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Lan Y, Hu D, Huang S, Ma Q, Chen L, Xu M, He Q. Comparison of Infection Risks Between Various Inhaled and Intranasal Corticosteroids: A Pharmacovigilance Analysis Based on the FAERS Database. Int J Chron Obstruct Pulmon Dis 2024; 19:1457-1469. [PMID: 38948909 PMCID: PMC11214551 DOI: 10.2147/copd.s466588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose This study conducted a pharmacovigilance analysis based on the FDA Adverse Event Reporting System (FAERS) database to compare the infection risk of inhaled or nasal Beclomethasone, Fluticasone, Budesonide, Ciclesonide, Mometasone, and Triamcinolone Acetonide. Methods We used proportional imbalance analysis to evaluate the correlation between ICS /INCs and infection events. The data was extracted from the FAERS database from April 2015 to September 2023. Further analysis was conducted on the clinical characteristics, site of infection, and pathogenic bacteria of ICS and INCs infection adverse events (AEs). We used bubble charts to display their top 5 infection adverse events. Results We analyzed 21,837 reports of infection AEs related to ICS and INCs, with an average age of 62.12 years. Among them, 61.14% of infection reports were related to females. One-third of infections reported to occur in the lower respiratory tract with Fluticasone, Budesonide, Ciclesonidec, and Mometasone; over 40% of infections reported by Triamcinolone Acetonide were eye infections; the rate of oral infections caused by Beclomethasone were 7.39%. The reported rates of fungal and viral infections caused by beclomethasone were 21.15% and 19.2%, respectively. The mycobacterial infections caused by Budesonide and Ciclesonidec account for 3.29% and 2.03%, respectively. Bubble plots showed that the ICS group had more fungal infections, oral infections, pneumonia, tracheitis, etc. The INCs group had more eye symptoms, rhinitis, sinusitis, nasopharyngitis, etc. Conclusion Women who use ICS and INCs are more prone to infection events. Compared to Budesonide, Fluticasone seemed to have a higher risk of pneumonia and oral candidiasis. Mometasone might lead to more upper respiratory tract infections. The risk of oral infection was higher with Beclomethasone. Beclomethasone causes more fungal and viral infections, while Ciclesonide and Budesonide are more susceptible to mycobacterial infections.
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Affiliation(s)
- Ying Lan
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Die Hu
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Shijing Huang
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Qing Ma
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Li Chen
- Department of Pharmacology, Faculty of Medicine, University of the Basque Country, UPV/EHU, Leioa, Spain
- Department of Pharmacy and Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Min Xu
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Qin He
- Department of Pharmacy, Affiliated Hospital of Southwest Jiaotong University, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, 610031, People’s Republic of China
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Melani AS, Croce S, Fabbri G, Messina M, Bargagli E. Inhaled Corticosteroids in Subjects with Chronic Obstructive Pulmonary Disease: An Old, Unfinished History. Biomolecules 2024; 14:195. [PMID: 38397432 PMCID: PMC10887366 DOI: 10.3390/biom14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the major causes of disability and death. Maintenance use of inhaled bronchodilator(s) is the cornerstone of COPD pharmacological therapy, but inhaled corticosteroids (ICSs) are also commonly used. This narrative paper reviews the role of ICSs as maintenance treatment in combination with bronchodilators, usually in a single inhaler, in stable COPD subjects. The guidelines strongly recommend the addition of an ICS in COPD subjects with a history of concomitant asthma or as a step-up on the top of dual bronchodilators in the presence of hospitalization for exacerbation or at least two moderate exacerbations per year plus high blood eosinophil counts (≥300/mcl). This indication would only involve some COPD subjects. In contrast, in real life, triple inhaled therapy is largely used in COPD, independently of symptoms and in the presence of exacerbations. We will discuss the results of recent randomized controlled trials that found reduced all-cause mortality with triple inhaled therapy compared with dual inhaled long-acting bronchodilator therapy. ICS use is frequently associated with common local adverse events, such as dysphonia, oral candidiasis, and increased risk of pneumonia. Other side effects, such as systemic toxicity and unfavorable changes in the lung microbiome, are suspected mainly at higher doses of ICS in elderly COPD subjects with comorbidities, even if not fully demonstrated. We conclude that, contrary to real life, the use of ICS should be carefully evaluated in stable COPD patients.
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Affiliation(s)
- Andrea S. Melani
- Respiratory Diseases Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (S.C.); (G.F.); (M.M.); (E.B.)
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Jana BK, Singh M, Dutta RS, Mazumder B. Current Drug Delivery Strategies for Buccal Cavity Ailments using Mouth Dissolving Wafer Technology: A Comprehensive Review on the Present State of the Art. Curr Drug Deliv 2024; 21:339-359. [PMID: 36443976 DOI: 10.2174/1567201820666221128152010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/02/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mouth-dissolving wafer is polymer-based matrice that incorporates various pharmaceutical agents for oral drug delivery. This polymeric wafer is ingenious in the way that it needs not be administered with water, like in conventional tablet dosage form. It has better compliance among the pediatric and geriatric groups owing to its ease of administration. OBJECTIVE The polymeric wafer dissolves quickly in the oral cavity and is highly effective for a targeted local effect in buccal-specific ailments. It is a safe, effective, and versatile drug delivery carrier for a range of drugs used to treat a plethora of oral cavity-specific ailments that inflict common people, like thrush, canker sores, periodontal disease, benign oral cavity tumors, buccal neoplasm, and malignancies. This review paper focuses thoroughly on the present state of the art in mouth-dissolving wafer technology for buccal drug delivery and targeting. Moreover, we have also addressed present-time limitations associated with wafer technology to aid researchers in future developments in the arena of buccal drug delivery. CONCLUSION This dynamic novel formulation has tremendous future implications for designing drug delivery systems to target pernicious ailments and diseases specific to the buccal mucosa. In a nutshell, this review paper aims to summarize the present state of the art in buccal targeted drug delivery.
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Affiliation(s)
- Bani Kumar Jana
- Department of Pharmaceutical sciences, Dibrugarh University, Dibrugarh-786004, Assam, India
| | - Mohini Singh
- Department of Pharmaceutical sciences, Dibrugarh University, Dibrugarh-786004, Assam, India
| | - Rajat Subhra Dutta
- Department of Pharmaceutical sciences, Dibrugarh University, Dibrugarh-786004, Assam, India
| | - Bhaskar Mazumder
- Department of Pharmaceutical sciences, Dibrugarh University, Dibrugarh-786004, Assam, India
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Zhang Q, Wang Z, Shi K, Zhou H, Wei X, Hall P. Improving Inhalation Performance with Particle Agglomeration via Combining Mechanical Dry Coating and Ultrasonic Vibration. Pharmaceutics 2023; 16:68. [PMID: 38258079 PMCID: PMC10821125 DOI: 10.3390/pharmaceutics16010068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Agglomerate formulations for dry powder inhalation (DPI) formed with fine particles are versatile means for the highly efficient delivery of budesonide. However, uncontrolled agglomeration induces high deposition in the upper airway, causing local side effects due to high mechanical strength, worse deagglomeration, and poor fine-particle delivery. In the present study, fine lactose was mechanically dry-coated prior to particle agglomeration, and the agglomerates were then spheroidized via ultrasonic vibration to improve their aerosol performance. The results showed that the agglomerate produced with the surface-enriched hydrophobic magnesium stearate and ultrasonic vibration demonstrated improved aerosolization properties, benefiting from their lower mechanical strength, less interactive cohesive force, and improved fine powder dispersion behavior. After dispersion utilizing a Turbuhaler® with a pharmaceutical cascade impactor test, a fine particle fraction (FPF) of 71.1 ± 1.3% and an artificial throat deposition of 19.3 ± 0.4% were achieved, suggesting the potential to improve the therapeutic outcomes of budesonide with less localized infections of the mouth and pharynx.
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Affiliation(s)
- Qingzhen Zhang
- Department of Chemical and Environmental Engineering, University of Nottingham Ningbo China, Ningbo 315100, China; (Q.Z.); (Z.W.)
| | - Zheng Wang
- Department of Chemical and Environmental Engineering, University of Nottingham Ningbo China, Ningbo 315100, China; (Q.Z.); (Z.W.)
- Key Laboratory for Carbonaceous Wastes Processing and Process Intensification Research of Zhejiang Province, University of Nottingham Ningbo China, Ningbo 315100, China
| | - Kaiqi Shi
- Suzhou Inhal Pharma Co., Ltd., Suzhou 215000, China;
| | - Hang Zhou
- College of Pharmacy, Zhejiang University of Technology, Hangzhou 310014, China;
| | - Xiaoyang Wei
- Nottingham Ningbo China Beacons of Excellence Research and Innovation Institute, University of Nottingham Ningbo China, Ningbo 315100, China;
| | - Philip Hall
- Department of Chemical and Environmental Engineering, University of Nottingham Ningbo China, Ningbo 315100, China; (Q.Z.); (Z.W.)
- Nottingham Ningbo China Beacons of Excellence Research and Innovation Institute, University of Nottingham Ningbo China, Ningbo 315100, China;
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Jan BM, Khayat MA, Bushnag AI, Zahid AI, Alkarim AS, Alshehri MT, Almasoudi FM, Zahran M, Almazrooa SA, Mawardi HH. The Association Between Long-Term Corticosteroids Use and Dental Caries: A Systematic Review. Cureus 2023; 15:e44600. [PMID: 37667783 PMCID: PMC10475248 DOI: 10.7759/cureus.44600] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/06/2023] Open
Abstract
Corticosteroids (CSs) are a group of medications prescribed regularly to treat a wide range of inflammatory and immune-related conditions with great benefit. The impact of long-term use of CSs on the oral cavity has been reported before, including increased risk of periodontal disease and dental caries. Thus, the aim of this study is to evaluate the prevalence of dental caries in patients using CSs. A literature review was completed using PubMed and Cochrane search engines. The search was based on questions related to adults and children (P); corticosteroids (I); no corticosteroids (C); and dental caries (O) (PICO questions) using the keywords "steroids" and "caries" with all relevant variations and MeSH terms. Decay missing filling tooth/decay missing filling surface (DMFT/DMFS) scores were selected as parameters to assess the effects of CSs on caries prevalence. Data was extracted and analyzed for comparisons. The search yielded 1,206 articles from January 2001 to January 2023, of which 21 papers were eligible for analysis. Overall, 14 studies reported an increase in caries with CSs use. However, seven studies failed to report an association of caries prevalence with CSs use. Current evidence supports the correlation between increased risk of caries with chronic CSs use, specifically for inhaler formulation. Future studies with randomized controlled clinical studies are warranted to confirm these findings.
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Affiliation(s)
- Basil M Jan
- Orthodontics, Jacksonville University, Jacksonville, USA
| | | | | | | | | | | | | | | | | | - Hani H Mawardi
- Oral Diagnostic Sciences, King Abdulaziz University, Jeddah, SAU
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Bahsoun A, Fakih Y, Zareef R, Bitar F, Arabi M. Corticosteroids in COVID-19: pros and cons. Front Med (Lausanne) 2023; 10:1202504. [PMID: 37644981 PMCID: PMC10461317 DOI: 10.3389/fmed.2023.1202504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
The wide and rapid spread of the COVID-19 pandemic has placed an unanticipated burden on the global healthcare sector. This necessitated a swift response from the international community to reach a solution. Efforts were made in parallel to develop preventative and therapeutic modalities. Since then, drug repurposing has blossomed as a potentially rapid resolution and has included various agents with anti-viral and anti-inflammatory properties. Corticosteroids, being potent anti-inflammatory agents, have been placed under extensive investigation. Various trials have recorded the beneficial outcome of corticosteroids in decreasing the mortality and morbidity of COVID-19. With the high pace of escalating events, the quality and study design of clinical trials are varied. Therefore, this study aims to explore the role of corticosteroids in COVID-19 disease. It inspects the molecular, pharmacologic, and clinical proof behind this theory.
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Affiliation(s)
- Aymen Bahsoun
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yeva Fakih
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Zareef
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
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Feldman WB, Avorn J, Kesselheim AS, Gagne JJ. Chronic Obstructive Pulmonary Disease Exacerbations and Pneumonia Hospitalizations Among New Users of Combination Maintenance Inhalers. JAMA Intern Med 2023; 183:685-695. [PMID: 37213116 PMCID: PMC10203971 DOI: 10.1001/jamainternmed.2023.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/07/2023] [Indexed: 05/23/2023]
Abstract
Importance Clinical guidelines on chronic obstructive pulmonary disease (COPD) recommend inhalers containing long-acting muscarinic antagonists (LAMAs) and long-acting β-agonists (LABAs) over inhalers containing inhaled corticosteroids (ICSs) and LABAs. However, data from randomized clinical trials comparing these combination inhalers (LAMA-LABAs vs ICS-LABAs) have been conflicting and raised concerns of generalizability. Objective To assess whether LAMA-LABA therapy is associated with reduced COPD exacerbations and pneumonia hospitalizations compared with ICS-LABA therapy in routine clinical practice. Design, Setting, and Participants This was a 1:1 propensity score-matched cohort study using Optum's Clinformatics Data Mart, a large commercial insurance-claims database. Patients must have had a diagnosis of COPD and filled a new prescription for a combination LAMA-LABA or ICS-LABA inhaler between January 1, 2014, and December 31, 2019. Patients younger than 40 years were excluded, as were those with a prior diagnosis of asthma. The current analysis was performed from February 2021 to March 2023. Exposures Combination LAMA-LABA inhalers (aclidinium-formoterol, glycopyrronium-formoterol, glycopyrronium-indacaterol, tiotropium-olodaterol, or umeclidinium-vilanterol) and combination ICS-LABA inhalers (budesonide-formoterol, fluticasone-salmeterol, fluticasone-vilanterol, or mometasone-formoterol). Main Outcome The primary effectiveness outcome was first moderate or severe COPD exacerbation, and the primary safety outcome was first pneumonia hospitalization. Propensity score matching was used to control for confounding between the 2 groups. Logistic regression analysis was used to estimate propensity scores. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards models stratified on matched pairs. Results Among 137 833 patients (mean [SD] age, 70.2 [9.9] years; 69 530 [50.4%] female) (107 004 new ICS-LABA users and 30 829 new LAMA-LABA users), 30 216 matched pairs were identified for the primary analysis. Compared with ICS-LABA use, LAMA-LABA use was associated with an 8% reduction in the rate of first moderate or severe COPD exacerbation (HR, 0.92; 95% CI, 0.89-0.96) and a 20% reduction in the rate of first pneumonia hospitalization (HR, 0.80; 95% CI, 0.75-0.86). These findings were robust across a range of prespecified subgroup and sensitivity analyses. Conclusion In this cohort study, LAMA-LABA therapy was associated with improved clinical outcomes compared with ICS-LABA therapy, suggesting that LAMA-LABA therapy should be preferred for patients with COPD.
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Affiliation(s)
- William B. Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Joshua J. Gagne
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Now with Johnson & Johnson, Cambridge, Massachusetts
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Julia Altube M, Perez N, Lilia Romero E, José Morilla M, Higa L, Paula Perez A. Inhaled lipid nanocarriers for pulmonary delivery of glucocorticoids: previous strategies, recent advances and key factors description. Int J Pharm 2023:123146. [PMID: 37330156 DOI: 10.1016/j.ijpharm.2023.123146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
In view of the strong anti-inflammatory activity of glucocorticoids (GC) they are used in the treatment of almost all inflammatory lung diseases. In particular, inhaled GC (IGC) allow high drug concentrations to be deposited in the lung and may reduce the incidence of adverse effects associated with systemic administration. However, rapid absorption through the highly absorbent surface of the lung epithelium may limit the success of localized therapy. Therefore, inhalation of GC incorporated into nanocarriers is a possible approach to overcome this drawback. In particular, lipid nanocarriers, which showed high pulmonary biocompatibility and are well known in the pharmaceutical industry, have the best prospects for pulmonary delivery of GC by inhalation. This review provides an overview of the pre-clinical applications of inhaled GC-lipid nanocarriers based on several key factors that will determine the efficiency of local pulmonary GC delivery: 1) stability to nebulization, 2) deposition profile in the lungs, 3) mucociliary clearance, 4) selective accumulation in target cells, 5) residence time in the lung and systemic absorption and 6) biocompatibility. Finally, novel preclinical pulmonary models for inflammatory lung diseases are also discussed.
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Affiliation(s)
- María Julia Altube
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Noelia Perez
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Eder Lilia Romero
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - María José Morilla
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Leticia Higa
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina
| | - Ana Paula Perez
- Nanomedicines Research and Development Centre (NARD), Science and Technology Department, National University of Quilmes, Roque Sáenz Peña 352, Bernal, Buenos Aires, Argentina.
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Alqahtani SS, Alabeedi FM. Association of oral candidiasis with oral lichen planus in patients using corticosteroid therapy - Meta-analysis. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY = JOURNAL DE LA THERAPEUTIQUE DES POPULATIONS ET DE LA PHARMACOLOGIE CLINIQUE 2023; 30:e1-e13. [PMID: 36631413 DOI: 10.47750/jptcp.2023.1020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 01/13/2023]
Abstract
Oral lichen planus (OLP) is a chronic inflammatory disease that commonly affects the skin and mucous membranes. There is a difference of opinion among clinicians about whether OLP has been associated with oral candidiasis. Nonetheless, in OLP patients, the oral candidiasis prevalence rate ranges from 7.7 to 16.6%, as established through biopsy findings, whereas 37-50% of the prevalence rate has been noticed in culture findings. Oral candidiasis has been linked to several local and systemic factors, including salivary gland dysfunction, dental prostheses, topical or inhaled corticosteroids, smoking, and the use of systemic medications. The aim was to highlight the association of Candida in patients diagnosed with OLP, correlate the use of steroid therapy, and enumerate the factors of using steroid therapy as implicated causes for oral candidiasis. A search was made using search engines such as PubMed, Scopus, Cochrane Database of Systematic Reviews, Science Citation Index, NIH Public Access, and Clarivate Analytics (Figure 1). The keywords using the research option for this field were "Oral Candidiasis" AND "Oral Lichen planus" or "Candidiasis" AND "Corticosteroids" or "Topical Corticosteroids" AND Oral Lichen planus or "Inhalation Corticosteroids" AND "Candidiasis" or "Oral Lichen planus" AND "Corticosteroids." The database search was made for the duration of 1991 to -2021 (Table 1). Additional articles were obtained regarding the literature on OLP and oral candidiasis and were considered background material. The incidence of oral candidiasis and associated lichen planus following steroid therapy enlisted by various authors has been addressed. According to the results of this study, there is a positive correlation between the presence of oral candidiasis in the OLP's patients treated with corticosteroids. Finally, this meta-analysis concluded that there is a positive correlation between the presence of Candida species in OLP and steroid medication.
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Affiliation(s)
- Sulaiman S Alqahtani
- Department of Oral & Maxillofacial Surgery and Diagnostic Sciences, Faculty of Dentistry, Najran University, Najran, Saudi Araxbia.;
| | - Faris M Alabeedi
- Department of Oral & Maxillofacial Surgery and Diagnostic Sciences, Faculty of Dentistry, Najran University, Najran, Saudi Araxbia
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Park JW, Hong Y, Rhee CK, Choi HS, Kim K, Yoo KH, Jung KS, Park JH. The Impact of Inhaled Corticosteroids on the Prognosis of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 18:733-743. [PMID: 37159577 PMCID: PMC10163892 DOI: 10.2147/copd.s388367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
Background A comprehensive analysis of the effects of inhaled corticosteroids (ICS) on COPD in a real-world setting is required due to safety concerns regarding ICS in COPD. This study aimed to explore the impact of ICS on the prognosis of Asian COPD patients in the real-life world. Methods We examined 978 COPD patients registered in the Korean National Health and Nutrition Examination Survey (KNHANES) database and with their data linked to Health Insurance and Review Assessment (HIRA) data. The outcome measures were ascertained by HIRA from January 1, 2009, to December 31, 2012. This study enrolled two arms; ICS users (N = 85, mean age = 66.7 ± 8.9 years) and non-ICS users (N = 893, mean age = 63.7 ± 9.7 years). Results Compared to the non-ICS users, the ICS users had a higher rate of pneumonia, tuberculosis, and acute exacerbations (P<0.05). Hospitalization due to respiratory causes was also higher among ICS users (P<0.05). Multivariate analysis showed that acute exacerbation was independently associated with the development of pneumonia (P<0.05), whereas ICS therapy had a tendency to be associated with pneumonia. Another multivariate analysis demonstrated that old age, FEV1, ICS therapy, and pneumonia were independently associated with the occurrence of acute exacerbation (P<0.05). The concomitant pneumonia (HR = 3.353, P = 0.004) was independently associated with higher mortality (P<0.05). Conclusion Our data demonstrated that the ICS users had a higher rate of pneumonia and tuberculosis and the concomitant pneumonia was independently associated with higher mortality, highlighting the importance of cautious and targeted administration of ICS in COPD.
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Affiliation(s)
- Ji Won Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Yoonki Hong
- Department of Internal Medicine, Kangwon National University, Chuncheon, South Korea
| | - Chin Kook Rhee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hye Sook Choi
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, South Korea
| | - Kyungjoo Kim
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kwang Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, South Korea
| | - Ki-Suck Jung
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea
- Correspondence: Joo Hun Park, Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Worldcup road 164, Suwon, Gyeonggi-do, 16499, South Korea, Tel +82-31-219-5116; +82-10-8379-8299, Fax +82-31-219-5124, Email ;
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Not All Inhaled Medicines Are Equal. Ann Am Thorac Soc 2022; 19:1948-1949. [PMID: 35939807 PMCID: PMC9667796 DOI: 10.1513/annalsats.202207-605le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Meccatti VM, Figueiredo-Godoi LMA, Pereira TC, de Lima PMN, Abu Hasna A, Senna LB, Marcucci MC, Junqueira JC, de Oliveira LD. The biocompatibility and antifungal effect of Rosmarinus officinalis against Candida albicans in Galleria mellonella model. Sci Rep 2022; 12:15611. [PMID: 36114199 PMCID: PMC9481548 DOI: 10.1038/s41598-022-19425-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
This study was performed to evaluate the biocompatibility and antifungal effect of Rosmarinus officinalis against Candida albicans in Galleria mellonella model. Five different concentrations of R. officinalis glycolic extract (50; 25; 12.5 e 6.25 mg/mL) were used to evaluate its biocompatibility in G. mellonella model, in which the nystatin suspension (100; 50; 25; 12.5 e 6.25%) was used as a control group. The antifungal action of R. officinalis glycolic extract was evaluated on C. albicans for 72, 48 and 12 h at two different phases: (1) using the extract as therapeutic agent; and (2) using the extract as prophylactic agent. PBS was used as a negative control group. G. mellonella survival curves were plotted using the Kaplan–Meier method and statistical analysis was performed using the log-rank test (Mantel–Cox) and the significance level was set at (α ≤ 0.05). There was no significant difference among the groups in which all were biocompatible except of a significant death rate of 26.6% with nystatin 100%. In phase 1, it was found that after 7 days, there was no statistically significant difference among the prophylactic treatment groups. In phase 2, the groups of R. officinalis 6.25 mg/mL for 72 h and R. officinalis of 12.5 mg/mL for 24 h promoted the survival rate of the larvae in comparison with the control group with a significant difference (p = 0.017) and (p = 0.032) respectively. Therefore, R. officinalis extract is biocompatible in different concentrations and can be used as a prophylactic agent against fungal infection.
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13
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Molecular Mapping of Antifungal Mechanisms Accessing Biomaterials and New Agents to Target Oral Candidiasis. Int J Mol Sci 2022; 23:ijms23147520. [PMID: 35886869 PMCID: PMC9320712 DOI: 10.3390/ijms23147520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 02/04/2023] Open
Abstract
Oral candidiasis has a high rate of development, especially in immunocompromised patients. Immunosuppressive and cytotoxic therapies in hospitalized HIV and cancer patients are known to induce the poor management of adverse reactions, where local and systemic candidiasis become highly resistant to conventional antifungal therapy. The development of oral candidiasis is triggered by several mechanisms that determine oral epithelium imbalances, resulting in poor local defense and a delayed immune system response. As a result, pathogenic fungi colonies disseminate and form resistant biofilms, promoting serious challenges in initiating a proper therapeutic protocol. Hence, this study of the literature aimed to discuss possibilities and new trends through antifungal therapy for buccal drug administration. A large number of studies explored the antifungal activity of new agents or synergic components that may enhance the effect of classic drugs. It was of significant interest to find connections between smart biomaterials and their activity, to find molecular responses and mechanisms that can conquer the multidrug resistance of fungi strains, and to transpose them into a molecular map. Overall, attention is focused on the nanocolloids domain, nanoparticles, nanocomposite synthesis, and the design of polymeric platforms to satisfy sustained antifungal activity and high biocompatibility with the oral mucosa.
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14
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Beeraka NM, Zhou R, Wang X, Vikram P R H, Kumar TP, Liu J, Greeshma MV, Mandal SP, Gurupadayya BM, Fan R. Immune Repertoire and Advancements in Nanotherapeutics for the Impediment of Severe Steroid Resistant Asthma (SSR). Int J Nanomedicine 2022; 17:2121-2138. [PMID: 35592101 PMCID: PMC9112344 DOI: 10.2147/ijn.s364693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/17/2022] [Indexed: 11/28/2022] Open
Abstract
Severe steroid-resistant asthma (SSR) patients do not respond to the corticosteroid therapies due to the heterogeneity, and genome-wide variations. However, there are very limited reports pertinent to the molecular signaling underlying SSR and making pharmacologists, and formulation scientists to identify the effective therapeutic targets in order to produce novel therapies using novel drug delivery systems (NDDS). We have substantially searched literature for the peer-reviewed and published reports delineating the role of glucocorticoid-altered gene expression, and the mechanisms responsible for SSR asthma, and NDDS for treating SSR asthma using public databases PubMed, National Library of Medicine (NLM), google scholar, and medline. Subsequently, we described reports underlying the SSR pathophysiology through several immunological and inflammatory phenotypes. Furthermore, various therapeutic strategies and the role of signaling pathways such as mORC1-STAT3-FGFBP1, NLRP3 inflammasomes, miR-21/PI3K/HDAC2 axis, PI3K were delineated and these can be considered as the therapeutic targets for mitigating the pathophysiology of SSR asthma. Finally, the possibility of nanomedicine-based formulation and their applications in order to enhance the long term retention of several antioxidant and anti-asthmatic drug molecules as a significant therapeutic modality against SSR asthma was described vividly.
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Affiliation(s)
- Narasimha M Beeraka
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
- Department of Human Anatomy, Sechenov First Moscow State Medical University (Sechenov University), Moscow, 119991, Russia
- Center of Excellence in Molecular Biology and Regenerative Medicine (CEMR), Department of Biochemistry, JSS Academy of Higher Education and Research (JSS AHER), JSS Medical college, Mysuru, Karnataka, India
| | - Runze Zhou
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
| | - Xiaoyan Wang
- Endocrinology Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
| | - Hemanth Vikram P R
- Department of Pharmaceutical Chemistry, JSS College of Pharmacy, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, 570015, Karnataka, India
| | - Tegginamath Pramod Kumar
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research (JSSAHER), Mysore, Karnataka, 570015, India
| | - Junqi Liu
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
| | - M V Greeshma
- Center of Excellence in Molecular Biology and Regenerative Medicine (CEMR), Department of Biochemistry, JSS Academy of Higher Education and Research (JSS AHER), JSS Medical college, Mysuru, Karnataka, India
| | - Subhankar P Mandal
- Department of Pharmaceutical Chemistry, JSS College of Pharmacy, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, 570015, Karnataka, India
| | - B M Gurupadayya
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
| | - Ruitai Fan
- Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People’s Republic of China
- Correspondence: Ruitai Fan, Department of Radiation Oncology, Cancer Center, The First Affiliated Hospital of Zhengzhou University, 1 Jianshedong Str., Zhengzhou, 450052, People’s Republic of China, Email
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15
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Yebyo HG, Braun J, Menges D, Ter Riet G, Sadatsafavi M, Puhan MA. Personalising add-on treatment with inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a benefit-harm modelling study. LANCET DIGITAL HEALTH 2021; 3:e644-e653. [PMID: 34452874 DOI: 10.1016/s2589-7500(21)00130-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the benefit-harm balance of adding inhaled corticosteroids to long-acting β2-agonists (LABA) and long-acting muscarinic antagonists (LAMA) for patients with chronic obstructive pulmonary disease is unclear, we evaluated this addition for a range of patient profiles. METHODS Analyses considered the effects of low-to-moderate doses of inhaled corticosteroids, LABA, and LAMA compared with LABA and LAMA alone, outcome incidences, and preference weights assigned to averted moderate-to-severe exacerbations (benefit) and severe pneumonia, candidiasis, and dysphonia (harm). Using exponential models, we estimated the preference weight-adjusted 2-year net clinical benefit (ie, benefits outweighing harms) indices. Exacerbation risk thresholds for triggering inhaled corticosteroids, LABA, and LAMA were established when the probability of a 2-year net clinical benefit reached 60%. We estimated the proportion of patients benefiting from added inhaled corticosteroids using an externally validated prediction model for acute exacerbations in primary care. FINDINGS Adding low-to-moderate dose inhaled corticosteroids to LABA and LAMA provided a net clinical benefit in patients with a 2-year baseline exacerbation risk of 54-83%. Low-dose inhaled corticosteroids showed a net clinical benefit if the baseline risk was 40-91%, but not at higher doses. The benefit was modified by blood eosinophil count (BEC) and age. Although no net benefit was associated with a BEC of less than 150 cells per μL, patients with a BEC of 150 cells per μL or more had a net benefit from low-dose inhaled corticosteroids with a 2-year exacerbation risk of 32-95% in those aged 40-79 years and 41-93% in those older than 80 years. A moderate dose of inhaled corticosteroids showed a net benefit in patients younger than 80 years with a BEC of 150 cells per μL or more at 52-86% 2-year exacerbation risk. Depending on the subgroups, the proportion of patients with a net benefit from added inhaled corticosteroids ranged from 0 to 68%. INTERPRETATION The net clinical benefit of adding different inhaled corticosteroid doses to LABA and LAMA varies greatly with exacerbation risk, BEC, and age. Personalised treatment decisions based on these factors and predicted exacerbation risks might reduce overtreatment and undertreatment with inhaled corticosteroids. FUNDING None.
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Affiliation(s)
- Henock G Yebyo
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Julia Braun
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dominik Menges
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Gerben Ter Riet
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Urban Vitality Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Programme, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Milo A Puhan
- Department of Epidemiology, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland.
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16
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Miravitlles M, Auladell-Rispau A, Monteagudo M, Vázquez-Niebla JC, Mohammed J, Nuñez A, Urrútia G. Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD. Eur Respir Rev 2021; 30:30/160/210075. [PMID: 34168063 DOI: 10.1183/16000617.0075-2021] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/26/2021] [Indexed: 11/05/2022] Open
Abstract
Inhaled corticosteroids (ICSs) are indicated for the prevention of exacerbations in COPD; however, a significant proportion of patients at low risk of exacerbations are treated with ICSs. We conducted a systematic review including a diversity of types of study designs and safety outcomes with the objective of describing the risk of adverse effects associated with the long-term use of ICSs in patients with COPD.A total of 90 references corresponding to 83 studies were included, including 26 randomised clinical trials (RCTs), 33 cohort studies, and 24 nested case-control (NCC) studies. Analysis of 19 RCTs showed that exposure to ICSs for ≥1 year increased the risk of pneumonia by 41% (risk ratio 1.41, 95% CI 1.23-1.61). Additionally, cohort and NCC studies showed an association between ICSs and risk of tuberculosis and mycobacterial disease. There was a strong association between ICS use and local disorders such as oral candidiasis and dysphonia. The association between ICSs and the risk of diabetes and fractures was less clear and appeared significant only at high doses of ICSs.Since most patients with COPD are elderly and with frequent comorbidities, an adequate risk-benefit balance is crucial for the indication of ICSs.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Both authors contributed equally and are considered first authors
| | - Ariadna Auladell-Rispau
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Both authors contributed equally and are considered first authors
| | - Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Medicine Dept, Universitat Autònoma de Barcelona (UAB), Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Juan Carlos Vázquez-Niebla
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Alexa Nuñez
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard Urrútia
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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17
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Ming SWY, Haughney J, Ryan D, Small I, Lavorini F, Papi A, Singh D, Halpin DMG, Hurst JR, Patel S, Ochel M, Kocks J, Carter V, Hardjojo A, Price DB. A Comparison of the Real-Life Clinical Effectiveness of the Leading Licensed ICS/LABA Combination Inhalers in the Treatment for COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:3093-3103. [PMID: 33273812 PMCID: PMC7705280 DOI: 10.2147/copd.s263745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/26/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Fostair® 100/6 (BDP/FF) pressurized metered-dose inhaler, delivering an extrafine formulation, is licensed for asthma and COPD in the UK. However, its real-life effectiveness for COPD has not been evaluated. This study compared the clinical effectiveness of BDP/FF against other licensed ICS/LABA combination inhalers: the Seretide® Accuhaler® (FP/SAL) and the Symbicort® Turbohaler® (BUD/FF). Methods A matched historical cohort study was conducted using records of patients with diagnostic codes for COPD from the Optimum Patient Care Research Database (OPCRD). Patients who had received BDP/FF as their first ICS/LABA were matched 1:1 with patients who had received FP/SAL or BUD/FF, resulting in two matched comparisons. Additional analysis was conducted on patients who had never had diagnostic codes for asthma. Noninferiority in terms of the proportion of patients with moderate/severe COPD exacerbations on the different inhalers in the following year was assessed. Noninferiority was achieved if the upper CI limit were ≤1.2. Results This study included 537 and 540 patient pairs in the BDP/FF vs FP/SAL cohort and the BDP/FF vs BUD/FF cohort, respectively. The proportion of patients with COPD exacerbations in the BDP/FF group was not significantly different from either the FP/SAL (68.7% vs 70.2%, AOR 0.89, 95% CI 0.67–1.19) or BUD/FF group (68.5% vs 69.4%, AOR 0.79, 95% CI 0.58–1.08). Noninferiority of BDP/FF in preventing COPD exacerbations was fulfilled in both comparisons. In patients without asthma, BDP/FF was also noninferior to BUD/FF (proportion with COPD exacerbations, 67.8% vs 64.7%, AOR 0.79, 95% CI 0.51–1.1997). Additionally, a significantly lower proportion of patients prescribed BDP/FF had COPD exacerbations than FP/SAL (64.8% vs 73.7%, AOR 0.64 95% CI 0.43–0.96). Conclusion Initiating ICS/LABA treatment of COPD with extrafine-formulation BDP/FF was noninferior in preventing moderate/severe exacerbations compared to FP/SAL and BUD/FF.
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Affiliation(s)
| | - John Haughney
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | | | - Dave Singh
- University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | | | - Janwillem Kocks
- Observational and Pragmatic Research Institute, Singapore, Singapore.,General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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18
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Inhalation of sustained release microparticles for the targeted treatment of respiratory diseases. Drug Deliv Transl Res 2020; 10:339-353. [PMID: 31872342 DOI: 10.1007/s13346-019-00690-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delivering drugs through inhalation for systemic and local applications has been in practice since several decades to treat various diseases. In recent times, inhalation drug delivery is becoming one of the highly focused areas of research in the pharmaceutical industry. It is being considered as one of the major portals for delivering drugs because of its wide range of advantages like requirement of low concentrations of drug to reach therapeutic efficacy, surpassing first pass metabolism and a very low incidence of side effects as compared to conventional delivery of drugs. Owing to these favorable characteristics of pulmonary drug delivery, diverse pharmaceutical formulations like liposomes, nanoparticles, and microparticles are developed through consistent efforts for delivery drugs to lungs in suitable form. However, drug-loaded microparticles have displayed various advantages over the other pharmaceutical dosage forms which give a cutting edge over other inhalational drug delivery systems. Assuring results with respect to sustained release through inhalational delivery of drug-loaded microparticles from pre-clinical studies are anticipative of similar benefits in the clinical settings. This review centralizes partly on the advantages of inhalational microparticles over other inhalational dosage forms and largely on the therapeutic applications and future perspectives of inhalable microparticle drug delivery systems.
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19
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Kumari M, Kumar T, Rai S, Rai A, Sultana R, Priya L. Evaluation of Dental Health in Terminally Ill Patients. J Med Life 2020; 13:321-328. [PMID: 33072203 PMCID: PMC7550152 DOI: 10.25122/jml-2020-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Dental health plays an imperative role in the general health and well-being of an individual. Terminally ill patients due to a compromised immune response are susceptible to a wide array of oral complications, which may affect their ability to speak and chew, leading to malnutrition. The present study was conducted to evaluate dental health and various oral manifestations in terminally ill patients. One hundred twenty terminally ill patients hospitalized with diseases of the respiratory tract, gastrointestinal tract, circulatory system, liver, and endocrinal disorders were included in the study. The evaluation of oral manifestations and their prevalence was done by a single examiner. The oral health was evaluated according to symptoms exhibited by the patients and clinical presentation. Of the patients included in the study, 78 were male, and 42 were female. All the individuals were adults between 25 to 55 years of age. Out of 120 admitted terminally ill patients, 27 subjects had respiratory diseases, 17 had gastrointestinal disorders, 5 had disorders of the circulatory system, 39 had liver disorders, and 32 had endocrine disorders. A need for added comprehension is mandatory to link the inter-relationships between dentistry and medicine to further perk up the management of the overall health of patients, which will further reinforce the partnership between dental and medical communities.
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Affiliation(s)
- Minti Kumari
- Department of Public Health Dentistry, Patna Dental College and Hospital, Patna, India
| | - Tanoj Kumar
- Department of Oral Pathology and Microbiology, Patna Dental College and Hospital, Patna, India
| | - Shweta Rai
- Department of Oral and Maxillofacial Surgery, Buddha Institute of Dental Sciences and Hospital, Kankarbagh, Patna, India
| | - Anurag Rai
- Department of Orthodontics, Patna Dental College and Hospital, Bankipore, Patna, India
| | | | - Leena Priya
- Department of Oral Medicine And Radiology, Buddha Institute of Dental Science and Hospital, Patna, India
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20
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Joao I, Bujdáková H, Jordao L. Opportunist Coinfections by Nontuberculous Mycobacteria and Fungi in Immunocompromised Patients. Antibiotics (Basel) 2020; 9:E771. [PMID: 33147819 PMCID: PMC7693372 DOI: 10.3390/antibiotics9110771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/14/2022] Open
Abstract
Nontuberculous mycobacteria (NTM) and many fungal species (spp.) are commonly associated with opportunistic infections (OPIs) in immunocompromised individuals. Moreover, occurrence of concomitant infection by NTM (mainly spp. of Mycobacterium avium complex and Mycobacterium abscessus complex) and fungal spp. (mainly, Aspergillus fumigatus, Histoplasma capsulatum and Cryptococcus neoformans) is very challenging and is associated with poor patient prognosis. The most frequent clinical symptoms for coinfection and infection by single agents (fungi or NTM) are similar. For this reason, the accurate identification of the aetiological agent(s) is crucial to select the best treatment approach. Despite the significance of this topic it has not been sufficiently addressed in the literature. This review aims at summarizing case reports and studies on NTM and fungi coinfection during the last 20 years. In addition, it briefly characterizes OPIs and coinfection, describes key features of opportunistic pathogens (e.g., NTM and fungi) and human host predisposing conditions to OPIs onset and outcome. The review could interest a wide spectrum of audiences, including medical doctors and scientists, to improve awareness of these infections, leading to early identification in clinical settings and increasing research in the field. Improved diagnosis and availability of therapeutic options might contribute to improve the prognosis of patients' survival.
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Affiliation(s)
- Ines Joao
- National Institute of Health Doutor Ricardo Jorge, 1649-016 Lisboa, Portugal;
| | - Helena Bujdáková
- Department of Microbiology and Virology, Faculty of Natural Sciences, Comenius University in Bratislava, 842 15 Bratislava, Slovakia
| | - Luisa Jordao
- National Institute of Health Doutor Ricardo Jorge, 1649-016 Lisboa, Portugal;
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21
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Lombardi A, Ouanounou A. Fungal infections in dentistry: Clinical presentations, diagnosis, and treatment alternatives. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:533-546. [DOI: 10.1016/j.oooo.2020.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/17/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
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22
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Xu Y, Liu H, Song L. Novel drug delivery systems targeting oxidative stress in chronic obstructive pulmonary disease: a review. J Nanobiotechnology 2020; 18:145. [PMID: 33076918 PMCID: PMC7570055 DOI: 10.1186/s12951-020-00703-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
Oxidative stress is significantly involved in the pathogenesis and progression of chronic obstructive pulmonary disease (COPD). Combining antioxidant drugs or nutrients results in a noteworthy therapeutic value in animal models of COPD. However, the benefits have not been reproduced in clinical applications, this may be attributed to the limited absorption, concentration, and half-life of exogenous antioxidants. Therefore, novel drug delivery systems to combat oxidative stress in COPD are needed. This review presents a brief insight into the current knowledge on the role of oxidative stress and highlights the recent trends in novel drug delivery carriers that could aid in combating oxidative stress in COPD. The introduction of nanotechnology has enabled researchers to overcome several problems and improve the pharmacokinetics and bioavailability of drugs. Large porous microparticles, and porous nanoparticle-encapsulated microparticles are the most promising carriers for achieving effective pulmonary deposition of inhaled medication and obtaining controlled drug release. However, translating drug delivery systems for administration in pulmonary clinical settings is still in its initial phases.
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Affiliation(s)
- You Xu
- Department of Respiratory Medicine, Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun, 130061, People's Republic of China
- Department of Pharmacy, Faculty of Health & Medical Sciences, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Hongmei Liu
- Department of Respiratory Medicine, Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun, 130061, People's Republic of China
| | - Lei Song
- Department of Respiratory Medicine, Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun, 130061, People's Republic of China.
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Solidoro P, Patrucco F, Bagnasco D. Comparing a fixed combination of budesonide/formoterol with other inhaled corticosteroid plus long-acting beta-agonist combinations in patients with chronic obstructive pulmonary disease: a review. Expert Rev Respir Med 2019; 13:1087-1094. [DOI: 10.1080/17476348.2019.1665514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Paolo Solidoro
- Cardiovascular and Thoracic Department, SC Pneumologia U, Città della Salute e della Scienza (Molinette) University Hospital, Turin, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, Pneumology Unit U, University of Piemonte Orientale, Vercelli, Italy
| | - Diego Bagnasco
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, University of Genoa, Genoa, Italy
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Comparison of adverse events associated with different spacers used with non-extrafine beclometasone dipropionate for asthma. NPJ Prim Care Respir Med 2019; 29:3. [PMID: 30737400 PMCID: PMC6368625 DOI: 10.1038/s41533-019-0115-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 12/05/2018] [Indexed: 11/30/2022] Open
Abstract
Co-prescription of Aerochamber® spacer with non-extrafine beclometasone diproprionate (non-EF BDP) is common but unlicensed. We report a comparison of inhaled corticosteroid (ICS)-related adverse events between patients co-prescribed Aerochamber compared to the licensed Volumatic® spacer. We utilised two historical cohorts: questionnaire-based and electronic medical record (EMR)-based, to assess patient-reported and EMR-recorded adverse events in patients with asthma prescribed non-EF BDP. Marginal effect estimate (MEE) was calculated to determine non-inferiority of Aerochamber compared to Volumatic in terms of patient-reported oral thrush and hoarseness with margin of 0.13. Other patient-reported adverse events (sore throat, bruising, weight gain, and coughing), and EMR-recorded adverse events were also assessed. Rate of patient-reported oral adverse events were non-inferior in 385 patients prescribed Aerochamber compared to 155 patients prescribed Volumatic (27.7 vs 29.9%; MEE, −0.043; 95% CI, −0.133 to 0.047). Total patient-reported adverse events did not differ significantly between Aerochamber and Volumatic (53.3 vs 49.7% with ≥1 adverse event). The EMR-based study of 1471 matched pairs of subjects did not show significantly different number of EMR-recorded adverse events between Aerochamber and Volumatic (12.5 vs 12.8% with ≥1 adverse events). Co-prescribing Aerochamber with non-EF BDP does not increase the risk for patient-reported and EMR-recorded ICS-related adverse events compared to co-prescribing Volumatic. A study of spacer devices for use with asthma inhalers shows no significant difference in the incidence of side-effects between licensed and unlicensed spacers. Spacers offer a way of improving the dose inhaled, particularly in children and those adults who struggle to use asthma inhalers correctly. However, non-extrafine beclomethasone dipropionate (like Clenil Modulite) inhalers are frequently co-prescribed with unlicensed Aerochamber spacers rather than the Volumatic spacer which is licensed for this drug. David Price at the University of Aberdeen, UK, and co-workers analysed data from two historical studies to verify whether Aerochamber use enhanced the risk of unpleasant side effects for patients, such as oral thrush or hoarseness. They found no significant difference between licensed and unlicensed spacers and the chances of adverse events, suggesting both are suitable for use with non-extrafine beclomethasone dipropionate inhalers.
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Wittbrodt ET, Millette LA, Evans KA, Bonafede M, Tkacz J, Ferguson GT. Differences in health care outcomes between postdischarge COPD patients treated with inhaled corticosteroid/long-acting β 2-agonist via dry-powder inhalers and pressurized metered-dose inhalers. Int J Chron Obstruct Pulmon Dis 2019; 14:101-114. [PMID: 30613140 PMCID: PMC6307496 DOI: 10.2147/copd.s177213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose The aim of this study was to examine real-world differences in health care resource use (HRU) and costs among COPD patients in the USA treated with a dry powder inhaler (DPI) or pressurized metered-dose inhaler (pMDI) following a COPD-related hospitalization. Methods This retrospective analysis used the Truven MarketScan® databases. Eligibility criteria included 1) age ≥40 years, 2) COPD diagnosis, 3) inpatient admission with a diagnosis of COPD exacerbation, 4) inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) prescription within 10 days of hospital discharge (index date), and 5) continuous enrollment for 12 months preindex and 90 days postindex. Outcomes included pre- and postindex HRU and costs. DPI and pMDI groups were compared on postindex outcomes via multivariate models controlling for demographic and baseline characteristics. Results The sample included 1,960 DPI and 1,086 pMDI ICS/LABA patients. During the preindex period, pMDI patients were significantly more likely to be prescribed a short-acting β-agonist, experienced more COPD exacerbation-related hospital days, and had a greater number of pulmonologist visits compared to DPI patients (P<0.05), all suggestive of greater disease severity. However, multivariate models revealed that pMDI patients incurred 10% lower all-cause postindex costs (predicted mean costs [2016 US dollars]: $2,673 vs $2,956) and 19% lower COPD-related costs (predicted mean costs: $138 vs $169; P<0.05). Additionally, pMDI patients were 28% less likely to experience a COPD exacerbation-related hospital readmission within 60 days postdischarge compared to the DPI patients (OR: 0.72, 95% CI: 0.52–0.99, P<0.05). Conclusion Despite greater COPD-related HRU and costs preceding index hospitalization, US patients using a pMDI after hospital discharge incurred significantly lower all-cause and COPD-related health care costs compared with those using a DPI, in addition to a decreased likelihood of a COPD exacerbation-related hospital readmission. Results suggest that inhaler device type may influence COPD outcomes and that COPD patients may derive greater clinical benefit from treatment delivered via pMDI vs DPI.
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Affiliation(s)
| | | | - Kristin A Evans
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Machaon Bonafede
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Joseph Tkacz
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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Agusti A, Fabbri LM, Singh D, Vestbo J, Celli B, Franssen FME, Rabe KF, Papi A. Inhaled corticosteroids in COPD: friend or foe? Eur Respir J 2018; 52:13993003.01219-2018. [PMID: 30190269 DOI: 10.1183/13993003.01219-2018] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/23/2018] [Indexed: 12/28/2022]
Abstract
The efficacy, safety and positioning of inhaled corticosteroids (ICS) in the treatment of patients with chronic obstructive pulmonary disease (COPD) is much debated, since it can result in clear clinical benefits in some patients ("friend") but can be ineffective or even associated with undesired side effects, e.g. pneumonia, in others ("foe"). After critically reviewing the evidence for and against ICS treatment in patients with COPD, we propose that: 1) ICS should not be used as a single, stand-alone therapy in COPD; 2) patients most likely to benefit from the addition of ICS to long-acting bronchodilators include those with history of multiple or severe exacerbations despite appropriate maintenance bronchodilator use, particularly if blood eosinophils are >300 cells·µL-1, and those with a history of and/or concomitant asthma; and 3) the risk of pneumonia in COPD patients using ICS is higher in those with older age, lower body mass index (BMI), greater overall fragility, receiving higher ICS doses and those with blood eosinophils <100 cells·µL-1 All these factors must be carefully considered and balanced in any individual COPD patient before adding ICS to her/his maintenance bronchodilator treatment. Further research is needed to clarify some of these issues and firmly establish these recommendations.
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Affiliation(s)
- Alvar Agusti
- Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBER Enfermedades Respiratorias, Spain
| | - Leonardo M Fabbri
- Dept of Medicine, University of Ferrara, Ferrara, Italy.,COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,Medicines Evaluation Unit, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Bartolome Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frits M E Franssen
- Dept of Research and Education, CIRO, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Hospital, Maastricht, The Netherlands
| | - Klaus F Rabe
- LungenClinic Großhansdorf, member of the German Center for Lung Research (DZL), Großhansdorf, Germany.,Christian Albrechts Universität Kiel, member of the German Center for Lung Research (DZL), Kiel, Germany
| | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
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Paik J, Scott LJ, Pleasants RA. Fluticasone Propionate/Salmeterol MDPI (AirDuo RespiClick ®): A Review in Asthma. Clin Drug Investig 2018; 38:463-473. [PMID: 29582249 DOI: 10.1007/s40261-018-0644-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The novel, easy-to-use, breath-actuated fluticasone propionate/salmeterol multidose dry powder inhaler (MDPI) (AirDuo RespiClick®) was recently approved in the USA for twice-daily treatment of asthma in patients aged ≥ 12 years. This inhaled corticosteroid (ICS) and long-acting β2-adrenoreceptor agonist (LABA) combination treatment is available in low-, mid- and high-dosage formulations (55/14, 113/14 and 232/14 μg, respectively). In 12-week, phase III trials in patients aged ≥ 12 years with persistent asthma, all three dosages of fluticasone propionate/salmeterol MDPI treatment produced significant improvements in lung function and other asthma symptoms compared with fluticasone propionate MDPI monotherapy or placebo MDPI. In a 26-week, phase III trial in this patient population, mid- and high-dosage fluticasone propionate/salmeterol MDPI were noninferior to mid- (250/50 μg) and high- (500/50 μg) dosage fluticasone propionate/salmeterol DPI (Advair Diskus®), respectively, in terms of improvements in lung function. Treatment-emergent adverse events (TEAEs) with fluticasone propionate/salmeterol MDPI were mostly of mild to moderate severity, with no severe TEAEs deemed to be treatment related. Although long-term pharmacovigilance is required to fully establish its safety, given the ease of use and favorable characteristics of the device and its clinical efficacy at relatively low metered doses of the active moieties, fluticasone propionate/salmeterol MDPI is an important emerging treatment option in patients aged ≥ 12 years with asthma.
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Affiliation(s)
- Julia Paik
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Roy A Pleasants
- Duke Clinical Research Institute and Durham Veterans Administration Medical Center, Durham, NC, USA
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Meira HC, De Oliveira BM, Pereira IF, Naves MD, Mesquita RA, Santos VR. Oral candidiasis: A retrospective study of 276 Brazilian patients. J Oral Maxillofac Pathol 2018; 21:351-355. [PMID: 29391707 PMCID: PMC5763855 DOI: 10.4103/jomfp.jomfp_77_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Although oral candidiasis (OC) is a very common fungal infection of oral cavity, clinical features of affected patients and their demographic profile are not well documented. Objective The objective of the study was to assess the demographic profile of patients diagnosed with OC and its clinical features in an import Brazilian center of oral and maxillofacial pathology. Materials and Methods A retrospective study consisted of 276 patients diagnosed with OC by cytopathology Periodic Acid-Schiff (PAS) staining, during the period of 20 years. The variables related to patients were gender, age and skin color. Regarding infection, the data collected were location, color, symptoms, early manifestation, or recurrent and associated factors. Results Male and female were equally affected, and the median age was 43 years. The majority of lesions were of primitive origin, asymptomatic and affecting only one site of oral cavity. The most affected site was the palate followed by tongue. More than a half of the patients (56.2%) had red lesions. The main associated factors related were the use of removable prostheses, bone marrow transplantation and AIDS. Conclusions OC affects predominantly adults and elderly, without difference between sex and skin color. Although clinical findings are crucial, cytopathology tests are important complementary examinations to reach a definitive diagnosis. PAS staining seems to be more used in cases of erythematous candidiasis since white lesions are easier to diagnose clinically.
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Affiliation(s)
- Henrique Cortes Meira
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bruna Mascarenhas De Oliveira
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Igor Figueiredo Pereira
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Marcelo Drumond Naves
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ricardo Alves Mesquita
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Vagner Rodrigues Santos
- Department of Clinical, Pathology and Surgery, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Inhaled Corticosteroids and Systemic or Topical Antifungal Therapy: A Symmetry Analysis. Ann Am Thorac Soc 2017; 14:1045-1047. [DOI: 10.1513/annalsats.201612-1043le] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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