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Johnson S, Zhang CD, Hangge PT, Yen TWF, Shaik TJ, Doffek K, Findling JW, Carroll T, Evans DB, Dream SY, Wang TS. Cosyntropin Stimulation Testing is More Selective than Postoperative Day 1 Basal Cortisol for Diagnosing Secondary Adrenal Insufficiency After Unilateral Adrenalectomy. Ann Surg Oncol 2024; 31:6883-6892. [PMID: 39069580 DOI: 10.1245/s10434-024-15773-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Secondary adrenal insufficiency (SAI) may occur in patients after unilateral adrenalectomy for adrenal-dependent hypercortisolism (HC) or primary aldosteronism (PA). This study aimed to assess whether postoperative day (POD) 1 basal cortisol was predictive of an abnormal cosyntropin stimulation test (CST) result and the need for glucocorticoid replacement (GR). METHODS A retrospective review of consecutive patients who underwent unilateral adrenalectomy for HC, PA, or both between September 2014 and September 2022 was performed. On POD1, CST was performed for all the patients with HC, and before 2021 for all the patients with PA. The patients with an abnormal CST result were deemed at risk of SAI and discharged with GR. Receiver operating characteristic (ROC) curves were generated to evaluate the sensitivity (SN) and specificity (SP) of basal cortisol thresholds to predict an abnormal CST result. RESULTS The patients underwent unilateral adrenalectomy for overt hypercortisolism (OH; n = 42), mild autonomous cortisol excess (MACE; n = 70), mixed PA/HC (n = 22), or PA (n = 73). On POD1, CST was performed for 152 patients (93% OH, 96% MACE,73% PA/HC, 41% PA), and 80 patients (53%) had SAI (67% OH, 55% MACE, 44% PA/HC, 33% PA). The SN and SP of a basal cortisol level of 10 µg/dL or lower to predict an abnormal CST were respectively 92% and 77% for OH, 94% and 73% for MACE, 100% and 85% for PA, and 100% and 67% for PA/HC. The optimal basal cortisol level for predicting an abnormal CST for patients with PA or PA/HC was 5 µg/dL or lower (SN/SP, 100%). CONCLUSIONS After unilateral adrenalectomy for HC, PA, or mixed PA/HC, POD1 CST improved identification of patients at risk for SAI compared with basal cortisol levels alone. The authors recommend that POD1 CST be performed to determine the risk for SAI and the need for postoperative GR after unilateral adrenalectomy for patients with HC.
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Affiliation(s)
- Sean Johnson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Catherine D Zhang
- Division of Endocrinology and Molecular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Tina W F Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tahseen J Shaik
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James W Findling
- Division of Endocrinology and Molecular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ty Carroll
- Division of Endocrinology and Molecular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sophie Y Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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Wu W, Qu X, Hu C, Zhu X, Wan M, Zhou Y, Cheng H. Gypenoside LXXV Alleviates Colitis by Reprograming Macrophage Polarization via the Glucocorticoid Receptor Pathway. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2024; 72:20444-20457. [PMID: 39250600 DOI: 10.1021/acs.jafc.4c04784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
An imbalance in the macrophage phenotype is closely related to various inflammatory diseases. Here, we discovered that gypenoside LXXV (GP-75), a type of saponin from Gynostemma pentaphyllum, can reprogram M1-like macrophages into M2-like ones. On a mechanistic level, GP-75 inhibits NF-κB-COX2 signaling by targeting the glucocorticoid receptor (GR). Administration of GP-75, either orally or by intraperitoneal injection, significantly alleviates ulcerative colitis in mice, a pathogenesis associated with macrophage polarization. Clodronate liposomes, which deplete macrophages in mice, as well as GR antagonist RU486, abrogate the anticolitis effect of GP-75, thus confirming the pivotal role of macrophages in GP-75 function. We also showed that GP-75 has no toxicity in mice. Overall, this is the first report that demonstrates the effect of GP-75 on macrophage reprograming and as an agent against colitis. Because G. pentaphyllum is gaining popularity as a functional food, our findings offer new perspectives on the use of gypenosides as potential nutraceuticals for medical purposes.
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Affiliation(s)
- Wenjing Wu
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Xian Qu
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Chenxing Hu
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Xuepeng Zhu
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Mengqi Wan
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Yifa Zhou
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
| | - Hairong Cheng
- Engineering Research Center of Glycoconjugates, Ministry of Education, Jilin Provincial Key Laboratory of Chemistry and Biology of Changbai Mountain Natural Drugs, School of Life Sciences, Northeast Normal University, Changchun 130024, China
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Luo S, Lai S, Wu Y, Hong J, Lin D, Lin S, Huang X, Xu X, Weng X. Cost-effectiveness analysis of bevacizumab for cerebral radiation necrosis treatment based on real-world utility value in China. Strahlenther Onkol 2024; 200:805-814. [PMID: 38829437 DOI: 10.1007/s00066-024-02242-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/01/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Bevacizumab shows superior efficacy in cerebral radiation necrosis (CRN) therapy, but its economic burden remains heavy due to the high drug price. This study aims to evaluate the cost-effectiveness of bevacizumab for CRN treatment from the Chinese payers' perspective. METHODS A decision tree model was developed to compare the costs and health outcomes of bevacizumab and corticosteroids for CRN therapy. Efficacy and safety data were derived from the NCT01621880 trial, which compared the effectiveness and safety of bevacizumab monotherapy with corticosteroids for CRN in nasopharyngeal cancer patients, and demonstrated that bevacizumab invoked a significantly higher response than corticosteroids (65.5% vs. 31.5%, P < 0.001) with no significant differences in adverse events between two groups. The utility value of the "non-recurrence" status was derived from real-world data. Costs and other utility values were collected from an authoritative Chinese network database and published literature. The primary outcomes were total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). The uncertainty of the model was evaluated via one-way and probabilistic sensitivity analyses. RESULTS Bevacizumab treatment added 0.12 (0.48 vs. 0.36) QALYs compared to corticosteroid therapy, along with incremental costs of $ 2010 ($ 4260 vs. $ 2160). The resultant ICER was $ 16,866/QALY, which was lower than the willingness-to-pay threshold of $ 38,223/QALY in China. The price of bevacizumab, body weight, and the utility value of recurrence status were the key influential parameters for ICER. Probabilistic sensitivity analysis revealed that the probability of bevacizumab being cost-effectiveness was 84.9%. CONCLUSION Compared with corticosteroids, bevacizumab is an economical option for CRN treatment in China.
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Affiliation(s)
- Shaohong Luo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
| | - Shufei Lai
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yajing Wu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
- School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jinsheng Hong
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Fuzhou, China
- Key Laboratory of Radiation Biology of Fujian higher education institutions, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
| | - Dong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
| | - Shen Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
| | - Xiaoting Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
| | - Xiongwei Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China
| | - Xiuhua Weng
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 350004, Fuzhou, China.
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 350212, Changle, Fujian Province, China.
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Lai S, Luo S, Lin S, Huang X, Wang X, Xu X, Weng X. Is Bevacizumab a Cost-Effective Regimen for Treating Cerebral Radiation Necrosis in the United States? Pract Radiat Oncol 2024:S1879-8500(24)00210-8. [PMID: 39216726 DOI: 10.1016/j.prro.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 08/01/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Bevacizumab has been demonstrated to have superior efficacy in the treatment of cerebral radiation necrosis (CRN), but its high cost may exacerbate the disease burden. This study aimed to assess the cost-effectiveness of bevacizumab in comparison to corticosteroids for treating CRN from the US payers' perspective. METHODS Decision tree models were constructed to simulate the process of bevacizumab and corticosteroids in CRN short-term and long-term therapy. Critical clinical data were derived from the NCT01621880 trial. Costs and utility values were obtained from the US official websites and published literature. The main outcomes were total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to assess the robustness of the models. RESULTS In the short-term and long-term models, bevacizumab added 0.11 (0.46 vs 0.35) and 0.16 (0.54 vs 0.38) QALYs compared with corticosteroids therapy, with corresponding incremental costs of $12,351 and $23,253, respectively. The resultant ICERs were $112,987/QALY and $150,245/QALY for short-term and long-term treatment, respectively. The one-way sensitivity analysis indicated that utility value of nonrecurrence status, body weight, and bevacizumab price per cycle were the most influential factors for ICER of both models. At the willingness-to-pay threshold of $150,000/QALY in the United States, the probabilities of bevacizumab being cost-effective for CRN short and long-term treatment were 63.9% and 49%, respectively. CONCLUSIONS Compared with corticosteroids, bevacizumab is an economical alternative for CRN short-term treatment from the US payers' perspective, whereas long-term therapy draws an opposite conclusion.
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Affiliation(s)
- Shufei Lai
- School of Pharmacy, Fujian Medical University, Fuzhou, China; Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Shaohong Luo
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Shen Lin
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Xiaoting Huang
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Xiangzhen Wang
- School of Pharmacy, Fujian Medical University, Fuzhou, China; Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Xiongwei Xu
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China
| | - Xiuhua Weng
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fujian Province, Changle, China.
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Jakes RW, Kwon N, Huynh L, Hwee J, Baylis L, Alfonso-Cristancho R, Du S, Khanal A, Duh MS, Terrier B. Burden of eosinophilic granulomatosis with polyangiitis in Europe. ERJ Open Res 2024; 10:00912-2023. [PMID: 39104949 PMCID: PMC11299011 DOI: 10.1183/23120541.00912-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/26/2024] [Indexed: 08/07/2024] Open
Abstract
Background and aims Real-world evidence characterising the burden of eosinophilic granulomatosis with polyangiitis (EGPA) in Europe is limited. The aim of this study was to characterise patients in a large European EGPA cohort. Methods This retrospective, non-interventional, longitudinal study (GSK ID: 214661) recruited cross-specialty physicians from France, Germany, Italy, Spain and the UK to conduct medical chart reviews for patients with a physician-confirmed diagnosis of EGPA. Patients were ≥12 years of age at diagnosis with ≥1 year of follow-up data from the first clinical visit with the physician (index date). Outcome measures collected from index date to end of follow-up included clinical manifestations and healthcare resource utilisation (HCRU). Results In total, 407 patient medical charts were reviewed by 204 physicians; median (interquartile range) duration of follow-up from index date was 2.2 (1.7-3.5) years. Most patients (73.5%) had asthma. Patients underwent multiple diagnostic assessments, and 74.9% received ≥3 different therapies between diagnosis and end of follow-up (98.8% oral corticosteroids, 63.9% immunosuppressive therapies, 45.5% biologics). During follow-up, 84.5% of patients experienced EGPA clinical manifestations; most were considered moderate or severe and commonly affected the lungs (55.8%; including lung infiltrates 25.8% and severe asthma 24.8%), ear, nose and throat (53.3%), and skin (41.8%). HCRU was substantial: 26.0% of patients made emergency department visits, 36.6% were hospitalised and 84.8% had outpatient visits. Conclusions These real-world data show that EGPA presents a substantial burden to patients and the healthcare system. Earlier and better differential diagnosis and appropriate treatment may help reduce incidence of clinical manifestations and HCRU.
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Affiliation(s)
| | - Namhee Kwon
- Clinical Sciences, Respiratory, GSK, London, UK
| | | | | | - Lee Baylis
- Global Medical Affairs, GSK, Durham, NC, USA
| | | | - Shawn Du
- Analysis Group, Inc., Boston, MA, USA
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Garcia AV, Martini LI, Abache AF. Pharmacologic interventions for primary glenohumeral osteoarthritis. JAAPA 2024; 37:1-8. [PMID: 38916373 DOI: 10.1097/01.jaa.0000000000000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
ABSTRACT Primary glenohumeral osteoarthritis is a multifactorial condition with a complex cause that affects patients across different age groups, impairing physiologic and psychologic well-being, and substantially reducing patient quality of life and overall productivity. To effectively manage this condition, healthcare providers need to be well informed about treatment guidelines, as well as the available therapeutic options and the evidence supporting their use. Nonsurgical interventions should be regarded as the primary treatment option, particularly for patients in the initial phases of this condition. No conclusive guidelines exist for treating young and active patients, and the literature lacks high-quality data to evaluate the efficacy, safety, and long-term consequences of several interventions, regardless of patient characteristics and expectations.
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Affiliation(s)
- Ausberto Velasquez Garcia
- Ausberto Velasquez Garcia practices orthopedic surgery at the Clinica Universidad de los Andes in Chile and is a research fellow at the Mayo Clinic in Rochester, Minn. Liborio Ingala Martini practices orthopedic surgery at IVSS Dr. Luis Ortega Hospital and the Hospital Clinicas del Este, both in Porlamar, Venezuela. Andres Franco Abache practices orthopedic surgery at the Hospital de Especialidades Guayaquil MSP in Guayaquil, Ecuador. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Torpy DJ, Lim WT. Glucocorticoid-induced adrenal suppression: physiological basis and strategies for glucocorticoid weaning. Med J Aust 2024; 220:539. [PMID: 38714501 DOI: 10.5694/mja2.52299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/11/2024] [Indexed: 05/10/2024]
Affiliation(s)
- David J Torpy
- University of Adelaide, Adelaide, SA
- Royal Adelaide Hospital, Adelaide, SA
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Syed S, Hines J, Baccile R, Rouhani S, Reid P. Studying Outcomes after Steroid-Sparing Immunosuppressive Agent vs. Steroid-Only Treatment for Immune-Related Adverse Events in Non-Small-Cell Lung Cancer (NSCLC) and Melanoma: A Retrospective Case-Control Study. Cancers (Basel) 2024; 16:1892. [PMID: 38791970 PMCID: PMC11119129 DOI: 10.3390/cancers16101892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/06/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The effects of steroid-sparing immunosuppressive agents (SSIAs), used for the treatment of immune-related adverse events (irAEs), on immune checkpoint inhibitor (ICI) antitumor activity is not well known. We compared tumor outcomes of patients who received corticosteroid monotherapy (CS) versus a corticosteroid plus SSIA (CS-SSIA) for irAE treatment, using statistical methods to address immortal time bias. METHODS We conducted a retrospective case-control study on patients ≥ 18 years with melanoma or non-small-cell lung cancer (NSCLC) treated with ≥1 ICI at a quaternary care center between 1 January 2016 and 11 January 2021. Patients were divided into two cohorts: CS or CS-SSIA. We used propensity score nearest-neighbor matching to match on tumor type, stage, and prior lines of therapy. Primary outcomes were progression-free survival (PFS) and overall survival (OS). Secondary outcomes included the time from the start of the irAE treatment to the irAE resolution. Hazard ratios (HRs) for PFS and OS were calculated using the Cox proportional hazard regression method with both (1) the time to the steroid and SSIA as time-varying covariates and (2) a binary exposure classification not accounting for the time to the treatment. RESULTS A total of 167 patients were included after matching (132 in the CS cohort and 35 in the CS-SSIA cohort). Sixty-six percent of all the patients had melanoma. The most common irAEs requiring treatment were gastroenterocolitis and hepatitis. In an adjusted analysis not accounting for immortal time bias, there were no significant differences in PFS (HR 0.75, 95% CI [0.46-1.23]) or OS (HR 0.82, 95% CI [0.46-1.47]). In analyses using a time-varying treatment indicator, there was a trend toward improved PFS in patients treated with SSIAs (HR 0.54, CI 0.26-1.10). There was no difference in OS (HR 1.11, CI 0.55-2.23). Patients with melanoma who specifically received infliximab had improved PFS compared to patients with CS only, after adjusting for immortal time bias (HR 0.32, CI 0.24-0.43). CONCLUSIONS The use of SSIAs with CS did not have worse outcomes than CS monotherapy. In melanoma, our findings showed improved PFS for the use of infliximab versus steroid monotherapy for irAEs. Large, prospective, randomized controlled trials are needed to confirm these findings and guide the optimal treatment of irAEs.
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Affiliation(s)
- Sharjeel Syed
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA;
| | - Jacobi Hines
- Division of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Rachel Baccile
- Center for Health and The Social Sciences, University of Chicago, Chicago, IL 60637, USA
| | - Sherin Rouhani
- Mass General Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Farinha I, Heaney LG. Barriers to clinical remission in severe asthma. Respir Res 2024; 25:178. [PMID: 38658975 PMCID: PMC11044532 DOI: 10.1186/s12931-024-02812-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Severe asthma is associated with an increased risk for exacerbations, reduced lung function, fixed airflow obstruction, and substantial morbidity and mortality. The concept of remission in severe asthma as a new treatment goal has recently gained attention due to the growing use of monoclonal antibody therapies, which target specific pathologic pathways of inflammation. This review evaluates the current definitions of asthma remission and unveils some of the barriers for achieving this state in the severe asthma population. Although there is no unified definition, the concept of clinical remission in asthma should be based on a sustained period of symptom control, elimination of oral corticosteroid exposure and exacerbations, and stabilization of pulmonary function. The conjugation of these criteria seems a realistic treatment target in a minority of asthmatic patients. Some unmet needs in severe asthma may affect the achievement of clinical remission. Late intervention with targeted therapies in the severe asthma population may increase the risk of corticosteroid exposure and the development of irreversible structural airway changes. Moreover, airway infection is an important component in persistent exacerbations in patients on biologic therapies. Phenotyping exacerbations may be useful to guide therapy decisions and to avoid the liberal use of oral corticosteroids. Another challenge associated with the aim of clinical remission in severe asthma is the multifaceted interaction between the disease and its associated comorbidities. Behavioural factors should be evaluated in case of persistent symptoms despite optimised treatment, and assessing biomarkers and targeting treatable traits may allow for a more objective way of reaching remission. The concept of clinical remission will benefit from an international consensus to establish unifying criteria for its assessment, and it should be addressed in the future management guidelines.
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Affiliation(s)
- Inês Farinha
- Pulmonology Department, Coimbra Hospital and University Centre, Praceta Prof. Mota Pinto, Coimbra, 3004-561, Portugal
| | - Liam G Heaney
- Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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Knox A, Wang T, Shackleton M, Ameratunga M. Symptomatic brain metastases in melanoma. Exp Dermatol 2024; 33:e15075. [PMID: 38610093 DOI: 10.1111/exd.15075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024]
Abstract
Although clinical outcomes in metastatic melanoma have improved in recent years, the morbidity and mortality of symptomatic brain metastases remain challenging. Response rates and survival outcomes of patients with symptomatic melanoma brain metastases (MBM) are significantly inferior to patients with asymptomatic disease. This review focusses upon the specific challenges associated with the management of symptomatic MBM, discussing current treatment paradigms, obstacles to improving clinical outcomes and directions for future research.
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Affiliation(s)
- Andrea Knox
- Department of Medical Oncology, Alfred Health, Melbourne, Australia
| | - Tim Wang
- Department of Radiation Oncology, Westmead Hospital, Sydney, Australia
| | - Mark Shackleton
- Department of Medical Oncology, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Malaka Ameratunga
- Department of Medical Oncology, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Monash University, Melbourne, Australia
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Casale TB, Corbridge T, Germain G, Laliberté F, MacKnight SD, Boudreau J, Duh MS, Deb A. Real-world association between systemic corticosteroid exposure and complications in US patients with severe asthma. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:25. [PMID: 38532489 DOI: 10.1186/s13223-024-00882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Systemic corticosteroid (SCS) use remains widespread among patients with severe asthma, despite associated complications. OBJECTIVE Evaluate the association between cumulative SCS exposure and SCS-related complications in severe asthma. METHODS This retrospective, longitudinal study used claims data from the Optum Clinformatics Data Mart database (GSK ID: 214469). Eligible patients (≥ 12 years old) had an asthma diagnosis and were divided into two cohorts: SCS use and non/burst-SCS use. Patients in the SCS use cohort had a claim for a daily prednisone-equivalent dose ≥ 5 mg SCS following ≥ 6 months of continuous SCS use; those in the non/burst-SCS cohort had no evidence of continuous SCS use and had a non-SCS controller/rescue medication initiation claim. For each cohort, the date of the qualifying claim was the index date. SCS users were further stratified by SCS use during each quarter of follow-up: low (≤ 6 mg/day), medium (> 6-12 mg/day), high (> 12 mg/day), and continuous high (≥ 20 mg/day for 90 days). SCS-related complications were evaluated in the quarter following SCS exposure. The adjusted odds ratios (OR) of experiencing SCS-related complications during follow-up in each of the SCS use groups versus the non/burst SCS cohort were calculated using generalized estimating equations models. RESULTS SCS and non/burst-SCS use cohorts included 7473 and 89,281 patients (mean follow-up: 24.6 and 24.2 months), respectively. Compared with the non/burst-SCS use cohort, medium, high, and continuous high SCS use was associated with greater odds of any SCS-related complication (adjusted OR [95% confidence interval]: 1.30 [1.21, 1.39], 1.49 [1.35, 1.64] and 1.63 [1.40, 1.89], respectively) including increased acute gastrointestinal, cardiovascular, and immune system-related complications, and chronic cardiovascular, metabolic/endocrine, central nervous system, bone-/muscle-related, ophthalmologic, and hematologic/oncologic complications. Low-dose SCS use was also associated with significantly increased odds of acute gastrointestinal and immune system-related complications, and chronic bone-/muscle-related and hematologic/oncologic complications versus the non/burst-SCS use cohort. CONCLUSION SCS use, even at low doses, is associated with increased risk of SCS-related complications among patients with severe asthma.
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Affiliation(s)
- Thomas B Casale
- Division of Allergy/Immunology, University of South Florida, Tampa, FL, USA
| | | | - Guillaume Germain
- Health Economics and Outcomes Research, Groupe d'analyse, Montréal, QC, Canada
| | - François Laliberté
- Health Economics and Outcomes Research, Groupe d'analyse, Montréal, QC, Canada
| | - Sean D MacKnight
- Health Economics and Outcomes Research, Groupe d'analyse, Montréal, QC, Canada
| | - Julien Boudreau
- Health Economics and Outcomes Research, Groupe d'analyse, Montréal, QC, Canada
| | - Mei S Duh
- Health Economics and Outcomes Research, Analysis Group Inc, Boston, MA, USA
| | - Arijita Deb
- Value Evidence and Outcomes, GSK, Upper Providence, PA, USA.
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13
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Howell TA, Matza LS, Stone JH, Gelinas D, Stone MN, Rao VTS, Phillips GA. Qualitative interviews to support development of a patient-reported companion measure to the Glucocorticoid Toxicity Index. J Neurol Sci 2024; 458:122907. [PMID: 38309251 DOI: 10.1016/j.jns.2024.122907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Glucocorticoids (GCs) are associated with multiple toxicities that have substantial impact on patients. We conducted qualitative interviews with patients to identify the toxicities that are most relevant from their perspective, with the goal of creating a patient-reported companion measure to the Glucocorticoid Toxicity Index (GTI), a clinician-facing instrument. METHODS Thirty-one patients with recent or current GC use participated in concept elicitation interviews. Participants received GC treatment for myasthenia gravis, chronic inflammatory demyelinating polyradiculoneuropathy, vasculitis, or systemic lupus erythematosus. Transcripts were coded following a thematic analysis approach. RESULTS Participants reported more than 100 toxicities they believed to be associated with their GC medications. Common toxicities included weight gain (87%), increased appetite (84%), insomnia/sleep problems (77%), cognitive impairment/brain fog (71%), easy bruising (68%), anxiety (65%), irritability/short temper (65%), and osteoporosis (39%). These toxicities often centered on self-esteem, neuropsychiatric effects, skin toxicities, and musculoskeletal function. They can be categorized into domains such emphasizing neuropsychiatric, metabolic/endocrine, musculoskeletal, and dermatological effects, highlighting aspects of GC toxicity that patients are uniquely positioned to appreciate and report. CONCLUSION Our results confirm that the toxicities associated with GCs are pervasive and diverse, with substantial impact on patients' lives. These data will be used to inform the development of a patient-reported outcome measure assessing GC toxicity. This patient-reported instrument will be designed to complement the clinician-reported GTI, facilitating a more detailed understanding of the nuances of change in GC toxicity.
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Affiliation(s)
| | - Louis S Matza
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Deborah Gelinas
- Health Economics and Outcomes Research, Argenx, Boston, MA, USA
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14
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Chen JF, Yu SF, Chiu WC, Ko CH, Hsu CY, Lai HM, Chen YC, Su YJ, Kang HY, Cheng TT. Development and Comparison of Treatment Decision Tools for Glucocorticoid-Induced Osteoporosis. Diagnostics (Basel) 2024; 14:452. [PMID: 38396490 PMCID: PMC10887529 DOI: 10.3390/diagnostics14040452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Long-term Glucocorticoid (GC) use results in compromised bone strength and fractures, and several treatment recommendations have been developed to prevent fractures, but none have been validated in a real-world setting. This study aims to create a treatment decision tool and compares this tool to the treatment suggestions from the American College of Rheumatology (ACR), International Osteoporosis Foundation and European Calcified Tissue Society (IOF-ECTS), and GC-adjusted Fracture Risk Assessment Tool (GC-FRAX), above the intervention threshold. We utilized registry data gathered at Chang Gung Memorial Hospital at Kaohsiung, Taiwan, between September 2014 and April 2021. This research is a single-center, observational, and case-controlled study. We recruited participants using prednisone for at least 2.5 mg/day or the equivalent dose for over 3 months, excluding those younger than 40, those with malignancies, or those currently undergoing anti-osteoporosis therapy. The primary endpoint was new fragility fractures within 3 years, including morphometric vertebral fractures detected at baseline and with a follow-up thoracic-lumbar spine X-ray. Participants were randomly allocated into derivation and validation sets. We developed the Steroid-Associated Fracture Evaluation (SAFE) tool in the derivation cohort by assessing the weights of exploratory variables via logistic regression. Prediction performance was compared in the validation set by the receiver operating characteristic (ROC) curve, the area under the curve (AUC), and sensitivity and specificity. A total of 424 treatment-naïve subjects were enrolled, and 83 (19.6%) experienced new fractures within 3 years. The final formula of the SAFE tool includes osteoporosis (1 point), an accumulated GC dose ≥ 750 mg within 6 months (or equivalent prednisolone of ≥4.5 mg/day for 6 months) (1 point), a BMI ≥ 23.5 (1 point), previous fractures (1 point), and elderliness of ≥70 years (2 points). In the validation set, a treatment decision based on the SAFE ≥ 2 points demonstrated an AUC of 0.65, with a sensitivity/specificity/accuracy of 75.9/54.0/58.9, with an ACR of 0.56 (100.0/11.0/31.0), IOF-ECTS 0.61 (75.9/46.0/52.7), and GC-FRAX 0.62 (82.8/42.0/51.2). Among current GIOP recommendations, the SAFE score serves as an appropriate treatment decision tool with increased accuracy and specificity.
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Affiliation(s)
- Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Han-Ming Lai
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Hong-Yo Kang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
- Center for Menopause and Reproductive Medicine Research, Department of Obstetrics and Gynecology, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
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Tsuji D, Nakagaki S, Yonezawa I, Suzuki K, Yokokawa T, Kawasaki Y, Yamaguchi T, Kawaguchi T, Hatori M, Matsumoto T, Sakata Y, Yamamoto K, Nishimura T, Kogure Y, Hayashi T, Osawa M, Itoh K, Watanabe M. A multicenter phase II trial of the triplet antiemetic therapy with palonosetron, aprepitant, and olanzapine for a cisplatin-containing regimen. - PATROL-I. Invest New Drugs 2024; 42:44-52. [PMID: 38055127 DOI: 10.1007/s10637-023-01414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
Dexamethasone is one of the key antiemetic agents and is widely used even now. However, dexamethasone has been associated with several adverse reactions even after short-term administration. Therefore, developing a steroid-free antiemetic regimen is an important issue to consider. Thus, the purpose of this study was to investigate the efficacy and safety of palonosetron, aprepitant, and olanzapine in a multi-institutional phase II study. Chemotherapy-naive patients scheduled to receive cisplatin were enrolled and evaluated for the occurrence of chemotherapy-induced nausea and vomiting during 120 h after chemotherapy. The primary endpoint of the study was total control (TC) in the overall phase. The key secondary endpoint was complete response (CR), which was assessed in the acute, delayed, and overall phase, respectively. Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events. Eighty-five patients were enrolled from 8 centers in Japan, of which 83 were evaluable for analyses. The percentage of patients who achieved TC during the overall phase was 31.3%. CR was achieved in 61.4%, 84.3%, and 65.1% of patients during the overall, acute, and delayed phases, respectively. The most frequently reported adverse event was anorexia. The primary endpoint was below the threshold and we could not find benefit in the dexamethasone-free regimen, but CR during the overall phase was similar to that of the conventional three-drug regimen. This antiemetic regimen without dexamethasone might be an option for patients for whom corticosteroids should not be an active application.
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Affiliation(s)
- Daiki Tsuji
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Suruga-ku, Shizuoka, Japan.
| | - Shigeru Nakagaki
- Department of Pharmacy, Shizuoka General Hospital, Shizuoka, Japan
| | - Itsuki Yonezawa
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Suruga-ku, Shizuoka, Japan
| | - Kenichi Suzuki
- Department of Clinical Pharmacology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Takashi Yokokawa
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yohei Kawasaki
- Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Takumi Yamaguchi
- Institute for Assistance of Academic and Education, IAAE, Kanagawa, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Masahiro Hatori
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuma Matsumoto
- Pharmaceutical Department, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yukio Sakata
- Department of Pharmacy, Hakodate Municipal Hospital, Hokkaido, Japan
| | - Keisuke Yamamoto
- Department of Pharmacy, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Tomoyasu Nishimura
- Department of Pharmacy, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yuki Kogure
- Department of Pharmacy, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Toshinobu Hayashi
- Department of Pharmaceutical and Health Care Management, Faculty of Pharmaceutical Sciences, Fukuoka University, Fukuoka, Japan
| | - Misa Osawa
- Department of Pharmacy, Shizuoka General Hospital, Shizuoka, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Suruga-ku, Shizuoka, Japan
| | - Masaya Watanabe
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
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16
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Howard JF, Bril V, Vu T, Karam C, Peric S, De Bleecker JL, Murai H, Meisel A, Beydoun SR, Pasnoor M, Guglietta A, Van Hoorick B, Steeland S, T’joen C, Utsugisawa K, Verschuuren J, Mantegazza R. Long-term safety, tolerability, and efficacy of efgartigimod (ADAPT+): interim results from a phase 3 open-label extension study in participants with generalized myasthenia gravis. Front Neurol 2024; 14:1284444. [PMID: 38318236 PMCID: PMC10842202 DOI: 10.3389/fneur.2023.1284444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/27/2023] [Indexed: 02/07/2024] Open
Abstract
Objective ADAPT+ assessed the long-term safety, tolerability, and efficacy of efgartigimod in adult participants with generalized myasthenia gravis (gMG). Methods ADAPT+ was an open-label, single-arm, multicenter, up to 3-year extension of the pivotal phase 3 ADAPT study. Efgartigimod was administered in treatment cycles of 4 intravenous infusions (one 10 mg/kg infusion per week). Initiation of subsequent treatment cycles was individualized based on clinical evaluation. Safety endpoints included incidence and severity of adverse events. Efficacy endpoints assessed disease severity using Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Results As of January 2022, 151 participants had rolled over to ADAPT+ and 145 had received ≥1 dose of efgartigimod, of whom, 111 (76.6%) were AChR-Ab+ and 34 (23.4%) were AChR-Ab-. Mean study duration (treatment plus follow-up) was 548 days, and participants received up to 17 treatment cycles, corresponding to 217.6 participant-years of exposure. In the overall population, 123 (84.8%) participants reported ≥1 treatment-emergent adverse event; most frequent were headache (36 [24.8%]), COVID-19 (22 [15.2%]), and nasopharyngitis (20 [13.8%]). Clinically meaningful improvement (CMI) in mean MG-ADL and QMG scores was seen as early as 1 week following the first infusion across multiple cycles in AChR-Ab+ and AChR-Ab- participants. Maximal MG-ADL and QMG improvements aligned with onset and magnitude of total IgG and AChR-Ab reductions. For AChR-Ab+ participants at any time point in each of the first 10 treatment cycles, more than 90% had a maximum reduction of ≥2 points (CMI) in MG-ADL total score; across the 7 cycles in which QMG was measured, 69.4% to 91.3% of participants demonstrated a maximum reduction of ≥3 points (CMI) in QMG total score. Many participants demonstrated improvements well beyond CMI thresholds. In AChR-Ab+ participants with ≥1 year of combined follow-up between ADAPT and ADAPT+, mean number of annualized cycles was 4.7 per year (median [range] 5.0 [0.5-7.6]). Conclusion Results of ADAPT+ corroborate the substantial clinical improvements seen with efgartigimod in ADAPT and support its long-term safety, tolerability, and efficacy, as well as an individualized dosing regimen for treatment of gMG. Clinical trial registration https://classic.clinicaltrials.gov/ct2/show/NCT03770403, NCT03770403.
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Affiliation(s)
- James F. Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Stojan Peric
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jan L. De Bleecker
- Department of Neurology and Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium
| | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Andreas Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Said R. Beydoun
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | | | | | | | | | | | - Jan Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Carlo Besta, Milan, Italy
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van Ouwerkerk L, Verschueren P, Boers M, Emery P, de Jong PHP, Landewé RB, Lems W, Smolen JS, Huizinga TW, Allaart CF, Bergstra SA. Initial glucocorticoid bridging in rheumatoid arthritis: does it affect glucocorticoid use over time? Ann Rheum Dis 2024; 83:65-71. [PMID: 37607810 DOI: 10.1136/ard-2023-224270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To compare the use of glucocorticoids (GC) over time in patients with rheumatoid arthritis (RA) who were or were not treated initially with GC bridging therapy. METHODS Data from the BeSt, CareRA and COBRA trials were combined in an individual patient data (IPD) meta-analysis. We compared GC use between bridgers and non-bridgers at 12, 18 and 24 months from baseline with mixed-effects regression analysis. Secondary outcomes were mean cumulative GC dose until 24 months after baseline with and without the bridging period, Disease Activity Score based on 28 joints (DAS28) over time and number of disease-modifying antirheumatic drug (DMARD) changes. RESULTS 252/625 patients (40%) were randomised to GC bridging (bridgers). Excluding the period of bridging, later GC use was low in both groups and cumulative doses were similar. Mean DAS28 was similar between the groups, but bridgers improved more rapidly (p<0.001) in the first 6 months and the bridgers required significantly fewer changes in DMARDs (incidence rate ratio 0.59 (95% CI 0.38 to 0.94)). GC use was higher in the bridgers at t=12 months (OR 3.27 (95% CI 1.06 to 10.08)) and the bridging schedules resulted in a difference in cumulative GC dose of 2406 mg (95% CI 1403 to 3408) over 24 months. CONCLUSION In randomised trials comparing GC bridging and no GC bridging, bridgers had a more rapid clinical improvement, fewer DMARD changes and similar late use of GC compared with non-bridgers. GC bridging per protocol resulted, as could be expected, in a higher cumulative GC dose over 2 years.
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Affiliation(s)
| | | | - Maarten Boers
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Paul Emery
- Rheumatology, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | | | - Robert Bm Landewé
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
- Rheumatology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Willem Lems
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
- Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Tom Wj Huizinga
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Cornelia F Allaart
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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Wang Y, Jiang Z, Deng L, Zhang G, Xu X, Alonge E, Zhang H, Guo C. Dendrobium offificinale polysaccharides prevents glucocorticoids-induced osteoporosis by destabilizing KEAP1-NRF2 interaction. Int J Biol Macromol 2023; 253:126600. [PMID: 37652317 DOI: 10.1016/j.ijbiomac.2023.126600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023]
Abstract
Glucocorticoid-induced osteoporosis (GIOP) represents the foremost cause of secondary osteoporosis and fragility fractures. Novel therapeutic strategies for GIOP are needed, with improved safety profiles and reduced costs compared to current options. Dendrobium officinale (D. officinale) is a traditional Chinese medicine that has been reported to have beneficial effects on bone metabolism. Here, we sought to investigate the impacts of D. officinale polysaccharides (DOP), the main active constituents of D. officinale, on GIOP in vivo models and dexamethasone (DEX)-treated osteoblast lineage cells. We found that low concentrations of DOP are relatively safe in vitro and in vivo, respectively. Importantly, we found that DOP treatment significantly inhibited DEX-induced osteoporosis in two in vivo models, zebrafish and mice, while boosting osteogenic differentiation of hBMSCs exposed to DEX. Futhermore, our data reveal that DOP elevates nuclear Nrf2 levels under DEX treatment, by suppressing of Nrf2 ubiquitination. Leveraging Keap1b knockout zebrafish and RNAi approach, we demonstrated that DOP disrupts the association of Nrf2/Keap1, resulting in the inhibition of Nrf2 ubiquitination. Taken together, these results illuminate that DOP stimulates osteogenesis in the presence of DEX by destabilizing the Nrf2/Keap1 interaction. These findings suggest that DOP may serve as a novel drug against osteoporosis caused by glucocorticoids.
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Affiliation(s)
- Yunjia Wang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Zhongjing Jiang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Linhua Deng
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Gengming Zhang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Xia Xu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Emmanuel Alonge
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Hongqi Zhang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Chaofeng Guo
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China.
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Silver J, Deb A, Packnett E, McMorrow D, Morrow C, Bogart M. Characteristics and Disease Burden of Patients With Eosinophilic Granulomatosis With Polyangiitis Initiating Mepolizumab in the United States. J Clin Rheumatol 2023; 29:381-387. [PMID: 37779234 PMCID: PMC10662597 DOI: 10.1097/rhu.0000000000002033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND/OBJECTIVE Although the high disease burden associated with eosinophilic granulomatosis with polyangiitis (EGPA) has been established, the disease burden in patients initiating mepolizumab in real-world practice is poorly understood. This study aimed to assess characteristics and burden of real-world patients with EGPA initiating mepolizumab. METHODS This was a database study (GSK study ID: 214156) of US patients (≥12 years old) with EGPA and ≥1 mepolizumab claim (index date) identified from the Merative MarketScan Commercial and Medicare Supplemental Databases (November 1, 2015, to March 31, 2020). Outcomes assessed in the 12-month baseline period before index (inclusive) included patient characteristics, treatment use, EGPA relapses, asthma exacerbations, health care resource utilization, and costs. RESULTS In the 103 patients included (mean age, 51.1 years; 63.1% female), the most common manifestations were asthma (89.3%), chronic sinusitis (57.3%), and allergic rhinitis (43.7%). In total, 91.3% of patients had ≥1 oral corticosteroid (OCS) claim (median dose, 7.4 mg/d prednisone-equivalent), 45.6% were chronic OCS users (≥10 mg/d during the 90 days preindex), 99.0% had ≥1 EGPA-related relapse, and 62.1% ≥1 asthma exacerbation. During the baseline period, 26.2% and 97.1% of patients had EGPA-related inpatient admissions and office visits, respectively. Median all-cause total health care costs per patient were $33,298, with total outpatient costs ($16,452) representing the largest driver. CONCLUSIONS Before initiating mepolizumab, a substantial real-world EGPA disease burden is evident for patients, with resulting impact on health care systems, and indicative of unmet medical needs. Mepolizumab treatment, with a demonstrated positive clinical benefit-risk profile may represent a useful treatment option for reducing EGPA disease burden.
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Affiliation(s)
| | - Arijita Deb
- Value, Evidence and Outcomes, GSK, Upper Providence, PA
| | | | - Donna McMorrow
- Real-World Data Research and Analytics, Merative, Cambridge, MA
| | - Cynthia Morrow
- Real-World Data Research and Analytics, Merative, Cambridge, MA
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Wang Y, Estee MM, Gan D, Lim YZ, Heritier S, Wluka AE, Hussain SM, Trevaskis NL, Cicuttini FM. Effect of 6-week treatment with topical betamethasone dipropionate in patients with symptomatic hand osteoarthritis: A randomized double-blind, placebo-controlled trial. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100382. [PMID: 37426293 PMCID: PMC10329169 DOI: 10.1016/j.ocarto.2023.100382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Objective To examine the efficacy and safety of topical corticosteroid over 6 weeks in patients with symptomatic hand osteoarthritis. Design In a randomized, double-blind, placebo-controlled trial, community-based participants with hand osteoarthritis were randomly assigned (1:1) to topical Diprosone OV (betamethasone dipropionate 0.5 mg/g in optimised vehicle, n=54) or placebo (plain paraffin, n=52) ointment to painful joints 3 times daily for 6 weeks. Primary outcome was pain reduction [assessed by 100 mm visual analogue scale (VAS)] at 6 weeks. Secondary outcomes included changes in pain and function using the Australian Canadian Osteoarthritis Hand Index (AUSCAN), Functional Index for Hand Osteoarthritis (FIHOA), and Michigan Hand Outcomes Questionnaire (MHQ) at 6 weeks. Adverse events were recorded. Results Of 106 participants (mean age 64.2 years, 85.9% female), 103 (97.2%) completed the study. Change in VAS at 6 weeks was similar in the Diprosone OV and placebo groups (-19.9 vs. -20.9, adjusted difference 0.6, 95% CI -8.9 to 10.2). There were no significant between-group differences in change in AUSCAN pain [adjusted difference 25.8 (-16.0 to 67.5)], AUSCAN function [21.2 (-55.0 to 97.4)], FIHOA [-0.1 (-1.7 to 1.5)], or MHQ [-1.2 (-6.0 to 3.6)]. Incidence of adverse events was 16.7% in Diprosone OV and 19.2% in placebo group. Conclusions Topical Diprosone OV ointment, although well-tolerated, was no better than placebo in improving pain or function over 6 weeks in patient with symptomatic hand osteoarthritis. Future studies should consider examining joints with synovitis and whether delivery approaches enhancing transdermal penetration of corticosteroids into joints are effective in hand osteoarthritis. Trial registration ACTRN 12620000599976. Registered May 22, 2020.
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Affiliation(s)
- Yuanyuan Wang
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Mahnuma Mahfuz Estee
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Desmond Gan
- Department of Dermatology, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Yuan Z. Lim
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Anita E. Wluka
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Natalie L. Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Flavia M. Cicuttini
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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Zhdanava M, Ding Z, Manceur AM, Zhao R, Holiday C, Kachroo S, Izanec J, Pilon D. Long-term persistence and other treatment patterns among bio-naïve patients with Crohn's disease treated with ustekinumab or adalimumab. Curr Med Res Opin 2023; 39:1215-1225. [PMID: 37563994 DOI: 10.1080/03007995.2023.2246882] [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: 03/10/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To estimate long-term persistence among bio-naïve patients with CD initiated on ustekinumab or adalimumab. METHODS Adults with CD initiating ustekinumab or adalimumab (index date, between September 23, 2016 and August 1, 2019) were sampled from the IBM MarketScan Commercial Database. Patients without CD-indicated biologics (bio-naïve) and with no diagnoses for other autoimmune diseases 12 months pre-index date (baseline) were included. Cohorts were balanced on baseline characteristics with inverse probability of treatment weighting. Persistence was defined as the absence of therapy exposure gaps >120 days (ustekinumab) or >60 (adalimumab) between days of supply. Composite endpoints were persistence and being corticosteroid-free (no corticosteroids >14 days of supply after day 90 post-index) and persistence while on monotherapy (no immunomodulators/non-index biologics). Persistence was analyzed using Kaplan-Meier and Cox's models. RESULTS Ustekinumab and adalimumab cohorts included 671 and 2,975 patients. At 12 months post-index, ustekinumab patients were significantly more persistent (hazard ratio [HR] = 1.60; 95% confidence interval [CI] = 1.33-1.93), persistent while on monotherapy (HR = 1.43; 95% CI = 1.24-1.65), and trended toward being more persistent and corticosteroid-free (HR = 1.14; 95% CI = 0.99-1.30) vs adalimumab. At 24 months post-index, ustekinumab patients were significantly more persistent (HR = 1.66; 95% CI = 1.40-1.97), persistent while on monotherapy (HR = 1.44; 95% CI = 1.26-1.64), and persistent and corticosteroid-free (HR = 1.15; 95% CI = 1.01-1.31) vs adalimumab. CONCLUSIONS Bio-naïve patients with CD initiated on ustekinumab demonstrated significantly more persistence than patients initiated on adalimumab at 12 and 24 months of treatment. Long-term persistence is a measure of a drug's real-world performance and findings may aid clinical decision-making.
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Affiliation(s)
| | - Zhijie Ding
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
| | | | - Ruizhi Zhao
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
| | | | | | - James Izanec
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
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22
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Patel NJ, Jayne DRW, Merkel PA, Bekker P, Zhang Y, McDowell PJ, Johal J, Heaney LG, Murrell D, Stone MN, Yue H, Stone JH. The Glucocorticoid Toxicity Index-Metabolic Domains, an abridged version of the Glucocorticoid Toxicity Index: post-hoc analysis of data from the ADVOCATE trial. THE LANCET. RHEUMATOLOGY 2023; 5:e413-e421. [PMID: 38251552 DOI: 10.1016/s2665-9913(23)00131-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Quantifying glucocorticoid toxicity is crucial to efforts to reduce it. The Glucocorticoid Toxicity Index (GTI) measures toxicity effectively in clinical trials by calculating two scores: the cumulative worsening score (CWS) and the aggregate improvement score (AIS). However, in clinical practice, high patient volumes limit the time available for standardised assessments. We aimed to compare the GTI with an abbreviated version of the GTI, the GTI-Metabolic Domains (GTI-MD), which could help to address this issue by using data that are collected easily at routine visits and do not require additional effort from clinicians. METHODS We did a post-hoc analysis of data from ADVOCATE, a randomised, double-blind, double-dummy, phase 3 trial in which avacopan replaced a standard prednisone taper in patients with antineutrophil cytoplasmic antibody-associated vasculitis. We calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each domain of the GTI-MD-comprising the BMI, glucose tolerance, blood pressure, and lipid metabolism domains of the GTI-to test its ability to differentiate the avacopan and prednisone groups by glucocorticoid toxicity. Data from two additional disease cohorts, one comprising patients with asthma and the other comprising patients with autoimmune blistering disease, constituted the validation set. FINDINGS Complete data were available for 321 (97%) of the 330 participants comprising the intention-to-treat population in the ADVOCATE trial at week 13, and 307 (93%) at week 26; data from these individuals were included in our post-hoc analysis. In ADVOCATE, 98 (59%) of 166 participants in the avacopan group were men and 68 (41%) were women, 88 (54%) of 164 in the prednisone group were men and 76 (46%) were women; the mean age of participants was 61·2 years [SD 14·6] in the avacopan group and 60·5 years [14·5] in the prednisone group. The validation cohort included 159 patients (89 with glucocorticoid-dependent asthma, of whom 40 [45%] were men and 49 [55%] were women, and 70 with autoimmune blistering disease of the skin, of whom 30 [43%] were men and 40 [57%] were women). The Spearman's rank correlation coefficient in ADVOCATE for the GTI-MD CWS with the GTI CWS for the treatment groups combined was 0·78 (95% CI 0·75-0·81; p<0·0001). The corresponding correlation for the AIS was 0·73 (0·69-0·77, p<0·0001). The GTI-MD distinguished the groups by glucocorticoid toxicity at both 13 weeks and 26 weeks. The mean GTI-MD CWS was lower in the avacopan group than in the prednisone group, consistent with less toxicity (15·9 vs 23·0 at 13 weeks [p=0·0010]; 26·7 vs 31·7 at 26 weeks [p=0·0092]). The GTI-MD AIS values were also consistent with less toxicity in the avacopan group (2·5 vs 13·0 at 13 weeks [p=0·0003], 4·4 vs 10·1 at 26 weeks [p=0·027]). A GTI-MD score of 0 corresponded to a low likelihood of toxicity in the other GTI domains. In the validation set, the Spearman's rank correlation coefficient for the GTI-MD CWS with the GTI CWS was 0·61 (95% CI 0·50-0·70; p<0·0001) and the corresponding correlation for the AIS was 0·58 (0·47-0·68; p<0·0001). INTERPRETATION The GTI-MD correlates well with the full GTI and could be incorporated readily into routine clinic workflows without additional input from the clinician. Using the GTI-MD on the background of electronic medical records systems could help clinicians to monitor glucocorticoid toxicity longitudinally, with the goals of preventing the burden of chronic, treatment-related harms and reducing long-term costs to health systems. FUNDING ChemoCentryx.
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Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yuqing Zhang
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - P Jane McDowell
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Joslin Johal
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Liam G Heaney
- Wellcome Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences, Queen's University Belfast, Belfast, UK
| | - Dedee Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | | | | | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA.
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Huang SP, DerSarkissian M, Gu YM, Duh MS, Wang MJ, Benson J, Vu JD, Averell CM, Bell CF. Health Care Costs With Sustained Oral Corticosteroid Use in Systemic Lupus Erythematosus. Clin Ther 2023; 45:619-626. [PMID: 37271712 DOI: 10.1016/j.clinthera.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/07/2023] [Accepted: 04/23/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE The goal of this study was to compare health care costs, health care resource utilization, and adverse events associated with sustained oral corticosteroid (OCS) use versus no OCS use in systemic lupus erythematosus. METHODS This retrospective cohort study used claims data (January 1, 2006-July 31, 2019) from patients with systemic lupus erythematosus aged ≥5 years with ≥24 months of continuous enrollment. Health care costs, health care resource utilization, and OCS-related adverse events were assessed. The sustained OCS cohort (defined as ≥12 months of continuous OCS use) was divided into exposure categories based on the number of 6-month classification periods with >5 mg/d OCS (0, 1-2, or 3-4). FINDINGS Of the 6234 patients in the sustained OCS use cohort, there were 1587 (25.5%) patients with 0 periods of >5 mg/d OCS use, 2087 (33.5%) patients with 1 to 2 periods of >5 mg/d OCS use, and 2560 (41.1%) patients with 3 to 4 periods of >5 mg/d OCS use; the no OCS use cohort included 7828 patients. Adjusted health care cost differences (95% CIs) were significantly greater for patients with 0, 1 to 2, and 3 to 4 periods of OCS use >5 mg/d versus the no OCS use cohort ($7774 [5426-10,223], $21,738 [18,898-25,321], and $30,119 [26,492-33,774], respectively). A higher proportion of patients in all OCS exposure categories required health care resource utilization (≥99.7% vs 93.4%) and experienced OCS-related adverse events (94.3%-96.8% vs 82.6%) versus the no OCS use cohort, with more periods of OCS use >5 mg/d associated with increased health care resource utilization and adverse events. IMPLICATIONS Sustained OCS use in systemic lupus erythematosus was associated with high economic burden, health care resource utilization, and OCS-related adverse events. These data highlight the need for health care providers to carefully consider OCS use in systemic lupus erythematosus.
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Affiliation(s)
- Shirley P Huang
- GSK, US Value Evidence and Outcomes, Durham, North Carolina, USA
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24
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Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
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Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
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DerSarkissian M, Gu YM, Duh MS, Benson J, Huang SP, Averell C, Vu J, Wang M, Bell CF. Clinical and Economic Burden in Patients With Systemic Lupus Erythematosus During the First Year After Initiating Oral Corticosteroids: A Retrospective US Database Study. ACR Open Rheumatol 2023; 5:318-328. [PMID: 37226045 PMCID: PMC10267805 DOI: 10.1002/acr2.11550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To characterize health care resource utilization (HCRU), health care costs, and adverse events (AEs) among patients with systemic lupus erythematosus (SLE) initiating oral corticosteroids (OCS) versus patients without OCS use. METHODS In this retrospective cohort study (GSK Study 213061), eligible patients (aged ≥5 years at first OCS claim) with SLE from the IQVIA Real-World Data Adjudicated Claims-US database (January 2006 to July 2019) had continuous enrollment during the 6-month preindex (baseline) and 12-month postindex (observation) periods and one or more inpatient or emergency department SLE diagnosis codes or two or more outpatient SLE diagnosis codes during baseline. The "OCS-initiator cohort" comprised patients with one or more OCS pharmacy claims during the study period and no evidence of preindex OCS use and was classified into three exposure categories based on the number of 6-month periods of more than 5 mg/day of OCS use (0, 1, 2). The "no-OCS-use cohort" comprised patients without OCS claims, although patients may have received OCS prior to the study period. Clinical and economic outcomes were reported over the observation period. RESULTS Adjusted health care costs differed significantly ($6542 [95% confidence interval (CI): $5761-$7368], $19,149 [95% CI: $16,954-$21,471], $28,985 [95% CI: $25,546-$32,885]). HCRU incidence rates were significantly greater for all OCS-initiator exposure categories (n = 16,216) versus the no-OCS-use cohort (n = 11,137; adjusted incidence rate ratios [95% CI]: 1.22 [1.19-1.24], 1.39 [1.34-1.43], 1.66 [1.60-1.73]). OCS-related AEs were experienced by 67.1% to 74.1% of patients with OCS initiation, most commonly affecting the immune system. CONCLUSION Within 12 months of OCS initiation, patients with SLE experienced substantial clinical and economic burden, which may imply a need to minimize OCS use.
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Affiliation(s)
- Maral DerSarkissian
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - Yuqian M. Gu
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - Mei Sheng Duh
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - John Benson
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - Shirley P. Huang
- Shirley P. Huang, PharmD, MS (current address: Seagen Inc., Bothwell, WA, United States), Carlyne Averell, MS, SM (no current affiliation), Christopher F. Bell, PharmDResearch Triangle ParkNorth CarolinaUnited States
| | - Carlyne Averell
- Shirley P. Huang, PharmD, MS (current address: Seagen Inc., Bothwell, WA, United States), Carlyne Averell, MS, SM (no current affiliation), Christopher F. Bell, PharmDResearch Triangle ParkNorth CarolinaUnited States
| | - Jensen Vu
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - Min‐Jung Wang
- Maral DerSarkissian, PhD, Yuqian M. Gu, MS (current address: Kaiser Permanente, Pasadena, CA, United States), Mei Sheng Duh, MPH, ScD, John Benson, MS, Jensen Vu, BA (current address: Republic, New York, NY, United States, and VietChallenge, Boston, MA, United States), Min‐Jung Wang, ScD,MS (current address: Amgen Inc., Thousand Oaks, CA, United States): Analysis Group, Inc.BostonMassachusettsUnited States
| | - Christopher F. Bell
- Shirley P. Huang, PharmD, MS (current address: Seagen Inc., Bothwell, WA, United States), Carlyne Averell, MS, SM (no current affiliation), Christopher F. Bell, PharmDResearch Triangle ParkNorth CarolinaUnited States
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Wechsler ME, Hellmich B, Cid MC, Jayne D, Tian X, Baylis L, Roufosse F. Unmet needs and evidence gaps in hypereosinophilic syndrome and eosinophilic granulomatosis with polyangiitis. J Allergy Clin Immunol 2023:S0091-6749(23)00334-2. [PMID: 37086239 DOI: 10.1016/j.jaci.2023.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/17/2023] [Accepted: 03/16/2023] [Indexed: 04/23/2023]
Abstract
Hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA) are rare systemic inflammatory disorders with overlapping symptoms, elevated eosinophil counts, and heterogenous clinical presentations. Although progress has been made in recent years, there are substantial gaps in our understanding of the pathologic mechanisms involved in these diseases, as well as numerous unmet needs relating to both diagnosis and patient management. For example, in most cases of HES, the underlying cause of hypereosinophilia is unknown, while in EGPA, although a polygenic genetic susceptibility has been found, understanding of the pathogenic mechanisms remains largely elusive. Delineating differences between certain disease variants may be challenging, and there are no reliable predictive markers of disease course. In addition, the current diagnostic criteria for HES and classification criteria for EGPA are not easy to implement in a nonspecialist setting, and specialist referral pathways need to be signposted more clearly. Furthermore, disease-specific activity scores need to be developed to aid the assessment of treatment effects, and improved biomarkers are needed to aid with treatment stratification. In this review, we outline the limitations of our current understanding of HES and EGPA and highlight areas for future work, which ultimately should help improve patient management and outcomes.
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Affiliation(s)
| | - Bernhard Hellmich
- Department of Medicine, Medius Kliniken, Academic Teaching Hospital, University of Tübingen, Kirchheim-Teck, Germany
| | - Maria C Cid
- Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Xinping Tian
- Peking Union Medical College Hospital, Beijing, China
| | | | - Florence Roufosse
- Department of Internal Medicine, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Huang SP, DerSarkissian M, Gu YM, Duh MS, Wang MJ, Benson J, Vu J, Averell C, Bell CF. Prolonged oral corticosteroid treatment in patients with systemic lupus erythematosus: An evaluation of 12-month economic and clinical burden. J Manag Care Spec Pharm 2023; 29:365-377. [PMID: 36989451 PMCID: PMC10387938 DOI: 10.18553/jmcp.2023.29.4.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND: Prolonged, high-dose corticosteroid treatment for systemic lupus erythematosus (SLE) is associated with substantial health care costs, health care resource utilization (HCRU), and adverse events (AEs). OBJECTIVE: To compare all-cause health care costs, HCRU, and oral corticosteroid (OCS)-related AEs among patients with prevalent OCS use and patients without OCS use. METHODS: This retrospective, longitudinal cohort study (GSK study 214100) used claims data from the IQVIA Real-World Data Adjudicated Claims - US, IQVIA, Inc, database between January 1, 2006, and July 31, 2019, to identify patients with SLE. Patients with at least 1 OCS pharmacy claim during the study period and continuous OCS use during the 6-month pre-index (baseline) period (index date is the date of the first OCS claim following 6 months' continuous use) formed the "prevalent OCS use cohort." This cohort was subdivided based on the level of OCS exposure during the 12-month observation period, ie, the number of 6-month periods of greater than 5 mg/day OCS use (0, 1, or 2). Patients without OCS claims formed the "no OCS use cohort." All patients had continuous enrollment during the baseline and observation periods, had at least 1 inpatient or at least 2 outpatient SLE diagnosis codes during baseline, and were aged at least 5 years at index. A 2-part model, a generalized linear regression model with a negative binomial distribution, and a multivariate logistic regression model were used to compare health care costs, HCRU, and the odds of developing an OCS-related AE between cohorts, respectively. RESULTS: The no OCS use and prevalent OCS use cohorts included 21,517 and 16,209 patients, respectively. Adjusted health care cost differences (95% CI) were significantly lower for the no OCS use cohort vs all prevalent OCS use exposure categories ($5,439 [$4,537-$6,371] vs $17,856 [$16,368-$19,498]), driven by inpatient stays and outpatient visits; HCRU was also significantly lower (adjusted incidence rate ratios vs no OCS use cohort [95% CI]: 1.20 [1.16-1.23] vs 1.47 [1.41-1.52]). Health care costs and HCRU increased with increasing length of OCS exposure. OCS-related AEs occurred more frequently for all prevalent OCS use exposure categories vs the no OCS use cohort (odds ratio [95% CI]: 1.39 [1.25-1.55] vs 2.32 [2.02-2.68]), driven by hematologic/oncologic and immune system-related AEs. The mean (SD) average daily dose of OCS increased with increasing periods of prevalent OCS use (2.5 [1.3], 6.9 [31.1], and 34.6 [1,717.3] mg/day, respectively, for patients with 0, 1, and 2 periods of OCS use). CONCLUSIONS: Prevalent OCS use incurs a substantial clinical and economic burden, highlighting the need for restricted OCS doses and durations. DISCLOSURES: This study (GSK Study 214100) was funded by GSK. GSK was involved in designing the study, contributing to the collection, analysis, and interpretation of the data, supporting the authors in the development of the manuscript, and funding the medical writing assistance. All authors, including those employed by GSK, approved the content of the submitted manuscript and were involved in the decision to submit the manuscript for publication. Dr DerSarkissian, Dr Duh, and Mr Benson are employees of Analysis Group, which received research funding from GSK to conduct this study. Dr Wang, Ms Gu, and Mr Vu are former employees of Analysis Group. Mr Bell is an employee of GSK and holds stocks and shares in the company. Ms Averell and Dr Huang are former employees of GSK and held stocks and shares in the company at the time of the study.
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Hwee J, Huynh L, Du S, Kwon N, Jakes RW, Alfonso-Cristancho R, Baylis L, Requena G, Khanal A, Rothenberg ME, Sheng Duh M. Hypereosinophilic syndrome in Europe: Retrospective study of treatment patterns, clinical manifestations, and healthcare resource utilization. Ann Allergy Asthma Immunol 2023:S1081-1206(23)00129-1. [PMID: 36863663 DOI: 10.1016/j.anai.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND The burden of hypereosinophilic syndrome (HES) in Europe is not well characterized. OBJECTIVE To evaluate real-world patient characteristics, treatment patterns, clinical manifestations, and healthcare resource utilization for patients with HES from France, Germany, Italy, Spain, and the United Kingdom. METHODS In this retrospective, noninterventional study, data for patients with a physician-confirmed diagnosis of HES were abstracted from medical chart reviews. Patients were aged 6 years or older at the time of HES diagnosis and had 1 or more years of follow-up from the index date (first clinic visit between January 2015 and December 2019). Data on treatment patterns, comorbidities, clinical manifestations, clinical outcomes, and healthcare resource utilization were collected from diagnosis or index date to end of follow-up. RESULTS Data for 280 patients were abstracted from medical charts by 121 physicians treating HES, with multiple specialties. Most patients (55%) had idiopathic HES, and 24% had myeloid HES; the median number (interquartile range [IQR]) of diagnostic tests per patient was 10 (6-12). The most common comorbidities were asthma (45%) and anxiety or depression (36%). Most patients (89%) used oral corticosteroids; 64% used immunosuppressants or cytotoxic agents, and 44% used biologics. Patients had a median (IQR) of 3 clinical manifestations (1-5), most commonly constitutional (63%), lung (49%), and skin (48%). Twenty-three percent of patients experienced a flare, and 40% had a complete treatment response. Some patients (30%) were hospitalized with a median (IQR) stay of 9 days (5-15) for HES-related issues. CONCLUSION Patients with HES across 5 European countries had a substantial disease burden despite extensive oral corticosteroids treatment, highlighting the need for additional targeted therapies.
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Affiliation(s)
| | - Lynn Huynh
- Analysis Group, Inc., Boston, Massachusetts, United States
| | - Shawn Du
- Analysis Group, Inc., Boston, Massachusetts, United States
| | - Namhee Kwon
- Clinical Sciences, Respiratory, GSK, Brentford, Middlesex, United Kingdom
| | | | | | - Lee Baylis
- Global Medical Affairs, GSK, Durham, North Carolina, United States
| | | | - Anamika Khanal
- Analysis Group, Inc., Boston, Massachusetts, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| | - Mei Sheng Duh
- Analysis Group, Inc., Boston, Massachusetts, United States
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McDowell PJ, Busby J, Heaney LG. Asthma Exacerbations in Severe Asthma: Why Systemic Corticosteroids May not Always Be the Best Treatment Option. CURRENT TREATMENT OPTIONS IN ALLERGY 2023. [DOI: 10.1007/s40521-023-00330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Abstract
Purpose
Advances in the management of severe, eosinophilic asthma have improved, but asthma exacerbations continue to occur. This review aims to look at the evidence we have about why exacerbations may occur; their phenotype and why oral corticosteroids may not always be the best treatment option for all exacerbation of symptoms in individuals with severe asthma.
Recent findings
Studies dating back to the 1990s showed that asthma exacerbations across the spectrum of asthma severity were of different inflammatory endotypes. In addition, there is a wealth of evidence suggesting that eosinophilic inflammation is very responsive to corticosteroid therapy, but that non-eosinophilic inflammation is less so. Two recent UK-based studies have undertaken systematic phenotyping of exacerbations in severe asthma and have shown that there are a significant minority of exacerbation events with an increase in asthma symptoms, fall in lung function, but without evidence of raised T2 biomarkers.
Summary
The evidence to date would suggest that T2 biomarker low asthma exacerbations do not benefit from the administration of oral corticosteroids; in fact, the effect of the oral corticosteroids is harmful. However, there is a paucity of data to answer this question directly. Further research is needed to assess the evolution of non-T2 exacerbations not treated with OCS in a randomised, placebo-controlled, manner.
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Zhdanava M, Ding Z, Manceur AM, Muser E, Lefebvre P, Holiday C, Lafeuille MH, Pilon D. Treatment persistence among bio-naïve patients with Crohn's disease initiated on ustekinumab or adalimumab. Curr Med Res Opin 2023; 39:533-543. [PMID: 36752586 DOI: 10.1080/03007995.2023.2178148] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To compare persistence and describe dose titration among bio-naïve patients with Crohn's disease (CD) initiated on ustekinumab or adalimumab. METHODS Bio-naïve adults with CD who initiated ustekinumab or adalimumab (index date) from 23 September 2016 (ustekinumab US approval for CD) to 1 August 2019 were selected from IQVIA PharMetrics Plus. Cohorts were balanced on baseline characteristics measured over 12 months pre-index using inverse probability of treatment weights. Persistence was defined as no gaps (ustekinumab: >120 days; adalimumab: >60 days) between days of supply. Dose escalation was defined as ≥2 consecutive sub-cutaneous claims 100% above the US label daily dose in the maintenance phase; de-escalation was a return to the daily dose for ≥2 consecutive claims. Outcomes were described using weighted Kaplan-Meier models; persistence outcomes were compared using Cox's proportional hazards models. RESULTS At 12 months post-index, patients in the ustekinumab (n = 948) versus adalimumab (n = 4143) cohort had a significantly higher rate of persistence on index biologic (hazard ratio [HR] 1.50; 95% confidence interval [CI]: 1.29-1.74). A total of 830 (87.6%) patients in the ustekinumab cohort and 3713 (89.6%) in the adalimumab cohort began the maintenance phase; within 12 months, 11.2% and 16.9%, underwent a dose escalation, and 26.6% and 6.3%, respectively, subsequently de-escalated to the per US label daily exposure. CONCLUSIONS Bio-naïve patients with CD initiated on ustekinumab were more persistent than patients initiated on adalimumab; moreover, these patients had numerically lower dose escalation and higher de-escalation rates than patients initiated on adalimumab. Findings support the use of ustekinumab as a first-line treatment for bio-naïve patients with CD.
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Affiliation(s)
| | - Zhijie Ding
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
| | | | - Erik Muser
- Janssen Scientific Affairs, LLC, Horsham, PA, USA
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Roche N, Nadif R, Fabry-Vendrand C, Pillot L, Thabut G, Teissier C, Bouée S, Goldberg M, Zins M. Asthma burden according to treatment steps in the French population-based cohort CONSTANCES. Respir Med 2023; 206:107057. [PMID: 36502568 DOI: 10.1016/j.rmed.2022.107057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/14/2022] [Accepted: 11/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data on health care consumption and costs of asthma in the French population are scarce. OBJECTIVES The study objective was to describe the burden of asthma according to GINA treatment steps in the CONSTANCES cohort. METHODS Data from 162,725 participants included between 2012 and 2019 were extracted. Participants were considered as current asthmatics if asthma was reported at inclusion and asthma symptoms and/or treatments were reported in 2019. Participants were classified in three categories according to GINA treatment steps. The results were compared to non-asthmatic participants matched with a propensity score calculated on age, sex, region of residence, precariousness score and year of inclusion. RESULTS Among 162,725 participants aged 18-69 years, 6783 asthmatics (1566 not treated for asthma, 2444 + 251 GINA steps 1 + 2, 1054 + 1315 GINA steps 3 + 4, and 153 GINA step 5) were matched with 6783 controls. Average annual ambulatory cost and average annual hospitalization cost were respectively €1925 and €719 for asthmatics versus €1376 and €511 for participants without asthma (p < 0,0001). Cardiovascular risk factors, co-morbidities, visits and hospitalizations were higher for asthma participants as compared to controls and increased with GINA steps, as well as inpatient and outpatient costs. However, for cardiovascular risk factors and co-morbidities, differences were non-significant in multivariate analyses. Pharmacy costs were ten times higher for GINA step 5 participants than for GINA steps 1-2 participants: €3187 versus €393 (p < 0,0001). CONCLUSION mean cost of asthma was estimated at €757 per patient/year and increased with GINA treatment step.
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Affiliation(s)
- Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, APHP Centre et Université Paris Cité, Institut Cochin, INSERM UMR 1016, Paris, France; Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, Villejuif, France.
| | - Rachel Nadif
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, Villejuif, France.
| | | | | | | | | | | | - Marcel Goldberg
- Université Paris-Saclay, UVSQ, Université de Paris, Inserm, Cohortes Epidémiologiques en population, Villejuif, France.
| | - Marie Zins
- Université Paris-Saclay, UVSQ, Université de Paris, Inserm, Cohortes Epidémiologiques en population, Villejuif, France.
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Tiotiu A, Bikov A, Gonzalez-Barcala FJ, Novakova S, Novakova P, Chong-Neto H, Santus P, Ansotegui I, Ivancevich JC, Kowal K, Mihaicuta S, Nedeva D, Canonica GW, Bernstein JA, Boulet LP, Braido F. Criteria to evaluate efficacy of biologics in asthma: a Global Asthma Association survey. Expert Rev Respir Med 2023; 17:507-516. [PMID: 37313643 DOI: 10.1080/17476348.2023.2223986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Currently, there are no universally accepted criteria to measure the response to biologics available as treatment for severe asthma. This survey aims to establish consensus criteria to use for the evaluation of response to biologics after 4 months of treatment. METHOD Using Delphi methodology, a questionnaire including 10 items was validated by 13 international experts in asthma. The electronic survey circulated within the Interasma Scientific Network platform. For each item, five answers were proposed graduated from 'no importance' to 'very high importance' and by a score (A = 2 points; B = 4 points; C = 6 points; D = 8 points; E = 10 points). The final criteria were selected if the median score for the item was ≥7 and > 60% of responses according 'high importance' and 'very high importance'. All selected criteria were validated by the experts. RESULTS Four criteria were identified: reduce daily systemic corticosteroids dose by ≥50%; decrease the number of asthma exacerbations requiring systemic corticosteroids by ≥50%; have no/minimal side effects; and obtain asthma control according validated questionnaires. The consensual decision was that ≥3 criteria define a good response to biologics. CONCLUSIONS Specific criteria were defined by an international panel of experts and could be used as tool in clinical practice.
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Affiliation(s)
- Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France
- Development, Adaptation and Disadvantage. Cardiorespiratory Regulations and Motor Control Unit (EA 3450 DevAh), University of Lorraine, Nancy, France
| | - Andras Bikov
- North West Lung Centre, Wythenshawe Hospital, Manchester University Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Francisco-Javier Gonzalez-Barcala
- Department of Respiratory Medicine, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Spanish Biomedical Research Networking Centre-CIBERES, Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela, Spain
| | - Silviya Novakova
- Allergy Unit, Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
| | - Plamena Novakova
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Herberto Chong-Neto
- Division of Allergy and Immunology, Complexo Hospital de Clínicas, Universidade Federal Do Paraná, Curitiba, Brazil
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
- Division of Respiratory Diseases, "L. Sacco" University Hospital, Milano, Italy
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quirónsalud Bizkaia, Bilbao, Spain
| | | | - Krzysztof Kowal
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Stefan Mihaicuta
- Center for Research and Innovation in Precision Medicine and Pharmacy, Timisoara, Romania
- Department of Pulmonology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Denislava Nedeva
- Clinic of Asthma and Allergology, UMBAL Alexandrovska, Medical University Sofia, Sofia, Bulgaria
| | - Gorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Asthma & Allergy Unit-IRCCS Humanitas Research Hospital, Milan, Italy
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section University of Cincinnati, Cincinnati, OH, USA
| | - Louis Philippe Boulet
- Department of Medicine, Québec Heart and Lung Institute-Laval University, Quebec, Canada
| | - Fulvio Braido
- Department of Internal Medicine, University of Genoa, Genova, Italy
- Respiratory Unit for Continuity of Care IRCCS, Ospedale Policlinico San Martino, Genova, Italy
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Tsioulos G, Kounatidis D, Vallianou NG, Koufopoulos N, Katsimbri P, Antoniadou A. Severe eosinophilic granulomatosis with polyangiitis responding to a combination of rituximab and mepolizumab. Am J Med Sci 2023; 365:93-98. [PMID: 35970248 DOI: 10.1016/j.amjms.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 01/04/2023]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss Syndrome, is a multisystem antineutrophil cytoplasmic antibody (ANCA) positive vasculitis, characterized by the presence of chronic rhinosinusitis, asthma and prominent peripheral blood eosinophilia. Although the most commonly involved organ is the lung, followed by the skin, EGPA can affect any organ system. Herein, we present the complicated case of an 18-year-old male patient with severe life-threatening EGPA, with central nervous system, cardiac and gasterointestinal involvement, which was resistant to initial treatment with glucocorticoids and cyclophosphamide. The patient responded well, achieving complete remission after the addition of rituximab and mepolizumab to glucocorticoids and cyclophosphamide.
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Affiliation(s)
- Georgios Tsioulos
- Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Dimitris Kounatidis
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Natalia G Vallianou
- Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece.
| | | | - Pelagia Katsimbri
- Department of Internal Medicine, Attikon University Hospital, Athens, Greece
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Fallo F, Di Dalmazi G, Beuschlein F, Biermasz NR, Castinetti F, Elenkova A, Fassnacht M, Isidori AM, Kastelan D, Korbonits M, Newell-Price J, Parati G, Petersenn S, Pivonello R, Ragnarsson O, Tabarin A, Theodoropoulou M, Tsagarakis S, Valassi E, Witek P, Reincke M. Diagnosis and management of hypertension in patients with Cushing's syndrome: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2022; 40:2085-2101. [PMID: 35950979 DOI: 10.1097/hjh.0000000000003252] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endogenous/exogenous Cushing's syndrome is characterized by a cluster of systemic manifestations of hypercortisolism, which cause increased cardiovascular risk. Its biological basis is glucocorticoid excess, acting on various pathogenic processes inducing cardiovascular damage. Hypertension is a common feature in Cushing's syndrome and may persist after normalizing hormone excess and discontinuing steroid therapy. In endogenous Cushing's syndrome, the earlier the diagnosis the sooner management can be employed to offset the deleterious effects of excess cortisol. Such management includes combined treatments directed against the underlying cause and tailored antihypertensive drugs aimed at controlling the consequences of glucocorticoid excess. Experts on endocrine hypertension and members of the Working Group on Endocrine Hypertension of the European Society of Hypertension (ESH) prepared this Consensus document, which summarizes the current knowledge in epidemiology, genetics, diagnosis, and treatment of hypertension in Cushing's syndrome.
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Affiliation(s)
- Francesco Fallo
- Clinica Medica 3, Department of Medicine, University of Padova, Padova
| | - Guido Di Dalmazi
- Unit of Endocrinology and Diabetes Prevention and Care, Department of Medical and Surgical Sciences, University of Bologna
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nienke R Biermasz
- Leiden University Medical Center and European Reference Center for Rare Endocrine Conditions (Endo-ERN), Leiden, Netherlands
| | - Frederic Castinetti
- Aix Marseille Université, Marseille Medical Genetics, INSERM
- Assistance Publique Hopitaux de Marseille
- Department of Endocrinology, La Conception Hospital, Marseille, France
| | - Atanaska Elenkova
- Department of Endocrinology, University Specialized Hospital for Active Treatment in Endocrinology (USHATE) "Acad. Ivan Penchev", Medical University - Sofia, Sofia, Bulgaria
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London
| | - John Newell-Price
- Department of Oncology and Metabolism, Medical School, University of Sheffield
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences Istituto Auxologico Italiano, IRCCS
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany and University of Duisburg-Essen, Essen, Germany
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli
- Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antoine Tabarin
- CHU de Bordeaux, Hôpital Haut Lévêque, University of Bordeaux, Bordeaux, France
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Elena Valassi
- Endocrinology Unit, Hospital Germans Trias i Pujol, Badalona
- Research Center for Pituitary Diseases (CIBERER Unit 747), Hospital Sant Pau, Barcelona, Spain
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Bródno Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
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Jones MM, Kimble LP. Body Image, Depression Symptoms, and Health-Related Quality of Life in Black Women With Systemic Lupus Erythematosus. Nurs Womens Health 2022; 26:363-370. [PMID: 36002068 PMCID: PMC9659411 DOI: 10.1016/j.nwh.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 07/10/2022] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To examine relationships among body image, depression symptoms, and quality of life in Black women with systemic lupus erythematosus (SLE). DESIGN Descriptive, correlational design. SETTING/SAMPLE Using social media advertising, we recruited Black women with self-reported SLE to complete a web-based survey. RESULTS The female sample (N = 43) was predominantly non-Hispanic (80%) and married (58%), with a mean age of 33.5 (SD = 6.9) years. The mean time since SLE diagnosis was 5.9 (SD = 4.0) years. The majority of respondents (51%) reported using oral steroid therapy for disease control. Mean body image and depression scores, 2.0 (SD = 0.6) and 62.4 (SD = 8.5), respectively, differed from population norms of 1.80 (SD = 0.9) and 50 (SD = 10), indicating greater body image disturbance and greater depression symptoms than reported by the general population. Greater body image disturbance was significantly associated with greater depression symptoms and poorer quality of life in the area of role disruption. CONCLUSION Depression and body image disturbance among Black women with SLE should be routinely assessed and addressed by nurses and other clinicians to help promote optimal quality of life.
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McDowell PJ, Busby J, Hanratty CE, Djukanovic R, Woodcock A, Walker S, Hardman TC, Arron JR, Choy DF, Bradding P, Brightling CE, Chaudhuri R, Cowan D, Mansur AH, Fowler SJ, Diver SE, Howarth P, Lordan J, Menzies-Gow A, Harrison T, Robinson DS, Holweg CTJ, Matthews JG, Pavord ID, Heaney LG. Exacerbation Profile and Risk Factors in a Type-2-Low Enriched Severe Asthma Cohort: A Clinical Trial to Assess Asthma Exacerbation Phenotypes. Am J Respir Crit Care Med 2022; 206:545-553. [PMID: 35549845 PMCID: PMC9716911 DOI: 10.1164/rccm.202201-0129oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The past 25 years have seen huge progress in understanding of the pathobiology of type-2 (T2) asthma, identification of measurable biomarkers, and the emergence of novel monoclonal antibody treatments. Although present in a minority of patients with severe asthma, very little is known about the mechanisms underlying T2-low asthma, making it a significant unmet need in asthma research. Objectives: The objective of this study was to explore the differences between study exacerbators and nonexacerbators, to describe physiological changes at exacerbation in those who are T2HIGH and T2LOW at the time of exacerbation, and to evaluate the stability of inflammatory phenotypes when stable and at exacerbation. Methods: Exacerbation assessment was a prespecified secondary analysis of data from a 48-week, multicenter, randomized controlled clinical study comparing the use of biomarkers and symptoms to adjust steroid treatment in a T2-low severe asthma-enriched cohort. Participants were phenotyped as T2LOW (fractional exhaled nitric oxide ⩽ 20 ppb and blood eosinophil count ⩽ 150 cells/µl) or T2HIGH (fractional exhaled nitric oxide > 20 or blood eosinophil count > 150) at study enrollment and at each exacerbation. Here, we report the findings of the exacerbation analyses, including comparison of exacerbators and nonexacerbators, the physiological changes at exacerbation in those who had evidence of T2 biology at exacerbation versus those that did not, and the stability of inflammatory phenotypes when stable and at exacerbation. Measurements and Main Results: Of the 301 participants, 60.8% (183) had one or more self-reported exacerbations (total of 390). Exacerbators were more likely to be female, have a higher body mass index, and have more exacerbations requiring oral corticosteroid and unscheduled primary care attendances for exacerbations. At enrollment, 23.6% (71) were T2LOW and 76.4% (230) T2HIGH. The T2LOW group had more asthma primary care attendances, were more likely to have a previous admission to HDU (high dependency unit)/ICU and to be receiving maintenance oral corticosteroids. At exacerbation, the T2LOW events were indistinguishable from T2HIGH exacerbations in terms of lung function (mean fall in T2LOW FEV1, 200 [400] ml vs. T2HIGH 200 [300] ml; P = 0.93) and symptom increase (ACQ5: T2LOW, 1.4 [0.8] vs. T2HIGH, 1.3 [0.8]; P = 0.72), with no increase in T2 biomarkers from stable to exacerbation state in the T2LOW exacerbations. The inflammatory phenotype within individual patients was dynamic; inflammatory phenotype at study entry did not have a significant association with exacerbation phenotype. Conclusions: Asthma exacerbations demonstrating a T2LOW phenotype were physiologically and symptomatically similar to T2HIGH exacerbations. T2LOW asthma was an unstable phenotype, suggesting that exacerbation phenotyping should occur at the time of exacerbation. The clinically significant exacerbations in participants without evidence of T2 biology at the time of exacerbation highlight the unmet and pressing need to further understand the mechanisms at play in non-T2 asthma. Clinical trial registered with www.clinicaltrials.gov (NCT02717689).
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Affiliation(s)
- P. Jane McDowell
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - John Busby
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Catherine E. Hanratty
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - Ashley Woodcock
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Samantha Walker
- Asthma UK and British Lung Foundation Partnership, London, United Kingdom
| | | | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Chris E. Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow and University of Glasgow, Glasgow, United Kingdom
| | - Douglas Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, United Kingdom
| | - Adel H. Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Stephen J. Fowler
- Manchester Academic Health Science Center and NIHR Manchester Biomedical Research Center, Manchester University Hospitals National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Sarah E. Diver
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Center, University of Leicester, Leicester, United Kingdom
| | - Peter Howarth
- School of Clinical and Experimental Sciences, University of Southampton, National Institute for Health and Care Research (NIHR) Southampton Biomedical Research Center, Southampton, United Kingdom
| | - James Lordan
- the Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Menzies-Gow
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, the University of Manchester, Royal Brompton and Harefield Hospitals, London, United Kingdom
| | - Timothy Harrison
- Nottingham Respiratory NIHR Biomedical Research Center, University of Nottingham, Nottingham, United Kingdom
| | | | | | | | - Ian D. Pavord
- Oxford Respiratory NIHR Biomedical Research Center, Nuffield Department of Medicine, the University of Oxford, Oxford, United Kingdom
| | - Liam G. Heaney
- Center for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
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Lee JH, Jung EJ, Ham HJ, Yang YJ, Kim NS, Kim HI, Baek SY. Application of LC-MS/MS and UHPLC-Q-Orbitrap methods for determining 54 steroids in illegal dietary supplements and other sample types. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2022; 36:e9334. [PMID: 35705484 DOI: 10.1002/rcm.9334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 06/15/2023]
Abstract
RATIONALE With the development of the Internet and social network services, the public access to or use of illegal products has been increased via on/offline black markets. Steroids refer to the compounds yielding strong treatment effects on some diseases or muscle building, and are classified as the pharmaceutical compounds that are prohibited for personal use without a prescription. The prohibition is made for their potential risk to cause serious adverse effects along with their efficacies. METHODS To monitor the distribution of illicit products containing steroids, a simple and reliable analytical method was established and validated, allowing rapid and simultaneous determination of 54 steroids in them. During the screening, LC-Q-Orbitrap/MS was performed first followed by quantitative analysis using LC-MS/MS. For the accurate and reliable analysis, the samples were extracted using QuEChERS to reduce the matrix effect. RESULTS After the screening of 617 illegal samples advertised as being effective in alleviating various diseases or improving athletic performance with the established LC-Q-Orbitrap/MS method, the validated LC-MS/MS method was used to perform the quantitative analysis of the detected steroids. Of these, 142 samples were adulterated with steroids, and several samples with two or more steroids were detected. Due to the lack of previous studies on the toxicity of these illicit products, the side effects of consuming them are unpredictable and could be harmful. CONCLUSIONS The development of LC-Q-Orbitrap/MS method accompanied by LC-MS/MS could be successfully applied to the inspection of illegal steroid products for public health, enabling the rapid and accurate detection of analytes and incorporation of non-analyte components.
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Affiliation(s)
- Ji Hyun Lee
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Eun Ju Jung
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Hyeon Joo Ham
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Yoon Ji Yang
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Nam Sook Kim
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Hyung Il Kim
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
| | - Sun Young Baek
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Center for Advanced Analysis, Cheongju, Republic of Korea
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Intractable middle ear effusion in EGPA patients might cause permanent hearing loss: a case-control study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:68. [PMID: 35933390 PMCID: PMC9357339 DOI: 10.1186/s13223-022-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Background Ear, nose, and throat involvement are common in eosinophilic granulomatosis with polyangiitis (EGPA). Among otologic manifestation, middle ear effusion (MEE) is less recognized but a problematic condition as it may progress to hearing impairment when left untreated. This study aimed to evaluate the characteristics, risk factors and clinical outcomes of MEE in EGPA patients. Methods This is a case–control study of patients who were diagnosed and treated for EGPA from January 1995 to November 2018. Patients with ear symptoms (ear fullness, ear discharge, tinnitus or hearing loss) were assessed by otologists and were included in the case group (n = 23) if clinically relevant. The other patients without MEE were included in the control group (n = 52). Risk of MEE was calculated using the Cox proportional-hazard model. Results During median follow-up of 9.9 years, 23 (30.7%) out of 75 patients had MEE. In MEE group, 12 (52.2%) patients had hearing loss; conductive type in 10 (10/12, 83.3%) and mixed type in two (2/12, 16.7%). In multivariable regression analysis, major organ involvement at diagnosis (adjusted hazard ratio [aHR] 65.4; 95% confidence interval [CI], 1.50—2838.39; P = 0.030] , early onset of ear symptom after systemic therapy (< 6 months) (aHR 40.0; 95% CI, 1.35—1183.43; P = 0.033) and continuing the maintenance steroid without cessation (aHR 8.59; 95% CI, 1.13—65.42; P = 0.038) were independently associated with a risk of MEE. To control MEE, 16 (69.6%) patients had to increase maintenance steroid dose and 9 (39.1%) patients experienced recurrent MEE whenever maintenance dose was tapered. Conclusions MEE is a common but frequently neglected condition in EGPA which is often intractable. The maintenance steroid dose should be adequately adjusted to control MEE and to prevent from progressive hearing loss. Novel biologic agents possibly have a role in controlling MEE in EGPA.
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Davis GE, Zeiger RS, Emmanuel B, Chung Y, Tran TN, Evans KA, Chen S, Katial R, Kreindler JL, Tkacz J. Systemic Corticosteroid–related Adverse Outcomes and Health Care Resource Utilization and Costs Among Patients with Chronic Rhinosinusitis with Nasal Polyposis. Clin Ther 2022; 44:1187-1202. [DOI: 10.1016/j.clinthera.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 11/03/2022]
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Spray-Dried and Spray-Freeze-Dried Powder Formulations of an Anti-Interleukin-4Rα Antibody for Pulmonary Delivery. Pharm Res 2022; 39:2291-2304. [PMID: 35879500 DOI: 10.1007/s11095-022-03331-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/03/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The therapeutic options for severe asthma are limited, and the biological therapies are all parenterally administered. The purpose of this study was to formulate a monoclonal antibody that targets the receptor for IL-4, an interleukin implicated in the pathogenesis of severe asthma, into a dry powder intended for delivery via inhalation. METHODS Dehydration was achieved using either spray drying or spray freeze drying, which exposes the thermolabile biomacromolecules to stresses such as shear and adverse temperatures. 2-hydroxypropyl-beta-cyclodextrin was incorporated into the formulation as protein stabiliser and aerosol performance enhancer. The powder formulations were characterised in terms of physical and aerodynamic properties, while the antibody was assessed with regard to its structural stability, antigen-binding ability, and in vitro biological activity after drying. RESULTS The spray-freeze-dried formulations exhibited satisfactory aerosol performance, with emitted fraction exceeding 80% and fine particle fraction of around 50%. The aerosolisation of the spray-dried powders was hindered possibly by high residual moisture. Nevertheless, the antigen-binding ability and inhibitory potency were unaffected for the antibody in the selected spray-dried and spray-freeze-dried formulations, and the antibody was physically stable even after one-year storage at ambient conditions. CONCLUSIONS The findings of this study establish the feasibility of developing an inhaled dry powder formulation of an anti-IL-4R antibody using spray drying and spray freeze drying techniques with potential for the treatment of severe asthma.
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Brogan P, Naden R, Ardoin SP, Cooper JC, De Benedetti F, Dicaire JF, Eleftheriou D, Feldman B, Goldin J, Karol SE, Price-Kuehne F, Skuse D, Stratakis CA, Webb N, Stone JH. The pediatric glucocorticoid toxicity index. Semin Arthritis Rheum 2022; 56:152068. [PMID: 35917759 DOI: 10.1016/j.semarthrit.2022.152068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop a Pediatric glucocorticoid toxicity index (pGTI), a standardized, weighted clinical outcome assessment that measures change in glucocorticoid (GC) toxicity over time. METHODS Fourteen physician experts from 7 subspecialties participated. The physician experts represented multiple subspecialties in which GCs play a major role in the treatment of inflammatory disease: nephrology, rheumatology, oncology, endocrinology, genetics, psychiatry, and maternal-fetal medicine. Nine investigators were from Canada, Europe, or New Zealand, and 5 were from the United States. Group consensus methods and multi-criteria decision analysis were used. The pGTI is an aggregate assessment of GC toxicities that are common, important, and dynamic. These toxicities are organized into health domains graded as minor, moderate, or major and are weighted according to severity. The relative weights were derived by group consensus and multi-criteria decision analysis using the 1000MindsTM software platform. Two quantitative scores comprise the overall toxicity profile derived from pGTI data: (1) the Cumulative Worsening Score; and (2) the Aggregate Improvement Score. The pGTI also includes a qualitative, unweighted record of GC side-effects known as the Damage Checklist, which documents less common toxicities that, although potentially severe, are unlikely to change with varying GC dosing. RESULTS One hundred and seven (107) toxicity items were included in the pGTI and thirty-two (32) in the Damage Checklist. To assess the degree to which the pGTI corresponds to expert clinical judgement, the investigators ranked 15 cases by clinical judgement from highest to lowest GC toxicity. Expert rankings were then compared to case ranking by the pGTI, yielding excellent agreement (weighted kappa 0.86). The pGTI was migrated to a digital environment following its development and initial validation. The digital platform is designed to ensure ease-of-use in the clinic, rigor in application, and accuracy of scoring. Clinic staff enter vital signs, laboratory results, and medication changes relevant to pGTI scoring. Clinicians record findings for GC myopathy, skin toxicity, mood dysfunction, and infection. The pGTI algorithms then apply the weights to these raw data and calculate scores. Embedded logic accounts for the impact of age- and sex-related reference ranges on several health domains: blood pressure, lipid metabolism, and bone mineral density. Other algorithms account for anticipated changes in the height Z-scores used in the growth domain, thereby addressing a concern unique to GC toxicity in children. The Damage Checklist ensures comprehensive measurement of GC toxicity but does not contribute to pGTI scoring, because the scored domains emphasize manifestations of GC toxicity that are likely to change over the course of a trial. CONCLUSIONS We describe the development and initial evaluation of a weighted, composite toxicity index for the assessment of morbidity related to GC use in children and adolescents. Developing the pGTI digital platform was essential for performing the nuanced calculations necessary to ensure rigor, accuracy, and ease-of-use in both clinic and research settings.
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Affiliation(s)
- Paul Brogan
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Ray Naden
- McMasterUniversity, Hamilton, Ontario, Canada
| | | | - Jennifer C Cooper
- University of Colorado Anschutz Medical Alifornia, San Francisco, CA, USA
| | | | | | - Despina Eleftheriou
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Brian Feldman
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jon Goldin
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Seth E Karol
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - David Skuse
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicholas Webb
- Royal Manchester Children's Hospital, Manchester, UK; Rheumatology Clinic, Bulfinch 165, Massachusetts General Hospital, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Stone
- Great Ormond Street Hospital NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London UK.
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Arantes VN, Ramos JA, White JR, Parra-Blanco A. Clinical effectiveness of short course oral prednisone for stricture prevention after semi-circumferential esophageal endoscopic submucosal dissection. Endosc Int Open 2022; 10:E753-E761. [PMID: 35692934 PMCID: PMC9187403 DOI: 10.1055/a-1789-0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background and study aims Esophageal strictures (ES) occur frequently after semi-circumferential endoscopic submucosal dissection (ESD) for the eradication of superficial esophageal neoplasms and negatively impact a patient's quality of life. Oral corticosteroids have been shown to be clinically effective, but the most appropriate drug, dose and duration is yet to be determined. The aim of the study was to investigate the clinical effectiveness and safety of 30 mg prednisone with a shortened tapering schedule on ES after semi-circumferential ESD. Patients and methods This was a retrospective observational study that analyzed consecutive patients with esophageal neoplasms who underwent semi-circumferential ESD with a resection defect greater than 75 % of the circumference that received a protocol of oral steroids for stricture prevention. On postoperative day 3, 30 mg prednisone was prescribed, tapering weekly to 20 mg/10 mg/5 mg over 4 weeks. Follow-up included clinic consultation and endoscopic review at weeks 2 and 4. Effectiveness outcomes included ES rates, safety, tolerability, resection, dilatation and recurrence rates. Results Ninety ESD procedures were carried out during the specified time period and 18 patients met the inclusion criteria for the final analysis. The mean age was 61.5 years, lesion size was 52.5 mm, and final histology was squamous cell carcinoma in all patients. Incidence of intra-procedure complications was: bleeding 5.5 % (1/18) and ES 5.5 % (1/18), requiring a median two endoscopic dilatations. En bloc, R0 and curative resection rates were 88.8 %, 72.2 %, and 55.5 %, respectively. Conclusions The short tapering schedule of 30 mg oral prednisone is clinically efficacious and safe for prevention of ES after semi-circumferential ESD in Latin American patients.
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Affiliation(s)
- Vitor N. Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Hospital Mater Dei Contorno, Belo Horizonte, Brazil
| | - Josué Aliaga Ramos
- Faculty of Medicine, Cayetano Heredia Peruvian University, Digestive Endoscopy Unit of San Pablo Clinic, Surco, Lima, Department of Gastroenterology, “Jose Agurto Tello” Hospital, Lima, Peru, Associate member of the Society of Gastroenterology of Peru
| | - Jonathan Richard White
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, UK.
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, UK.
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Laurent MR, Goemaere S, Verroken C, Bergmann P, Body JJ, Bruyère O, Cavalier E, Rozenberg S, Lapauw B, Gielen E. Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club. Front Endocrinol (Lausanne) 2022; 13:908727. [PMID: 35757436 PMCID: PMC9219603 DOI: 10.3389/fendo.2022.908727] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 01/13/2023] Open
Abstract
Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatrics, Imelda Hospital, Bonheiden, Belgium
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Serge Rozenberg
- Department of Gynaecology and Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Evelien Gielen
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, University Hospitals Leuven and KU Leuven, Leuven, Belgium
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Nakai T, Fukui S, Ikeda Y, Suda M, Tamaki H, Okada M. Glucocorticoid discontinuation in patients with SLE with prior severe organ involvement: a single-center retrospective analysis. Lupus Sci Med 2022; 9:9/1/e000682. [PMID: 35654482 PMCID: PMC9163542 DOI: 10.1136/lupus-2022-000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/19/2022] [Indexed: 12/13/2022]
Abstract
Objective Long-term glucocorticoid use in SLE may have significant side effects; however, glucocorticoid discontinuation is occasionally associated with disease flare-ups. Therefore, we evaluated the risk factors for disease flares and the flare rate on glucocorticoid tapering in patients with prior severe organ involvement. Methods Data of patients with SLE with glucocorticoid tapering at our institution were retrospectively analysed. We divided the patients by the presence of prior severe organ involvement and compared flare rates after glucocorticoid discontinuation. Furthermore, we determined risk factors for flares after glucocorticoid discontinuation. Results In total, 309 patients with SLE were screened, 73 of whom met the inclusion criteria; 49 were classified as SLE with prior severe organ involvement. No significant differences were noted in the 52-week flare rate after glucocorticoid discontinuation between patients with and without prior severe organ involvement (16.7% vs 18.2%, p=1.0). Hypocomplementaemia, elevated anti-dsDNA antibody titres more than twice the upper limit of the laboratory reference range, positive anti-Smith/anti-ribonucleoprotein antibody, and use of any immunosuppressant on the day of glucocorticoid discontinuation were negatively associated with flare-free remission. Conclusions Glucocorticoid discontinuation after gradual tapering can often be achieved in patients with SLE, even with prior severe organ involvement, especially when the disease is clinically and serologically stable.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Center for Clinical Epidemiology, St Luke's International University, Chuo-ku, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masei Suda
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan.,Department of Rheumatology, Suwa Central Hospital, Nagano, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St Luke's International Hospital, Chuo-ku, Japan
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Martins DT, Carlos K, Carvalho LB, Prado LB, Fransolin C, Atallah AN, do Prado GF. A randomized clinical trial on inhaled ciclesonide for managing acute asthma in the emergency room. SAO PAULO MED J 2022; 140:430-438. [PMID: 35508008 PMCID: PMC9671241 DOI: 10.1590/1516-3180.2021.0542.r1.15092021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Use of inhaled corticosteroids for managing acute asthma exacerbations has been tested since the 1990s. OBJECTIVE To compare high doses of inhaled ciclesonide with systemic hydrocortisone for managing acute asthma exacerbations in the emergency department. DESIGN AND SETTING Double-blind, randomized clinical trial in the public healthcare system of the city of São Paulo. METHODS Fifty-eight patients with moderate or severe asthma with peak flow < 50% of predicted were randomized into two groups. Over the course of four hours, one group received 1440 mcg of inhaled ciclesonide plus hydrocortisone-identical placebo (ciclesonide + placebo), while the other received 500 mg of intravenous hydrocortisone plus ciclesonide-identical placebo (hydrocortisone + placebo). Both groups received short-acting bronchodilators (fenoterol hydrobromide and ipratropium bromide). The research protocol included spirometry, clinical evaluation, vital signs and electrocardiogram monitoring. Data were obtained at 30 (baseline), 60, 90, 120, 180, and 240 minutes. We compared data from baseline to hour 4, between and within groups. RESULTS Overall, 31 patients received ciclesonide + placebo and 27 received hydrocortisone + placebo. Inhaled ciclesonide was as effective as intravenous hydrocortisone for improving clinical parameters (Borg-scored dyspnea, P = 0.95; sternocleidomastoid muscle use, P = 0.55; wheezing, P = 0.55; respiratory effort, P = 0.95); and spirometric parameters (forced vital capacity, P = 0.50; forced expiratory volume in the first second, P = 0.83; peak expiratory flow, P = 0.51). CONCLUSIONS Inhaled ciclesonide was not inferior to systemic hydrocortisone for managing acute asthma exacerbations, and it improved both clinical and spirometric parameters. TRIAL REGISTRATION RBR-6XWC26 - Registro Brasileiro de Ensaios Clínicos (http://www.ensaiosclinicos.gov.br/rg/RBR-6xwc26/).
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Affiliation(s)
- Demétrius Tierno Martins
- MD. Physician, Department of Emergency Medicine and Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Karla Carlos
- PhD. Physiotherapist, Neuro-Sono Sleep Center, Department of Neurology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Luciane Bizari Carvalho
- PhD. Psychologist, Neuro-Sono Sleep Center, Department of Neurology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Lucila Bizari Prado
- MD. Physician, Neuro-Sono Sleep Center, Department of Neurology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Carolina Fransolin
- MSc. Physiotherapist, Neuro-Sono Sleep Center, Department of Neurology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Alvaro Nagib Atallah
- MD, PhD. Professor, Department of Emergency Medicine and Evidence-Based Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
| | - Gilmar Fernandes do Prado
- MD, PhD. Professor, Neuro-Sono Sleep Center, Department of Neurology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
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Pinnell J, Tiivas C, Mehta P, Dubey S. Corticosteroids reduce vascular ultrasound sensitivity in fast- track pathways (FTP): results from Coventry Multi-Disciplinary FTP for cranial Giant Cell Arteritis. Scand J Rheumatol 2022; 52:283-292. [PMID: 35442157 DOI: 10.1080/03009742.2022.2051279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study aims to assess the feasibility of the Coventry multidisciplinary fast-track cranial giant cell arteritis (FTGCA) pathway, which was set up in 2013 in collaboration with vascular physiology and ophthalmology to enable prompt multidisciplinary assessment, including ultrasound (US). This study also looks at the impact of prior corticosteroid (CS) use on the performance of US in real life. METHOD Data were collected retrospectively for patients who attended the Coventry FTGCA pathway between 1 January 2014 and 31 December 2017. Patients were identified from US lists and clinical details were obtained from electronic medical records. RESULTS In total, 620 eligible patients were included in this study. US had a sensitivity of 50%, which improved to nearly 56% in CS-naïve patients. The median duration of CS use prior to US was 2 days, and sensitivity was around 46% in this group. The specificity of US was > 96%, and CS use was avoided completely in 345 patients (56%). CSs negatively impacted on the utility of US, with US more likely to be false negative. CONCLUSIONS This novel multidisciplinary pathway demonstrates excellent feasibility and minimizes the use of CSs in patients without giant cell arteritis. US was performed promptly, was cost effective- and had reassuring real-life sensitivity and specificity in this cohort, with excellent patient feedback. CS-naïve patients showed higher sensitivity for US despite the short duration of CS use.
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Affiliation(s)
- J Pinnell
- Deptartment of Rheumatology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.,Department of Rheumatology Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - C Tiivas
- Department of Clinical Physics and Bioengineering, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - P Mehta
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - S Dubey
- Deptartment of Rheumatology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.,Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yu J, Luo J, Zhu H, Sui Z, Liu H, Li L, Zheng Q. Quantitative Comparison of the Clinical Efficacy of 6 Classes Drugs for IgA Nephropathy: A Model-Based Meta-Analysis of Drugs for Clinical Treatments. Front Immunol 2022; 13:825677. [PMID: 35419000 PMCID: PMC9000973 DOI: 10.3389/fimmu.2022.825677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/03/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction There is a wide variety of drugs for the clinical treatment of immunoglobulin A (IgA) nephropathy; however, previous studies have failed to clarify the quantitative differences in the efficacy of various drugs. In this study, we aimed to quantitatively compare the clinical efficacy of 6 classes of drugs with different pharmacological mechanisms for the treatment of IgA nephropathy and to identify relevant influencing factors. Methods Clinical trials of drugs for the treatment of IgA nephropathy were obtained from public databases. The change in daily urinary protein excretion from baseline was used as the efficacy index, and the time–effect model was established using a model-based meta-analysis method. Based on the final model, the typical efficacy was simulated, and the differences in efficacy were compared. Results A total of 40 studies with 2288 subjects were included in this study. The results showed that the time–effect relationship of the placebo and 6 classes of drugs was consistent with the Emax model. The placebo reduced urinary protein excretion by up to 0.44 g/day, and it took more than 27 months to reach half of its maximum effect. The onset of the 6 classes of drugs were the same; they all reached half of their maximum effect after 5.59 months. More importantly, we found a significant influence of urinary protein baseline on drug efficacy, as indicated by an increase of 0.63 g/day in the theoretical maximum effect of drugs for every 1 g/day increase in urinary protein baseline. After correcting for the urinary protein baseline, the order of efficacy of the 6 classes of drugs was as follows: corticosteroids > immunosuppressants > other drugs > renin–angiotensin system blockers > antiplatelet agents > N-3 fatty acids. Conclusion This study provides the first comprehensive quantitative analysis of the differences in the efficacy of 6 classes of drugs with different pharmacological mechanisms for treating IgA nephropathy. The results of this study provide an important reference for the rational clinical use of drugs for IgA nephropathy, and also provide a reliable efficacy standard for the development of new drugs for IgA nephropathy.
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Affiliation(s)
- Jiesen Yu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jieren Luo
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Haoxiang Zhu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zichao Sui
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongxia Liu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lujin Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Ylisaukko-Oja T, Puttonen M, Jokelainen J, Koivusalo M, Tamminen K, Torvinen S, Voutilainen M. Dose-escalation of adalimumab, golimumab or ustekinumab in inflammatory bowel diseases: characterization and implications in real-life clinical practice. Scand J Gastroenterol 2022; 57:415-423. [PMID: 34927504 DOI: 10.1080/00365521.2021.2014950] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Dose-escalation is a common practice to optimize treatment with subcutaneously administered biologicals in Crohn's disease (CD) and ulcerative colitis (UC). However, limited data is available on the extent of dose-escalation in real-life. Here, we analyzed treatment persistence, dose-escalation, concomitant corticosteroid use, and costs of adalimumab, golimumab, and ustekinumab in inflammatory bowel diseases (IBD). METHODS This was a nationwide, retrospective, non-interventional registry study. All adult patients who were diagnosed with CD or UC and had purchased adalimumab, golimumab, or ustekinumab from Finnish pharmacies between 2008 and 2018 were included in the study and followed up for 24 months after treatment initiation. RESULTS A total of 2884 patients were included in the analyses. For adalimumab, treatment persistence was higher for CD patients compared to UC patients both at months 12 (46.2% versus 37.1%; p < .0001) and 24 (26.1% versus 19.7%; p < 0.0001). For golimumab (UC), treatment persistence was 48.3% at month 12 and 28.1% at month 24. The 12-month treatment persistence rate for patients on ustekinumab (CD) was 47.1%. Cumulative doses exceeding the regular dosing according to the summary of product characteristics (SPC), was observed for adalimumab in CD during the first 6 months of treatment (62.9% of the treatment periods), golimumab in the later stages of the UC treatment (52-54% of treatment periods at months 7-24), and ustekinumab during the first 6 months (70.7%). CONCLUSIONS Based on this study, dose-escalation of subcutaneously administered biologicals is a common clinical practice in IBD. This has implications for treatment costs, use of concomitant medications, and treatment outcomes.
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Affiliation(s)
- Tero Ylisaukko-Oja
- MedEngine Oy, Helsinki, Finland.,Faculty of Medicine, Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Minna Puttonen
- Takeda Oy, Helsinki, Finland.,Division of Pharmaceutical Technology and Chemistry, Industrial Pharmacy, University of Helsinki, Helsinki, Finland
| | - Jari Jokelainen
- MedEngine Oy, Helsinki, Finland.,Faculty of Medicine, Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | | | | | | | - Markku Voutilainen
- Division of Medicine, Turku University Hospital, Turku, Finland.,Department of Medicine, University of Turku, Turku, Finland
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Rençber S, Köse FA, Karavana SY. Development of novel mucoadhesive gels containing nanoparticle for buccal administration of dexamethasone. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e20041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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50
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Einarsdottir MJ, Ekman P, Molin M, Trimpou P, Olsson DS, Johannsson G, Ragnarsson O. High Mortality Rate in Oral Glucocorticoid Users: A Population-Based Matched Cohort Study. Front Endocrinol (Lausanne) 2022; 13:918356. [PMID: 35872995 PMCID: PMC9304700 DOI: 10.3389/fendo.2022.918356] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of the study was to investigate all-cause and disease-specific mortality in a large population-based cohort of oral glucocorticoid (GC) users. METHODS This was a retrospective, matched cohort study. Information on dispensed prescriptions was obtained from the Swedish Prescribed Drug Register. The cause of death was obtained from the Swedish Cause-of-Death Registry. Patients receiving prednisolone ≥5 mg/day (or equivalent dose of other GC) for ≥21 days between 2007-2014 were included. For each patient, one control subject matched for age and sex was included. The study period was divided into 3-month periods and patients were divided into groups according to a defined daily dose (DDD) of GC used per day. The groups were: Non-users (0 DDD per day), low-dose users (>0 but <0.5 DDD per day), medium-dose users (0.5-1.5 DDD per day) and high-dose users (>1.5 DDD per day). Hazard ratios (HRs), unadjusted and adjusted for age, sex and comorbidities, were calculated using a time-dependent Cox proportional hazard model. RESULTS Cases (n=223 211) had significantly higher all-cause mortality compared to controls (HR adjusted for age, sex and comorbidities 2.08, 95% confidence interval 2.04 to 2.13). After dividing the cases into subgroups, adjusted HR was 1.31 (1.28 to 1.34) in non-users, 3.64 (3.51 to 3.77) in low-dose users, 5.43 (5.27 to 5.60) in medium-dose users and, 5.12 (4.84 to 5.42) in high-dose users. The highest adjusted hazard ratio was observed in high-dose users for deaths from sepsis 6.71 (5.12 to 8.81) and pulmonary embolism 7.83 (5.71 to 10.74). CONCLUSION Oral GC users have an increased mortality rate compared to the background population, even after adjustment for comorbidities. High-dose users have an increased risk of dying from sepsis, and pulmonary embolism compared to controls. Whether the relationship between GC exposure and the excess mortality is causal remains to be elucidated.
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Affiliation(s)
- Margret J. Einarsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- *Correspondence: Margret J. Einarsdottir,
| | - Per Ekman
- Statistiska Konsultgruppen, Gothenburg, Sweden
| | | | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniel S. Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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