Inhaled steroids for children: effects on growth, bone, and adrenal function

Hair cortisol and inhaled corticosteroid use in asthmatic children

BACKGROUND

Adrenal suppression is a side effect of long-term use of inhaled corticosteroids (ICS). Hair cortisol concentration (HCC) measurement is a noninvasive tool for measuring adrenal function that may be useful for asthmatic patients who are on long-term ICS treatment. The aim of this study was to compare HCC between children with and without asthma and to explore the association between HCC and ICS dose in asthmatic children.

METHODS

A cross-sectional observational study in subjects with or without asthma (n = 72 and 226, respectively, age 6-21 years). Hair samples were obtained from the posterior vertex for each subject and data on medication use were collected using questionnaires. HCC was analyzed by liquid chromatography-mass spectrometry in the most proximal 3 cm of hair.

RESULTS

Median HCC was significantly lower in subjects with asthma than in subjects without asthma: 1.83 pg/mg and 2.39 pg/mg, respectively (P value after adjustment for age, sex, and body mass index: .036). Median HCC was 1.98 pg/mg in asthmatics using no ICS, 1.84 pg/mg in those using a low dose, 1.75 pg/mg in those on a medium dose, and 1.46 in those using a high ICS dose (P = .54).

CONCLUSION

We observed a significantly lower HCC in asthmatics than in healthy controls and a nonsignificant trend of lower HCC with increasing ICS dose. Whether HCC measurement may be used to detect individuals at risk for hypocortisolism and may be useful to monitor adrenal function in asthmatic children using ICS needs to be further investigated.

Tulobuterol patch alleviates allergic asthmic inflammation by blockade of Syk and NF-κB activation in mice

Background

Tulobuterol patch, one of strongest bronchodilators, was recently shown to improve bronchial hyperresponsiveness and significantly decrease the sputum eosinophil counts by combining with nonspecific anti-inflammatory drugs on patients with asthma. However, there is limited study on the anti-inflammatory activities of tulobuterol patch and its potential machenism.

Results

The tulobuterol patch significantly ameliorated inflammatory cell infiltration in the lung tissue, reduced the number of total leukocytes and its differential count, markedly reduced the production of IL-1β, TNF-α, IL-6, CCL-11 and IL-4 in bronchial alveolar lavage fluid, as well as a reduction in IL-4/IFN-γ ratio. Tulobuterol patch exhibited the best effect on allergic inflammation compared with formoterol and salbutamol. Furthermore, tulobuterol patch treatment significantly suppressed the expression and activation of Syk and its downdream signaling NF-κB and p-NF-κB.

Conclusions

The present studies revealed that tulobuterol patch effectively ameliorated airway inflammatory responses in allergic asthma, and its mechanisms, at least partially, via down-regulating Syk/NF-κB pathway.

Methods

An ovalbumin induced allergic asthma mouse model were used, and the effects of tulobuterol patch on allergic airway inflammation were evaluated. Also, its anti-airway inflammatory potential was compared with two other β₂-agonists, salbutamol and formoterol. Its possible anti-inflammatory mechanisms were identified by using western blotting and immunohistochemistry.

Early treatment in preschool children: an evidence-based approach

PURPOSE OF REVIEW

Wheezing is a common symptom in early childhood but only some of these children will experience continued wheezing symptoms in later childhood making the diagnosis and treatment of these children challenging. This review covers recent findings regarding the epidemiology, diagnosis, evaluation, and treatment of preschool-aged children with asthma.

RECENT FINDINGS

Key characteristics that distinguish the childhood asthma-predictive phenotype include male sex, history of wheezing with lower respiratory tract infections, history of parental asthma, history of atopic dermatitis, eosinophilia, early sensitization to food or aeroallergens, or lower lung function in early life. The preschool-aged asthma population tends to be characterized as exacerbation prone with relatively limited impairment. The diagnosis of asthma in preschool-aged children is often based on symptom patterns, presence of risk factors, and therapeutic responses. Asthma management includes intermittent and daily inhaled corticosteroids, daily leukotriene-receptor antagonists, and, in rare cases, combination therapies.

SUMMARY

The diagnosis of asthma in preschool-aged children is based on symptom patterns and the presence of risk factors, and the goals of asthma management are achieved through a partnership between the family and the healthcare team using regular assessment of symptom control and response to daily controller therapy.

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

OBJECTIVE

The aim of the study was to evaluate the association between previous use of ICS and bone mineral density (BMD) at school age in a cohort followed after early childhood wheezing.

METHODS

As part of a prospective follow-up study after hospitalization for wheezing at <24 months of age, BMD was measured in 89 children at 12.3 (median) years of age. Data on ICS use were collected by interviewing the parents, and this was supplemented with data from patient records. Cumulative doses and the duration of ICS use were calculated. Areal BMD (BMDareal , g/cm(2) ) was measured by dual energy X-ray absorptiometry (DXA), and apparent volumetric BMD (aBMDvol , g/cm(3) ) was calculated, for the lumbar spine and femoral neck. Weight, height and pubertal stage were recorded.

FINDINGS

Age, sex, and pubertal stage were significantly associated with BMDareal and aBMDvol of the lumbar spine and BMDareal of the femoral neck. The regular use of ICS for >6 months at age <6 years was associated with a lower BMD of the lumbar spine. A lower BMDareal and aBMDvol of the femoral neck were associated with higher cumulative doses of ICS at age 0-12.3 (median) years. The results were robust to adjustment for age, sex, pubertal stage, height, weight, and use of systemic steroids.

CONCLUSION

ICS use during childhood may be related to a decrease in BMD at late school age. It is important to use the lowest possible ICS dose that maintains adequate asthma control.

Medication adherence and the risk of severe asthma exacerbations: a systematic review

The benefits of drug therapy for asthma have been well established, but adherence to treatment is poor, and this might be associated with an increased risk of asthma exacerbations. The aim of this study was to review the literature on the association between adherence to asthma controller treatment and risk of severe asthma exacerbations in children and adults.

A systematic literature search was performed in PubMed, Embase and Web of Science, from inception until January 2014. Studies were included if data on the association between medication adherence and severe asthma exacerbations were presented. Quality was assessed using a modified version of the Newcastle–Ottawa Scale.

The search yielded 2319 unique publications, of which 23 met the inclusion criteria and underwent data extraction and quality scoring. High levels of heterogeneity across studies with regard to adherence and exacerbation measurements, designs and analysis precluded a formal meta-analysis. Although effect measures varied widely, good adherence was associated with fewer severe asthma exacerbations in high-quality studies.

Good adherence tended to be associated with lower risk of severe asthma exacerbations. Future studies should use standardised methodology to assess adherence and exacerbations, and should consider inhaler competence.

Demographic predictors of leukotriene antagonist monotherapy among children with persistent asthma

OBJECTIVE

To describe the children with persistent asthma receiving non-preferred controller therapy in the form of leukotriene receptor antagonist monotherapy (LTRAM).

STUDY DESIGN

In this cross-sectional study, we analyzed 2007-2009 South Carolina Medicaid data of children aged 2- to 18 years with persistent asthma, defined by Healthcare Effectiveness Data and Information Set (HEDIS). Those without either LTRAM or inhaled corticosteroids (ICS) were excluded. With multivariable logistic regression modeling, we compared the outcome of LTRAM with the primary predictor of age and adjusted for covariates of race, sex, HEDIS class, rurality, and disease severity. We also used negative binomial regression to compare outcomes of albuterol and oral steroid claims, outpatient and emergency department visits, and hospitalizations with predictors of LTRAM vs ICS therapy.

RESULTS

A total of 19,512 patients with asthma aged 2- to 18-years were studied: 2658 (13.6%) without controllers were excluded, 2508 (12.9%) received LTRAM, and 14 346 (73.5%) received ICS. Age, race, rurality, and HEDIS classification were all significantly associated with LTRAM (all P < .01): 5- to 13-year-olds relative to children <5 years old (OR 1.46, 95% CI 1.30-1.64), Caucasians relative to African Americans (OR 1.40, 95% CI 1.27-1.53), and rural children relative to urban (OR 1.18, 95% CI 1.08-1.3) were all more likely to receive LTRAM. Albuterol, oral steroid, and outpatient visits were lower in LTRAM (P < .01). No difference was detected in emergency department visits or admissions.

CONCLUSIONS

Children 5- to 13-years of age, rural children, and Caucasian children were more likely to receive LTRAM. Uncovering provider rationale and practices as well as patient influences on this prescribing pattern may be helpful in optimizing asthma controller therapy.

Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy

Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory agents available for the treatment of asthma and represent the mainstay of therapy for most patients with the disease. Although these medications are considered safe at low-to-moderate doses, safety concerns with prolonged use of high ICS doses remain; among these concerns is the risk of adrenal suppression (AS). AS is a condition characterized by the inability to produce adequate amounts of the glucocorticoid, cortisol, which is critical during periods of physiological stress. It is a proven, yet under-recognized, complication of most forms of glucocorticoid therapy that can persist for up to 1 year after cessation of corticosteroid treatment. If left unnoticed, AS can lead to significant morbidity and even mortality. More than 60 recent cases of AS have been described in the literature and almost all cases have involved children being treated with ≥500 μg/day of fluticasone.

The risk for AS can be minimized through increased awareness and early recognition of at-risk patients, regular patient follow-up to ensure that the lowest effective ICS doses are being utilized to control asthma symptoms, and by choosing an ICS medication with minimal adrenal effects. Screening for AS should be considered in any child with symptoms of AS, children using high ICS doses, or those with a history of prolonged oral corticosteroid use. Cases of AS should be managed in consultation with a pediatric endocrinologist whenever possible. In patients with proven AS, stress steroid dosing during times of illness or surgery is needed to simulate the protective endogenous elevations in cortisol levels that occur with physiological stress.

This article provides an overview of current literature on AS as well as practical recommendations for the prevention, screening and management of this serious complication of ICS therapy.

Steroid-sparing effects with allergen-specific immunotherapy in children with asthma: a randomized controlled trial

BACKGROUND

Asthma control is now recognized as the main goal of asthma therapy. Guidelines recommend finding the lowest effective dose of inhaled corticosteroids in children with persistent asthma.

OBJECTIVE

The aim of this study was to investigate the efficacy of an allergen-specific immunotherapy with a high-dose hypoallergenic mite preparation (allergoid) as steroid-sparing agent in children with allergic asthma.

METHODS

Sixty-five children with asthma (Global Initiative for Asthma treatment levels II and III; 6-17 years old), after reaching asthma control with inhaled steroids during a 5-month baseline period, were randomized for subcutaneous mite allergoid immunotherapy (SCIT) plus fluticasone propionate (FP) or FP therapy alone for 2 years. During 2 subsequent 5-month winter periods, steroid therapy was adjusted according to predefined dose steps, determining and comparing the changes in FP dosages and the lowest FP dose sufficient to maintain asthma control. Immunologic and functional investigations were also carried out.

RESULTS

Children treated with house dust mite SCIT plus FP were able to significantly reduce the FP dose by more steps (P < .05), compared with the control group on FP alone. The mean daily dose in the immunotherapy group decreased from 330.3 μg in the baseline period to 151.5 μg after 2 treatment years, whereas in the control group the dose decreased from 290.6 μg to 206.3 μg. Compared with the control group, significant improvement was also observed in morning peak expiratory flow (P = .0315). Significantly increased levels of specific IgG(1) (P = .0001) and IgG(4) (P < .0001) were also observed.

CONCLUSION

Adding a mite allergoid SCIT to pharmacologic treatment is an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma.

Long-term consequences of drugs on the paediatric cardiovascular system

Many pharmacological and toxicological actions of drugs in children cannot be fully predicted from adult clinical experience or from standard non-clinical toxicology studies. Numerous drugs have direct or indirect pharmacological effects on the heart and are prescribed for children of all ages. Toxicity or secondary effects may be immediate or delayed for years after drug exposure has ceased. Originally, the aim of this review was to compile information on the effect of specific drugs on the post-natal development of the cardiovascular system and to examine long-term follow-up of the use of cardio-active drugs in children. The limited database of published information caused the original question to evolve into an examination of the medical literature for three areas of information: (i) whether vulnerable developmental windows have been identified that reflect the substantial functional development that the cardiovascular system undergoes after birth; (ii) what is known about pharmacological perturbation of development; and (iii) what the likelihood is of drug exposure during childhood. We examined different scenarios for exposure including random, isolated exposure, conditions historically associated with adults, primary or secondary cardiac disease, psychiatric and neurological conditions, asthma, cancer and HIV. Except for random, isolated drug exposures, each category of possible exposure contained numerous drugs known to have either primary or secondary effects on the cardiovascular system or to influence factors associated with atherosclerosis. It is likely that a significant number of children will be prescribed drugs having either direct or indirect effects upon the immature cardiovascular system. A confounding factor is the simultaneous use of over-the-counter medications and herbal or nutraceutical preparations that a patient, parent or guardian does not mention to a prescribing physician. Metabolism is also important in assessing drug effects in children. Differences in body water : body fat ratio, age-related gastrointestinal absorption, distribution, excretion, renal function and drug metabolizing capabilities make it possible for children to have a different metabolite profile for a drug compared with adults. There is little examination of drug effects on the interdependent processes of cardiac maturation and less examination of metabolite effects. It is difficult to identify delayed toxicities in children as these adverse events may take years to manifest with many patients lost to follow-up. Clearly this is an area of study where intermediate endpoints and surrogate markers would be of great benefit. Pharmacogenomics may be useful in providing markers of increased risk or susceptibility. A perspective must be kept in balancing the possibility of a problem with the very real benefits that many children experience from the use of these pharmaceuticals.

A randomized, controlled trial to investigate the effect of ciclesonide and beclomethasone dipropionate on eye lens opacity

BACKGROUND

Inhaled corticosteroids (ICS) are recommended first-line therapy for the treatment of persistent asthma. However, reports from observational studies have suggested that the use of ICS may be associated with systemic adverse events, such as glaucoma and cataract (opacity of the lens) formation.

OBJECTIVE

To compare two ICS over 1 year regarding the formation/progression of lenticular opacities in patients with asthma.

METHODS

Adults (>or=18 years of age) with moderate-to-severe asthma were randomized to ciclesonide 640 micro g/day (n = 785) or beclomethasone dipropionate 640 micro g/day (n = 783) in a multinational, double-blind, active-controlled, parallel-group study. The primary endpoint was the occurrence of a positive Class I grading shift (increase [worsening] in Lens Opacities Classification System [LOCS] III score of >or= 0.5 for nuclear opalescence, >or= 0.8 for cortical opacification, or >or= 0.5 for posterior subcapsular opacification, or cataract surgery) in either eye at any visit over the 12-month, double-blind treatment period.

RESULTS

Mean changes (+/- standard error) in nuclear opalescence and cortical and posterior subcapsular opacification were small and similar between groups (ciclesonide 640 micro g/day: 0.10 +/- 0.02, 0.07 +/- 0.02 and 0.04 +/- 0.01, respectively; beclomethasone dipropionate 640 micro g/day: 0.11 +/- 0.02, 0.09 +/- 0.02 and 0.03 +/- 0.01, respectively). Class I shifts were observed in 34.3% versus 36.8% of ciclesonide-treated and beclomethasone dipropionate-treated patients, respectively. Ciclesonide 640 micro g/day was non-inferior to beclomethasone dipropionate 640 micro g/day regarding Class I shifts (risk ratio of ciclesonide to beclomethasone dipropionate, 0.940 [95% confidence interval, 0.820-1.077]); the 95% confidence interval upper bound was lower than the pre-specified non-inferiority bound of 1.333 (p < 0.0001), thereby excluding the possibility of higher risk ratio values.

CONCLUSIONS

Mean changes in LOCS III scores were very small in both groups. Treatment with ciclesonide 640 micro g/day or beclomethasone dipropionate 640 micro g/day for 1 year has a minimal impact on lenticular opacities development and/or progression.

Asthma in infants and children

Asthma is the most common chronic illness in childhood and represents a significant burden to health care and educational systems. Between one quarter and two thirds of childhood asthma cases persist into adulthood. Childhood asthma may be particularly difficult to diagnose because of the high prevalence of episodic wheezing and cough in childhood illnesses such as upper respiratory tract infections. National and worldwide guidelines for the management of asthma in children are continually being updated. These guidelines recommend first establishing a diagnosis and assessing the severity of disease, initiating pharmacologic therapy based on symptoms and lung function, and adjusting doses and agents as required based on the level of asthma control. Inhaled corticosteroids are the cornerstone of long-term asthma management in children of all ages. Recent research efforts have focused on ways to improve inhalant drug delivery to the lungs and minimize oral and systemic bioavailability so as to improve the therapeutic benefit:risk ratio.

Pediatric asthma

Asthma is one of the most common chronic illnesses affecting children. However, distinguishing true asthma from recurrent respiratory symptoms is often a challenge for primary care providers. Many risk factors can help predict persistent disease, including presence of allergies or eczema, family history, symptoms apart from obvious infection, and the severity of previous episodes. Because neither cure nor prevention is currently a viable option, the treatment is aimed at minimizing symptoms and maximizing asthma control.

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report

Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.

Evaluation of tests of hypothalamic-pituitary-adrenal axis function used to measure effects of inhaled corticosteroids

OBJECTIVES

To review the evidence supporting the evaluation of hypothalamic-pituitary-adrenal (HPA) axis function as a measure of systemic exposure and clinical adverse events, discuss factors that affect systemic exposure to inhaled corticosteroids (ICSs), and review the effects of various ICSs that are currently available or under development on HPA axis function from a therapeutic perspective.

DATA SOURCES

Randomized published clinical trials and review articles on the topic of HPA axis suppression were retrieved in MEDLINE. Searches dating back to 1988 were restricted to human studies published in English.

STUDY SELECTION

Studies that evaluated HPA axis function and the methods used to measure its activities and the effects of ICSs (fluticasone propionate, budesonide, beclomethasone dipropionate, mometasone furoate, and ciclesonide) were selected.

RESULTS

Factors that influence adverse events caused by ICSs include pharmacokinetic and pharmacodynamic properties, delivery devices, and therapeutic dose and duration. Basal measurements of blood and urinary cortisol levels, reflecting basal HPA axis function, are the most sensitive markers for assessing systemic ICS bioavailability but, compared with dynamic stimulation tests, are poor clinical predictors of adrenal dysfunction.

CONCLUSIONS

Basal serologic and urinary cortisol tests provide the best measures of assessing and comparing systemic ICS exposure. Long-term clinical studies are needed to determine whether such tests are predictive of ICS toxicity.

Noninvasive monitoring of airway inflammation and steroid reduction in children with asthma

PURPOSE OF REVIEW

Management of pediatric asthma is currently based on symptoms (often a second-hand report from parents) and lung function. Inhaled steroids are the mainstay of asthma management targeted at controlling airway inflammation. They should be used in the lowest possible doses. A number of noninvasive methods to assess inflammation have been developed in an effort to optimize anti-inflammatory treatment.

RECENT FINDINGS

The first longitudinal studies have been published demonstrating an improvement in asthma control in children by adding noninvasive monitoring of inflammation into the clinical management. New methods include exhaled nitric oxide measurements, induced sputum and markers in exhaled breath condensate.

SUMMARY

Further studies will show the practicability of including these measurement methods into everyday clinical practice. Their addition to the conventional assessment of asthma control appears promising. Using these methods to evaluate the current inflammatory state seems obligatory in research into new asthma therapeutics and management strategies. Managing asthma in children in specialist practice relying only on symptoms and lung function is no longer state of the art.