Corticosteroid Therapy in Asthma

The spectrum of therapeutic activity of mepolizumab

Introduction: The basis of the development of the anti-interleukin-5 monoclonal antibody mepolizumab was the acknowledgment of the crucial importance of this cytokine in promoting eosinophils production, activation, and survival, which is associated with the eosinophilic asthma phenotype, as well as with other disorders characterized by high levels of eosinophils. Areas covered: All the available literature on the outcomes treatment with mepolizumab in eosinophilic disorders are reviewed, including asthma, chronic rhinosinusitis, esophagitis, granulomatosis with polyangiitis, eosinophilic chronic obstructive pulmonary disease, hypereosinophilic syndrome, and allergic bronchopulmonary aspergillosis. Expert opinion: The efficacy of mepolizumab in eosinophilic asthma is clearly demonstrated by a number of controlled trials and by meta-analyses. Among other eosinophilic disorders, controlled trials are available for chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, and eosinophilic chronic obstructive pulmonary disease. Allergic bronchopulmonary aspergillosis, as well as other minor eosinophilic disorders, are backed only by case reports and are waiting controlled trials to verify the therapeutic role of mepolizumab.

iPSC- and mesenchymoangioblast-derived mesenchymal stem cells provide greater protection against experimental chronic allergic airways disease compared with a clinically used corticosteroid

The airway remodeling (AWR) associated with chronic allergic airways disease (AAD)/asthma contributes to irreversible airway obstruction. This study compared and combined the antiremodeling and other effects of induced pluripotent stem cell and mesenchymoangioblast-derived mesenchymal stem cells (MCA-MSCs) with the corticosteroid dexamethasone (Dex) in experimental chronic AAD/asthma. Female BALB/c mice subjected to 11 wk of ovalbumin (Ova)-induced chronic AAD were intranasally administered MCA-MSCs (1 × 10⁶ cells/mouse; once weekly on wk 10 and 11), Dex (0.5 mg/ml; once daily for 2 wk), or both combined. MCA-MSC detection and changes in airway inflammation (AI), AWR, and airway hyperresponsiveness (AHR) were measured at the end of wk 11. Mice with chronic AAD had significant AI, goblet cell metaplasia, epithelial damage/thickening, aberrant TGF-β1 levels, subepithelial myofibroblast accumulation, airway/lung fibrosis, and AHR (all P < 0.001 vs. healthy controls). MCA-MSCs were detected in the lungs up to 5-7 d postadministration and demonstrated modest anti-inflammatory but striking antifibrotic effects against Ova-induced AAD, effectively decreasing AHR by 70-75% (all P < 0.05 vs. Ova alone). In comparison, Dex predominantly demonstrated anti-inflammatory effects, decreasing AHR by ∼30%. Combining MCA-MSCs with Dex provided equivalent protection to that offered by either therapy alone. MCA-MSCs reduce chronic AAD-induced AWR and AHR to a greater extent than Dex and may act as a suitable adjunct therapy to corticosteroid treatment of asthma.-Royce, S. G., Mao, W., Lim, R., Kelly, K., Samuel, C. S. iPSC- and mesenchymoangioblast-derived mesenchymal stem cells provide greater protection against experimental chronic allergic airways disease compared with a clinically used corticosteroid.

Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit

OBJECTIVES

An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients.

METHODS

Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980-2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.

RESULTS

Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status.

CONCLUSIONS

Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.

Prostaglandin as a target molecule for pharmacotherapy of allergic inflammatory diseases

The purpose of this review is to summarize the role of prostaglandins (PGs) in allergic inflammation and to know the value of PGs, as a target molecule for an anti-allergic drug. PGD(2) is the major PG produced by the cyclooxygenase pathway in mast cells. Our and others findings indicate that PGD(2) is one of the potent allergic inflammatory mediators and must be a target molecule of anti-allergic agent. From our data, one of PGD(2) receptor antagonists show clear inhibition of airway hypersensitivity caused by allergic reaction. Concerning the role of PGE(2) in allergic inflammation, conflicting results have been reported. Many experimental data suggest an individual role of each PGE(2) receptor, EP(1), EP(2), EP(3) and EP(4) in allergic reaction. Our results indicate the protective action of PGE(2) on allergic reaction via EP(3). In addition, one of EP(3) agonists clearly inhibits the allergic airway inflammation. These findings indicate the value of EP(3) agonists as an anti-allergic agent. In addition, some investigators including us reported that PGI(2) plays an important role for the protection of the onset of allergic reaction. However, the efficacy of PGI(2) analogue as an anti-allergic agent is not yet fully investigated. Finally, the role of thromboxane A(2) (TxA(2)) in allergic reaction is discussed. Our experimental results suggest a different participation of TxA(2) in allergic reaction of airway and skin. In this review, the role of PGs in allergic inflammation is summarized and the value of PGs as a target molecule for developing a new anti-allergic agent will be discussed.

Complications associated with the use of corticosteroids in the treatment of athletic injuries

BACKGROUND

The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear.

OBJECTIVE

To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries.

DATA SOURCES

A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion.

STUDY SELECTION

For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy.

MAIN RESULTS

Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions.

CONCLUSIONS

This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

Intravenous versus oral corticosteroids for treatment of acute asthma exacerbations

OBJECTIVE

To compare the duration of hospitalization of patients treated with either oral or intravenous corticosteroids for an acute asthma exacerbation.

METHODS

A retrospective chart review was performed on a random sample of inpatients. Patients were included with the following: a discharge diagnosis of an acute asthma exacerbation, a past medical history significant for asthma, age between 16 and 60 years, and treatment with either oral or intravenous corticosteroids at the time of admission. Exclusion criteria included: patients receiving chronic prednisone therapy, a past medical history significant for chronic obstructive pulmonary disease, an admission to the intensive care unit, or a consistent smoking habit of at least 1 pack daily. Length of hospitalization was the primary outcome measured. Secondary outcomes included 24-hour peak expiratory flow rate, 24-hour pulse oximetry (pO(2)), and amount of beta-agonist and ipratropium used.

RESULTS

Fifty-three patients were included in the final data analysis. Patients were grouped by route of corticosteroid administration (intravenous or oral). No significant differences were noted between the 2 groups for race, gender, age, height, weight, admission peak expiratory flow rate, admission pO(2), or types of asthma medications used prior to admission. No significant differences were demonstrated in any of the outcome measures.

CONCLUSIONS

Both the intravenous and oral corticosteroid groups demonstrated similar clinical outcomes and lengths of hospitalization in the treatment of acute asthma exacerbations. These results support the initial use of oral corticosteroids for the treatment of acute asthma exacerbations in adult patients admitted to a general medical service.

Emergency physician practice and steroid use in the management of acute exacerbations of asthma

This study seeks to determine patterns of emergency physician (EP) practice regarding steroid use in the management of acute asthma attacks in the emergency department (ED), and to compare practices of academic and private practice EPs. Two hundred eight questionnaires were mailed to academic and private practice EPs. The survey requested information regarding the preferred initial route (oral or intravenous) for steroid administration; the initial dose of steroid; the preferred steroid regimen for outpatient management; and whether or not inhaled steroids were routinely prescribed at the time of discharge. The overall response rate was 74%; 91% for the academic EPs and 56% for private practice EPs. Sixty-five percent (99/143) of all EPs used the intravenous route for their initial dose of steroids. A significantly greater percentage of private practice EPs (45/58 or 78%) used intravenous steroids compared with academic EPs (54/95 or 57%; P = .009). A total of 41% (63/153) of EPs used a tapering steroid regime for outpatient therapy; a significantly greater percentage (34/58 or 59%; P = .0006) of private practice EPs used a tapering regimen of steroids compared with academic EPs (29/95 or 31%). A total of 32%(31) academic and 34% (20) private practice EPs prescribed inhaled steroids as part of their routine discharge instructions. Emergency physician practice patterns regarding initial steroid route of administration and dose, and outpatient-dosing regimens are variable. Only a minority of EPs prescribe steroid metered dose inhalers as part of their outpatient management of asthma.

Status asthmaticus in children: a review

About 10% of American children have asthma, and its prevalence, morbidity, and mortality have been increasing. Asthma is an inflammatory disease with edema, bronchial constriction, and mucous plugging. Status asthmaticus in children requires aggressive treatment with beta-agonists, anticholinergics, and corticosteroids. Intubation and mechanical ventilation should be avoided if at all possible, as the underlying dynamic hyperinflation will worsen with positive-pressure ventilation. If mechanical ventilation becomes necessary, controlled hypoventilation with low tidal volume and long expiratory time may lessen the risk of barotrauma and hypotension. Unusual and nonestablished therapies for severe asthma are discussed.

The effect of different corticosteroids and cyclosporin A on interleukin-4 and interleukin-5 release from murine TH2-type T cells

By secretion of interleukin-4 and interleukin-5, TH2-type T cells are thought to play an important role in the pathogenesis of asthma. Corticosteroids are currently the most effective therapy available for asthma, but recently it has been demonstrated that cyclosporin A improves lung function in patients with severe corticosteroid-dependent asthma. In order to examine the effects of corticosteroids and cyclosporin A on anti-CD3-induced production of interleukin-4 and interleukin-5 we used the murine TH2-type cell clone D10.G4.1. Interleukin-4/interleukin-5 release was inhibited by all drugs tested with the following IC50 values (nmol/l) for interleukin-4 and interleukin-5, respectively: budesonide (0.32/0.22), beclomethasone (0.65/0.33), dexamethasone (4.70/3.52), 6 alpha-methyl-prednisolone (24.04/17.02), hydrocortisone (34.27/22.55), and cyclosporin A (72.59/242.21). In conclusion, corticosteroids exert strong inhibitory effects on cytokine production by TH2-cells, which may explain, at least partly, its clinical efficacy in asthma. Cyclosporin A also showed a concentration-dependent inhibition; however, in relation to corticosteroids the inhibitory activity of cyclosporin A was found to be weaker.

Preoperative evaluation of children

Preoperative evaluation and preparation are directed toward minimizing the intrinsic risks of anesthesia and surgery by having the child in the healthiest possible condition prior to surgery. The pediatrician can contribute to this goal by understanding the effects of general anesthesia on the physiology of children. This knowledge allows an appreciation of the anesthesiologists' concerns regarding underlying diseases, which may seem "stable" (and, therefore, of little present concern to the pediatrician) but which may have grave consequences during anesthesia. The preoperative evaluation is designed to ensure that the child's preoperative needs may be met by providing the anesthesiologist both qualitative and quantitative information regarding the child's state of health and disease. The relationship between the child, parents, and pediatrician places the pediatrician in an ideal position to prepare families for their children's surgical experience.

Risk of osteoporosis in men with chronic bronchitis

Theoretically, patients with chronic bronchitis are at risk for osteoporosis. Bone metabolism was assessed in 44 male chronic bronchitics treated with oral prednisolone (C+; n = 19) or with bronchodilatory drugs alone (C-; n = 25). In both groups, serum osteocalcin was lower (p less than 0.001) than in age- and sex-matched controls (mean (ng/ml) C+ 1.0, C- 1.9, controls 4.2), while testosterone was at the lower limit of the reference range. Low trabecular bone mineral density (BMD) was noted in the C- group (median Z score -1.0), but both cortical and trabecular BMD were depressed in the C+ group (-1.0 and -1.4, respectively). In conclusion, chronic bronchitics treated with corticosteroids, even at low doses, are at risk for osteoporosis. In both groups, additional factors such as hypogonadism might be responsible for low BMD and low osteocalcin levels. A decrease in bone formation is a possible mechanism of action.

Steroid dose sparing: pharmacodynamic responses to single versus divided doses of methylprednisolone in man

Inhibitory drug interactions affecting the metabolism of methylprednisolone (MP) may produce either steroid sparing or adverse effects partly by increasing the exposure time to the steroid. This phenomenon can be mimicked by administering MP in divided doses. Two types of responses were compared after a single MP dose (40 mg bolus) and a divided regimen (20 mg bolus and a 5 mg bolus 8 hours later) in six healthy male volunteers. The suppression of basophils measured as whole blood histamine and plasma cortisol concentrations was assessed during 32 hours. The 37.5% reduction in dose produced a 23% overall decreased blood histamine response. A pharmacodynamic model for basophil cell distribution to and from an extravascular compartment describes the effects of MP after both regimens. A slower initial decline in blood histamine after the divided regimen may be related to incomplete suppression of basophil cell return to blood. The 50% inhibitory concentrations of MP of about 5 ng/ml were similar for both regimens. The decline and return of cortisol concentrations were similar between MP treatments with suppression continuing for 24 hours. The 50% inhibitory concentrations of MP values for adrenal suppression were about 1 ng/ml. Pharmacodynamic modeling is useful in quantitating corticosteroid responses and generally predicted the "dose-sparing" effects that were achieved by prolonging MP plasma concentrations. This study supports previous clinical observations that patients may require morning through evening exposure to MP to optimize efficacy while adrenal suppression is being minimized.

Lower airway obstruction in the PICU

Lower airway obstruction is one of the most frequent causes of admission to pediatric intensive care unit. A thorough understanding of the pathophysiology underlying the disease will lead to effective management and decreased mortality and morbidity.

Minimal complications in a surgical population with severe asthma receiving prophylactic corticosteroids

Sixty-eight patients with asthma followed by the Northwestern Allergy Service underwent a total of 92 surgical procedures from July 1973 to December 1986. In 41 of 92 procedures outpatient prednisone was administered, and in 92 procedures a pretreatment regimen of 100 mg hydrocortisone parenterally every 8 hours beginning the night before surgery was administered. Postoperatively, the overall incidence of pulmonary complications (either pulmonary infection or asthma) was 9.7%. Three patients developed pneumonia, demonstrated by an infiltrate on chest x-ray examination, and two patients developed wheezing requiring epinephrine, giving a complication rate of 5.4%. In addition, four patients developed mild wheezing postoperatively. Statistical analyses to compare the overall infection rate in this asthmatic population with that in two other surgical populations showed no statistical differences. There were no deaths and no patient developed any wound complication or adrenocortical insufficiency. These results indicate that patients with asthma in optimal respiratory condition who have received preoperative clinical evaluation and a hydrocortisone pretreatment regimen can undergo surgery with minimal complications.

Comparison of the oral and intravenous routes for treating asthma with methylprednisolone and theophylline

To compare intravenous and orally administered corticosteroids and theophylline in treating acute episodes of airways obstruction, patients with recent worsening of obstructive symptoms were randomly divided into two groups. Group A received methylprednisolone, 80 mg/24 h, and aminophylline by continuous infusion. Group B received a comparable dose of a sustained-release theophylline and methylprednisolone, 80 mg in two equally divided doses, by mouth. Assessment of response was based on daily spirometric tests and evaluation of dyspnea and wheezing. Arterial blood gas and serum theophylline levels were also measured. The groups were comparable with respect to age, sex distribution, smoking history, and spirometric evidence of obstruction. Initial spirometric test results showed moderate obstruction, equal in the two groups. Obstruction improved markedly by both spirometric and clinical criteria in the four-day study period. The improvement in FEV1 and dyspnea index was slightly greater for group B, but the differences were not significant. We conclude that oral administration of steroids and theophylline is as effective as intravenous use in treating hospitalized patients with moderate exacerbations of airways obstruction.

Comparison between high and moderate doses of hydrocortisone in the treatment of status asthmaticus

In a group of 40 adult patients in status asthmaticus, the responses to two different dosages of hydrocortisone were studied. All patients received a uniform treatment and were sequentially assigned to one of the following two groups: high dosage of hydrocortisone (80 mg/kg/day); or moderate dosage (6 mg/kg/day). The hydrocortisone was given intravenously in divided doses every six hours. The study lasted five days, and forced spirometry was performed daily at noon. The condition of all of the patients improved gradually, and when comparing both groups, no statistically significant differences were found in their spirometric measurements. We did not find any difference in the reversal of airway obstruction in the treatment of status asthmaticus by using a high dosage of hydrocortisone when compared with a lower moderate one.