan
- Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Yufang Zhang
- Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Hannah M Flood
- Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Bo Han
- Department of Pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - Jeffrey A Whitsett
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tanya V Kalin
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Vladimir V Kalinichenko
- Center for Lung Regenerative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA. .,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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11
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Kirkland SW, Cross E, Campbell S, Villa-Roel C, Rowe BH. Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma. Hippokratia 2017. [DOI: 10.1002/14651858.cd012629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Scott W Kirkland
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
| | - Elfriede Cross
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
| | - Sandra Campbell
- University of Alberta; John W. Scott Health Sciences Library; Edmonton AB Canada
| | | | - Brian H Rowe
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
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12
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Rowe BH, Kirkland SW, Vandermeer B, Campbell S, Newton A, Ducharme FM, Villa‐Roel C. Prioritizing Systemic Corticosteroid Treatments to Mitigate Relapse in Adults With Acute Asthma: A Systematic Review and Network Meta-analysis. Acad Emerg Med 2017; 24:371-381. [PMID: 27664401 DOI: 10.1111/acem.13107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/14/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES While systemic corticosteroids (SCS) are widely used to prevent relapse in adults with acute asthma discharged from the emergency department, the most effective route of administration is unclear. The objective of this review was to examine the effectiveness of SCS in adults and to identify the most effective route of SCS to preventing relapse. METHODS A search was conducted to identify randomized controlled trials comparing the effectiveness of intramuscular (IM) or oral (PO) short-course or long-course corticosteroids to prevent relapse in adults with acute asthma. Two independent reviewers judged study relevance, inclusion, and risk of bias. Pooled statistics were calculated as risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (CI) and credibility intervals (CrI) using a random-effects model. A Bayesian network meta-analysis was performed for indirect comparisons of SCS to placebo. Probability of best (PB) analysis was reported for comparisons between the routes of administration. RESULTS Thirteen studies of moderate quality were included. Four studies compared SCS to placebo, in which SCS significantly reduced relapse (RR = 0.43; 95% CI = 0.25 to 0.74). In the network meta-analysis, a significant reduction in relapse within 10 days of discharge was found in adults receiving IM (OR = 0.21; 95% CrI = 0.05 to 0.73) and PO long-course (OR = 0.31; 95% CrI = 0.09 to 0.95) corticosteroids. Relapse rates between PO short-course corticosteroids and placebo were not statistically significantly different (OR = 0.37; 95% CrI = 0.04 to 3.38). PB analysis favored IM corticosteroids (62%) followed by PO short-course (20.3%) and PO long-course (14.1%) corticosteroids. CONCLUSIONS The network analysis identified IM corticosteroids and PO long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to PO short-course corticosteroids. The lack of significant findings with PO short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer PO SCS treatment options in adults.
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Affiliation(s)
- Brian H. Rowe
- Department of Emergency Medicine University of Alberta Edmonton Alberta
- School of Public Health University of Alberta Edmonton Alberta
| | - Scott W. Kirkland
- Department of Emergency Medicine University of Alberta Edmonton Alberta
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence University of Alberta Edmonton Alberta
| | - Sandy Campbell
- J.W. Scott Health Sciences Library University of Alberta Walter C. Mackenzie Health Sciences Centre Edmonton Alberta
| | - Amanda Newton
- Department of Pediatrics University of Alberta Edmonton Clinic Health Academy Edmonton Alberta
| | - Francine M. Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine University of Montreal Montreal Quebec Canada
| | - Cristina Villa‐Roel
- Department of Emergency Medicine University of Alberta Edmonton Alberta
- School of Public Health University of Alberta Edmonton Alberta
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13
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Lefebvre P, Duh MS, Lafeuille MH, Gozalo L, Desai U, Robitaille MN, Albers F, Yancey S, Ortega H, Forshag M, Lin X, Dalal AA. Burden of systemic glucocorticoid-related complications in severe asthma. Curr Med Res Opin 2017; 33:57-65. [PMID: 27627132 DOI: 10.1080/03007995.2016.1233101] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Although systemic glucocorticoids (SGCs) are efficacious, their chronic use is associated with a range of complications. Yet limited data are available about the risks following chronic use in patients with severe asthma, who are at risk of long-term SGC-related complications. This study was carried out to investigate the risks of developing SGC-related complications, and to quantify the associated healthcare resource utilization and costs for patients with severe asthma in the United States. METHODS This was a longitudinal, open-cohort, observational study. Medicaid claims data (1997-2013) for patients ≥12 years old with ≥2 asthma diagnoses were used. A total of 26,987 SGC non-users were identified for inclusion in the study, alongside 3628 SGC users with ≥6 months' continuous SGC use. RESULTS Multivariate generalized estimating equation models were used to estimate the adjusted risk of developing SGC-related complications, and to quantify the associated healthcare resource utilization and costs. This analysis compared SGC users with SGC non-users, and found that SGC users had an increased likelihood of developing complications. A significant dose-response relationship was demonstrated between chronic SGC use and risk of developing any complications (odds ratios for low, medium, and high SGC exposure were 2.03 [p = .0511], 2.85 [p < .0001], and 3.64 [p < .0001], respectively, vs. SGC non-users). The increased likelihood of SGC-related complications translated into estimated annual healthcare costs for SGC users of $2712 to $8560 above those of SGC non-users. A key limitation of this study is the disparity in age between the SGC users and the SGC non-users; however, age was included as a confounding factor in the analysis. CONCLUSIONS These findings confirm the risk associated with chronic use of SGCs, irrespective of dose level, and highlight the need for new SGC-sparing treatment strategies for patients with severe asthma.
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Affiliation(s)
| | | | | | | | - Urvi Desai
- b Analysis Group Inc. , Boston , MA , USA
| | | | | | | | | | | | - Xiwu Lin
- c GlaxoSmithKline , Durham , NC , USA
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14
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Calderó G, Montes R, Llinàs M, García-Celma M, Porras M, Solans C. Studies on the formation of polymeric nano-emulsions obtained via low-energy emulsification and their use as templates for drug delivery nanoparticle dispersions. Colloids Surf B Biointerfaces 2016; 145:922-931. [DOI: 10.1016/j.colsurfb.2016.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 05/31/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
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15
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Abstract
BACKGROUND Asthma is a common long-term breathing condition that affects approximately 300 million people worldwide. People with asthma may experience short-term worsening of their asthma symptoms; these episodes are often known as 'exacerbations', 'flare-ups', 'attacks' or 'acute asthma'. Oral steroids, which have a potent anti-inflammatory effect, are recommended for all but the most mild asthma exacerbations; they should be initiated promptly. The most often prescribed oral steroids are prednisolone and dexamethasone, but current guidelines on dosing vary between countries, and often among different guideline producers within the same country. Despite their proven efficacy, use of steroids needs to be balanced against their potential to cause important adverse events. Evidence is somewhat limited regarding optimal dosing of oral steroids for asthma exacerbations to maximise recovery while minimising potential side effects, which is the topic of this review. OBJECTIVES To assess the efficacy and safety of any dose or duration of oral steroids versus any other dose or duration of oral steroids for adults and children with an asthma exacerbation. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/) and reference lists of all primary studies and review articles. This search was up to date as of April 2016. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), irrespective of blinding or duration, that evaluated one dose or duration of oral steroid versus any other dose or duration, for management of asthma exacerbations. We included studies involving both adults and children with asthma of any severity, in which investigators analysed adults and children separately. We allowed any other co-intervention in the management of an asthma exacerbation, provided it was not part of the randomised treatment. We included studies reported as full text, those published as abstract only and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data and assessed risk of bias; all data were cross-checked for accuracy. We resolved disagreements by discussion with the third review author or with an external advisor.We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs). We used a random-effects model, and we carried out a fixed-effect analysis if we detected statistical heterogeneity. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We included 18 studies that randomised a total of 2438 participants - both adults and children - and performed comparisons of interest. Included studies assessed higher versus lower doses of prednisolone (n = 4); longer versus shorter courses of prednisolone (n = 3) or dexamethasone (n = 1); tapered versus non-tapered courses of prednisolone (n = 4); and prednisolone versus dexamethasone (n = 6). Follow-up duration ranged from seven days to six months. The smallest study randomised just 15 participants, and the largest 638 (median 93). The varied interventions and outcomes reported limited the number of meaningful meta-analyses that we could perform.For two of our primary outcomes - hospital admission and serious adverse events - events were too infrequent to permit conclusions about the superiority of one treatment over the other, or their equivalence. Researchers in the included studies reported asthma symptoms in different ways and rarely used validated scales, again limiting our conclusions. Secondary outcome meta-analysis was similarly hampered by heterogeneity among interventions and outcome measures used. Overall, we found no convincing evidence of differences in outcomes between a higher dose or longer course and a lower dose or shorter course of prednisolone or dexamethasone, or between prednisolone and dexamethasone.Included studies were generally of reasonable methodological quality. Review authors assessed most outcomes in the review as having low or very low quality, meaning we are not confident in the effect estimates. The predominant reason for downgrading was imprecision, but indirectness and risk of bias also reduced our confidence in some estimates. AUTHORS' CONCLUSIONS Evidence is not strong enough to reveal whether shorter or lower-dose regimens are generally less effective than longer or higher-dose regimens, or indeed that the latter are associated with more adverse events. Any changes recommended for current practice should be supported by data from larger, well-designed trials. Varied study design and outcome measures limited the number of meta-analyses that we could perform. Greater emphasis on palatability and on whether some regimens might be easier to adhere to than others could better inform clinical decisions for individual patients.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
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16
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Berthon BS, Gibson PG, McElduff P, MacDonald-Wicks LK, Wood LG. Effects of short-term oral corticosteroid intake on dietary intake, body weight and body composition in adults with asthma - a randomized controlled trial. Clin Exp Allergy 2016; 45:908-919. [PMID: 25640664 DOI: 10.1111/cea.12505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/02/2014] [Accepted: 11/12/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral corticosteroids (OCS) are an efficacious treatment for asthma exacerbations, yet risk of adverse effects may decrease patient adherence to therapy. In particular, changes in appetite and dietary intake, which lead to weight gain and changes in body composition, are considered undesirable. OBJECTIVE To determine whether 10-day OCS therapy in adults with asthma causes changes in leptin, appetite, dietary intake, body weight and body composition. METHODS Double-blinded, placebo-controlled randomized cross-over trial of 10 days prednisolone (50 mg) in adults with stable asthma (n = 55) (ACTRN12611000562976). Pre- and post-assessment included spirometry, body weight, body composition measured by dual-energy X-ray absorptiometry and bioelectrical impedance analysis, appetite measured using a validated visual analogue scale (VAS) and dietary intake assessed using 4-day food records. Leptin was measured as a biomarker of appetite and eosinophils as an adherence biomarker. Outcomes were analysed by generalized linear mixed models. RESULTS Subject adherence was confirmed by a significant decrease in blood eosinophils (× 10(9) /L) following prednisolone compared to placebo [Coef. -0.29, 95% CI: (-0.39, -0.19) P < 0.001]. There was no difference in serum leptin (ng/mL) [Coef. 0.13, 95% CI: (-3.47, 3.72) P = 0.945] or appetite measured by VAS (mm) [Coef. -4.93, 95% CI: (-13.64, 3.79) P = 0.267] following prednisolone vs. placebo. There was no difference in dietary intake (kJ/day) [Coef. 255, 95% CI: (-380, 891) P = 0.431], body weight (kg) [Coef. -0.38, 95% CI: (-0.81, 0.05) P = 0.083] or body fat (%) [Coef. -0.31, 95% CI: (-0.81, 0.20) P = 0.230]. Symptoms including sleep and gastrointestinal disturbance were reported significantly more often during prednisolone vs. placebo. CONCLUSIONS AND CLINICAL RELEVANCE Short-term OCS in stable asthma did not induce significant changes in appetite, dietary intake, body weight or composition, although other adverse effects may require medical management. This evidence may assist in increasing medication adherence of asthmatics prescribed OCS for exacerbations.
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Affiliation(s)
- B S Berthon
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P G Gibson
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - L K MacDonald-Wicks
- School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - L G Wood
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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17
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Franzese C. Management of acute asthma exacerbations. Int Forum Allergy Rhinol 2015; 5 Suppl 1:S51-6. [PMID: 26034013 DOI: 10.1002/alr.21554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 04/17/2015] [Accepted: 04/20/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute asthma exacerbations are common events in the lives of asthmatics, and even the best-managed asthma patients will have acute asthma exacerbations. There are different levels of severity of exacerbations with corresponding management strategies the physician can use to treat acute events. These strategies, including some adjunctive therapies, are reviewed in this article. METHODS A review of the English-language scientific literature was performed regarding management of acute asthma exacerbations, focusing of published guidelines, meta-analyses, and database reviews. RESULTS Symptoms of exacerbations are reviewed with attention to determining the severity of the exacerbation and the place of management, either at home or in a more acute care setting. Medical therapies for the treatment of each severity level are reviewed as to their effectiveness. Post-exacerbation care is also discussed. CONCLUSION Asthma exacerbations will happen and both the provider and patient need to be educated on how to manage these occurrences. Whether the patient is managed at home or in a hospital setting will be determined by the level of severity. Regardless of the medical therapies employed, continued focus should be on further prevention of additional exacerbations.
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Affiliation(s)
- Christine Franzese
- Department of Otolaryngology, Eastern Virginia School of Medicine, Norfolk, VA
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18
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Schivo M, Phan C, Louie S, Harper RW. Critical asthma syndrome in the ICU. Clin Rev Allergy Immunol 2015; 48:31-44. [PMID: 25759905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids. Almost all critical asthma syndrome cases require emergency care, and most cases require hospitalization, often in an intensive care unit. Among asthmatics, those with the critical asthma syndrome are difficult to manage and there is little room for error. Patients with the critical asthma syndrome are prone to complications, they utilize immense resources, and they incite anxiety in many care providers. Managing this syndrome is anything but routine, and it requires attention, alacrity, and accuracy. The specific management strategies of adults with the critical asthma syndrome in the hospital with a focus on intensive care are discussed. Topics include the initial assessment for critical illness, initial ventilation management, hemodynamic issues, novel diagnostic tools and interventions, and common pitfalls. We highlight the use of critical care ultrasound, and we provide practical guidelines on how to manage deteriorating patients such as those with pneumothoraces. When standard asthma management fails, we provide experience-driven recommendations coupled with available evidence to guide the care team through advanced treatment. Though we do not discuss medications in detail, we highlight recent advances.
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19
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Alangari AA. Corticosteroids in the treatment of acute asthma. Ann Thorac Med 2014; 9:187-92. [PMID: 25276236 PMCID: PMC4166064 DOI: 10.4103/1817-1737.140120] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/10/2014] [Indexed: 01/25/2023] Open
Abstract
Asthma is a prevalent chronic disease of the respiratory system and acute asthma exacerbations are among the most common causes of presentation to the emergency department (ED) and admission to hospital particularly in children. Bronchial airways inflammation is the most prominent pathological feature of asthma. Inhaled corticosteroids (ICS), through their anti-inflammatory effects have been the mainstay of treatment of asthma for many years. Systemic and ICS are also used in the treatment of acute asthma exacerbations. Several international asthma management guidelines recommend the use of systemic corticosteroids in the management of moderate to severe acute asthma early upon presentation to the ED. On the other hand, ICS use in the management acute asthma has been studied in different contexts with encouraging results in some and negative in others. This review sheds some light on the role of systemic and ICS in the management of acute asthma and discusses the current evidence behind their different ways of application particularly in relation to new developments in the field.
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Affiliation(s)
- Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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20
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Rafii B, Sridharan S, Taliercio S, Govil N, Paul B, Garabedian MJ, Amin MR, Branski RC. Glucocorticoids in laryngology: a review. Laryngoscope 2014; 124:1668-73. [PMID: 24474440 DOI: 10.1002/lary.24556] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/02/2013] [Accepted: 12/09/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVES/HYPOTHESIS To provide the otolaryngologist an evidence-based sound review of glucocorticoid use for laryngeal pathology. STUDY DESIGN Review of contemporary peer-reviewed literature as well as review articles. METHODS A review of the literature regarding glucocorticoids as a therapeutic intervention for the treatment of benign laryngeal pathology and laryngeal manifestations of systemic disease was performed. Review included both systemic administration as well as local injection. RESULTS Glucocorticoids, administered in the critical care setting for planned extubation, markedly reducing the risk of reintubation and remain a rudimentary pharmacologic adjunct in laryngeal manifestations of common autoimmune and inflammatory disorders. Intralesional injection has reduced the rate of surgical intervention for benign inflammatory primary laryngeal pathology. CONCLUSIONS Glucocorticoids are effective in the treatment of a number of laryngeal pathologies, through both systemic and intralesional administration. However, a clear consensus for utilization of glucocorticoids in the treatment of specific laryngeal disorders has yet to be published.
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Affiliation(s)
- Benjamin Rafii
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York
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21
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Beggs S, Mortyn E, Cunliffe T, Walters JAE. Systemic steroids versus placebo for acute wheeze in preschool aged children. Hippokratia 2013. [DOI: 10.1002/14651858.cd010865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sean Beggs
- Royal Hobart Hospital; Department of Paediatrics; 48 Liverpool Street Hobart Tasmania Australia 7000
- University of Tasmania; School of Medicine; Hobart Tasmania Australia
| | - Emma Mortyn
- University of Tasmania; School of Medicine; Hobart Tasmania Australia
| | - Tessa Cunliffe
- University of Tasmania; School of Medicine; Hobart Tasmania Australia
| | - Julia AE Walters
- University of Tasmania; School of Medicine; Hobart Tasmania Australia
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22
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Abstract
Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids. Almost all critical asthma syndrome cases require emergency care, and most cases require hospitalization, often in an intensive care unit. Among asthmatics, those with the critical asthma syndrome are difficult to manage and there is little room for error. Patients with the critical asthma syndrome are prone to complications, they utilize immense resources, and they incite anxiety in many care providers. Managing this syndrome is anything but routine, and it requires attention, alacrity, and accuracy. The specific management strategies of adults with the critical asthma syndrome in the hospital with a focus on intensive care are discussed. Topics include the initial assessment for critical illness, initial ventilation management, hemodynamic issues, novel diagnostic tools and interventions, and common pitfalls. We highlight the use of critical care ultrasound, and we provide practical guidelines on how to manage deteriorating patients such as those with pneumothoraces. When standard asthma management fails, we provide experience-driven recommendations coupled with available evidence to guide the care team through advanced treatment. Though we do not discuss medications in detail, we highlight recent advances.
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Affiliation(s)
- Michael Schivo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, 4150 V Street, PSSB 3400, Sacramento, CA, 95817, USA,
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23
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Redman E, Powell C. Question 1: Prednisolone or dexamethasone for acute exacerbations of asthma: do they have similar efficacy in the management of exacerbations of childhood asthma? Arch Dis Child 2013; 98:916-9. [PMID: 24123403 DOI: 10.1136/archdischild-2013-304937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Elisabeth Redman
- Department of Child Health, Noah's Ark Children's Hospital for Wales, Cardiff University, , Cardiff, Wales, UK
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24
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Vaughan OR, Sferruzzi-Perri AN, Coan PM, Fowden AL. Adaptations in placental phenotype depend on route and timing of maternal dexamethasone administration in mice. Biol Reprod 2013; 89:80. [PMID: 23986571 DOI: 10.1095/biolreprod.113.109678] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Synthetic glucocorticoids, like dexamethasone (dex), restrict growth of the fetus and program its adult physiology, in part by altering placental phenotype. The route and timing of dex administration determine the fetal and adult outcomes, but whether these factors affect placental phenotype remains unknown. This study compared placental morphology, amino acid transport, and gene expression in mice given dex orally or by subcutaneous injection over the periods of most rapid placental (Days [D] 11-16) or fetal (D14-19) growth (term is D21). Compared with untreated and saline-injected controls, both dex treatments reduced placental weight at D16 and 19 and fetal weight and total labyrinthine volume at D19 to a similar extent. Only oral dex treatment from D11 to D16 reduced labyrinthine fetal capillary volume on D16 and increased placental ¹⁴C-methylaminoisobutyric acid (MeAIB) clearance at D19, 3 days after treatment ended. Neither route of dex treatment altered placental expression of Slc38a, Hsd11b, or the glucocorticoid receptor, Nr3c1, at D16. In contrast, both routes of dex treatment from D14 to D19 increased placental Hsd11b2 expression and labyrinthine maternal vessel volume. Furthermore, injection per se altered placental expression of Nr3c1, Hsd11b1, and specific Slc38a isoforms in an age-related manner. Overall, MeAIB clearance was not related to Slc38a transporter expression but was correlated inversely with maternal corticosterone concentrations when dex was undetectable in maternal plasma at D19. The effects of dex on placental phenotype, therefore, depend on both the route and timing of administration and may relate to local glucocorticoid availability during and after the treatment period.
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Affiliation(s)
- Owen R Vaughan
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, Cambridge, United Kingdom
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Trebble PJ, Woolven JM, Saunders KA, Simpson KD, Farrow SN, Matthews LC, Ray DW. A ligand-specific kinetic switch regulates glucocorticoid receptor trafficking and function. J Cell Sci 2013; 126:3159-69. [PMID: 23687373 DOI: 10.1242/jcs.124784] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The ubiquitously expressed glucocorticoid receptor (GR) is a major drug target for inflammatory disease, but issues of specificity and target tissue sensitivity remain. We now identify high potency, non-steroidal GR ligands, GSK47867A and GSK47869A, which induce a novel conformation of the GR ligand-binding domain (LBD) and augment the efficacy of cellular action. Despite their high potency, GSK47867A and GSK47869A both induce surprisingly slow GR nuclear translocation, followed by prolonged nuclear GR retention, and transcriptional activity following washout. We reveal that GSK47867A and GSK47869A specifically alter the GR LBD structure at the HSP90-binding site. The alteration in the HSP90-binding site was accompanied by resistance to HSP90 antagonism, with persisting transactivation seen after geldanamycin treatment. Taken together, our studies reveal a new mechanism governing GR intracellular trafficking regulated by ligand binding that relies on a specific surface charge patch within the LBD. This conformational change permits extended GR action, probably because of altered GR-HSP90 interaction. This chemical series may offer anti-inflammatory drugs with prolonged duration of action due to altered pharmacodynamics rather than altered pharmacokinetics.
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Affiliation(s)
- Peter J Trebble
- Manchester Centre for Nuclear Hormone Research in Disease, University of Manchester, Oxford Road, Manchester M13 9PT, UK
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26
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Adams JY, Sutter ME, Albertson TE. The patient with asthma in the emergency department. Clin Rev Allergy Immunol 2013; 43:14-29. [PMID: 21597902 DOI: 10.1007/s12016-011-8273-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a highly prevalent disease that presents commonly to the emergency department (ED) in acute exacerbation. Recent asthma treatment guidelines have added content dedicated to the management of acute exacerbations. Effective management of an exacerbation requires rapid assessment of severity through physical examination, measurement of peak expiratory flow rate, and response to initial treatment. Most therapies are directed at alleviating bronchospasm and decreasing airway inflammation. While inhaled short-acting beta-agonists, systemic corticosteroids, and supplemental oxygen are the initial and often only therapies required for patients with mild moderate exacerbations, high-dose beta agonists and inhaled anti-cholinergics should also be given to patients with severe exacerbations. Adjunctive therapy with intravenous magnesium and Heliox-driven nebulization of bronchodilators should be considered for patients presenting with severe and very severe exacerbations. Early recognition and appropriate management of respiratory failure are required to mitigate the risk of complications including death. Disposition should be determined based on serial assessments of the response to therapy over the first 4 h in the ED. Patients stable for discharge should receive medications, asthma education including a written asthma action plan, and should have follow-up scheduled for them by ED staff. Rapid implementation of evidence-based, multi-disciplinary care is required to ensure the best possible outcomes for this potentially treatable disease.
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Affiliation(s)
- Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis Medical Center, 4150 V Street, Sacramento, CA 95817, USA.
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27
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ZAP-70 tyrosines 315 and 492 transmit non-genomic glucocorticoid (GC) effects in T cells. Mol Immunol 2013; 53:111-7. [DOI: 10.1016/j.molimm.2012.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 07/20/2012] [Accepted: 07/21/2012] [Indexed: 01/16/2023]
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Myles P, Nguyen-Van-Tam JS, Semple MG, Brett SJ, Bannister B, Read RC, Taylor BL, McMenamin J, Enstone JE, Nicholson KG, Openshaw PJ, Lim WS. Differences between asthmatics and nonasthmatics hospitalised with influenza A infection. Eur Respir J 2012; 41:824-31. [PMID: 22903963 PMCID: PMC3612580 DOI: 10.1183/09031936.00015512] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Asthmatics hospitalised because of influenza A infection are less likely to
require intensive care or die compared with nonasthmatics. The reasons for this
are unknown. We performed a retrospective analysis of data on 1520 patients admitted to 75 UK
hospitals with confirmed influenza A/H1N1 2009 infection. A multivariable model
was used to investigate reasons for the association between asthma and severe
outcomes (intensive care unit support or death). Asthmatics were less likely than nonasthmatics to have severe outcome
(11.2% versus 19.8%, unadjusted OR 0.51,
95% CI 0.36–0.72) despite a greater proportion requiring
oxygen on admission (36.4% versus 26%,
unadjusted OR 1.63) and similar rates of pneumonia (17.1%
versus 16.6%, unadjusted OR 1.04). The results
of multivariable logistic regression suggest the association of asthma with
outcome (adjusted OR 0.62, 95% CI 0.36–1.05;
p=0.075) are explained by pre-admission inhaled corticosteroid use
(adjusted OR 0.34, 95% CI 0.18–0.66) and earlier
admission (≤4 days from symptom onset) (adjusted OR 0.60,
95% CI 0.38–0.94). In asthmatics, systemic corticosteroids
were associated with a decreased likelihood of severe outcomes (adjusted OR
0.36, 95% CI 0.18–0.72). Corticosteroid use and earlier hospital admission explained the association of
asthma with less severe outcomes in hospitalised patients.
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29
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Siller H, Taylor JD, Middleton B. Two-start design within a Sephadex inflammatory model--a means to generate reliable ED50 data whilst significantly reducing the number of animals used. Pulm Pharmacol Ther 2012; 25:223-7. [PMID: 22446025 DOI: 10.1016/j.pupt.2012.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 01/10/2012] [Accepted: 03/02/2012] [Indexed: 11/29/2022]
Abstract
Pulmonary inflammation disorders represent a major healthcare burden, and novel anti-inflammatory agents are critically needed for the treatment of patients unresponsive to current therapies. In vivo animal models play a key role in the preclinical assessment of novel anti-inflammatory compounds. The implementation of streamlined in vivo experimental designs that are time-and cost-efficient, while keeping animal usage low, is a key consideration for drug optimization programs. The Sephadex rat model of pulmonary inflammation captures many pathophysiologic characteristics of clinical asthma and allergy, such as eosinophilic infiltration andinterstitial edema. Using the in vivo Sephadex model, we compared two different study designs that were implemented to screen and select two novel candidate drugs for a drug discovery project. The traditional one-start design, which utilizes few dose-testing groups with many animals per group, was used to select the first candidate drug. Due to tight timelines, the selection process for the second candidate drug had to be optimized, leading to the development of the novel two-start design, an approach whereby dose ranges are optimized in two experimental phases. Here we show that both study designs were comparable in their generation of robust median effective dose values for selected candidate drugs, as represented by similar confidence interval ratios. However, implementation of the two-start design resulted in approximately 50% fewer animals and 50% less time taken to assess the efficacy of an equal number of compounds compared with the one-start design. These results demonstrate that the two-start design is a more efficient experimental approach, and its widespread implementation in drug optimization programs will impact upon the selection process for candidate drugs with regards to time, cost, and animal usage.
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Affiliation(s)
- Helena Siller
- Integrative Pharmacology, Biosciences, AstraZeneca Research and Development, Lund, Sweden.
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Schultz A, Brand PLP. Phenotype-directed treatment of pre-school-aged children with recurrent wheeze. J Paediatr Child Health 2012; 48:E73-8. [PMID: 21679334 DOI: 10.1111/j.1440-1754.2011.02123.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Wheeze in childhood may comprise different underlying diseases. Disease-specific treatment could potentially improve treatment efficacy. Various attempts have been made to differentiate between pre-school wheeze phenotypes. In this review, the results of clinical trials evaluating treatment of pre-school wheeze are discussed, with specific emphasis on the characteristics and phenotype of the study populations. Evidence suggests that systemic corticosteroids are not beneficial for the treatment of mild-to-moderate exacerbations of pre-school wheeze, irrespective of phenotype. The use of high-dose intermittent inhaled corticosteroid treatment cannot be recommended because of unacceptable side effects. Treatment with regular inhaled corticosteroids and leukotriene antagonists offer modest benefit, but neither treatment reduces hospitalisation rates. There is currently some evidence for a phenotype-specific effect of treatment. Phenotype-directed treatment of pre-school wheeze is currently limited by our ability to accurately differentiate between clinically useful phenotypes.
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Affiliation(s)
- André Schultz
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.
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Abstract
Anaphylaxis is a serious allergic reaction that is rapid in onset and sometimes leads to death. Understanding mechanisms, triggers, and patient-specific risk factors for severe or fatal anaphylaxis is critically important. Diagnosis of anaphylaxis is currently based on established clinical criteria. Epinephrine (adrenaline) is the first-line medication for anaphylaxis treatment and delay in injecting it contributes to biphasic reactions, hypoxic-ischemic encephalopathy, and fatality. Here, we focus on four important areas of translational research in anaphylaxis: studies of potential new biomarkers to support the clinical diagnosis of anaphylaxis, laboratory tests to distinguish allergen sensitization from clinical risk of anaphylaxis, the primary role of epinephrine (adrenaline) in anaphylaxis treatment, and strengthening the overall evidence base for anaphylaxis treatment.
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Glucocorticoids target suppressor of cytokine signaling 1 (SOCS1) and type 1 interferons to regulate Toll-like receptor-induced STAT1 activation. Proc Natl Acad Sci U S A 2011; 108:9554-9. [PMID: 21606371 DOI: 10.1073/pnas.1017296108] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Endogenous and pharmacologic glucocorticoids (GCs) limit inflammatory cascades initiated by Toll-like receptor (TLR) activation. A long-standing clinical observation has been the delay between GC administration and the manifestation of GC's anti-inflammatory actions. We hypothesized that the GCs would have inhibitory effects that target late temporal pathways that propagate proinflammatory signals. Here we interrogated signal transducer and activator of transcription 1 (STAT1) regulation by GC and its consequences for cytokine production during activation of macrophages with TLR-specific ligands. We found that robust STAT1 activation does not occur until 2-3 h after TLR engagement, and that GC suppression of STAT1 phosphorylation first manifests at this time. GC attenuates TLR4-mediated STAT1 activation only through induction of suppressor of cytokine signaling 1 (SOCS1), which increases throughout the 6-h period after treatment. Inhibition of TLR3-mediated STAT1 activation occurs via two mechanisms, impairment of type I IFN secretion and induction of SOCS1. Our data show that SOCS1 and type I interferons are critical GC targets for regulating STAT1 activity and may account for overall GC effectiveness in inflammation suppression in the clinically relevant time frame.
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Zhao J, Endoh I, Hsu K, Tedla N, Endoh Y, Geczy CL. S100A8 modulates mast cell function and suppresses eosinophil migration in acute asthma. Antioxid Redox Signal 2011; 14:1589-600. [PMID: 21142608 DOI: 10.1089/ars.2010.3583] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
S100A8 is implicated in the pathogenesis of inflammatory diseases. S100A8 is upregulated in macrophages by Toll-like receptors (TLR)-3, 4, and 9 agonists in an IL-10-dependent manner, and by corticosteroids in vitro and in vivo, and scavenges oxidants generated by activated phagocytes. Because if its elevated expression in various lung disorders, we asked whether S100A8 was protective in allergic inflammation. S100A8, but not Cys(41)-Ala S100A8, in which the single reactive Cys residue was replaced by Ala, reduced mast cell (MC) degranulation and production of particular cytokines (IL-6, IL-4, and granulocyte macrophage colony-stimulating factor) in response to IgE-crosslinking in vitro, likely by inhibiting intracellular reactive oxygen species production, thereby reducing downstream linker for activation of T cells and extracellular signal regulated kinase/mitogen-activated protein kinase phosphorylation. In lungs of mice with acute asthma, S100A8, but not Cys(41)-Ala S100A8, reduced MC degranulation, production of eosinophil chemoattractants (IL-5, eotaxin, and monocyte chemoattractant protein-1), and eosinophil infiltration. Suppression of IL-6 and IL-13 could have contributed to reduced mucus production seen in lungs of S100A8-treated mice. IgE production was unaffected. In asthma, there is an imbalance of anti-oxidant systems that are generally protective. Our results strongly support a protective role for S100A8 in allergic inflammation by modulating MC activation and eosinophil recruitment, and by scavenging oxidants generated by activated leukocytes, in processes reliant on its thiol-scavenging capacity.
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Affiliation(s)
- Jing Zhao
- Inflammation and Infection Research Centre, School of Medical Sciences, University of New South Wales, Sydney, Australia
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34
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World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J 2011; 4:13-37. [PMID: 23268454 PMCID: PMC3500036 DOI: 10.1097/wox.0b013e318211496c] [Citation(s) in RCA: 501] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.
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35
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Affiliation(s)
- Stephen C Lazarus
- Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143-0111, USA.
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