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Grosso A, Cerveri I, Cazzoletti L, Zanolin ME, Mattioli V, Piloni D, Gini E, Albicini F, Ronzoni V, Jarvis D, Janson C, Corsico AG. Inhaled corticosteroids and risk of osteoporosis in late-middle-aged subjects: a multicenter European cohort study. Minerva Med 2023; 114:15-21. [PMID: 34114441 DOI: 10.23736/s0026-4806.21.07431-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled corticosteroids have been widely used for the regular treatment of asthma and chronic obstructive pulmonary diseases (COPD) over the past few decades. To date, studies investigating the effects of inhaled corticosteroids (ICS) on bone in populations including asthma and COPD patients, show conflicting results. The skeletal effects of ICS remain poorly understood. We assessed the association between ICS exposure and self-reported osteoporosis diagnosis in a European cohort study. METHODS The analysis was carried out by using clinical and questionnaire data available for subjects participating in the ECRHS III (European Community Respiratory Health Survey) with age >55 years. RESULTS Among the 3004 enrolled subjects, 245 were ICS users with an exposure ≥12 months. Osteoporosis was reported by 16 subjects in the ICS group (6.5%) and by 167 in the not exposed group (6.1%). The adjusted risk of osteoporosis in ICS users (≥12 months) was not greater in exposed subjects when compared with the unexposed ones (OR=1.02, 95CI%: 0.51, 2.03). The same result was observed even when considering in the analysis a longer exposure to the ICS use (≥36.5 months, the median ICS exposure for all subjects). History of COPD, use of oral corticosteroids, Body Mass Index, smoking and physical activity did not show any evidence of an association with osteoporosis. CONCLUSIONS Our study did not show any significant association between long- term ICS use and self-reported diagnosis of osteoporosis in subjects aged >55 years. To explore the real effect of ICS on bone status, further studies are needed, especially in the long-term ICS exposure.
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Affiliation(s)
- Amelia Grosso
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy -
| | - Isa Cerveri
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Lucia Cazzoletti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria E Zanolin
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Veronica Mattioli
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Erica Gini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Federica Albicini
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Vanessa Ronzoni
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Debbie Jarvis
- Department of Population Health and Occupational Diseases, National Heart and Lung Institute, Imperial College London, London, UK
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Angelo G Corsico
- Division of Respiratory Diseases, Department of Internal Medicine, and Therapeutics, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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Balde A, Kim SK, Benjakul S, Nazeer RA. Pulmonary drug delivery applications of natural polysaccharide polymer derived nano/micro-carrier systems: A review. Int J Biol Macromol 2022; 220:1464-1479. [PMID: 36116588 DOI: 10.1016/j.ijbiomac.2022.09.116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/05/2022]
Abstract
Respiratory distress syndrome and pneumothorax are the foremost causes of death as a result of the changing lifestyle and increasing air pollution. Numerous approaches have been studied for the pulmonary delivery of drugs, proteins as well as peptides using meso/nanoparticles, nanocrystals, and liposomes. These nano/microcarrier systems (NMCs) loaded with drug provide better systemic as well as local action. Furthermore, natural polysaccharide-based polymers such as chitosan (CS), alginate (AG), hyaluronic acid, dextran, and cellulose are highly used for the preparation of nanoparticles and delivery of the drug into the pulmonary tract due to their advantageous properties such as low toxicity, high hydrophobicity, supplementary mucociliary clearance, mucoadhesivity, and biological efficacy. These properties ease the delivery of drugs onto the targeted site. Herein, recent advances in the natural polymer-derived NMCs have been reviewed for their transport and mechanism of action into the bronchiolar region as well as the respiratory region. Various physicochemical properties such as surface charge, size of nanocarrier system, surface modifications, and toxicological effects of these nanocarriers in vitro and in vivo are elucidated as well. Furthermore, challenges faced for the preparation of a model NMCs for pulmonary drug delivery are also discoursed.
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Affiliation(s)
- Akshad Balde
- Biopharmaceuticals Lab, Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur, Chennai 603203, Tamilnadu, India
| | - Se-Kwon Kim
- Department of Marine Science and Convergence Engineering, Hanyang University, Ansan-si, Gyeonggi-do 11558, South Korea
| | - Soottawat Benjakul
- Department of Food Technology, Faculty of Agro-Industry, Prince of Songkhla University, 90112 Hat Yai, Songkhla, Thailand
| | - Rasool Abdul Nazeer
- Biopharmaceuticals Lab, Department of Biotechnology, School of Bioengineering, SRM Institute of Science and Technology, Kattankulathur, Chennai 603203, Tamilnadu, India.
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Kunøe A, Sevelsted A, Chawes BLK, Stokholm J, Krakauer M, Bønnelykke K, Bisgaard H. Height and bone mineral content after inhaled corticosteroid use in the first 6 years of life. Thorax 2022; 77:745-751. [PMID: 35046091 DOI: 10.1136/thoraxjnl-2020-216755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 12/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Infants and young children might be particularly susceptible to the potential side effects from inhaled corticosteroid (ICS) on height and bone mineral content (BMC), but this has rarely been studied in long-term prospective studies. METHODS Children from two Copenhagen Prospective Studies on Asthma in Childhood cohorts were included. ICS use was registered prospectively from birth to age 6 and the cumulative dose was calculated. Primary outcomes were height and BMC from dual-energy X-ray absorptiometry (DXA) scans at age 6. RESULTS At age 6, a total of 930 children (84%) from the cohorts had a valid height measurement and 792 (71%) had a DXA scan. 291 children (31%) received a cumulated ICS dose equivalent to or above 10 weeks of standard treatment before age 6. We found an inverse association between ICS use and height, -0.26 cm (95% CI: -0.45 to -0.07) per 1 year standard treatment from 0 to 6 years of age, p=0.006. This effect was mainly driven by children with ongoing treatment between age 5 and 6 years (-0.31 cm (95% CI: -0.52 to -0.1), p=0.004), while there was no significant association in children who stopped treatment at least 1 year before age 6 (-0.09 cm (95% CI: -0.46 to 0.28), p=0.64). There was no association between ICS use and BMC at age 6. CONCLUSIONS ICS use in early childhood was associated with reduced height at age 6 years but only in children with continued treatment in the sixth year of life.
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Affiliation(s)
- Asja Kunøe
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Astrid Sevelsted
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Bo L K Chawes
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Department of Pediatrics, Næstved Hospital, Næstved, Denmark
| | - Martin Krakauer
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, Gentofte, Denmark.,Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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de Benedictis FM, Carloni I, Guidi R. Safety of anti-inflammatory drugs in children with asthma. Curr Opin Allergy Clin Immunol 2021; 21:144-150. [PMID: 33470588 DOI: 10.1097/aci.0000000000000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Inhaled corticosteroids (ICS) are widely used as the first-line treatment of asthma. When the disease is not controlled by standard doses of ICS, other anti-inflammatory drugs should be considered. The aim of this report is to review the main adverse events induced by anti-inflammatory drugs in children with asthma and discuss possible actions to prevent or mitigate these effects. RECENT FINDINGS Proper interpretation of ICS safety studies requires knowledge of the pharmaceutical properties and delivery device systems of the different ICS available. Genetic variants affecting susceptibility to corticosteroid-induced adrenal suppression were found in children and adults who use ICS to treat their asthma. There is evidence of the association between montelukast use and neuropsychiatric events. SUMMARY Benefits of ICS, properly prescribed and used, outweigh their potential adverse effects. There is substantial evidence that the combination of ICS with long-acting beta2 agonists is safe for asthmatic children. Awareness of the potential risks of neuropsychiatric events in children taking montelukast should inform the clinicians' prescribing practices. Omalizumab is generally well-tolerated, but the evidence on the safety of other biologic agents in children is scanty. The risk of systemic adverse events with anti-inflammatory drugs must be balanced against the risks of uncontrolled asthma and/or frequent oral steroid use.
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Affiliation(s)
| | | | - Roberto Guidi
- Pediatric Emergency Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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Weare-Regales N, Hudey SN, Lockey RF. Practical Guidance for Prevention and Management of Glucocorticoid-Induced Osteoporosis for the Allergist/Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1841-1850. [PMID: 33444813 DOI: 10.1016/j.jaip.2020.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a silent disorder with dire consequences, and glucocorticoid use remains the most common iatrogenic cause illustrated by the fact that 30% to 50% of subjects on such long-term therapy experience fractures (Oimomi M, Nakamichi T, Ohara T, Sakai M, Igaki N, Hata F, et al. Fructose-related glycation. Diabetes Res Clin Pract 1989;7:137-9; Reid IR. Glucocorticoid osteoporosis--mechanisms and management. Eur J Endocrinol 1997;137:209-17). By directly affecting bone quality while actively used, glucocorticoids increase the risk of fracture that is independent of a subject's bone density status at the time (Weinstein RS. True strength. J Bone Miner Res 2000;15:621-5). A large number of subjects seen in an allergy and immunology clinic have asthma, chronic rhinosinusitis, or other chronic inflammatory diseases, necessitating the use of these medications and placing them at higher risk for this disease. Data on the effects of both oral and inhaled glucocorticoids on fracture risk are presented. This review concretizes the importance of osteoporosis, its pathophysiology, and provides practical guidelines to prevent and treat it. Management recommendations are tailored to 2 different age groups. The first group consists of children, adolescents, and adults 40 years or younger with a focus on attaining peak bone mass. The second group consists of adults 40 years or older where the use of imaging modalities and Fracture Risk Assessment Tool scores helps triage subjects into fracture risk categories. Those at moderate to high risk require bone-sparing medications. Universal preventive measures for both groups are reviewed. Complicated and severe cases may need additional expertise by an endocrinologist or rheumatologist.
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Affiliation(s)
- Natalia Weare-Regales
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, University of South Florida, Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | - Stephanie N Hudey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla.
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla
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6
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Abstract
Asthma is the most common chronic inflammatory disease of children, and inhaled corticosteroids (ICSs) are the most effective and commonly used treatment of persistent asthma. ICSs currently approved for and commonly used by children with asthma include beclomethasone dipropionate, budesonide, fluticasone propionate, mometasone furoate, ciclesonide, and triamcinolone acetonide. This article reviews 4 areas critical to understanding potential adverse endocrine outcomes of ICSs and placing them in proper perspective: (1) influence of drug/delivery device properties on systemic steroid burden; (2) adrenal insufficiency during ICS treatment; (3) growth effects of ICS and asthma itself; and (4) bone mineral accretion during ICS therapy.
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Affiliation(s)
- David B Allen
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, H4/448 CSC - Pediatrics, 600 Highland Avenue, Madison, WI 53792-4108, USA.
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7
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Baan EJ, van den Akker ELT, Engelkes M, de Rijke YB, de Jongste JC, Sturkenboom MCJM, Verhamme KM, Janssens HM. Hair cortisol and inhaled corticosteroid use in asthmatic children. Pediatr Pulmonol 2020; 55:316-321. [PMID: 31651095 PMCID: PMC7003950 DOI: 10.1002/ppul.24551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/26/2019] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Esmé J Baan
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Marjolein Engelkes
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Yolanda B de Rijke
- Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan C de Jongste
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | | | - Katia M Verhamme
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
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Axelsson I, Naumburg E, Prietsch SOM, Zhang L. Inhaled corticosteroids in children with persistent asthma: effects of different drugs and delivery devices on growth. Cochrane Database Syst Rev 2019; 6:CD010126. [PMID: 31194879 PMCID: PMC6564081 DOI: 10.1002/14651858.cd010126.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are the most effective treatment for children with persistent asthma. Although treatment with ICS is generally considered to be safe in children, the potential adverse effects of these drugs on growth remains a matter of concern for parents and physicians. OBJECTIVES To assess the impact of different inhaled corticosteroid drugs and delivery devices on the linear growth of children with persistent asthma. SEARCH METHODS We searched the Cochrane Airways Trials Register, which is derived from systematic searches of bibliographic databases including CENTRAL, MEDLINE, Embase, CINAHL, AMED and PsycINFO. We handsearched respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov and manufacturers' clinical trial databases, or contacted the manufacturer, to search for potential relevant unpublished studies. The literature search was initially conducted in September 2014, and updated in November 2015, September 2018, and April 2019. SELECTION CRITERIA We selected parallel-group randomized controlled trials of at least three months' duration. To be included, trials had to compare linear growth between different inhaled corticosteroid molecules at equivalent doses, delivered by the same type of device, or between different devices used to deliver the same inhaled corticosteroid molecule at the same dose, in children up to 18 years of age with persistent asthma. DATA COLLECTION AND ANALYSIS At least two review authors independently selected studies and assessed risk of bias in included studies. The data were extracted by one author and checked by another. The primary outcome was linear growth velocity. We conducted meta-analyses using Review Manager 5.3 software. We used mean differences (MDs) and 95% confidence intervals (CIs ) as the metrics for treatment effects, and the random-effects model for meta-analyses. We did not perform planned subgroup analyses due to there being too few included trials. MAIN RESULTS We included six randomized trials involving 1199 children aged from 4 to 12 years (per-protocol population: 1008), with mild-to-moderate persistent asthma. Two trials were from single hospitals, and the remaining four trials were multicentre studies. The duration of trials varied from six to 20 months.One trial with 23 participants compared fluticasone with beclomethasone, and showed that fluticasone given at an equivalent dose was associated with a significant greater linear growth velocity (MD 0.81 cm/year, 95% CI 0.46 to 1.16, low certainty evidence). Three trials compared fluticasone with budesonide. Fluticasone given at an equivalent dose had a less suppressive effect than budesonide on growth, as measured by change in height over a period from 20 weeks to 12 months (MD 0.97 cm, 95% CI 0.62 to 1.32; 2 trials, 359 participants; moderate certainty evidence). However, we observed no significant difference in linear growth velocity between fluticasone and budesonide at equivalent doses (MD 0.39 cm/year, 95% CI -0.94 to 1.73; 2 trials, 236 participants; very low certainty evidence).Two trials compared inhalation devices. One trial with 212 participants revealed a comparable linear growth velocity between beclomethasone administered via hydrofluoroalkane-metered dose inhaler (HFA-MDI) and beclomethasone administered via chlorofluorocarbon-metered dose inhaler (CFC-MDI) at an equivalent dose (MD -0.44 cm/year, 95% CI -1.00 to 0.12; low certainty evidence). Another trial with 229 participants showed a small but statistically significant greater increase in height over a period of six months in favour of budesonide via Easyhaler, compared to budesonide given at the same dose via Turbuhaler (MD 0.37 cm, 95% CI 0.12 to 0.62; low certainty evidence). AUTHORS' CONCLUSIONS This review suggests that the drug molecule and delivery device may impact the effect size of ICS on growth in children with persistent asthma. Fluticasone at an equivalent dose seems to inhibit growth less than beclomethasone and budesonide. Easyhaler is likely to have less adverse effect on growth than Turbuhaler when used for delivery of budesonide. However, the evidence from this systematic review of head-to-head trials is not certain enough to inform the selection of inhaled corticosteroid or inhalation device for the treatment of children with persistent asthma. Further studies are needed, and pragmatic trials and real-life observational studies seem more attractive and feasible.
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Affiliation(s)
- Inge Axelsson
- Östersund HospitalUnit of Research, Education and DevelopmentÖstersundSweden
- Mid Sweden UniversityDepartment of Nursing SciencesÖstersundSweden
| | - Estelle Naumburg
- Umea UniversityInstitution of Clinical Science, Department of PediatricsUmeaSweden
| | - Sílvio OM Prietsch
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Linjie Zhang
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
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Heffler E, Madeira LNG, Ferrando M, Puggioni F, Racca F, Malvezzi L, Passalacqua G, Canonica GW. Inhaled Corticosteroids Safety and Adverse Effects in Patients with Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:776-781. [DOI: 10.1016/j.jaip.2018.01.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/13/2018] [Accepted: 01/18/2018] [Indexed: 01/06/2023]
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10
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Benefits and Risks of Long-Term Asthma Management in Children: Where Are We Heading? Drug Saf 2017; 40:201-210. [PMID: 27928727 DOI: 10.1007/s40264-016-0483-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
International guidelines provide recommendations for a stepwise approach to the management of asthma in children 0-4 years old, 5-11 years old, and adolescents who are treated as adults. Therapy is aimed at two domains of control: current impairment and future risk. The long-term controller medications, inhaled corticosteroids (ICSs), ICSs in combination with long-acting β2 agonists, leukotriene receptor antagonists, and immunomodulators, exhibit different efficacies for these domains. The risk:benefit ratios of the available medications need to be carefully assessed. This review briefly presents the benefits and the potential risks of available asthma medications in children to assist the practitioner in the optimal use of asthma medications. Specifically, the systemic activity of the ICSs and how to minimize their effects on growth and adrenal activity are reviewed as well as other potential adverse effects. Dosing strategies such as intermittent therapy are also assessed.
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11
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Richardson E, Seibert T, Uli NK. Growth perturbations from stimulant medications and inhaled corticosteroids. Transl Pediatr 2017; 6:237-247. [PMID: 29184805 PMCID: PMC5682374 DOI: 10.21037/tp.2017.09.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Stimulant medications for the treatment of attention deficit hyperactivity disorder (ADHD) and inhaled corticosteroids (ICS) for the treatment of asthma are two classes of medications that are commonly prescribed in pediatrics. Among other adverse effects of these medications, growth attenuation has long been a focus of investigation. With stimulants, growth deficits of 1-1.4 cm/year have been observed in the short term, mainly in the first 2 years of treatment, in a dose-dependent manner. Long-term studies on stimulants have reported divergent effects on growth, with many studies showing no clinically significant height deficits by adulthood. The study that followed the largest cohort of children on stimulants, however, reported an overall adult height deficit of 1.29 cm in subjects who had received stimulant medications, with mean adult height deficit of 4.7 cm among those taking the medication consistently. With ICS use, mild growth suppression is seen in the short term (particularly in the first year of therapy) with growth rates reduced by 0.4-1.5 cm/year. Available current evidence indicates that the impact of ICS use on adult height is not clinically significant, with effects limited to 1.2 cm or less. There is significant individual variability in growth suppression with ICS use, with the specific pharmacologic agent, formulation, dose exposure, age, puberty, medication adherence, and timing of administration being important modifying factors. Based on currently available evidence, the therapeutic benefits of ICS for management of asthma and stimulant medications for management of ADHD outweigh the potential risk for growth suppression. Strategies to minimize growth attenuation and other potential adverse effects of these medications include using the lowest efficacious dose, frequent assessments and dose titration. Particular vigilance is essential with concomitant use of multiple medications that can attenuate growth and to evaluate for potential adrenal insufficiency from ICS use.
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Affiliation(s)
- Erin Richardson
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Tasa Seibert
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Naveen K Uli
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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12
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Renosto LC, Acatauassu C, Andrade I, Rafael M, Paulino TL, Suano-Souza FI, Solé D, Sarni ROS. Growth velocity and weight gain in prepubertal asthmatic children. Rev Assoc Med Bras (1992) 2017; 63:236-241. [PMID: 28489129 DOI: 10.1590/1806-9282.63.03.236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/19/2016] [Indexed: 01/19/2023] Open
Abstract
Objective: To evaluate the stature growth rate (GR) and the weight gain of prepubertal asthmatic children. Method: A retrospective cohort study evaluating medical records of 85 children diagnosed with asthma, aged less than 9 years, of both sexes, with at least one year of follow-up in the allergy outpatient clinic. The data on the disease, weights and heights were collected through a standardized questionnaire on two occasions, with an interval of one year. The curves proposed by Tanner were applied for the analysis of the GR, and the Z-score of the GR (ZGR) was calculated. Results: Excess weight (risk for overweight, overweight and obesity) was observed in 31.8% (27/85) of the patients, but there was no association with the severity of asthma. Low GR (ZGR < -2) was found in 13.9% (11/79) of patients, most frequently among children with moderate/severe persistent asthma compared to persistent mild and intermittent forms (7/11 - 63.6% vs. 21/68 - 30.2%, respectively, p=0.047). Use of steroids (dose, type and time of use) was not associated with GR. Conclusion: GR was most affected in children with moderate/severe asthma.
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Affiliation(s)
- Larissa Celiberto Renosto
- Resident in Pediatrics at Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | - Itana Andrade
- Nutritionist. MSc from EPM-Unifesp, São Paulo, SP, Brazil
| | - Marina Rafael
- Nutritionist. MSc Student at EPM-Unifesp, São Paulo, SP, Brazil
| | | | - Fabíola Isabel Suano-Souza
- PhD in Science from EPM-Unifesp. Adjunct Professor, Department of Pediatrics, EPM-Unifesp. Assistant Professor, Department of Pediatrics, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brazil
| | - Dirceu Solé
- Habilitation (BR: Livre-docência), Full Professor of the Department of Pediatrics, EPM-Unifesp, São Paulo, SP, Brazil
| | - Roseli Oselka Saccardo Sarni
- Habilitation (BR: Livre-docência), Full Professor of the Department of Pediatrics, FMABC, Santo André, SP, Brazil
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13
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Leung JS, Johnson DW, Sperou AJ, Crotts J, Saude E, Hartling L, Stang A. A systematic review of adverse drug events associated with administration of common asthma medications in children. PLoS One 2017; 12:e0182738. [PMID: 28793336 PMCID: PMC5549998 DOI: 10.1371/journal.pone.0182738] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/24/2017] [Indexed: 12/16/2022] Open
Abstract
Objective To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications. Methods Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency. Findings Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments. Conclusion The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.
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Affiliation(s)
- James S. Leung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - David W. Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | - Arissa J. Sperou
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Crotts
- Departments of Pediatrics, Emergency Medicine, Pediatric Emergency Research Institute, Calgary, Alberta, Canada
| | - Erik Saude
- Departments of Emergency Medicine and Pediatric Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Center for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Antonia Stang
- Departments of Pediatrics, Emergency Medicine, and Community Health Sciences, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
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Wolfgram PM, Allen DB. Effects of Inhaled Corticosteroids on Growth, Bone Metabolism, and Adrenal Function. Adv Pediatr 2017; 64:331-345. [PMID: 28688596 DOI: 10.1016/j.yapd.2017.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Peter M Wolfgram
- Department of Pediatrics, Medical College of Wisconsin, CCC540, 9000 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, H4/448 CSC-Pediatrics, 600 Highland Avenue, Madison, WI 53792-4108, USA.
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15
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Wolfgram PM, Allen DB. Factors influencing growth effects of inhaled corticosteroids in children. J Allergy Clin Immunol 2016; 136:1711-1712.e2. [PMID: 26654199 DOI: 10.1016/j.jaci.2015.09.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/08/2015] [Accepted: 09/17/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Peter M Wolfgram
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wis.
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16
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Hoch HE, Szefler SJ. Intermittent steroid inhalation for the treatment of childhood asthma. Expert Rev Clin Immunol 2015; 12:183-94. [PMID: 26561351 DOI: 10.1586/1744666x.2016.1105741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Inhaled corticosteroids have long been considered a mainstay of therapy for asthma in children. However, concerns over long-term side effects of chronic steroid administration have led providers to turn to intermittent dosing of these medications in an attempt to treat exacerbations while limiting total corticosteroid received. The data have been somewhat mixed in this area, likely at least partially due to the difficulty providers have in classifying asthma phenotypes in young children. This review will analyze the evidence for chronic daily inhaled corticosteroid use, intermittent inhaled corticosteroid use, and dynamic dosing approaches utilizing inhaled corticosteroid/long-acting beta agonist combination therapy.
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Affiliation(s)
- Heather E Hoch
- a Section of Pediatric Pulmonology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Stanley J Szefler
- a Section of Pediatric Pulmonology , University of Colorado School of Medicine , Aurora , CO , USA
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