1
|
Strategies to reduce corticosteroid-related adverse events in asthma. Curr Opin Allergy Clin Immunol 2019; 19:61-67. [PMID: 30407207 DOI: 10.1097/aci.0000000000000493] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Severe asthmatics, despite the chronic use of high inhaled corticosteroids (ICS) doses and frequent intake of systemic corticosteroids, remains clinically and/or functionally uncontrolled. These patients are also often affected by rhinitis or chronic rhinosinusitis requiring frequent use of intranasal corticosteroids. Therefore, severe asthmatics are exposed to an overload of corticosteroids that is frequently associated with relevant and costly adverse events. This clinical problem and the strategies to overcome it are here summarized. RECENT FINDINGS Different therapeutic options may help in reducing the corticosteroid load in asthmatics, ranging from allergy immunotherapy (nonsuitable for severe uncontrolled patients), immunosuppressant agents like methotrexate or cyclosporine, novel biologic drugs (mainly anti-IgE, anti-IL5 and anti-IL4-receptor-alpha), and aspirin desensitization (for patients with anti-inflammatory drugs exacerbated respiratory disease). SUMMARY The evidence of even serious corticosteroid-related adverse events associated with consistent health-care costs, should prompt the entire scientific community and health regulatory authorities to promote actions to increase the use of well tolerated and effective strategies to reduce the corticosteroid need in asthmatics; the most promising option seems to be the add-on use of biologic agents.
Collapse
|
2
|
Anderson DJ, Lo DJ, Leopardi F, Song M, Strobert EA, Jenkins JB, Larsen CP, Kirk AD. Corticosteroids and methotrexate as adjuvants to costimulation blockade in non-human primate renal transplantation. Clin Transplant 2019; 33:e13568. [PMID: 31006146 PMCID: PMC6597274 DOI: 10.1111/ctr.13568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/18/2019] [Accepted: 04/04/2019] [Indexed: 12/21/2022]
Abstract
Belatacept, the CD28-B7 costimulation pathway inhibitor, has been approved as a calcineurin inhibitor (CNI) alternative in kidney transplantation. Although costimulation blockade (CoB) allows for CNI avoidance, it is associated with increased rates of early rejection, prompting a search for agents to pair with belatacept. Methotrexate (MTX) is an antimetabolite that has been found to be complimentary with abatacept, a lower affinity CD28-B7-specific analogue of belatacept, in the treatment of rheumatoid arthritis (RA). We examined whether this synergy would extend to prevention of kidney allograft rejection. Rhesus macaques underwent kidney transplantation treated with abatacept maintenance therapy with either a steroid taper, MTX, or both. The combination of abatacept maintenance with steroids prolonged graft survival compared to untreated historical controls and previous reports of abatacept monotherapy. The addition of MTX did not provide additional benefit. These data demonstrate that abatacept with adjuvant therapy may delay the onset of acute rejection, but fail to show synergy between abatacept and MTX beyond that of steroids. These findings indicate that MTX is unlikely to be a suitable adjuvant to CoB in kidney transplantation, but also suggest that with further modification, a CoB regimen used for advanced RA may suffice for RA patients requiring kidney transplantation.
Collapse
Affiliation(s)
| | - Denise J. Lo
- Emory Transplant Center, Emory University, Atlanta, GA
| | | | | | | | - Joe B. Jenkins
- Yerkes National Primate Center, Emory University, Atlanta, GA
| | | | - Allan D. Kirk
- Emory Transplant Center, Emory University, Atlanta, GA
- Department of Surgery, Duke University, Durham, NC
| |
Collapse
|
3
|
Domingo C, Pomares X, Navarro A, Amengual MJ, Montón C, Sogo A, Mirapeix RM. A step-down protocol for omalizumab treatment in oral corticosteroid-dependent allergic asthma patients. Br J Clin Pharmacol 2017; 84:339-348. [PMID: 29044640 DOI: 10.1111/bcp.13453] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 10/04/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022] Open
Abstract
AIMS There are no specific criteria for a step-down or withdrawal dose of omalizumab (OMA). Our purpose was to evaluate the viability of a protocol for OMAlizumab DOse REduction (the OMADORE study) in severe allergic asthma (SAA). METHODS The study population included 35 SAA patients treated during a minimum period of 1 year with oral corticosteroids (OC) equivalent to a mean daily dose of 4 mg of methyl-prednisolone. To qualify for the protocol, the patients had to have received treatment with OMA for at least one and a half years, OC dose had to have reached the lowest tolerated dose and spirometry had to be greater than or equal to that at entry. The interventions were (a) OMA dose was reduced by half; (b) if patients were clinically stable after 6 months, the dose was halved again; (c) if repeated OC boosters were needed and/or spirometry worsened by more than 10%, OMA dose was raised to the previous figure until stabilization. RESULTS Mean age was 52.5 (17) years, median monthly OC dose was 120 (IQR: 225) mg. Pulmonary function: FVC: 79.7 (20.2)%; FEV1 : 64.8 (21.7)%; FEV1 / FVC: 61.7(13.8)%. OMA could be withdrawn in 34.3% of the patients; 22.9% tolerated a reduction, and in 42.9% the dose could not be modified. Follow-up time after reduction or withdrawal ranged from 12 to 30 months. There were no severe exacerbations requiring emergency assistance or admission. CONCLUSIONS The OMADORE study found that in more than 50% of SAA patients on OC, OMA dose can be safely reduced or withdrawn based on a progressive dose reduction protocol.
Collapse
Affiliation(s)
- Christian Domingo
- Pulmonary Service, Corporació Sanitària Parc Taulí, Barcelona, Spain.,Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Xavier Pomares
- Pulmonary Service, Corporació Sanitària Parc Taulí, Barcelona, Spain.,Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Albert Navarro
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - María José Amengual
- Laboratory Department, Immunology unit, UDIAT, Corporació Sanitària Parc Taulí, Barcelona, Spain
| | - Concepción Montón
- Pulmonary Service, Corporació Sanitària Parc Taulí, Barcelona, Spain.,Health Services Research on Chronic Diseases Network-REDISSEC, Galdakao, Spain
| | - Ana Sogo
- Pulmonary Service, Corporació Sanitària Parc Taulí, Barcelona, Spain
| | - Rosa M Mirapeix
- Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| |
Collapse
|
4
|
Tauber PA, Pickl WF. Pharmacological targeting of allergen-specific T lymphocytes. Immunol Lett 2017; 189:27-39. [PMID: 28322861 DOI: 10.1016/j.imlet.2017.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 03/15/2017] [Indexed: 12/18/2022]
Abstract
Allergic disorders are the result of a complex pathophysiology, involving major cellular lineages and a multitude of humoral factors of the innate and adaptive immune system, and have the tendency to involve multiple organs. Consequently, even standard pharmacological treatment of allergies is rarely specific but usually targets more than one pathway/cellular system at a time. Accordingly, many of the classic anti-allergic drugs have a critical impact also on T helper cells, which are pivotal not only during the sensitization but also the maintenance phase of allergic diseases. Recent years have seen a dramatic increase of novel drugs with the potency to interfere, more or less specifically, with T lymphocyte function, which might, possibly together with classic anti-allergic drugs, help harnessing one of the central cellular players in allergic responses. A major theme in the years to come will be a thoughtful combination of previously established with recently developed treatment modalities.
Collapse
Affiliation(s)
- Peter A Tauber
- Institute of Immunology, Center for Pathophysiology, Infectiology, and Immunology, Medical University of Vienna, Vienna, Austria
| | - Winfried F Pickl
- Institute of Immunology, Center for Pathophysiology, Infectiology, and Immunology, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
5
|
van Buul AR, Taube C. Treatment of severe asthma: entering the era of targeted therapy. Expert Opin Biol Ther 2015; 15:1713-25. [PMID: 26331583 DOI: 10.1517/14712598.2015.1084283] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION It is estimated that 5 - 10% of asthma patients suffer from severe asthma. Severe asthma is associated with increased morbidity and mortality. These patients are not controlled with currently available treatments and therefore additional treatment options are needed. Asthma is a heterogeneous disease, and different asthma patient groups probably have different underlying pathophysiology. Novel therapies with, for example, monoclonal antibodies that target certain immunological pathways have become available. These novel treatments are not effective in all patients but only in certain phenotypes. AREAS COVERED This review covers the current evidence and novel developments in treatment with monoclonal antibodies in different asthma phenotypes. This includes monoclonal antibodies against IgE, against interleukin (IL)-5 and antibodies targeting IL-13 pathways. Although there is a certain overlap between patient groups benefiting from these treatments, a more detailed identification of responder profiles for these therapies is needed for personalized therapy. EXPERT OPINION In recent years, novel monoclonal antibodies have been developed, which are a promising addition to existing therapy in the treatment of severe asthma with eosinophilic inflammation and Th2-driven disease. We expect that several of the new antibodies will become available for clinical practice. In addition, it must be acknowledged that so far no effective strategies are available for patients with non-eosinophilic asthma and further research and development is necessary for this patient group.
Collapse
Affiliation(s)
- Amanda R van Buul
- a Leiden University Medical Center, Department of Pulmonology , Leiden, The Netherlands +31 7 15 26 29 50 ; +31 7 15 26 69 27 ;
| | - Christian Taube
- a Leiden University Medical Center, Department of Pulmonology , Leiden, The Netherlands +31 7 15 26 29 50 ; +31 7 15 26 69 27 ;
| |
Collapse
|
6
|
Abstract
Several years ago, omalizumab became commercially available for the treatment of severe asthma. It remains the only monoclonal antibody to be marketed for this purpose. Since then, many studies have been published endorsing its efficacy and effectiveness. Concomitantly, evidence of an overlap between atopic and non-atopic severe asthma has emerged. However, there also appears to be some disagreement regarding the value of omalizumab in the management of non-atopic disease, as some studies have failed to show any benefit in these patients. The recent literature has also sought to identify appropriate prognostic biomarkers for the use of omalizumab, other than immunoglobulin (IgE) levels. This article briefly summarizes the evolution of asthma treatment, the pathophysiology of the condition, and the method of action of omalizumab. The author describes the controlled and uncontrolled studies (also named "real-life studies") published in adult and pediatric populations in different countries and expresses his view on the current place of the drug in the management of severe allergic asthma. He offers a personal perspective on the recent evidence for the use of omalizumab in non-atopic patients, highlighting the implications for current clinical practice and the gaps in our knowledge. The author justifies his belief that omalizumab is not only an IgE-blocking drug and should be considered as a disease-modifying therapy because of its multiple effects on different biologic pathways. Finally, some areas for future research are indicated.
Collapse
Affiliation(s)
- Christian Domingo
- Pulmonary Service, Hospital de Sabadell (Corporació Sanitària i Universitària Parc Taulí), Parc Taulí 1, 08208, Sabadell (Barcelona), Spain,
| |
Collapse
|
7
|
Polosa R, Bellinvia S, Caruso M, Emma R, Alamo A, Kowalski ML, Domingo C. Weekly low-dose methotrexate for reduction of Global Initiative for Asthma Step 5 treatment in severe refractory asthma: study protocol for a randomized controlled trial. Trials 2014; 15:492. [PMID: 25523634 PMCID: PMC4302097 DOI: 10.1186/1745-6215-15-492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 12/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with chronic severe asthma (CSA) have a crippling disease and current available treatments are not satisfactory. Thus, management of CSA remains a major unmet need. Although the evidence from existing randomized controlled trials fails to support a definite role for immunomodulatory drugs in these patients due to major methodologic drawbacks, findings with low-dose methotrexate (MTX) are encouraging. However, larger and well-designed clinical trials are required to establish the beneficial role of MTX in CSA, and for the detection of the key characteristics of those who are going to respond to this drug. METHODS/DESIGN Patients will be recruited from the accessible asthmatic patients lists of tertiary referral centers. All patients will meet the stringent diagnostic criteria for CSA, including the requirement for the regular use of Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention Step 5 medications (oral prednisone and/or omalizumab). The experimental design of the proposed study will take the form of a double-blind parallel-randomized placebo-controlled trial consisting of a total of eight visits, including run-in and run-out periods. Patients will be randomly allocated to receive either MTX or a matched placebo once a week as an add-on therapy to their existing medication after run-in. Physiological, laboratory and clinical assessments will be measured regularly throughout the study and compared with baseline assessments. DISCUSSION We expect that MTX will reduce Step 5 medications dosage in patients with CSA without compromising the overall disease control. Improvement in several indicators of asthma severity and control will be also investigated. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02124226 (assigned 25 April 2014).
Collapse
Affiliation(s)
- Riccardo Polosa
- Department of Clinical and Biomolecular Medicine, University of Catania, Ospedale Garibaldi Nesima, 636 Via Palermo, 95122 Catania, Italy.
| | | | | | | | | | | | | |
Collapse
|
8
|
Kane B, Fowler SJ, Niven R. Refractory asthma - beyond step 5, the role of new and emerging adjuvant therapies. Chron Respir Dis 2014; 12:69-77. [PMID: 25492977 DOI: 10.1177/1479972314562210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
A small percentage of asthmatics have 'severe refractory asthma', where there is suboptimal response to currently available therapies. A number of novel therapies targeting key biological targets are becoming available. Asthma is a heterogeneous disease, and systematic evaluation of patients is important to target therapies to the underlying inflammatory subtype and clinical features. This review article outlines new and emerging treatments for severe asthma, including monoclonal antibodies targeting eosinophilic disease, anti-neutrophil strategies, novel bronchodilators and bronchial thermoplasty. We highlight the importance of individualized investigation, treatment and management of severe asthmatics.
Collapse
Affiliation(s)
- Binita Kane
- Manchester Academic Health Science Centre, University Hospital of South Manchester, University of Manchester, Southmoor Road, Manchester, UK
| | - Stephen J Fowler
- Manchester Academic Health Science Centre, University Hospital of South Manchester, University of Manchester, Southmoor Road, Manchester, UK Respiratory Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Rob Niven
- Manchester Academic Health Science Centre, University Hospital of South Manchester, University of Manchester, Southmoor Road, Manchester, UK
| |
Collapse
|
9
|
Knarborg M, Hilberg O, Hoffmann HJ, Dahl R. Methotrexate as an oral corticosteroid-sparing agent in severe asthma: the emergence of a responder asthma endotype. Eur Clin Respir J 2014; 1:25037. [PMID: 26557239 PMCID: PMC4629721 DOI: 10.3402/ecrj.v1.25037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/10/2014] [Indexed: 11/14/2022] Open
Abstract
Background Sustained use of oral corticosteroids is associated with significant side effects. It is therefore of interest to find a corticosteroid-sparing agent. In two meta-analyses, methotrexate resulted in a rather small reduction in the oral corticosteroid maintenance dose. We have used methotrexate as an oral corticosteroid-sparing agent in consecutive patients with severe bronchial asthma and find a need for a real-life observational study to evaluate the effect of methotrexate in clinical practice. Methods We analyzed the clinical data of 13 oral corticosteroid-dependent asthma patients with a mean prednisolone dose of 15 mg/day for up to 8 years. The diagnosis of asthma based on the clinical history, positive bronchodilator reversibility test, and variable airflow obstruction was secured by bronchial biopsies in all patients. We reviewed the literature and found 12 studies evaluating methotrexate as an oral corticosteroid-sparing agent in severe asthma and calculated the mean daily reduction in mg of prednisolone. Results Oral corticosteroids could be reduced in 8/13 patients, 61.5% (mean reduction 9.0 mg/day), and stopped in six of these patients. Five patients had no reduction and remained oral corticosteroid-dependent. Patients with the highest oral corticosteroid doses experienced the greatest reductions. Two patients stopped methotrexate due to side effects. FEV1 remained unaffected by methotrexate treatment and corticosteroid reduction. Conclusions Methotrexate has significant oral corticosteroid-sparing effect while maintaining an unaltered asthma control and spirometry. Methotrexate seems an effective oral corticosteroid-sparing agent in a significant proportion of patients with severe asthma. The specific asthma phenotype/endotype that responds needs further study.
Collapse
Affiliation(s)
- Malene Knarborg
- Department of Pulmonary Medicine and Allergology, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Hilberg
- Department of Pulmonary Medicine and Allergology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans-Jürgen Hoffmann
- Department of Pulmonary Medicine and Allergology, Aarhus University Hospital, Aarhus, Denmark ; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ronald Dahl
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| |
Collapse
|
10
|
Linking GATA-3 and interleukin-13: implications in asthma. Inflamm Res 2013; 63:255-65. [PMID: 24363163 DOI: 10.1007/s00011-013-0700-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 12/02/2013] [Accepted: 12/12/2013] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Asthma is one of the serious global health problems and cause of huge mortality and morbidity. It is characterized by persistent airway inflammation, airway hyperresponsiveness, increased IgE levels and mucus hypersecretion. Asthma is mediated by dominant Th2 immune response, causing enhanced expression of Th2 cytokines. These cytokines are responsible for the various pathological changes associated with allergic asthma. MATERIALS AND METHODS The role of Th2 cells in the pathogenesis of the asthma is primarily mediated through the cytokine IL-13, also produced by type 2 innate lymphoid cells, that comes under the transcriptional regulation of GATA3. In this review we will try to explore the link between IL-13 and GATA3 in the progression and regulation of asthma and its possible role as a therapeutic target. CONCLUSION Inhibition of GATA3 activity or blockade of GATA3 expression may attenuate the interleukin-13 mediated asthma phenotypes. So, GATA3 might be a potential therapeutic target for the treatment of allergic asthma.
Collapse
|
11
|
Prevalence of bronchiectasis in asthma according to oral steroid requirement: influence of immunoglobulin levels. BIOMED RESEARCH INTERNATIONAL 2013; 2013:109219. [PMID: 24324951 PMCID: PMC3845843 DOI: 10.1155/2013/109219] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/01/2013] [Accepted: 10/01/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE To establish the prevalence of bronchiectasis in asthma in relation to patients' oral corticosteroid requirements and to explore whether the increased risk is due to blood immunoglobulin (Ig) concentration. METHODS Case-control cross-sectional study, including 100 sex- and age-matched patients, 50 with non-steroid-dependent asthma (NSDA) and 50 with steroid-dependent asthma (SDA). STUDY PROTOCOL (a) measurement of Ig and gG subclass concentration; (b) forced spirometry; and (c) high-resolution thoracic computed tomography. When bronchiectasis was detected, a specific etiological protocol was applied to establish its etiology. RESULTS The overall prevalence of bronchiectasis was 12/50 in the SDA group and 6/50 in the NSDA group (p = ns). The etiology was documented in six patients (four NSDA and two SDA). After excluding these patients, the prevalence of bronchiectasis was 20% (10/50) in the SDA group and 2/50 (4%) in the NSDA group (P < 0.05). Patients with asthma-associated bronchiectasis presented lower FEV1 values than patients without bronchiectasis, but the levels of Ig and subclasses of IgG did not present differences. CONCLUSIONS Steroid-dependent asthma seems to be associated with a greater risk of developing bronchiectasis than non-steroid-dependent asthma. This is probably due to the disease itself rather than to other influencing factors such as immunoglobulin levels.
Collapse
|
12
|
Kalkanis A, Judson MA. Distinguishing asthma from sarcoidosis: an approach to a problem that is not always solvable. J Asthma 2012; 50:1-6. [PMID: 23215952 DOI: 10.3109/02770903.2012.747204] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Because pulmonary sarcoidosis often affects the airway, it is commonly confused with asthma. METHODS This article reviews the mechanisms of airflow obstruction in sarcoidosis, the symptoms associated with this phenomenon, and the approach to distinguish sarcoidosis from asthma. DISCUSSION Because asthma is highly likely in a patient with wheeze, cough, and chest tightness, sarcoidosis is usually not considered unless the patient has extrapulmonary manifestations of sarcoidosis or a family history of the disease. When pulmonary sarcoidosis is a consideration, a chest radiograph should be performed. A chest radiograph should also be performed in an asthmatic patient when the presentation is atypical, or fails to respond to standard asthma treatment; chest radiography should be performed in this situation to consider not only pulmonary sarcoidosis but also other possible cardiopulmonary disorders. In a patient with confirmed pulmonary sarcoidosis, the diagnosis of concomitant asthma is problematic. The symptoms associated with the two disorders are often identical. Airflow obstruction is common in sarcoidosis so that pulmonary function testing is unlikely to differentiate these two diseases. Demonstration of airway hyperreactivity may fail to distinguish these disorders as this is common in sarcoidosis. Serum IgE, serum angiotensin-converting enzyme levels, sputum eosinophilia, and exhaled nitric oxide measurements show promise as distinguishing tests, although they have not been studied specifically. Pulmonary imaging is probably of limited value unless baseline studies are available for comparison. We suspect that historical information will be more useful in distinguishing these two diseases. Not infrequently, it may be impossible to exclude or confirm an asthmatic component in a confirmed pulmonary sarcoidosis patient. Fortunately, exacerbations of both these diseases are often treated with systemic corticosteroids initially. Significant variability in pulmonary symptoms and airflow obstruction suggest that an asthma component is present, and inhaled corticosteroids and bronchodilators should be considered in these cases, CONCLUSIONS Asthma and sarcoidosis share many of the same symptoms, as sarcoidosis commonly affects the airways. Therefore, it is problematic to distinguish these two diseases. In this article, we have outlined an approach to assess the presence of each of these diseases and an approach to therapy.
Collapse
Affiliation(s)
- Alexandros Kalkanis
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, NY 12208, USA
| | | |
Collapse
|
13
|
Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, Culver D, Harrod CG, Hayney MS, Highland KB, Limper AH, Patrick H, Strange C, Whelan T. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 142:e1S-e111S. [PMID: 23131960 PMCID: PMC3610695 DOI: 10.1378/chest.12-1044] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2012] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.
Collapse
Affiliation(s)
| | - Keith C Meyer
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Luis Angel
- University of Texas Health Sciences, San Antonio, TX
| | | | - Kevin M Chan
- University of Michigan Health Systems, Ann Arbor, MI
| | | | | | - Mary S Hayney
- University of Wisconsin School of Pharmacy, Madison, WI
| | | | | | | | | | | |
Collapse
|
14
|
Mathew J, Aronow WS, Chandy D. Therapeutic options for severe asthma. Arch Med Sci 2012; 8:589-97. [PMID: 23056066 PMCID: PMC3460493 DOI: 10.5114/aoms.2012.30280] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 03/22/2012] [Accepted: 03/22/2012] [Indexed: 11/17/2022] Open
Abstract
As the overall prevalence of asthma has escalated in the past decades, so has the population of patients with severe asthma. This condition is often difficult to manage due to the relative limitation of effective therapeutic options for the physician and the social and economic burden of the disease on the patient. Management should include an evaluation and elimination of modifiable risk factors such as smoking, allergen exposure, obesity and non-adherence, as well as therapy for co-morbidities like gastro-esophageal reflux disease and obstructive sleep apnea. Current treatment options include conventional agents such as inhalational corticosteroids, long acting β(2) agonists, leukotriene antagonists, and oral corticosteroids. Less conventional treatment options include immunotherapy with methotrexate, cyclosporine and tacrolimus, biological drugs like monoclonal antibodies, tumor necrosis factor-α blockers and oligonucleotides, phosphodiesterase inhibitors, antimicrobials and bronchial thermoplasty.
Collapse
Affiliation(s)
- Jilcy Mathew
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, USA
| | - Wilbert S. Aronow
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, USA
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, USA
| | - Dipak Chandy
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, USA
| |
Collapse
|
15
|
Domingo C, Moreno A, Mirapeix R. Rationale for the use of immunomodulatory therapies in the Global Initiative for Asthma (GINA) step V asthma other than oral glucocorticosteroids. Intern Med J 2012; 41:525-36. [PMID: 21762333 DOI: 10.1111/j.1445-5994.2011.02481.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Asthma is a major problem worldwide, which is estimated to affect 300 million individuals. The global prevalence ranges from 1% to 18% of the population. The incidence, morbidity and mortality of the condition have increased over the last 50 years despite the development of new anti-asthmatic drugs. Fewer than 1% of the asthmatic population are steroid-dependent, but these patients consume most of the resources and time at asthma units. The consensus documents published by professional societies all support a stepwise therapeutic approach for asthma. However, patients who require frequent or continuous oral corticosteroid administration have received little attention. Due to the severe side-effects of oral corticosteroids when administered over long periods or at high doses, many drugs have been assessed in the search for a possible corticosteroid-sparing agent. Recently, the update of the Global Initiative for Asthma (GINA) introduced a new drug--omalizumab--as an alternative to oral corticosteroids in patients included in step V. Other alternatives include immunosuppressive drugs, among which methotrexate has been found to offer the best benefit/risk ratio. This paper will review, comment and criticize the evidence of the effectiveness of immunomodulatory drugs, as an alternative to oral glucocorticosteroid treatment in GINA step V asthma patients. The experience of the authors combined with the information of the literature will lead to the conclusion that methotrexate and omalizumab are the only advisable drugs and will clarify when and how these drugs should be used.
Collapse
Affiliation(s)
- C Domingo
- Pulmonary Service, Corporació Parc Taulí, Sabadell, Barcelona, Spain.
| | | | | |
Collapse
|
16
|
Abstract
BACKGROUND Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis. METHODS A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy. RESULTS Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation. CONCLUSION Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.
Collapse
Affiliation(s)
- Rony K Aouad
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine, Sacramento, USA
| | | |
Collapse
|
17
|
Watanabe H, Uruma T, Tsunoda T, Ishii H, Tazaki G, Kondo T. Bronchial asthma developing after 15 years of immunosuppressive treatment following renal transplantation. Intern Med 2012; 51:3057-60. [PMID: 23124150 DOI: 10.2169/internalmedicine.51.7575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 42-year-old woman who underwent renal transplantation from her mother at the age of 26 due to IgA nephropathy had since been treated with immunosuppressive agents, including prednisolone (PSL), azathioprine (AZA) and cyclosporine (CsA). The patient had remained clinically stable for 15 years. However, in the middle of May 2010, she developed bronchial asthma for the first time after performing house-cleaning activities and was treated with corticosteroids and antiasthmatic agents. The use of immunosuppressive agents as a treatment for severe bronchial asthma might have been related to the manifestation of bronchial asthma in this case.
Collapse
Affiliation(s)
- Hidehiro Watanabe
- Department of Respiratory Medicine, Tokai University Hachioji Hospital, Tokai University School of Medicine, Japan.
| | | | | | | | | | | |
Collapse
|
18
|
Park SK, Kim HI, Yang YI, Hur DY. Effects of methotrexate on vascular endothelial growth factor, angiopoietin 1, and angiopoietin 2 in nasal polyps. Am J Rhinol Allergy 2011; 25:e129-32. [PMID: 21819747 DOI: 10.2500/ajra.2011.25.3618] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Methotrexate (MTX) is a very effective treatment for chronic inflammatory diseases, which are often associated with increased angiogenesis. Angiogenesis is dependent on a perfectly coordinated balance between endogenous-positive and -negative regulatory factors, including vascular endothelial growth factor (VEGF) and the angiopoietins (Ang). The aim of this study was to investigate the effects of MTX on levels of VEGF, Ang-1, and Ang-2 in organ-cultured nasal polyps (NPs). METHODS To determine the effects of MTX, NP tissues were cultured using an air-liquid interface method. Cultures were maintained in the absence or presence of MTX (10 or 100 micromoles) for 24 hours. Hematoxylin and eosin, and TUNEL (terminal deoxynucleotidyl transferase [Tdt]-mediated dUTP-biotin nick-end labeling) staining were performed to observe apoptosis. Enzyme-linked immunosorbent assay was used to quantify tissue concentrations of VEGF, Ang-1, and Ang-2. RESULTS MTX treatment resulted in marked alterations in inflammatory cells, especially eosinophils. In contrast, the mucosal epithelium, microvessels including arterioles, veins and capillaries, and fibroblasts maintained their structure. TUNEL(+) cells (apoptotic cells) were seen in the MTX-treated specimens. The more induction of TUNEL(+) cells was observed 100-micromolar MTX-treated specimens. VEGF and Ang-1 levels were significantly lower, and Ang-2 levels were significantly higher in NPs treated with 100-micromolar MTX than in nontreated NPs (p < 0.01). CONCLUSION MTX may inhibit the growth of NPs via local regulation of VEGF, Ang-1, and Ang-2 protein levels. We suggest that MTX can be used to treat NPs.
Collapse
Affiliation(s)
- Seong Kook Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Inje University School of Medicine, Busan Paik Hospital, Busan, Korea.
| | | | | | | |
Collapse
|
19
|
Domingo C, Moreno A, José Amengual M, Montón C, Suárez D, Pomares X. Omalizumab in the management of oral corticosteroid-dependent IGE-mediated asthma patients. Curr Med Res Opin 2011; 27:45-53. [PMID: 21083517 DOI: 10.1185/03007995.2010.536208] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Several studies have demonstrated the beneficial effects of omalizumab in asthma patients. Here we describe the drug's tolerance and oral corticosteroid sparing capacity in a long-term observational study. METHODS Thirty-two patients aged ≥18 years with obstructive airway disease and FEV(1) reversibility ≥12% and 200 mL, with an oral steroid requirement ≥7.5 mg per day of prednisolone during a period of ≥1 year, a positive prick test or in vitro reactivity (RAST) to at least one perennial aeroallergen and a baseline immunoglobulin E level ranking between 30-700 IU/mL were prospectively followed for 17.2 ± 8.5 months. Patients were visited once or twice a month, depending on their schedule for omalizumab administration. INTERVENTION blood analysis every six months; spirometry and nitric oxide measurement at every visit. RESULTS One patient who dropped out early was excluded. Follow-up period: the treatment benefited 83.9% (26/31) of the cohort; oral corticosteroids were reduced from 7.19 ± 11.1 to 3.29 ± 11.03 mg (p < 0.002) and withdrawn in 74.2% of patients. FEV(1) (percent predicted) was 64.4 ± 22.7 at the beginning and 62.9 ± 24.3 at the end. IgE at entry was 322.2 ± 334.2 IU/mL and increased 2.34-fold. Respiratory function and NO did not present statistically significant changes. We identified three groups of patients: the first (n = 17) receiving oral steroid at entry in whom the accumulated dose of oral steroids progressively decreased; another (n = 10) including patients who had quit oral steroids before starting omalizumab although they had not been instructed to do so and whose oral steroid dose at the end of follow-up was zero; and a third group (n = 4) that did not benefit from omalizumab treatment. The only relevant side effect was a flu-like syndrome which required discontinuation of treatment in one patient. CONCLUSION In our series, a substantial, safe decrease in oral corticosteroid requirements was observed due, at least to some extent, to omalizumab therapy. Oral corticosteroids were withdrawn in three-quarters of the patients. We were unable to identify a factor able to predict which patients would benefit most from omalizumab treatment.
Collapse
|
20
|
Morjaria JB, Polosa R. Recommendation for optimal management of severe refractory asthma. J Asthma Allergy 2010; 3:43-56. [PMID: 21437039 PMCID: PMC3047913 DOI: 10.2147/jaa.s6710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Indexed: 11/23/2022] Open
Abstract
Patients whose asthma is not adequately controlled despite treatment with a combination of high dose inhaled corticosteroids and long-acting bronchodilators pose a major clinical challenge and an important health care problem. Patients with severe refractory disease often require regular oral corticosteroid use with an increased risk of steroid-related adverse events. Alternatively, immunomodulatory and biologic therapies may be considered, but they show wide variation in efficacy across studies thus limiting their generalizability. Managing asthma that is refractory to standard treatment requires a systematic approach to evaluate adherence, ensure a correct diagnosis, and identify coexisting disorders and trigger factors. In future, phenotyping of patients with severe refractory asthma will also become an important element of this systematic approach, because it could be of help in guiding and tailoring treatments. Here, we propose a pragmatic management approach in diagnosing and treating this challenging subset of asthmatic patients.
Collapse
|
21
|
Buyukozturk S, Gelincik A, Aslan I, Aydin S, Colakoglu B, Dal M. Methotrexate: can it be a choice for nasal polyposis in aspirin exacerbated respiratory disease? J Asthma 2010; 46:1037-41. [PMID: 19995143 DOI: 10.3109/02770900903242704] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Nasal polyposis (NP) is considered a subgroup of chronic rhinosinusitis and is commonly associated with asthma, bronchiectasis, and cystic fibrosis. A certain subgroup of nasal polyposis is known as Aspirin Exacerbated Respiratory Disease (AERD), previously called Samter's Triad or aspirin triad, comprising polyposis, asthma, and aspirin hypersensitivity and makes up almost 10% of cases of NP. Therapy of NP involves a combination of medical and surgical treatments. However, recurrences are common, particularly in patients with asthma and aspirin hypersensitivity. Both topical and systemic corticosteroids form the mainstay of conservative therapy for NP as well as a primary treatment and prevention for recurrences. They have been shown to improve nasal breathing, rhinitis symptoms, and reduce the size of NP, along with the rate of recurrence. There is great concern about the adverse effects of systemic steroids, especially when long-term usage is necessary to maintain improvement. So far, no knowledge exists about the effects of methotrexate (MTX) on NP of the patients with asthma. We report two patients whose NP dramatically reduced in size after a course of MTX therapy administered as an additional treatment for their steroid- dependent asthma.
Collapse
Affiliation(s)
- S Buyukozturk
- Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Allergy, Istanbul University, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
22
|
Lyakhovitsky A, Barzilai A, Heyman R, Baum S, Amichai B, Solomon M, Shpiro D, Trau H. Low-dose methotrexate treatment for moderate-to-severe atopic dermatitis in adults. J Eur Acad Dermatol Venereol 2009; 24:43-9. [PMID: 19552716 DOI: 10.1111/j.1468-3083.2009.03351.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atopic dermatitis (AD) is a common inflammatory skin disease. Methotrexate (MTX) was suggested as an effective treatment option in cases of moderate-to-severe atopic dermatitis. This study assessed the efficacy and safety of treatment with low weekly doses of methotrexate for moderate-to-severe AD in adults. METHODS Twenty adult patients with moderate-to-severe AD were included in this retrospective study. Those patients were unresponsive to topical treatments, antihistamines and at least one of the second-line treatments. MTX in low weekly doses of 10-25 mg was administered orally or intramuscularly with folic acid supplementation 5 mg per week for at least 8-12 weeks. The response to treatment was evaluated by change in SCORAD (SCORing Atopic Dermatitis), DLQI (Dermatology Quality of Life Index) and the global assessment of the clinical response score. RESULTS After 8-12 weeks of treatment, we observed an objective response in most patients. There were 16 responders and 4 non-responders. The mean SCORAD and DLQI decreased by 28.65 units (44.3%) and 10.15 units (43.5%), respectively. The first improvement was observed after a period ranging from 2 weeks to 3 months (mean 9.95 w +/- 3.17). Treatment was more effective in adult onset AD than in childhood onset. Tolerance of treatment was good. However, nausea and an increase of liver enzymes were observed in 5 patients and 3 of them required a transient discontinuation of MTX. One patient developed peripheral neuropathy, which was resolved several weeks after the discontinuation of MTX. CONCLUSION MTX seems to be an effective and safe second-line treatment for patients with moderate-to-severe atopic dermatitis. A randomized, controlled study is warranted.
Collapse
Affiliation(s)
- A Lyakhovitsky
- Sheba Medical Center - Dermatology Department, Tel-Hashomer, Ramat-Gan, Israel.
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Polosa R, Benfatto GT. Managing patients with chronic severe asthma: rise to the challenge. Eur J Intern Med 2009; 20:114-24. [PMID: 19327598 DOI: 10.1016/j.ejim.2008.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 05/03/2008] [Accepted: 06/09/2008] [Indexed: 11/17/2022]
Abstract
Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are perhaps 10% of the asthmatic population with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regime. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease with distinct sub-phenotypes. A systematic diagnostic work-up may help to identify these distinct sub-phenotypes and this may help guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with chronic severe asthma. This review article aims at summarizing the evidence regarding various therapeutic modalities for chronic severe asthma and also aims to provide a practical approach to diagnosis and management for the benefit of those who have a specific interest in this problematic condition.
Collapse
Affiliation(s)
- Riccardo Polosa
- Dipartimento di Medicina Interna, Ospedale S. Marta, Università di Catania, Catania, Italy.
| | | |
Collapse
|
24
|
Abstract
Management decisions for pediatric asthma (in patients younger than 12 years of age) based on extrapolation from available evidence in adolescents and adults (age 12 years and older) is common but rarely appropriate. This article addresses the disparity in response between the two age groups, presents the available pediatric evidence, and highlights the important areas in which further research is required. Evidence-based recommendations for acute and interval management of pediatric asthma are provided.
Collapse
Affiliation(s)
- Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Sydney, Australia.
| | | |
Collapse
|
25
|
Polosa R, Morjaria J. Immunomodulatory and biologic therapies for severe refractory asthma. Respir Med 2009; 102:1499-510. [PMID: 19012848 DOI: 10.1016/j.rmed.2008.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2008] [Indexed: 11/30/2022]
Abstract
Despite undoubted efficacy of the combination of inhaled corticosteroids and beta(2)-agonists for most asthmatic patients with moderate-to-severe disease, there remains approximately 10% of the asthmatic population with serious unremitting symptoms, resulting in considerable impact on quality of life, disproportionate use of health care resources, and adverse effects from regular systemic steroid use. In an ideal world, optimal treatment of severe refractory asthma should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent are dictated by the severity of disease and may include immunological modifiers and biologic therapies. Unfortunately, current asthma guidelines offer little contribution to the management of the challenging patient with severe refractory asthma and none of them have addressed therapeutic alternatives to oral corticosteroids. This article reviews the current evidence for immunomodulating and biologic approaches in severe refractory asthma.
Collapse
Affiliation(s)
- Riccardo Polosa
- Ospedale Santa Marta, U.O.C di Medicina Interna e Medicina d'Urgenza, Via Gesualdo Clementi 36, 95124 Catania, Italy.
| | | |
Collapse
|
26
|
Katzilakis N, Paraskakis E, Mantadakis E, Stiakaki E, Kalmanti M. Bronchial asthma and acute lymphoblastic leukemia in childhood. Pediatr Pulmonol 2008; 43:206. [PMID: 18085680 DOI: 10.1002/ppul.20754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
27
|
Randhawa I, Klaustermeyer WB. Oral corticosteroid-dependent asthma: a 30-year review. Ann Allergy Asthma Immunol 2007; 99:291-302; quiz 302-3, 370. [PMID: 17941275 DOI: 10.1016/s1081-1206(10)60543-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma. DATA SOURCES PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies. STUDY SELECTION Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers. RESULTS High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma. CONCLUSIONS With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.
Collapse
|
28
|
Abstract
Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are a few with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regimen. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease and a systematic diagnostic work-up may help to guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma (CSA) should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with CSA. In this review, a diagnostic and therapeutic overview of CSA is provided for the benefit of those who have a specific interest in this problematic condition.
Collapse
Affiliation(s)
- R Polosa
- Department of Internal Medicine, University of Catania, Catania, Italy.
| |
Collapse
|
29
|
Abstract
BACKGROUND Sustained oral corticosteroid use can lead to complications, so there is interest in identifying agents that can reduce oral steroid use in people with asthma. Methotrexate has attracted attention as a possible steroid sparing agent in patients with chronic oral steroid dependent asthma. OBJECTIVES The objective of this review was to assess the effects of adding methotrexate to oral corticosteroids in adults with stable asthma who are dependent on oral corticosteroids. SEARCH STRATEGY The Cochrane Airways Group trials register and reference lists of identified articles were searched. SELECTION CRITERIA Randomised trials of the addition of methotrexate compared with placebo in adult steroid dependent asthmatics. Duration of therapy needed to be at least 12 weeks. DATA COLLECTION AND ANALYSIS Trial quality was assessed and data extraction was carried out by two reviewers independently. Study authors were contacted for missing information. MAIN RESULTS Ten trials involving a total of 185 people were included. Study design and quality, corticosteroid dosages and outcomes varied widely. There was a reduction in oral corticosteroid dose favouring methotrexate in parallel trials (weighted mean difference -4.1 mg per day, 95% confidence interval -6.8 to -1.3) and also in cross-over trials (weighted mean difference -2.9 mg per day, 95% confidence interval -5.9 to -0.2). There was no difference between methotrexate and placebo for forced expiratory volume in one minute (weighted mean difference 0.12 litre, 95% confidence interval -0.21 to 0.45). Hepatotoxicity was a common adverse effect with methotrexate compared to placebo (odds ratio 6.9, 95% confidence interval 3.1 to 15.5). REVIEWER'S CONCLUSIONS Methotrexate may have a small steroid sparing effect in adults with asthma who are dependent on oral corticosteroids. However, the overall reduction in daily steroid use is probably not large enough to reduce steroid-induced adverse effects. This small potential to reduce the impact of steroid side-effects is probably insufficient to offset the adverse effects of methotrexate.
Collapse
Affiliation(s)
- H Davies
- Respiratory Medicine, John Hunter Hospital, Locked Bag 1, Newcastle Mail Centre, Newcastle, NSW, Australia, 2310.
| | | | | |
Collapse
|