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Tran DT, Chen Y, Zheng Y, Hecker J, Hawcutt DB, Pirmohamed M, Lasky‐Su J, Wu AC, Tantisira KG, McGeachie MJ, Weiss ST, Dahlin A. Urine metabolomics signature reveals novel determinants of adrenal suppression in children taking inhaled corticosteroids to control asthma symptoms. Immun Inflamm Dis 2024; 12:e1315. [PMID: 39031511 PMCID: PMC11259003 DOI: 10.1002/iid3.1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Asthma is routinely treated with inhaled corticosteroids (ICS). Asthma patients on ICS are at increased risk of adrenal suppression, a potentially serious effect of long-term glucocorticoid exposure; however, this relationship is poorly understood. Therefore, this study aims to identify metabolite biomarkers related to adrenal suppression in asthma patients taking ICS. METHODS A total of 571 urine metabolites from 200 children with asthma on ICS in the Pharmacogenetics of Adrenal Suppression with Inhaled Steroids (PASS) cohort were profiled. Samples were grouped by peak plasma cortisol measurement as adrenal sufficient (>350 nmol/L) or insufficient (≤350 nmol/L) (outcome). Regression and discriminant-based statistical models combined with network analyses were utilized to assess relationships between metabolites and the outcome. Finally, prioritized metabolites were validated using data from an ancillary study of the Childhood Asthma Management (CAMP) cohort with similar characteristics to PASS. RESULTS Ninety metabolites were significantly associated with adrenal suppression, of which 57 also could discriminate adrenal status. While 26 metabolites (primarily steroids) were present at lower levels in the adrenal insufficient patients, 14 were significantly elevated in this group; the top metabolite, mannitol/sorbitol, was previously associated with asthma exacerbations. Network analyses identified unique clusters of metabolites related to steroids, fatty acid oxidation, and nucleoside metabolism, respectively. Four metabolites including urocanic acid, acetylcarnitine, uracil, and sorbitol were validated in CAMP cohort for adrenal suppression. CONCLUSIONS Urinary metabolites differ among asthma patients on ICS, by adrenal status. While steroid metabolites were reduced in patients with poor adrenal function, our findings also implicate previously unreported metabolites involved in amino acid, lipid, and nucleoside metabolism.
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Affiliation(s)
- Dung T. Tran
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yulu Chen
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yi Zheng
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Julian Hecker
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Jessica Lasky‐Su
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Ann C. Wu
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMassachusettsUSA
| | - Kelan G. Tantisira
- Division of Pediatric Respiratory MedicineUniversity of California San Diego and Rady Children's HospitalSan DiegoCaliforniaUSA
| | - Michael J. McGeachie
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Scott T. Weiss
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Amber Dahlin
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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Singh R, Jadhav K, Kamboj R, Malhotra H, Ray E, Jhilta A, Dhir V, Verma RK. Self-actuating inflammation responsive hydrogel microsphere formulation for controlled drug release in rheumatoid arthritis (RA): Animal trials and study in human fibroblast like synoviocytes (hFLS) of RA patients. BIOMATERIALS ADVANCES 2024; 160:213853. [PMID: 38636119 DOI: 10.1016/j.bioadv.2024.213853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 03/23/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
Patients with rheumatoid arthritis (RA) often have one or more painfuljoints despite adequate medicine. Local drug delivery to the synovial cavity bids for high drug concentration with minimal systemic adverse effects. However, anti-RA drugs show short half-lives in inflamed joints after intra-articular delivery. To improve the therapeutic efficacy, it is essential to ensure that a drug is only released from the formulation when it is needed. In this work, we developed an intelligent "Self-actuating" drug delivery system where Disease-modifying anti-rheumatic Drug (DMARD) methotrexate is incorporated within a matrix intended to be injected directly into joints. This formulation has the property to sense the need and release medication only when joints are inflamed in response to inflammatory enzyme Matrix metalloproteinases (MMP). These enzymes are important proteases in RA pathology, and several MMP are present in augmented levels in synovial fluid and tissues. A high level of MMP present in synovial tissues of RA patients would facilitate the release of drugs in response and ascertain controlled drug release. The formulation is designed to be stable within the joint environment, but to dis-assemble in response to inflammation. The synthesized enzyme-responsive methotrexate (Mtx) encapsulated micron-sized polymer-lipid hybrid hydrogel microspheres (Mtx-PLHM) was physiochemically characterized and tested in synovial fluid, Human Fibroblast like synoviocytes (h-FLS) (derived from RA patients) and a rat arthritic animal model. Mtx-PLHM can self-actuate and augment the release of Mtx drug upon contact with either exogenously added MMP or endogenous MMP present in the synovial fluid of patients with RA. The drug release from the prepared formulation is significantly amplified to several folds in the presence of MMP-2 and MMP-9 enzymes. In the rat arthritic model, Mtx-PLHM showed promising therapeutic results with the significant alleviation of RA symptoms through decrease in joint inflammation, swelling, bone erosion, and joint damage examined by X-ray analysis, histopathology and immune-histology. This drug delivery system would be nontoxic as it releases more drug only during the period of exacerbation of inflammation. This will simultaneously protect patients from unwanted side effects when the disease is inactive and lower the need for repeated joint injections.
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Affiliation(s)
- Raghuraj Singh
- Institute of Nano Science and Technology (INST), Sector 81. Mohali, Punjab 140306, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh 201002, India
| | - Krishna Jadhav
- Institute of Nano Science and Technology (INST), Sector 81. Mohali, Punjab 140306, India
| | - Rohit Kamboj
- Guru Gobind Singh College of Pharmacy, Yamuna Nagar, Haryana 135001, India
| | - Hitesh Malhotra
- Guru Gobind Singh College of Pharmacy, Yamuna Nagar, Haryana 135001, India
| | - Eupa Ray
- Institute of Nano Science and Technology (INST), Sector 81. Mohali, Punjab 140306, India
| | - Agrim Jhilta
- Institute of Nano Science and Technology (INST), Sector 81. Mohali, Punjab 140306, India
| | - Varun Dhir
- Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh 160012, India
| | - Rahul Kumar Verma
- Institute of Nano Science and Technology (INST), Sector 81. Mohali, Punjab 140306, India.
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Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A. Diagnosis and management of secondary adrenal crisis. Rev Endocr Metab Disord 2024; 25:619-637. [PMID: 38411891 DOI: 10.1007/s11154-024-09877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 02/28/2024]
Abstract
Adrenal crisis (AC) is a life threatening acute adrenal insufficiency (AI) episode which can occur in patients with primary AI but also secondary AI (SAI), tertiary AI (TAI) and iatrogenic AI (IAI). In SAI, TAI and IAI, AC may develop when the HPA axis is unable to mount an adequate glucocorticoid response to severe stress due to pituitary or hypothalamic disruption. It manifests as an acute deterioration in multi-organ homeostasis that, if untreated, leads to shock and death. Despite the availability of effective preventive strategies, its prevalence is increasing in patients with SAI, TAI and IAI due to more frequent exogenous steroid administration, pituitary immune-related effects of immune checkpoint inhibitors and opioid use in pain management. The delayed diagnosis of acute AI which remains infrequently suspected increases the risk of AC. Its main precipitating factors are infections, emotional distress, surgery, cessation or reduction in GC doses, pituitary infarction or surgical cure of endogenous Cushing's syndrome. In patients not known previously to have SAI/TAI/IAI, recognition of its symptoms, signs, and biochemical abnormalities can be challenging and cause delay in proper diagnosis and therapy. Effective therapy of AC is rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h) and 0.9% saline. In diagnosed patients, preventive education in sick-day rules adjustment of glucocorticoid replacement and hydrocortisone parenteral self-administration must be performed repeatedly by trained health care providers. Strategies to improve the adequate preventive education in patients at risk for secondary AI should be promoted in collaboration with various medical specialist societies and patients support associations.
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Affiliation(s)
- Luciana Martel-Duguech
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada.
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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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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Moll M, Silverman EK. Precision Approaches to Chronic Obstructive Pulmonary Disease Management. Annu Rev Med 2024; 75:247-262. [PMID: 37827193 DOI: 10.1146/annurev-med-060622-101239] [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] [Indexed: 10/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD heterogeneity has hampered progress in developing pharmacotherapies that affect disease progression. This issue can be addressed by precision medicine approaches, which focus on understanding an individual's disease risk, and tailoring management based on pathobiology, environmental exposures, and psychosocial issues. There is an urgent need to identify COPD patients at high risk for poor outcomes and to understand at a mechanistic level why certain individuals are at high risk. Genetics, omics, and network analytic techniques have started to dissect COPD heterogeneity and identify patients with specific pathobiology. Drug repurposing approaches based on biomarkers of specific inflammatory processes (i.e., type 2 inflammation) are promising. As larger data sets, additional omics, and new analytical approaches become available, there will be enormous opportunities to identify high-risk individuals and treat COPD patients based on their specific pathophysiological derangements. These approaches show great promise for risk stratification, early intervention, drug repurposing, and developing novel therapeutic approaches for COPD.
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Affiliation(s)
- Matthew Moll
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care, Sleep and Allergy, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin K Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Silva BRC, Tyler MA, Ma Y, Wang J, Nayak JV, Patel ZM, Hwang PH. Incidence of hypocortisolism with long-term budesonide irrigation for chronic rhinosinusitis. Int Forum Allergy Rhinol 2024; 14:78-85. [PMID: 37389470 DOI: 10.1002/alr.23227] [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: 04/18/2023] [Revised: 06/05/2023] [Accepted: 06/28/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Budesonide irrigations (BIs) are commonly used to control inflammation in chronic rhinosinusitis (CRS). In 2016 we reported an analysis of long-term BI with regard to hypothalamic-pituitary-adrenal axis function. We present a follow-up analysis in a larger cohort of patients with longer follow-up. METHODS Patients were candidates for stimulated cortisol testing after regularly performing BI for CRS at least daily for ≥6 months. We retrospectively evaluated all patients who received stimulated cortisol testing at our center between 2012 and 2022. We correlated cortisol levels with the use of BI and other forms of corticosteroids. RESULTS We analyzed 401 cortisol test results in 285 patients. The mean duration of use was 34 months. Overall, 21.8% of patients were hypocortisolemic (<18 ug/dL) at first test. In patients who used only BI, the rate of hypocortisolemia was 7.5%, whereas in patients who also used concurrent oral and inhaled corticosteroids, the rate was 40% to 50%. Lower cortisol levels were associated with male sex (p < 0.0001) and concomitant use of oral and inhaled steroids (p < 0.0001). Duration of BI use was not significantly associated with lower cortisol levels (p = 0.701), nor was greater dosing frequency (p = 0.289). CONCLUSION Prolonged use of BI alone is not likely to cause hypocortisolemia in the majority of patients. However, concomitant use of inhaled and oral steroids and male sex may be associated with hypocortisolemia. Surveillance of cortisol levels may be considered in vulnerable populations who use BI regularly, particularly in patients using other forms of corticosteroids with known systemic absorption.
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Affiliation(s)
- Bruna R C Silva
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yifei Ma
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jane Wang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jayakar V Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zara M Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter H Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Fortin-Boudreault RP, Ahmet A, Lawrence S, Schlosser MP, Bassal M. Adrenal Suppression in Children During the Treatment for Acute Lymphoblastic Leukemia Beyond Induction. J Pediatr Hematol Oncol 2024; 46:46-50. [PMID: 37938058 DOI: 10.1097/mph.0000000000002784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/08/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Adrenal suppression (AS) is an iatrogenic, life-threatening condition that can occur after glucocorticoid exposure. Despite recognition that AS occurs after induction phase treatment in children with acute lymphoblastic leukemia (ALL), the risk of AS in phases beyond induction is unknown. We conducted a pilot study in pediatric patients with ALL to ascertain whether the risk of AS persists in post-induction phases of treatment. PROCEDURE Patients diagnosed between 12 months to younger than 18 years with B or T-ALL and starting any new phase of treatment were eligible for the study. Relapsed or infant ALL were excluded. Low dose ACTH stimulation testing (LDST), measurement of albumin and cortisol binding globulin were performed in all patients. Screening for symptoms of AS was done. RESULTS Twenty-four patients enrolled in the study. One was diagnosed with clear AS. Five others had a borderline cortisol peak, representing possible mild AS. Symptoms were nonspecific and did not help distinguish patients with normal LDST from those with borderline or abnormal results. CONCLUSION Patients on treatment for ALL continue to be at risk of AS beyond induction treatment. Although this risk appears small, physicians must be vigilant as patients may be asymptomatic but could develop adrenal crisis during treatment.
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Affiliation(s)
| | - Alexandra Ahmet
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sarah Lawrence
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Mary-Pat Schlosser
- Division of Pediatric Immunology/Allergy, Hematology/Oncology, Palliative Care and Environmental Health, Stollery Children's Hospital, Edmonton, AB, Canada
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Nistel M, Furuta GT, Pan Z, Hsu S. Impact of Dose Reduction of Topical Steroids to Manage Adrenal Insufficiency in Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 76:786-792. [PMID: 36306502 PMCID: PMC10147844 DOI: 10.1097/mpg.0000000000003647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the impact of type and dose of swallowed topical steroids (STS) and concurrent steroid therapy on the development and resolution of adrenal insufficiency (AI) in pediatric eosinophilic esophagitis (EoE). METHODS We performed a retrospective case-control study of pediatric EoE subjects in a single tertiary care center, who were treated with STS for at least 3 months and diagnosed with AI based on a peak stimulated cortisol level of <18 µg/dL (500 nmol/L). Steroid forms and doses, and endoscopy data were collected at the time of AI diagnosis and AI resolution or the last known evaluation. Steroid formulations were converted to a fluticasone-equivalent dose for analysis. RESULTS Thirty-two EoE subjects with AI were identified, and 20 had AI resolution, including 12 who remained on lower dose STS. Eight of the 32 patients were also treated with extended-release budesonide (ER budesonide), which resulted in a 7-fold higher total daily steroid dose, and thus were analyzed separately. When the 24 cases that were not on ER budesonide were compared to the 81 controls, no difference was found in the STS dose nor total daily steroid dose, although the inhaled steroid dose had marginal significance. Peak eosinophil counts tended to increase when STS doses were decreased, except in subjects on ER budesonide at AI diagnosis. CONCLUSION Altering the total daily steroid regimen can lead to resolution of AI in patients with EoE, though this may come at the expense of disease control.
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Affiliation(s)
- Mason Nistel
- Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
| | - Zhaoxing Pan
- Gastrointestinal Eosinophilic Disease Program, University of Colorado School of Medicine, Aurora, CO
- Biostatistics Core of the Children’s Hospital Colorado Research Institute, Aurora, CO
| | - Stephanie Hsu
- Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO
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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Abstract
Inter-individual variability in drug response, be it efficacy or safety, is common and likely to become an increasing problem globally given the growing elderly population requiring treatment. Reasons for this inter-individual variability include genomic factors, an area of study called pharmacogenomics. With genotyping technologies now widely available and decreasing in cost, implementing pharmacogenomics into clinical practice - widely regarded as one of the initial steps in mainstreaming genomic medicine - is currently a focus in many countries worldwide. However, major challenges of implementation lie at the point of delivery into health-care systems, including the modification of current clinical pathways coupled with a massive knowledge gap in pharmacogenomics in the health-care workforce. Pharmacogenomics can also be used in a broader sense for drug discovery and development, with increasing evidence suggesting that genomically defined targets have an increased success rate during clinical development.
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Parry CM, Chan LF, Carr DF, Hawcutt DB. Platelet-derived growth factor D expression in adrenal cells is modulated by corticosteroids: putative role in adrenal suppression. Pediatr Res 2023; 93:97-101. [PMID: 35568735 PMCID: PMC9876782 DOI: 10.1038/s41390-022-02094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/15/2022] [Accepted: 04/10/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adrenal suppression is a clinically concerning side effect of inhaled corticosteroid (ICS) treatment in patients with asthma. Increased susceptibility to ICS-induced adrenal suppression has previously been identified in those with the rs591118 polymorphism in platelet-derived growth factor D (PDGFD). The mechanism underpinning this relationship is not known. METHODS H295R cells were genotyped for rs591118 using a validated Taqman PCR allelic discrimination assay. H295R cell viability was determined after treatment with beclometasone and fluticasone (range 0-330 μM). Cortisol was measured in cell culture medium using competitive enzyme immunoassay. RESULTS PDGFD protein expression in H295R cells was confirmed using Western blotting. When ACTH and forskolin were added to H295R cells, a reduction in PDGFD expression was seen, which was then restored by incubation with prochloraz, a known inhibitor of steroidogenesis. A dose-dependent, decrease in PDGFD expression was observed with beclometasone (over a 24 h incubation period) but not with beclometasone incubations beyond 24 h nor with fluticasone (at 24 or 48 h). CONCLUSIONS H295R cells express PDGFD protein, which can be modulated by incubation with steroidogenesis agonists and antagonists and additionally with exogenous beclometasone. IMPACT PDGFD is expressed in the human adrenal cell line, H295R, and expression can be modulated by beclometasone as well as agonists/antagonists of steroidogenesis. This builds on previous research that identified a SNP in PDGFD (rs591118) as an independent risk factor for adrenal suppression in adults and children with obstructive airway disease treated with inhaled corticosteroids. First in vitro experiments to support a link between the PDGF and cortisol production pathways, supporting the hypothesis that PDGFD variants can affect an individual's sensitivity to corticosteroid-induced adrenal suppression.
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Affiliation(s)
- Christopher M. Parry
- NIHR Alder Hey Clinical Research Facility, Liverpool, UK ,grid.10025.360000 0004 1936 8470Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Li F. Chan
- grid.4868.20000 0001 2171 1133Centre for Endocrinology, Queen Mary University of London, London, UK
| | - Daniel F. Carr
- grid.10025.360000 0004 1936 8470Department of Pharmacology and Therapeutics, Institute of Molecular, Systems and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Daniel B. Hawcutt
- NIHR Alder Hey Clinical Research Facility, Liverpool, UK ,grid.10025.360000 0004 1936 8470Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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13
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Khan S, Ouaalaya EH, Chamberlain JD, Dufourg MN, Charles MA, Semjen CR. The external validation of the asthma prediction tool in the French ELFE cohort. Pediatr Pulmonol 2022; 57:2696-2706. [PMID: 35927215 DOI: 10.1002/ppul.26085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/13/2022] [Accepted: 07/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Existing predictive scores for early identification of children at high risk of developing asthma include invasive procedures, and hence have limited utility in a primary care setting. The Leicestershire respiratory cohort (LRC) has developed a noninvasive asthma prediction tool (APT) for children with promising results. We aimed to perform its external validation in the French general population Étude Longitudinale Française depuis l'Enfance (ELFE) cohort. METHODS Predictive scores were determined at Age 1 and the primary outcome of asthma was defined as parental reporting of "asthma ever or "wheezing in the past 12 months" at Age 5. Logistic regression was used to calculate the odds ratio (OR) and performance measures, and discriminative performance was reported using the receiver operating curve and area under curve (AUC). Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and visualized with a calibration plot. Overall performance was determined using Brier scores. RESULTS Of the 10,689 children analyzed: 84.9% were at low, 13.1% medium, and 2% at high risk of developing asthma at Age 5. Children in the medium-risk category were three times more likely to develop asthma (OR = 3.3, 95% confidence interval [CI] = 2.97-3.78) whereas 13 times more likely in the high-risk category (OR = 13.8, 95% CI = 10.2-18.8). The tool's AUC was comparable: LRC 0.74 versus ELFE 0.68; as were the Brier scores LRC 0.16 versus ELFE 0.14. The tool's performance was robust to changes in inclusion criteria and outcome definitions. CONCLUSIONS AND RELEVANCE Results of the present study and previous validation studies performed in high-risk populations provide a comprehensive measure of the effectiveness of the APT, providing encouragement for its application by general practitioners.
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Affiliation(s)
- Sadia Khan
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
| | - El Hassane Ouaalaya
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
| | - Jonviea D Chamberlain
- Bordeaux Population Health Research Center, Inserm UMR 1219, University of Bordeaux, Bordeaux, France.,CIC1401-EC, Inserm, Bordeaux, France
| | | | | | - Chantal R Semjen
- Bordeaux Population Health Research Center, EPICENE Team, INSERM, UMR 1219, Bordeaux University, Bordeaux, France
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14
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Radzikowska U, Baerenfaller K, Cornejo‐Garcia JA, Karaaslan C, Barletta E, Sarac BE, Zhakparov D, Villaseñor A, Eguiluz‐Gracia I, Mayorga C, Sokolowska M, Barbas C, Barber D, Ollert M, Chivato T, Agache I, Escribese MM. Omics technologies in allergy and asthma research: An EAACI position paper. Allergy 2022; 77:2888-2908. [PMID: 35713644 PMCID: PMC9796060 DOI: 10.1111/all.15412] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/30/2022] [Accepted: 06/06/2022] [Indexed: 01/27/2023]
Abstract
Allergic diseases and asthma are heterogenous chronic inflammatory conditions with several distinct complex endotypes. Both environmental and genetic factors can influence the development and progression of allergy. Complex pathogenetic pathways observed in allergic disorders present a challenge in patient management and successful targeted treatment strategies. The increasing availability of high-throughput omics technologies, such as genomics, epigenomics, transcriptomics, proteomics, and metabolomics allows studying biochemical systems and pathophysiological processes underlying allergic responses. Additionally, omics techniques present clinical applicability by functional identification and validation of biomarkers. Therefore, finding molecules or patterns characteristic for distinct immune-inflammatory endotypes, can subsequently influence its development, progression, and treatment. There is a great potential to further increase the effectiveness of single omics approaches by integrating them with other omics, and nonomics data. Systems biology aims to simultaneously and longitudinally understand multiple layers of a complex and multifactorial disease, such as allergy, or asthma by integrating several, separated data sets and generating a complete molecular profile of the condition. With the use of sophisticated biostatistics and machine learning techniques, these approaches provide in-depth insight into individual biological systems and will allow efficient and customized healthcare approaches, called precision medicine. In this EAACI Position Paper, the Task Force "Omics technologies in allergic research" broadly reviewed current advances and applicability of omics techniques in allergic diseases and asthma research, with a focus on methodology and data analysis, aiming to provide researchers (basic and clinical) with a desk reference in the field. The potential of omics strategies in understanding disease pathophysiology and key tools to reach unmet needs in allergy precision medicine, such as successful patients' stratification, accurate disease prognosis, and prediction of treatment efficacy and successful prevention measures are highlighted.
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Affiliation(s)
- Urszula Radzikowska
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland,Christine‐Kühne Center for Allergy Research and Education (CK‐CARE)DavosSwitzerland
| | - Katja Baerenfaller
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland,Swiss Institute of Bioinformatics (SIB)DavosSwitzerland
| | - José Antonio Cornejo‐Garcia
- Research LaboratoryIBIMA, ARADyAL Instituto de Salud Carlos III, Regional University Hospital of Málaga, UMAMálagaSpain
| | - Cagatay Karaaslan
- Department of Biology, Molecular Biology SectionFaculty of ScienceHacettepe UniversityAnkaraTurkey
| | - Elena Barletta
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland,Swiss Institute of Bioinformatics (SIB)DavosSwitzerland
| | - Basak Ezgi Sarac
- Department of Biology, Molecular Biology SectionFaculty of ScienceHacettepe UniversityAnkaraTurkey
| | - Damir Zhakparov
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland,Swiss Institute of Bioinformatics (SIB)DavosSwitzerland
| | - Alma Villaseñor
- Centre for Metabolomics and Bioanalysis (CEMBIO)Department of Chemistry and BiochemistryFacultad de FarmaciaUniversidad San Pablo‐CEU, CEU UniversitiesMadridSpain,Institute of Applied Molecular Medicine Nemesio Diaz (IMMAND)Department of Basic Medical SciencesFacultad de MedicinaUniversidad San Pablo CEU, CEU UniversitiesMadridSpain
| | - Ibon Eguiluz‐Gracia
- Allergy UnitHospital Regional Universitario de MálagaMálagaSpain,Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain
| | - Cristobalina Mayorga
- Allergy UnitHospital Regional Universitario de MálagaMálagaSpain,Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain,Andalusian Centre for Nanomedicine and Biotechnology – BIONANDMálagaSpain
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland,Christine‐Kühne Center for Allergy Research and Education (CK‐CARE)DavosSwitzerland
| | - Coral Barbas
- Centre for Metabolomics and Bioanalysis (CEMBIO)Department of Chemistry and BiochemistryFacultad de FarmaciaUniversidad San Pablo‐CEU, CEU UniversitiesMadridSpain
| | - Domingo Barber
- Institute of Applied Molecular Medicine Nemesio Diaz (IMMAND)Department of Basic Medical SciencesFacultad de MedicinaUniversidad San Pablo CEU, CEU UniversitiesMadridSpain
| | - Markus Ollert
- Department of Infection and ImmunityLuxembourg Institute of HealthyEsch‐sur‐AlzetteLuxembourg,Department of Dermatology and Allergy CenterOdense Research Center for AnaphylaxisOdense University Hospital, University of Southern DenmarkOdenseDenmark
| | - Tomas Chivato
- Institute of Applied Molecular Medicine Nemesio Diaz (IMMAND)Department of Basic Medical SciencesFacultad de MedicinaUniversidad San Pablo CEU, CEU UniversitiesMadridSpain,Department of Clinic Medical SciencesFacultad de MedicinaUniversidad San Pablo CEU, CEU UniversitiesMadridSpain
| | | | - Maria M. Escribese
- Institute of Applied Molecular Medicine Nemesio Diaz (IMMAND)Department of Basic Medical SciencesFacultad de MedicinaUniversidad San Pablo CEU, CEU UniversitiesMadridSpain
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15
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Borresen SW, Klose M, Glintborg D, Watt T, Andersen MS, Feldt-Rasmussen U. Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2022; 107:2065-2076. [PMID: 35302603 DOI: 10.1210/clinem/dgac151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 11/19/2022]
Abstract
Glucocorticoid-induced adrenal insufficiency is caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis and is the most prevalent form of adrenal insufficiency. The condition is important to diagnose given the risk of life-threatening adrenal crisis and impact on patients' quality of life. The diagnosis is made with a stimulation test such as the ACTH test. Until now, testing for glucocorticoid-induced adrenal insufficiency has often been based on clinical suspicion rather than routinely but accumulating evidence indicates that a significant number of cases will remain unrecognized. During ongoing oral glucocorticoid treatment or initially after withdrawal, ~50% of patients have adrenal insufficiency, but, outside clinical studies, ≤ 1% of patients have adrenal testing recorded. More than 70% of cases are identified during acute hospital admission, where the diagnosis can easily be missed because symptoms of adrenal insufficiency are nonspecific and overlap those of the underlying and intercurrent conditions. Treatment of severe glucocorticoid-induced adrenal insufficiency should follow the principles for treatment of central adrenal insufficiency. The clinical implications and thus indication to treat mild-moderate adrenal deficiency after glucocorticoid withdrawal has not been established. Also, the indication of adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear. In patients with established glucocorticoid-induced adrenal insufficiency, high rates of poor confidence in self-management and delayed glucocorticoid administration in the acute setting with an imminent adrenal crisis call for improved awareness and education of clinicians and patients. This article reviews different facets of glucocorticoid-induced adrenal insufficiency and discusses approaches to the condition in common clinical situations.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Torquil Watt
- Department of Endocrinology and Internal Medicine, Herlev and Gentofte Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marianne Skovsager Andersen
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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16
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van Nijnatten J, Brandsma CA, Steiling K, Hiemstra PS, Timens W, van den Berge M, Faiz A. High miR203a-3p and miR-375 expression in the airways of smokers with and without COPD. Sci Rep 2022; 12:5610. [PMID: 35379844 PMCID: PMC8980043 DOI: 10.1038/s41598-022-09093-0] [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: 08/11/2021] [Accepted: 02/02/2022] [Indexed: 11/21/2022] Open
Abstract
Smoking is a leading cause of chronic obstructive pulmonary disease (COPD). It is known to have a significant impact on gene expression and (inflammatory) cell populations in the airways involved in COPD pathogenesis. In this study, we investigated the impact of smoking on the expression of miRNAs in healthy and COPD individuals. We aimed to elucidate the overall smoking-induced miRNA changes and those specific to COPD. In addition, we investigated the downstream effects on regulatory gene expression and the correlation to cellular composition. We performed a genome-wide miRNA expression analysis on a dataset of 40 current- and 22 ex-smoking COPD patients and a dataset of 35 current- and 38 non-smoking respiratory healthy controls and validated the results in an independent dataset. miRNA expression was then correlated with mRNA expression in the same patients to assess potential regulatory effects of the miRNAs. Finally, cellular deconvolution analysis was used to relate miRNAs changes to specific cell populations. Current smoking was associated with increased expression of three miRNAs in the COPD patients and 18 miRNAs in the asymptomatic smokers compared to respiratory healthy controls. In comparison, four miRNAs were lower expressed with current smoking in asymptomatic controls. Two of the three smoking-related miRNAs in COPD, miR-203a-3p and miR-375, were also higher expressed with current smoking in COPD patients and the asymptomatic controls. The other smoking-related miRNA in COPD patients, i.e. miR-31-3p, was not present in the respiratory healthy control dataset. miRNA-mRNA correlations demonstrated that miR-203a-3p, miR-375 and also miR-31-3p expression were negatively associated with genes involved in pro-inflammatory pathways and positively associated with genes involved in the xenobiotic pathway. Cellular deconvolution showed that higher levels of miR-203a-3p were associated with higher proportions of proliferating-basal cells and secretory (club and goblet) cells and lower levels of fibroblasts, luminal macrophages, endothelial cells, B-cells, amongst other cell types. MiR-375 expression was associated with lower levels of secretory cells, ionocytes and submucosal cells, but higher levels of endothelial cells, smooth muscle cells, and mast cells, amongst other cell types. In conclusion, we identified two smoking-induced miRNAs (miR-375 and miR-203a-3p) that play a role in regulating inflammation and detoxification pathways, regardless of the presence or absence of COPD. Additionally, in patients with COPD, we identified miR-31-3p as a miRNA induced by smoking. Our identified miRNAs should be studied further to unravel which smoking-induced inflammatory mechanisms are reactive and which are involved in COPD pathogenesis.
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17
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Parry CM, Seddon G, Rogers N, Sinha IP, Bracken L, King C, Peak M, Hawcutt DB. Pharmacogenomics and asthma treatment: acceptability to children, families and healthcare professionals. Arch Dis Child 2022; 107:394-399. [PMID: 35074833 DOI: 10.1136/archdischild-2021-322396] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence supporting personalised treatment for asthma based on an individual's genetics is mounting. The views of children and young people (CYP), parents and healthcare professionals (HCPs) about this evolution of clinical care are not known. METHODS A pilot prospective questionnaire-based study was undertaken of CYP with asthma, their parents and HCPs at a secondary/tertiary children's hospital in the UK. RESULTS Fifty-nine questionnaires were distributed and 50 returned (response rate 84.7%), comprising 26 CYP (10 were 5-11 years, 11 were 12-15 years and 5 were 16-18 years old), 13 parents and 11 HCPs. For all types of data, personal information was ranked as the 'most important' (n=19, 47.5%) and 'most private' (n=16, 40%), but with considerable variation across groups. Within health data, allergies were rated as 'most important' (n=12, 30.8%), and mental health records the 'most private' (n=21, 53.8%), again with variation across groups. A 'personalised genetic asthma plan' was acceptable to the majority overall (n=40, 80.0%). With regard to sharing CYP's genetic data, 23 (46%) of participants were happy for unconditional sharing between HCPs, and 23 (46%) agreed to sharing solely in relation to the CYP's asthma management. Forty-two (84.0%) of participants felt CYP should be informed about genetic data being shared, and the majority felt this should commence by 12 years of age. CONCLUSION The use of genetic information to guide management of asthma in CYP is largely acceptable to CYP, parents/guardians and HCPs. However, there are key differences between the opinions of CYP, parents and HCPs.
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Affiliation(s)
- Christopher Mark Parry
- Department of Research, NIHR Alder Hey Clinical Research Facility, Liverpool, UK.,Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Gabrielle Seddon
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Naomi Rogers
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Ian P Sinha
- Department of Respiratory Medicine, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Louise Bracken
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Charlotte King
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Research and Development, NIHR Alder Hey Clinical Research Facility, Liverpool, UK
| | - Daniel B Hawcutt
- Department of Research, NIHR Alder Hey Clinical Research Facility, Liverpool, UK .,Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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18
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Kachroo P, Stewart ID, Kelly RS, Stav M, Mendez K, Dahlin A, Soeteman DI, Chu SH, Huang M, Cote M, Knihtilä HM, Lee-Sarwar K, McGeachie M, Wang A, Wu AC, Virkud Y, Zhang P, Wareham NJ, Karlson EW, Wheelock CE, Clish C, Weiss ST, Langenberg C, Lasky-Su JA. Metabolomic profiling reveals extensive adrenal suppression due to inhaled corticosteroid therapy in asthma. Nat Med 2022; 28:814-822. [PMID: 35314841 PMCID: PMC9350737 DOI: 10.1038/s41591-022-01714-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 01/24/2022] [Indexed: 02/02/2023]
Abstract
The application of large-scale metabolomic profiling provides new opportunities for realizing the potential of omics-based precision medicine for asthma. By leveraging data from over 14,000 individuals in four distinct cohorts, this study identifies and independently replicates 17 steroid metabolites whose levels were significantly reduced in individuals with prevalent asthma. Although steroid levels were reduced among all asthma cases regardless of medication use, the largest reductions were associated with inhaled corticosteroid (ICS) treatment, as confirmed in a 4-year low-dose ICS clinical trial. Effects of ICS treatment on steroid levels were dose dependent; however, significant reductions also occurred with low-dose ICS treatment. Using information from electronic medical records, we found that cortisol levels were substantially reduced throughout the entire 24-hour daily period in patients with asthma who were treated with ICS compared to those who were untreated and to patients without asthma. Moreover, patients with asthma who were treated with ICS showed significant increases in fatigue and anemia as compared to those without ICS treatment. Adrenal suppression in patients with asthma treated with ICS might, therefore, represent a larger public health problem than previously recognized. Regular cortisol monitoring of patients with asthma treated with ICS is needed to provide the optimal balance between minimizing adverse effects of adrenal suppression while capitalizing on the established benefits of ICS treatment.
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Affiliation(s)
- Priyadarshini Kachroo
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Rachel S Kelly
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Meryl Stav
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kevin Mendez
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Amber Dahlin
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Djøra I Soeteman
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Su H Chu
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mengna Huang
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Margaret Cote
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hanna M Knihtilä
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Kathleen Lee-Sarwar
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael McGeachie
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alberta Wang
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ann Chen Wu
- Harvard Pilgrim Health Care Institute and Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Yamini Virkud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Pei Zhang
- Gunma University Initiative for Advanced Research (GIAR), Gunma University, Maebashi, Japan
- Department of Medical Biochemistry and Biophysics, Division of Physiological Chemistry 2, Karolinska Institute, Stockholm, Sweden
| | | | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Craig E Wheelock
- Gunma University Initiative for Advanced Research (GIAR), Gunma University, Maebashi, Japan
- Department of Medical Biochemistry and Biophysics, Division of Physiological Chemistry 2, Karolinska Institute, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | | | - Scott T Weiss
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Claudia Langenberg
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Computational Medicine, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica A Lasky-Su
- Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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19
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Inhaled corticosteroid use for asthma is linked to adrenal suppression. Nat Med 2022; 28:645-646. [PMID: 35314845 DOI: 10.1038/s41591-022-01732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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20
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Sivapalan P, Borresen SW, Eklöf J, Klose M, Holm FS, Feldt-Rasmussen U, Rossing M, Jørgensen NR, Marvig RL, Saeed MI, Wilcke T, Seersholm N, Mathioudakis AG, Vestbo J, Jensen JUS. Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: Role of specific glucocorticoid receptor polymorphisms. PLoS One 2022; 17:e0262898. [PMID: 35120172 PMCID: PMC8815987 DOI: 10.1371/journal.pone.0262898] [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: 03/04/2021] [Accepted: 01/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Single-nucleotide polymorphisms (SNPs) of the glucocorticoid receptor (GR) gene NR3C1 have been associated with an altered sensitivity to glucocorticoids, and thus may alter the therapeutic effects of glucocorticoids. We investigated the prevalence of adrenal suppression after treatment with glucocorticoids and evaluated whether GR SNPs were associated with altered risks of adrenal suppression and metabolic disorders in patients with chronic obstructive pulmonary disease (COPD). Methods In an observational prospective cohort study, we recruited 78 patients with severe COPD receiving 5 days glucocorticoid treatment for an exacerbation of COPD. In total, 55% of these patients were also receiving regular inhaled corticosteroids (ICS). Adrenal function was evaluated with a corticotropin test 30 days after the exacerbation. Patients were genotyped for Bcl1, N363S, ER22/23EK, and 9β SNPs. Results The prevalence of adrenal suppression (corticotropin-stimulated plasma-cortisol ≤ 420 nmol/L) 30 days after glucocorticoid treatment was 4/78 (5%). There was no difference between carriers and non-carriers of the polymorphisms (Bcl1, 9β, ER22/23K, and N363S) in corticotropin stimulated plasma-cortisol concentrations. In the haplotype analyses, we included the 50 patients who had a high-sensitivity (76%), a low-sensitivity (4%), or a wild-type (20%) GR haplotype. There was no difference in the frequency of adrenal suppression or metabolic disorders between the two stratified groups: (a) high-sensitivity (Bcl1 and/or N363S) haplotypes vs. (b) low-sensitivity (9β and/or ER22/23K) plus wild-type haplotypes (p > 0.05). Carriers of the high-sensitivity GR gene haplotype exhibited a steeper decline in stimulated P-cortisol with increased ICS dose (slope, –1.35 vs. 0.94; p = 0.17), compared to the group with low-sensitivity or wild-type haplotypes, respectively. Conclusions In total, 5% of patients exhibited insufficient adrenal function. The Bcl1 and N363S polymorphisms did not seem to increase the risk of glucocorticoid suppression or metabolic disorders in adults treated with glucocorticoids for COPD exacerbations.
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Affiliation(s)
- Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Internal Medicine, Zealand Hospital, University of Copenhagen, Roskilde, Denmark
- * E-mail:
| | - Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
| | - Josefin Eklöf
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
| | - Freja S. Holm
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria Rossing
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niklas R. Jørgensen
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Rasmus L. Marvig
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mohamad Isam Saeed
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Torgny Wilcke
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Niels Seersholm
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jens-Ulrik Stæhr Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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21
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Kunøe A, Sevelsted A, Chawes BLK, Stokholm J, Krakauer M, Bønnelykke K, Bisgaard H. Height and bone mineral content after inhaled corticosteroid use in the first 6 years of life. Thorax 2022; 77:745-751. [PMID: 35046091 DOI: 10.1136/thoraxjnl-2020-216755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 12/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Infants and young children might be particularly susceptible to the potential side effects from inhaled corticosteroid (ICS) on height and bone mineral content (BMC), but this has rarely been studied in long-term prospective studies. METHODS Children from two Copenhagen Prospective Studies on Asthma in Childhood cohorts were included. ICS use was registered prospectively from birth to age 6 and the cumulative dose was calculated. Primary outcomes were height and BMC from dual-energy X-ray absorptiometry (DXA) scans at age 6. RESULTS At age 6, a total of 930 children (84%) from the cohorts had a valid height measurement and 792 (71%) had a DXA scan. 291 children (31%) received a cumulated ICS dose equivalent to or above 10 weeks of standard treatment before age 6. We found an inverse association between ICS use and height, -0.26 cm (95% CI: -0.45 to -0.07) per 1 year standard treatment from 0 to 6 years of age, p=0.006. This effect was mainly driven by children with ongoing treatment between age 5 and 6 years (-0.31 cm (95% CI: -0.52 to -0.1), p=0.004), while there was no significant association in children who stopped treatment at least 1 year before age 6 (-0.09 cm (95% CI: -0.46 to 0.28), p=0.64). There was no association between ICS use and BMC at age 6. CONCLUSIONS ICS use in early childhood was associated with reduced height at age 6 years but only in children with continued treatment in the sixth year of life.
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Affiliation(s)
- Asja Kunøe
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Astrid Sevelsted
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Bo L K Chawes
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Department of Pediatrics, Næstved Hospital, Næstved, Denmark
| | - Martin Krakauer
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, Gentofte, Denmark.,Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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22
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Laulhé M, Dumaine C, Chevenne D, Leye F, Faye A, Dozières B, Strullu M, Viala J, Hogan J, Houdouin V, Léger J, Simon D, Carel JC, Storey C, Guilmin-Crépon S, Martinerie L. Glucocorticoid induced adrenal insufficiency in children: Morning cortisol values to avoid LDSST. Front Pediatr 2022; 10:981765. [PMID: 36589156 PMCID: PMC9798323 DOI: 10.3389/fped.2022.981765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Glucocorticoid-induced adrenal insufficiency (GI-AI) is a common side effect of glucocorticoid therapy. However, its diagnosis currently relies on the realization of a Low Dose Short Synacthen Test (LD-SST) that requires an outpatient hospital and several blood samples. Our goal was to evaluate whether morning cortisol values could predict the response to LD-SST, in children, to avoid useless dynamic tests and facilitate diagnosis of glucocorticoid induced adrenal insufficiency. STUDY DESIGN We recorded data of 91 pediatric patients who underwent a LD-SST in our center between 2016 and 2020 in a retrospective observational study. We selected LD-SST realized following administration of supra-physiologic doses of glucocorticoids during more than 3 weeks and performed at least four weeks after treatment was stopped. Adrenal deficiency was defined as a plasma cortisol concentration inferior to 500 nmol/l at LD-SST. RESULTS Glucocorticoid-induced adrenal insufficiency was diagnosed in 60% of our cohort. Morning cortisol values were predictive of the response to the LD-SST (AUC ROC 0.78). A plasma cortisol concentration of less than 144 nmol/l predicted glucocorticoid induced adrenal insufficiency with a specificity of 94% and a value over 317 nmol/l predicted recovery of the HPA axis with a sensitivity of 95%. We did not find any other predictive factor for glucocorticoid-induced adrenal insufficiency. CONCLUSIONS Morning cortisol values can safely assess recovery of the HPA axis in children treated chronically with glucocorticoids. Using these thresholds, more than 50% of LD-SST could be avoided in children.
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Affiliation(s)
- Margaux Laulhé
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Cécile Dumaine
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Didier Chevenne
- Biochemistry Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Fallou Leye
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Albert Faye
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Blandine Dozières
- Pediatric Neurology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Marion Strullu
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Hematology and Immunology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Jérome Viala
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Gastroenterology and Hepatology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Julien Hogan
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Nephrology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Véronique Houdouin
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Pulmonology and Allergology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Juliane Léger
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Dominique Simon
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Jean-Claude Carel
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France.,Université Paris Cité, Inserm 1141, NeuroDiderot, Paris, France
| | - Caroline Storey
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Sophie Guilmin-Crépon
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Laetitia Martinerie
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.,UFR Médecine, Université Paris Cité, Paris, France
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23
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Ahmet A, Rowan-Legg A, Pancer L. Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity. Paediatr Child Health 2021; 26:242-254. [PMID: 34630779 DOI: 10.1093/pch/pxab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.
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Affiliation(s)
- Alexandra Ahmet
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Anne Rowan-Legg
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Larry Pancer
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
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24
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Karimi L, Vijverberg SJ, Engelkes M, Hernandez-Pacheco N, Farzan N, Soares P, Pino-Yanes M, Jorgensen AL, Eng C, Mukhopadhyay S, Schieck M, Kabesch M, Burchard EG, Chew FT, Sio YY, Potočnik U, Gorenjak M, Hawcutt DB, Palmer CN, Turner S, Janssens HM, Maitland-van der Zee AH, Verhamme KM. ADRB2 haplotypes and asthma exacerbations in children and young adults: An individual participant data meta-analysis. Clin Exp Allergy 2021; 51:1157-1171. [PMID: 34128573 PMCID: PMC8503671 DOI: 10.1111/cea.13965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The polymorphism Arg16 in β2 -adrenergic receptor (ADRB2) gene has been associated with an increased risk of exacerbations in asthmatic children treated with long-acting β2 -agonists (LABA). However, it remains unclear whether this increased risk is mainly attributed to this single variant or the combined effect of the haplotypes of polymorphisms at codons 16 and 27. OBJECTIVE We assessed whether the haplotype analysis could explain the association between the polymorphisms at codons 16 (Arg16Gly) and 27 (Gln27Glu) in ADRB2 and risk of asthma exacerbations in patients treated with inhaled corticosteroids (ICS) plus LABA. METHODS The study was undertaken using data from 10 independent studies (n = 5903) participating in the multi-ethnic Pharmacogenomics in Childhood Asthma (PiCA) consortium. Asthma exacerbations were defined as asthma-related use of oral corticosteroids or hospitalizations/emergency department visits in the past 6 or 12 months prior to the study visit/enrolment. The association between the haplotypes and the risk of asthma exacerbations was performed per study using haplo.stats package adjusted for age and sex. Results were meta-analysed using the inverse variance weighting method assuming random-effects. RESULTS In subjects treated with ICS and LABA (n = 832, age: 3-21 years), Arg16/Gln27 versus Gly16/Glu27 (OR: 1.40, 95% CI: 1.05-1.87, I2 = 0.0%) and Arg16/Gln27 versus Gly16/Gln27 (OR: 1.43, 95% CI: 1.05-1.94, I2 = 0.0%), but not Gly16/Gln27 versus Gly16/Glu27 (OR: 0.99, 95% CI: 0.71-1.39, I2 = 0.0%), were significantly associated with an increased risk of asthma exacerbations. The sensitivity analyses indicated no significant association between the ADRB2 haplotypes and asthma exacerbations in the other treatment categories, namely as-required short-acting β2 -agonists (n = 973), ICS monotherapy (n = 2623), ICS plus leukotriene receptor antagonists (LTRA; n = 338), or ICS plus LABA plus LTRA (n = 686). CONCLUSION AND CLINICAL RELEVANCE The ADRB2 Arg16 haplotype, presumably mainly driven by the Arg16, increased the risk of asthma exacerbations in patients treated with ICS plus LABA. This finding could be beneficial in ADRB2 genotype-guided treatment which might improve clinical outcomes in asthmatic patients.
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Affiliation(s)
- Leila Karimi
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Susanne J. Vijverberg
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Marjolein Engelkes
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Natalia Hernandez-Pacheco
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
| | - Niloufar Farzan
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Patricia Soares
- Academic department of Pediatrics, Brighton & Sussex Medical School, Royal Alexandra Children’s Hospital, Brighton, United Kingdom
| | - Maria Pino-Yanes
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Andrea L. Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Celeste Eng
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States
| | - Somnath Mukhopadhyay
- Academic department of Pediatrics, Brighton & Sussex Medical School, Royal Alexandra Children’s Hospital, Brighton, United Kingdom
| | - Maximilian Schieck
- Department of Pediatric Pneumology and Allergy, University Children’s Hospital Regensburg (KUNO), Regensburg, Germany
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Michael Kabesch
- Department of Pediatric Pneumology and Allergy, University Children’s Hospital Regensburg (KUNO), Regensburg, Germany
| | - Esteban G. Burchard
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, United States
| | - Fook Tim Chew
- Department of Biological Science, National University of Singapore, Singapore
| | - Yang Yie Sio
- Department of Biological Science, National University of Singapore, Singapore
| | - Uroš Potočnik
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Laboratory for Biochemistry, Molecular Biology and Genomics, Faculty of Chemistry and Chemical Engineering, University of Maribor, Maribor, Slovenia
| | - Mario Gorenjak
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Daniel B. Hawcutt
- University of Liverpool and Alder Hey Children’s Hospital, members of Liverpool Health Partners, Liverpool, UK
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children’s Hospital, Liverpool, UK
| | - Colin N. Palmer
- Division of Cardiovascular and Diabetes Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Steve Turner
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Hettie M. Janssens
- Department of Pediatrics/division Respiratory Medicine and Allergology Erasmus MC/Sophia Children’s Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anke H. Maitland-van der Zee
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Katia M.C. Verhamme
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Bioanalysis, Ghent University, Ghent, Belgium
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25
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Slob EMA, Richards LB, Vijverberg SJH, Longo C, Koppelman GH, Pijnenburg MWH, Bel EHD, Neerincx AH, Herrera Luis E, Perez-Garcia J, Tim Chew F, Yie Sio Y, Andiappan AK, Turner SW, Mukhopadhyay S, Palmer CNA, Hawcutt D, Jorgensen AL, Burchard EG, Hernandez-Pacheco N, Pino-Yanes M, Maitland-van der Zee AH. Genome-wide association studies of exacerbations in children using long-acting beta2-agonists. Pediatr Allergy Immunol 2021; 32:1197-1207. [PMID: 33706416 PMCID: PMC8328929 DOI: 10.1111/pai.13494] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Some children with asthma experience exacerbations despite long-acting beta2-agonist (LABA) treatment. While this variability is partly caused by genetic variation, no genome-wide study until now has investigated which genetic factors associated with risk of exacerbations despite LABA use in children with asthma. We aimed to assess whether genetic variation was associated with exacerbations in children treated with LABA from a global consortium. METHODS A meta-analysis of genome-wide association studies (meta-GWAS) was performed in 1,425 children and young adults with asthma (age 6-21 years) with reported regular use of LABA from six studies within the PiCA consortium using a random effects model. The primary outcome of each study was defined as any exacerbation within the past 6 or 12 months, including at least one of the following: 1) hospital admissions for asthma, 2) a course of oral corticosteroids or 3) emergency room visits because of asthma. RESULTS Genome-wide association results for a total of 82 996 common single nucleotide polymorphisms (SNPs, MAF ≥1%) with high imputation quality were meta-analysed. Eight independent variants were suggestively (P-value threshold ≤5 × 10-6 ) associated with exacerbations despite LABA use. CONCLUSION No strong effects of single nucleotide polymorphisms (SNPs) on exacerbations during LABA use were identified. We identified two loci (TBX3 and EPHA7) that were previously implicated in the response to short-acting beta2-agonists (SABA). These loci merit further investigation in response to LABA and SABA use.
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Affiliation(s)
- Elise M A Slob
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Pediatric Respiratory Medicine, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - Levi B Richards
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne J H Vijverberg
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Pediatric Respiratory Medicine, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Cristina Longo
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard H Koppelman
- Department of Paediatric, Pulmonology & Paediatric Allergology, University Medical Center Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, The Netherlands.,University Medical Center Groningen, Groningen Research Institute for Asthma & COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Mariëlle W H Pijnenburg
- Division of Respiratory Medicine and Allergology, Department of Paediatrics, Erasmus MC - Sophia, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisabeth H D Bel
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne H Neerincx
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Esther Herrera Luis
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Javier Perez-Garcia
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Fook Tim Chew
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Yang Yie Sio
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Anand K Andiappan
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.,Department of Biological Sciences, National University of Singapore, Singapore, Singapore
| | - Steve W Turner
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Somnath Mukhopadhyay
- Academic Department of Paediatrics, Royal Alexandra Children's Hospital, Brighton and Sussex Medical School, Brighton, UK.,Population Pharmacogenetics Group, Biomedical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Colin N A Palmer
- Population Pharmacogenetics Group, Biomedical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Daniel Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.,NIHR Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, Liverpool, UK
| | - Andrea L Jorgensen
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Esteban G Burchard
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Natalia Hernandez-Pacheco
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Maria Pino-Yanes
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Santa Cruz de Tenerife, Spain.,Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Anke H Maitland-van der Zee
- Department of Respiratory Disease, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Pediatric Respiratory Medicine, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, Netherlands
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26
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Ahmet A, Rowan-Legg A, Pancer L. La suppression surrénalienne causée par les glucocorticoïdes exogènes : en reconnaître les facteurs de risque et en prévenir les effets. Paediatr Child Health 2021; 26:248-254. [PMID: 34136054 DOI: 10.1093/pch/pxab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Résumé
La suppression surrénalienne, un effet secondaire potentiel du traitement aux glucocorticoïdes (y compris les corticostéroïdes inhalés), peut avoir des conséquences graves et même fatales. Au Canada, on continue de déclarer des poussées d’insuffisance corticosurrénalienne consécutives à une suppression surrénalienne chez les enfants. Avant de prescrire des glucocorticoïdes, le clinicien doit absolument connaître les symptômes de suppression surrénalienne, comprendre les facteurs de risque de cette affection et être au courant des stratégies susceptibles d’en réduire les risques.
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Affiliation(s)
- Alexandra Ahmet
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Anne Rowan-Legg
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Larry Pancer
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
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27
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Kanthagnany SK, Lane LC, Wood C, Sachdev P, Drake AJ, Cheetham T. Fifteen-minute consultation: An approach to the child receiving glucocorticoids. Arch Dis Child Educ Pract Ed 2021; 106:130-135. [PMID: 32769084 DOI: 10.1136/archdischild-2019-317812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 11/03/2022]
Abstract
Glucocorticoids (GC) are used in paediatric practice for a broad range of conditions and all paediatricians will prescribe GC, in some form, during their career. A wide variety of GC formulations, doses and administration routes are used for periods of time ranging from days to years. Exposure to exogenous GC can result in hypothalamic-pituitary-adrenal axis suppression-otherwise known as adrenal suppression (AS). Patients with AS may be well most of the time but if GC therapy is reduced or stopped or if additional endogenous GC cannot be generated during illness, then an absolute or relative lack of GC can result in severe illness or death. Here, we highlight the relevance of AS to all paediatricians by providing an overview of the background and discussing the presentation and approaches to the management of this clinical entity.
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Affiliation(s)
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire Wood
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Pooja Sachdev
- Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Jane Drake
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK .,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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28
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Kunøe A, Sevelsted A, Chawes BL, Stokholm J, Eliasen A, Krakauer M, Bønnelykke K, Bisgaard H. Associations between Inhaled Corticosteroid in the First 6 Years of Life and Obesity Related Traits. Am J Respir Crit Care Med 2021; 204:642-650. [PMID: 33975528 DOI: 10.1164/rccm.202009-3537oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Infants and young children might be particularly susceptible to the potential clinical side effects of inhaled corticosteroids (ICS) on body mass index (BMI), adiposity rebound and body composition, but this has rarely been studied in long-term studies in this age-group. Objective To determine the association between ICS exposure in the first 6 years of life on BMI, adiposity rebound, body composition and blood lipid levels. Methods Children from the two Copenhagen Prospective Studies on Asthma in Childhood mother-child cohorts were included. ICS use was registered prospectively to age 6 and the cumulative dose was calculated. Multiple linear regression models were used for analysis. Measurements and Main Results A total of 932 (84%) of the 1111 children from the COPSAC cohorts had data on BMI, 786 (71%) had DXA scan data at age 6 years, and 815 (73%) had adiposity rebound age calculated. 291 children (31%) received a cumulative ICS dose > 10 weeks of standard treatment before age 6. ICS treatment during 0-6 years of age was associated with an increased BMI z-score; 0.05 SD [95% CI: 0.005 to 0.09] per one-year standard treatment, p=0.03, an earlier age at adiposity rebound; -0.18 year [95% CI: -0.28 to -0.08], p=0.0006, and a 2 % increased geometric mean android fat percentage, p=0.05. ICS exposure and DXA scan data were not associated. Conclusions ICS use in early childhood was associated with increased BMI z-score at age six, an earlier adiposity rebound and a trend of association with increased android body fat percentage.
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Affiliation(s)
- Asja Kunøe
- University of Copenhagen, 4321, COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, Kobenhavn, Denmark
| | - Astrid Sevelsted
- University of Copenhagen, 4321, COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, Kobenhavn, Denmark
| | - Bo L Chawes
- Brigham and Women's Hospital, 1861, Channing Division of Network Medicine, Boston, Massachusetts, United States.,University of Copenhagen, 4321, COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Kobenhavn, Denmark
| | - Jakob Stokholm
- University of Copenhagen, 4321, COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, Kobenhavn, Denmark
| | - Anders Eliasen
- University of Copenhagen, 4321, COPSAC Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, Kobenhavn, Denmark
| | - Martin Krakauer
- Gentofte University Hospital, 53147, Department of Clinical Physiology and Nuclear Medicine, Hellerup, Denmark
| | - Klaus Bønnelykke
- University of Copenhagen, 4321, Copenhagen Prospective Studies on Asthma in Childhood; The Danish Pediatric Asthma Center, Kobenhavn, Denmark
| | - Hans Bisgaard
- University of Copenhagen, 4321, COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, Kobenhavn, Denmark;
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de Benedictis FM, Carloni I, Guidi R. Safety of anti-inflammatory drugs in children with asthma. Curr Opin Allergy Clin Immunol 2021; 21:144-150. [PMID: 33470588 DOI: 10.1097/aci.0000000000000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Inhaled corticosteroids (ICS) are widely used as the first-line treatment of asthma. When the disease is not controlled by standard doses of ICS, other anti-inflammatory drugs should be considered. The aim of this report is to review the main adverse events induced by anti-inflammatory drugs in children with asthma and discuss possible actions to prevent or mitigate these effects. RECENT FINDINGS Proper interpretation of ICS safety studies requires knowledge of the pharmaceutical properties and delivery device systems of the different ICS available. Genetic variants affecting susceptibility to corticosteroid-induced adrenal suppression were found in children and adults who use ICS to treat their asthma. There is evidence of the association between montelukast use and neuropsychiatric events. SUMMARY Benefits of ICS, properly prescribed and used, outweigh their potential adverse effects. There is substantial evidence that the combination of ICS with long-acting beta2 agonists is safe for asthmatic children. Awareness of the potential risks of neuropsychiatric events in children taking montelukast should inform the clinicians' prescribing practices. Omalizumab is generally well-tolerated, but the evidence on the safety of other biologic agents in children is scanty. The risk of systemic adverse events with anti-inflammatory drugs must be balanced against the risks of uncontrolled asthma and/or frequent oral steroid use.
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Affiliation(s)
| | | | - Roberto Guidi
- Pediatric Emergency Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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Akurugu WA, Van Heerden CJ, Mulder N, Zöllner EW. Hypothalamic-pituitary-adrenal axis suppression in asthma: A glucocorticoid receptor polymorphism may protect. Pediatr Allergy Immunol 2021; 32:273-279. [PMID: 32969491 DOI: 10.1111/pai.13379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Asthmatic children on corticosteroids can develop hypothalamic-pituitary-adrenal axis suppression (HPAS). Single nucleotide polymorphisms (SNPs) rs242941 and rs1876828 of the corticotrophin-releasing hormone receptor 1 (CRHR1) gene were associated with lower stimulated cortisol (F) levels, whereas rs41423247 of the glucocorticoid receptor (NR3C1) gene was associated with higher basal F levels. The objective of the current study was to confirm whether these three SNPs are associated with HPAS in asthmatic children. METHODS DNA was extracted from saliva obtained from 95 asthmatic children, who had previously undergone basal F and metyrapone testing. Thirty-six children were classified as suppressed. Non-suppressed children were subclassified according to their post-metyrapone adrenocorticotropin (PMTP ACTH) level into a middle (106-319 pg/mL) and a high (>319 pg/mL) ACTH response group. TaqMan® polymerase chain reaction assays were utilized. RESULTS Only rs41423247 was inversely associated with HPAS (OR = 0.27 [95% CI 0.06-0.90]). Its GC genotype was inversely associated with HPAS (log odds = -1.28, P = .021). √PMTP ACTH was associated with CC (effect size = 10.85, P = .005) and GC genotypes (effect size = 4.06, P = .023). The C allele is inherited as a dominant trait (effect size = -1.31 (95% CI -2.39--0.33; P = .012). In the high ACTH response group, both genotypes affected the PMTP ACTH (effect sizes 1.41 and 15.46; P-values .023 and <2 × 10-26 for GC and CC, respectively). CONCLUSIONS The C allele of rs41423247 was found to be protective against HPAS. CC genotype is associated with the highest PMTP ACTH response.
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Affiliation(s)
- Wisdom Alemya Akurugu
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Nicola Mulder
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Ekkehard Werner Zöllner
- Paediatric Endocrine & Diabetes Unit, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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Rayas MS, Kelly A, Hughan KS, Daley T, Zangen D. Adrenal function in cystic fibrosis. J Cyst Fibros 2020; 18 Suppl 2:S74-S81. [PMID: 31679732 DOI: 10.1016/j.jcf.2019.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Cystic fibrosis (CF) is not known to directly affect the adrenal gland, but commonly used CF therapies do impact the function of the hypothalamic-pituitary-adrenal (HPA) axis. By binding to the glucocorticoid receptor, medications such as inhaled and oral corticosteroids can enhance the systemic effects of cortisol and result in iatrogenic Cushing syndrome. Prolonged use suppresses the body's ability to make cortisol, resulting in iatrogenic adrenal insufficiency upon medication discontinuation. Chronic use of inhaled and oral corticosteroids can negatively affect bone health, growth, and glucose metabolism. This chapter provides practical guidelines regarding the screening, diagnosis, and treatment of iatrogenic adrenal insufficiency. As the guidelines are mainly derived from the asthma literature, this chapter also highlights the need for studies to evaluate the impact of CF therapies on adrenal function and other CF-endocrinopathies.
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Affiliation(s)
- Maria Socorro Rayas
- Division of Pediatric Endocrinology and Diabetes, University of Texas Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA.
| | - Andrea Kelly
- Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine of University of Pennsylvania, 2716 South Street, Philadelphia, PA 19146, USA.
| | - Kara S Hughan
- Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tanicia Daley
- Division of Pediatric Endocrinology and Metabolism, Emory Children's Center/Emory Pediatric Institute, Emory University School of Medicine, 1400 Tullie Road, Atlanta, GA 30329, USA.
| | - David Zangen
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem 91240, Israel.
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Hassan R, Allali I, Agamah FE, Elsheikh SSM, Thomford NE, Dandara C, Chimusa ER. Drug response in association with pharmacogenomics and pharmacomicrobiomics: towards a better personalized medicine. Brief Bioinform 2020; 22:6012864. [PMID: 33253350 DOI: 10.1093/bib/bbaa292] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/19/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Researchers have long been presented with the challenge imposed by the role of genetic heterogeneity in drug response. For many years, Pharmacogenomics and pharmacomicrobiomics has been investigating the influence of an individual's genetic background to drug response and disposition. More recently, the human gut microbiome has proven to play a crucial role in the way patients respond to different therapeutic drugs and it has been shown that by understanding the composition of the human microbiome, we can improve the drug efficacy and effectively identify drug targets. However, our knowledge on the effect of host genetics on specific gut microbes related to variation in drug metabolizing enzymes, the drug remains limited and therefore limits the application of joint host-microbiome genome-wide association studies. In this paper, we provide a historical overview of the complex interactions between the host, human microbiome and drugs. While discussing applications, challenges and opportunities of these studies, we draw attention to the critical need for inclusion of diverse populations and the development of an innovative and combined pharmacogenomics and pharmacomicrobiomics approach, that may provide an important basis in personalized medicine.
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Affiliation(s)
- Radia Hassan
- Division of Human Genetics, Department of Pathology, University of Cape Town
| | - Imane Allali
- Department of Biology, Faculty of Sciences, Mohammed V University in Rabat, Morocco
| | - Francis E Agamah
- Division of Human Genetics, Department of Pathology, University of Cape Town
| | | | - Nicholas E Thomford
- Lecturers at the Department of Medical Biochemistry School of Medical Sciences, University of Cape Coast, Ghana
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology, University of Cape Town
| | - Emile R Chimusa
- Division of Human Genetics, Department of Pathology, University of Cape Town
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33
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Asthma genomics and pharmacogenomics. Curr Opin Immunol 2020; 66:136-142. [PMID: 33171417 DOI: 10.1016/j.coi.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/04/2020] [Indexed: 12/16/2022]
Abstract
In this review, we summarize recent published work interrogating the relationship between genetic variation or gene expression regulation across the genome and asthma or asthma treatment outcomes. This includes 11 genome-wide association studies of asthma phenotypes that collectively identified 64 novel loci; transcriptome-wide asthma association studies which identified genes involved in virus recognition, bacterial infection, lung tissue remodeling, eosinophilic and neutrophilic inflammation and genes in the chromosome 17q12 asthma susceptibility locus; and three epigenome-wide studies of asthma that had robust sample sizes and replicated findings. We also highlight pharmacogenomic studies of corticosteroids, bronchodilator response to albuterol and zileuton, although finding from these studies may still be preliminary due to their relatively small sample sizes and limited availability of replication cohorts.
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35
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King C, McKenna A, Farzan N, Vijverberg SJ, van der Schee MP, Maitland-van der Zee AH, Arianto L, Bisgaard H, BØnnelykke K, Berce V, PotoČnik U, Repnik K, Carleton B, Daley D, Chew FT, Chiang WC, Sio YY, Cloutier MM, Den Dekker HT, Duijts L, de Jongste JC, Dijk FN, Flores C, Hernandez-Pacheco N, Mukhopadhyay S, Basu K, Tantisira KG, Verhamme KM, Celedón JC, Forno E, Canino G, Francis B, Pirmohamed M, Sinha I, Hawcutt DB. Pharmacogenomic associations of adverse drug reactions in asthma: systematic review and research prioritisation. THE PHARMACOGENOMICS JOURNAL 2020; 20:621-628. [PMID: 31949291 PMCID: PMC7502355 DOI: 10.1038/s41397-019-0140-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/22/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022]
Abstract
A systematic review of pharmacogenomic studies capturing adverse drug reactions (ADRs) related to asthma medications was undertaken, and a survey of Pharmacogenomics in Childhood Asthma (PiCA) consortia members was conducted. Studies were eligible if genetic polymorphisms were compared with suspected ADR(s) in a patient with asthma, as either a primary or secondary outcome. Five studies met the inclusion criteria. The ADRs and polymorphisms identified were change in lung function tests (rs1042713), adrenal suppression (rs591118), and decreased bone mineral density (rs6461639) and accretion (rs9896933, rs2074439). Two of these polymorphisms were replicated within the paper, but none had external replication. Priorities from PiCA consortia members (representing 15 institution in eight countries) for future studies were tachycardia (SABA/LABA), adrenal suppression/crisis and growth suppression (corticosteroids), sleep/behaviour disturbances (leukotriene receptor antagonists), and nausea and vomiting (theophylline). Future pharmacogenomic studies in asthma should collect relevant ADR data as well as markers of efficacy.
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Affiliation(s)
- Charlotte King
- Department of Women and Child's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, England
| | - Amanda McKenna
- Department of Women and Child's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, England
| | - Niloufar Farzan
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne J Vijverberg
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Marc P van der Schee
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Anke H Maitland-van der Zee
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Lambang Arianto
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Klaus BØnnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Vojko Berce
- Department of Pediatrics, University Medical Centre Maribor, Maribor, Slovenia
- Centre for Human Molecular Genetics & Pharmacogenomics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Uros PotoČnik
- Centre for Human Molecular Genetics & Pharmacogenomics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Katja Repnik
- Centre for Human Molecular Genetics & Pharmacogenomics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Bruce Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital and Research Institute, Vancouver, Canada
| | - Denise Daley
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital and Research Institute, Vancouver, Canada
| | - Fook Tim Chew
- Department of Biological Sciences, National University of Singapore, Singapore, Singapore
- Allergy & Immunology Division, Department of Paediatric Medicine, KK Children's Hospital, Singapore, Singapore
| | - Wen Chin Chiang
- Department of Biological Sciences, National University of Singapore, Singapore, Singapore
- Allergy & Immunology Division, Department of Paediatric Medicine, KK Children's Hospital, Singapore, Singapore
| | - Yang Yie Sio
- Department of Biological Sciences, National University of Singapore, Singapore, Singapore
- Allergy & Immunology Division, Department of Paediatric Medicine, KK Children's Hospital, Singapore, Singapore
| | - Michelle M Cloutier
- Asthma Center, Connecticut Children's Medical Center, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Herman T Den Dekker
- Department of Pediatrics, Division of Respiratory Medicine & Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Liesbeth Duijts
- Department of Pediatrics, Division of Respiratory Medicine & Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan C de Jongste
- Department of Pediatric Pulmonology & Pediatric Allergology, University Medical Center Groningen, University of Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - F Nicole Dijk
- Department of Pediatric Pulmonology & Pediatric Allergology, University Medical Center Groningen, University of Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
- Groningen Research Institute for Asthma & COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlos Flores
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain
| | - Natalia Hernandez-Pacheco
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
| | - Somnath Mukhopadhyay
- Academic Department of Paediatrics, Brighton & Sussex Medical School, Royal Alexandra Children's Hospital, Brighton, UK
| | - Kaninika Basu
- Academic Department of Paediatrics, Brighton & Sussex Medical School, Royal Alexandra Children's Hospital, Brighton, UK
| | - Kelan G Tantisira
- The Channing Division of Network Medicine, Department of Medicine, Boston, MA, 02115, USA
- Division of Pulmonary & Critical Care Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, 02115, USA
| | - Katia M Verhamme
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Juan C Celedón
- Division of Pediatric Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Erick Forno
- Division of Pediatric Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Glorisa Canino
- Behavioral Sciences Research Institute, University of Puerto Rico, San Juan, Puerto Rico
| | - Ben Francis
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, England
| | - Munir Pirmohamed
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, England
| | - Ian Sinha
- Department of Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, England
| | - Daniel B Hawcutt
- Department of Women and Child's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, England.
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, Liverpool, England.
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Insights into glucocorticoid responses derived from omics studies. Pharmacol Ther 2020; 218:107674. [PMID: 32910934 DOI: 10.1016/j.pharmthera.2020.107674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/20/2020] [Indexed: 12/26/2022]
Abstract
Glucocorticoid drugs are commonly used in the treatment of several conditions, including autoimmune diseases, asthma and cancer. Despite their widespread use and knowledge of biological pathways via which they act, much remains to be learned about the cell type-specific mechanisms of glucocorticoid action and the reasons why patients respond differently to them. In recent years, human and in vitro studies have addressed these questions with genomics, transcriptomics and other omics approaches. Here, we summarize key insights derived from omics studies of glucocorticoid response, and we identify existing knowledge gaps related to mechanisms of glucocorticoid action that future studies can address.
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Bleecker ER, Menzies-Gow AN, Price DB, Bourdin A, Sweet S, Martin AL, Alacqua M, Tran TN. Systematic Literature Review of Systemic Corticosteroid Use for Asthma Management. Am J Respir Crit Care Med 2020; 201:276-293. [PMID: 31525297 PMCID: PMC6999108 DOI: 10.1164/rccm.201904-0903so] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Systemic corticosteroid use to manage uncontrolled asthma and its associated healthcare burden may account for important health-related adverse effects. We conducted a systematic literature review to investigate the real-world extent and burden of systemic corticosteroid use in asthma. We searched MEDLINE and Embase databases to identify English-language articles published in 2010–2017, using search terms for asthma with keywords for oral corticosteroids and systemic corticosteroids. Observational studies, prescription database analyses, economic analyses, and surveys on oral/systemic corticosteroid use in children (>5 yr old), adolescents (12–17 yr old), and adults with asthma were included. We identified and reviewed 387 full-text articles, and our review included data from 139 studies. The included studies were conducted in Europe, North America, and Asia. Overall, oral/systemic corticosteroids were commonly used for asthma management and were more frequently used in patients with severe asthma than in those with milder disease. Long-term oral/systemic corticosteroid use was, in general, less frequent than short-term use. Compared with no use, long-term and repeated short-term oral/systemic corticosteroid use were associated with an increased risk of acute and chronic adverse events, even when doses were comparatively low. Greater oral/systemic corticosteroid exposure was also associated with increased costs and healthcare resource use. This review provides a comprehensive overview of oral/systemic corticosteroid use and associated adverse events for patients with all degrees of asthma severity and exposure duration. We report that oral/systemic corticosteroid use is prevalent in asthma management, and the risks of acute and chronic complications increase with the cumulative oral corticosteroid dosage.
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Affiliation(s)
- Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona Health Sciences, Tucson, Arizona
| | | | - David B Price
- Department of Primary Care Respiratory Medicine, University of Aberdeen, Aberdeen, United Kingdom.,Observational and Pragmatic Research Institute, Singapore
| | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, Montpellier, France
| | - Stephen Sweet
- Research Evaluation Unit, Oxford PharmaGenesis Ltd., Oxford, United Kingdom
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Parry CM, Hawcutt D. Fifteen-minute consultation: Pharmacogenomics: a guide for busy clinicians. Arch Dis Child Educ Pract Ed 2020; 105:107-110. [PMID: 31092398 DOI: 10.1136/archdischild-2019-316971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/31/2022]
Abstract
The ultimate goal of pharmacogenomics is to understand how the effects of interindividual genetic variation impact on the response of patients to treatments and in turn optimise those treatments while minimising potential side effects. This review article provides a brief overview of pharmacogenomics, focusing on the methods used to understand how genes of interest are identified, how pharmacogenomics is currently used within paediatric clinical practice within the UK, potential areas for future use and some of the caveats specific to paediatric medicine.
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Affiliation(s)
- Christopher Mark Parry
- Members of Liverpool Health Partners, University of Liverpool, Liverpool, Merseyside, UK.,Alder Hey Clinical Research Facility, NIHR, Liverpool, UK
| | - Daniel Hawcutt
- Members of Liverpool Health Partners, University of Liverpool, Liverpool, Merseyside, UK.,Alder Hey Clinical Research Facility, NIHR, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Childhood asthma is a heterogeneous disease and many children have uncontrolled disease. Therefore an individualized approach is needed to improve asthma outcomes in children. Precision medicine using clinical characteristics, biomarkers, and the rapidly involving field of genomics and pharmacogenomics aims to achieve asthma control and reduce future risks with less side-effects in individual children with asthma. RECENT FINDINGS It is not yet possible to select treatment options on clinical characteristics. Novel monoclonal antibodies are efficacious in patients with severe, eosinophilic asthma. Reduced lung function growth and early decline is a prevalent finding in children with persistent asthma. Pharmacogenetic studies have identified children at risk for cortisol suppression when using inhaled corticosteroids. SUMMARY Clinical characteristics and simple biomarkers like eosinophils, IgE, and the fraction of exhaled nitric oxide may be used in clinical practice for a basic precision medicine approach, deciding which children will have the best chance to respond to inhaled corticosteroids and to the biologicals omalizumab and mepolizumab.Further application of pharmacogenomics and breathomics needs additional studies before they can be applied as tools for precision medicine in individual children with asthma.
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Bourdin A, Adcock I, Berger P, Bonniaud P, Chanson P, Chenivesse C, de Blic J, Deschildre A, Devillier P, Devouassoux G, Didier A, Garcia G, Magnan A, Martinat Y, Perez T, Roche N, Taillé C, Val P, Chanez P. How can we minimise the use of regular oral corticosteroids in asthma? Eur Respir Rev 2020; 29:29/155/190085. [PMID: 32024721 PMCID: PMC9488989 DOI: 10.1183/16000617.0085-2019] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023] Open
Abstract
Options to achieve oral corticosteroid (OCS)-sparing have been triggering increasing interest since the 1970s because of the side-effects of OCSs, and this has now become achievable with biologics. The Société de Pneumologie de Langue Française workshop on OCSs aimed to conduct a comprehensive review of the basics for OCS use in asthma and issue key research questions. Pharmacology and definition of regular use were reviewed by the first working group (WG1). WG2 examined whether regular OCS use is associated with T2 endotype. WG3 reported on the specificities of the paediatric area. Key “research statement proposals” were suggested by WG4. It was found that the benefits of regular OCS use in asthma outside episodes of exacerbations are poorly supported by the existing evidence. However, complete OCS elimination couldn’t be achieved in any available studies for all patients and the panel felt that it was too early to conclude that regular OCS use could be declared criminal. Repeated or prolonged need for OCS beyond 1 g·year−1 should indicate the need for referral to secondary/tertiary care. A strategic sequential plan aiming at reducing overall exposure to OCS in severe asthma was then held as a conclusion of the workshop. A yearly cumulative OCS dose above 1 g should be considered unacceptable in severe asthma and should make the case for referralhttp://bit.ly/34GAYLX
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Affiliation(s)
- Arnaud Bourdin
- Service des Maladies Respirartoires, CHU Arnaud de Villeneuve, University of Montpellier, Montpellier, France
| | - Ian Adcock
- Thoracic Medicine, Imperial College London, London, UK
| | - Patrick Berger
- Centre de Recherche Cardiothoracique de Bordeaux, Université de Bordeaux, Bordeaux, France
| | | | | | - Cécile Chenivesse
- Centre Hospitalier Regional Universitaire de Lille, Lille, France.,Universite de Lille II, Lille, France
| | - Jacques de Blic
- Pediatric Respiratory Diseases, Necker-Enfants Malades Hospitals, Paris, France
| | | | | | - Gilles Devouassoux
- Pneumologie, Hopital de la Croix-Rousse, HCL, Lyon, France.,Université Claude Bernard lyon1 et INSERM U851, Lyon, France
| | | | | | | | | | - Thierry Perez
- Respiratory, Hopital Calmette, CHRU Lille, Lille, France.,Lung function, Hôpital Calmette, CHRU Lille, Lille, France
| | | | - Camille Taillé
- Service de Pneumologie, Hopital Bichat - Claude-Bernard, Paris, France
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41
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Baan EJ, van den Akker ELT, Engelkes M, de Rijke YB, de Jongste JC, Sturkenboom MCJM, Verhamme KM, Janssens HM. Hair cortisol and inhaled corticosteroid use in asthmatic children. Pediatr Pulmonol 2020; 55:316-321. [PMID: 31651095 PMCID: PMC7003950 DOI: 10.1002/ppul.24551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/26/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adrenal suppression is a side effect of long-term use of inhaled corticosteroids (ICS). Hair cortisol concentration (HCC) measurement is a noninvasive tool for measuring adrenal function that may be useful for asthmatic patients who are on long-term ICS treatment. The aim of this study was to compare HCC between children with and without asthma and to explore the association between HCC and ICS dose in asthmatic children. METHODS A cross-sectional observational study in subjects with or without asthma (n = 72 and 226, respectively, age 6-21 years). Hair samples were obtained from the posterior vertex for each subject and data on medication use were collected using questionnaires. HCC was analyzed by liquid chromatography-mass spectrometry in the most proximal 3 cm of hair. RESULTS Median HCC was significantly lower in subjects with asthma than in subjects without asthma: 1.83 pg/mg and 2.39 pg/mg, respectively (P value after adjustment for age, sex, and body mass index: .036). Median HCC was 1.98 pg/mg in asthmatics using no ICS, 1.84 pg/mg in those using a low dose, 1.75 pg/mg in those on a medium dose, and 1.46 in those using a high ICS dose (P = .54). CONCLUSION We observed a significantly lower HCC in asthmatics than in healthy controls and a nonsignificant trend of lower HCC with increasing ICS dose. Whether HCC measurement may be used to detect individuals at risk for hypocortisolism and may be useful to monitor adrenal function in asthmatic children using ICS needs to be further investigated.
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Affiliation(s)
- Esmé J Baan
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Marjolein Engelkes
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Yolanda B de Rijke
- Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan C de Jongste
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | | | - Katia M Verhamme
- Department of Medical Informatics, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, Rotterdam, The Netherlands
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42
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Frezza D, Martinez-Labarga C, Giambra V, Serone E, Scano G, Rickards O, D'Addabbo P, Novelletto A. Concerted variation of the 3' regulatory region of Ig heavy chain and Gm haplotypes across human continental populations. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2020; 171:671-682. [PMID: 31957883 DOI: 10.1002/ajpa.24011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/29/2019] [Accepted: 01/02/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The 3' regulatory region of the immunoglobulin heavy chain gene (IGH) includes the HS1.2 enhancer displaying length polymorphism with four known variants. The goal of the research was to provide an overview of this variability and of its evolutionary significance across human populations. MATERIALS AND METHODS We compiled published and original data on HS1.2 polymorphism in 3,100 subjects from 26 human populations. Moreover, we imputed the haplotypic arrangement of the HS1.2 region in the 1000 Genomes Project (1KGP). In this dataset, imputation could also be obtained for the G1m-G3m allotype by virtue of the precise correspondence between serological types and amino acid (and DNA) substitutions in IGHG1 and IGHG3. RESULTS HS1.2 variant frequencies displayed similar patterns of continental partitioning as those reported in the literature for the physically neighboring IGHG1-IGHG3 system. The 1KGP data revealed that linkage disequilibrium (LD) can explain the spread of joint HS1.2-IGHG1-IGHG3 associations across continents and within continental populations, with stronger LD out of Africa and the features of an evolutionarily stable genomic block with differential expression in lymphoblastoid cell lines. DISCUSSION Strong population structuring involves at least the entire 70 kb genomic region here considered, due to the tight LD which maintained HS1.2, IGHG1, and IGHG3 in nonrandom arrangements. This might be key to better understand the evolutionary path of the entire genomic region driven by immune response capabilities, during the formation of continental gene pools.
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Affiliation(s)
- Domenico Frezza
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | | | - Vincenzo Giambra
- Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
| | - Eliseo Serone
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Giuseppina Scano
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | - Olga Rickards
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
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43
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Abdel-Aziz MI, Neerincx AH, Vijverberg SJ, Kraneveld AD, Maitland-van der Zee AH. Omics for the future in asthma. Semin Immunopathol 2020; 42:111-126. [PMID: 31942640 DOI: 10.1007/s00281-019-00776-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/22/2019] [Indexed: 12/31/2022]
Abstract
Asthma is a common, complex, multifaceted disease. It comprises multiple phenotypes, which might benefit from treatment with different types of innovative targeted therapies. Refining these phenotypes and understanding their underlying biological structure would help to apply precision medicine approaches. Using different omics methods, such as (epi)genomics, transcriptomics, proteomics, metabolomics, microbiomics, and exposomics, allowed to view and investigate asthma from diverse angles. Technological advancement led to a large increase in the application of omics studies in the asthma field. Although the use of omics technologies has reduced the gap between bench to bedside, several design and methodological challenges still need to be tackled before omics can be applied in asthma patient care. Collaborating under a centralized harmonized work frame (such as in consortia, under consistent methodologies) could help worldwide research teams to tackle these challenges. In this review, we discuss the transition of single biomarker research to multi-omics studies. In addition, we deliberate challenges such as the lack of standardization of sampling and analytical methodologies and validation of findings, which comes in between omics and personalized patient care. The future of omics in asthma is encouraging but not completely clear with some unanswered questions, which have not been adequately addressed before. Therefore, we highlight these questions and emphasize on the importance of fulfilling them.
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Affiliation(s)
- Mahmoud I Abdel-Aziz
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.,Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Anne H Neerincx
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Susanne J Vijverberg
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Aletta D Kraneveld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands.,Institute for Risk Assessment Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Anke H Maitland-van der Zee
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands. .,Department of Pediatric Respiratory Medicine, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands.
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44
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Van Moortel L, Gevaert K, De Bosscher K. Improved Glucocorticoid Receptor Ligands: Fantastic Beasts, but How to Find Them? Front Endocrinol (Lausanne) 2020; 11:559673. [PMID: 33071974 PMCID: PMC7541956 DOI: 10.3389/fendo.2020.559673] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/26/2020] [Indexed: 01/01/2023] Open
Abstract
Exogenous glucocorticoids are widely used in the clinic for the treatment of inflammatory disorders and hematological cancers. Unfortunately, their use is associated with debilitating side effects, including hyperglycemia, osteoporosis, mood swings, and weight gain. Despite the continued efforts of pharma as well as academia, the search for so-called selective glucocorticoid receptor modulators (SEGRMs), compounds with strong anti-inflammatory or anti-cancer properties but a reduced number or level of side effects, has had limited success so far. Although monoclonal antibody therapies have been successfully introduced for the treatment of certain disorders (such as anti-TNF for rheumatoid arthritis), glucocorticoids remain the first-in-line option for many other chronic diseases including asthma, multiple sclerosis, and multiple myeloma. This perspective offers our opinion on why a continued search for SEGRMs remains highly relevant in an era where small molecules are sometimes unrightfully considered old-fashioned. Besides a discussion on which bottlenecks and pitfalls might have been overlooked in the past, we elaborate on potential solutions and recent developments that may push future research in the right direction.
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Affiliation(s)
- Laura Van Moortel
- Translational Nuclear Receptor Research (TNRR) Laboratory, VIB, Ghent, Belgium
- VIB Center for Medical Biotechnology, VIB, Ghent, Belgium
- Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Kris Gevaert
- VIB Center for Medical Biotechnology, VIB, Ghent, Belgium
- Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Karolien De Bosscher
- Translational Nuclear Receptor Research (TNRR) Laboratory, VIB, Ghent, Belgium
- VIB Center for Medical Biotechnology, VIB, Ghent, Belgium
- Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
- *Correspondence: Karolien De Bosscher
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45
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Newey PJ. Clinical genetic testing in endocrinology: Current concepts and contemporary challenges. Clin Endocrinol (Oxf) 2019; 91:587-607. [PMID: 31254405 DOI: 10.1111/cen.14053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/29/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
Recent advances in DNA sequencing technology have led to an unprecedented period of disease-gene discovery offering many new opportunities for genetic testing in the clinical setting. Endocrinology has seen a rapid expansion in the taxonomy of monogenic disorders, which can be detected by an expanding portfolio of genetic tests in both diagnostic and predictive settings. Successful testing relies on many factors including the ability to identify those at increased risk of genetic disease in the busy clinic as well as a working knowledge of the various testing platforms and their limitations. The clinical utility of a given test is dependent upon many factors, which include the reliability of the genetic testing platform, the accuracy of the test result interpretation and knowledge of disease penetrance and expression. The increasing adoption of "high-content" genetic testing based on next-generation sequencing (NGS) to diagnose hereditary endocrine disorders brings a number of challenges including the potential for uncertain test results and/or genetic findings unrelated to the indication for testing. Therefore, it is increasingly important that the clinician is aware of the current evolution in genetic testing, and understands the different settings in which it may be employed. This review provides an overview of the genetic testing workflow, focusing on each of the major components required for successful testing in adult and paediatric endocrine settings. In addition, the challenges of variant interpretation are highlighted, as are issues related to informed consent, prenatal diagnosis and predictive testing. Finally, the future directions of genetic testing relevant to endocrinology are discussed.
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Affiliation(s)
- Paul J Newey
- Division of Molecular & Clinical Medicine, Ninewells Hospital & Medical School, University of Dundee, Scotland, UK
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46
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Younis RM, Taylor RM, Beardsley PM, McClay JL. The ANKS1B gene and its associated phenotypes: focus on CNS drug response. Pharmacogenomics 2019; 20:669-684. [PMID: 31250731 PMCID: PMC6912848 DOI: 10.2217/pgs-2019-0015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022] Open
Abstract
The ANKS1B gene was a top finding in genome-wide association studies (GWAS) of antipsychotic drug response. Subsequent GWAS findings for ANKS1B include cognitive ability, educational attainment, body mass index, response to corticosteroids and drug dependence. We review current human association evidence for ANKS1B, in addition to functional studies that include two published mouse knockouts. The several GWAS findings in humans indicate that phenotypically relevant variation is segregating at the ANKS1B locus. ANKS1B shows strong plausibility for involvement in CNS drug response because it encodes a postsynaptic effector protein that mediates long-term changes to neuronal biology. Forthcoming data from large biobanks should further delineate the role of ANKS1B in CNS drug response.
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Affiliation(s)
- Rabha M Younis
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298, USA
| | - Rachel M Taylor
- Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MA 20910, USA
| | - Patrick M Beardsley
- Department of Pharmacology & Toxicology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
- Center for Biomarker Research & Personalized Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Joseph L McClay
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298, USA
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47
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Hersh CP. Pharmacogenomics of chronic obstructive pulmonary disease. Expert Rev Respir Med 2019; 13:459-470. [PMID: 30925849 PMCID: PMC6482089 DOI: 10.1080/17476348.2019.1601559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/27/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition, which presents the opportunity for precision therapy based on genetics or other biomarkers. Areas covered: Alpha-1 antitrypsin deficiency, a genetic form of emphysema, provides an example of this precision approach to diagnosis and therapy. To date, research in COPD pharmacogenomics has been limited by small sample sizes, lack of accessible target tissue, failure to consider COPD subtypes, and different outcomes relevant for various medications. There have been several published genome-wide association studies and other omics studies in COPD pharmacogenomics; however, clinical implementation remains far away. There is a growing evidence base for precision prescription of inhaled corticosteroids in COPD, based on clinical phenotypes and blood biomarkers, but not yet based on pharmacogenomics. Expert opinion: At this time, there is insufficient evidence for clinical implementation of COPD pharmacogenomics. Additional genome-wide studies will be required to discover predictors of drug response and to identify genomic biomarkers of COPD subtypes, which could be targeted with subtype-directed therapies.
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Affiliation(s)
- Craig P Hersh
- a Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
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48
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Ding WY, Beresford MW, Saleem MA, Ramanan AV. Big data and stratified medicine: what does it mean for children? Arch Dis Child 2019; 104:389-394. [PMID: 30266876 DOI: 10.1136/archdischild-2018-315125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 01/15/2023]
Abstract
Stratified medicine in paediatrics is increasingly becoming a reality, as our understanding of disease pathogenesis improves and novel treatment targets emerge. We have already seen some success in paediatrics in targeted therapies such as cystic fibrosis for specific cystic fibrosis transmembrane conductance regulator variants. With the increased speed and decreased cost of processing and analysing data from rare disease registries, we are increasingly able to use a systems biology approach (including '-omics') to screen across populations for molecules and genes of interest. Improving our understanding of the molecular mechanisms underlying disease, and how to classify patients according to these will lead the way for targeted therapies for individual patients. This review article will summarise how 'big data' and the 'omics' are being used and developed, and taking examples from paediatric renal medicine and rheumatology, demonstrate progress being made towards stratified medicine for children.
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Affiliation(s)
- Wen Y Ding
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael W Beresford
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Moin A Saleem
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Department of Paediatric Nephrology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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49
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Agache I, Akdis CA. Precision medicine and phenotypes, endotypes, genotypes, regiotypes, and theratypes of allergic diseases. J Clin Invest 2019; 129:1493-1503. [PMID: 30855278 PMCID: PMC6436902 DOI: 10.1172/jci124611] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A rapidly developing paradigm for modern health care is a proactive and individualized response to patients' symptoms, combining precision diagnosis and personalized treatment. Precision medicine is becoming an overarching medical discipline that will require a better understanding of biomarkers, phenotypes, endotypes, genotypes, regiotypes, and theratypes of diseases. The 100-year-old personalized allergen-specific management of allergic diseases has particularly contributed to early awareness in precision medicine. Polyomics, big data, and systems biology have demonstrated a profound complexity and dynamic variability in allergic disease between individuals, as well as between regions. Escalating health care costs together with questionable efficacy of the current management of allergic diseases facilitated the emergence of the endotype-driven approach. We describe here a precision medicine approach that stratifies patients based on disease mechanisms to optimize management of allergic diseases.
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Affiliation(s)
- Ioana Agache
- Transylvania University, Faculty of Medicine, Brasov, Romania
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
- Christine Kühne – Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
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50
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Ahmet A, Mokashi A, Goldbloom EB, Huot C, Jurencak R, Krishnamoorthy P, Rowan-Legg A, Kim H, Pancer L, Kovesi T. Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children. BMJ Paediatr Open 2019; 3:e000569. [PMID: 31750407 PMCID: PMC6830460 DOI: 10.1136/bmjpo-2019-000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022] Open
Abstract
Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.
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Affiliation(s)
- Alexandra Ahmet
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Pediatrics, Division of Endocrinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ellen B Goldbloom
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Celine Huot
- Pediatrics, Division of Endocrinology, University of Montreal, Montreal, Quebec, Canada.,Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Roman Jurencak
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Preetha Krishnamoorthy
- Pediatrics, Division of Endocrinology, Montreal Childrens Hospital, Montreal, Quebec, Canada.,Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Anne Rowan-Legg
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Joseph's Hospital, London, Ontario, Canada
| | - Larry Pancer
- Pediatrics, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Tom Kovesi
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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