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Chastain DB, Spradlin M, Ahmad H, Henao-Martínez AF. Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults. Clin Infect Dis 2024; 78:e37-e56. [PMID: 37669916 DOI: 10.1093/cid/ciad474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 09/07/2023] Open
Abstract
Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Megan Spradlin
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hiba Ahmad
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Okihara M, Takeuchi H, Kikuchi Y, Akashi I, Kihara Y, Konno O, Iwamoto H, Oda T, Tanaka S, Unezaki S, Hirano T. Individual Lymphocyte Sensitivity to Steroids as a Reliable Biomarker for Clinical Outcome after Steroid Withdrawal in Japanese Renal Transplantation. J Clin Med 2021; 10:jcm10081670. [PMID: 33924724 PMCID: PMC8070672 DOI: 10.3390/jcm10081670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/17/2022] Open
Abstract
Recently, steroid reduction/withdrawal regimens have been attempted to minimize the side effects of steroids in renal transplantation. However, some recipients have experienced an increase/resumption of steroid administrations and acute graft rejection (AR). Therefore, we investigated the relationship between the individual lymphocyte sensitivity to steroids and the clinical outcome after steroid reduction/withdrawal. We cultured peripheral blood mononuclear cells (PBMCs) isolated from 24 recipients with concanavalin A (Con A) in the presence of methylprednisolone (MPSL) or cortisol (COR) for four days, and the 50% of PBMC proliferation (IC50) values and the PBMC sensitivity to steroids were calculated. Regarding the experience of steroid increase/resumption and incidence of AR within one year of steroid reduction/withdrawal, the IC50 values of these drugs before transplantation in the clinical event group were significantly higher than those in the event-free group. The cumulative incidence of steroid increase/resumption and AR in the PBMC high-sensitivity groups to these drugs before transplantation were significantly lower than those in the low-sensitivity groups. These observations suggested that an individual’s lymphocyte sensitivity to steroids could be a reliable biomarker to predict the clinical outcome after steroid reduction/withdrawal and to select the patients whose dose of steroids can be decreased and/or withdrawn after transplantation.
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Affiliation(s)
- Masaaki Okihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hironori Takeuchi
- Department of Pharmacy, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Yukiko Kikuchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Isao Akashi
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Yu Kihara
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Osamu Konno
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan; (M.O.); (I.A.); (Y.K.); (O.K.); (H.I.)
| | - Takashi Oda
- Department of Nephrology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan;
| | - Sachiko Tanaka
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
| | - Sakae Unezaki
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (Y.K.); (S.U.)
| | - Toshihiko Hirano
- Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan;
- Correspondence: ; Tel.: +81-042-676-5794
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Hirano T. Cellular pharmacodynamics of immunosuppressive drugs for individualized medicine. Int Immunopharmacol 2007; 7:3-22. [PMID: 17161812 DOI: 10.1016/j.intimp.2006.09.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 09/04/2006] [Accepted: 09/17/2006] [Indexed: 12/13/2022]
Abstract
The therapeutic effects of immunosuppressive drugs are known to deviate largely between patients, but efficient strategies for the differentiation of patients who show clinical resistance to immunosuppressive therapies have not been established. Accordingly, a considerable number of patients receive treatment with immunosuppressive drugs despite the onset of serious side effects and poor responses. Cellular pharmacodynamics of immunosuppressive drugs in vitro using peripheral lymphocytes derived from each patient, an attractive way to distinguish resistant patients, is respected and has been applied to the carrying out of individualized immunosuppressive therapy. In this article, I summarize experimental procedures for assaying immune cell responses to immunosuppressive drugs in vitro, and highlight the relationship between cellular sensitivity to immunosuppressive drugs and the therapeutic efficacy of drugs in organ transplantation and several immunological disorders. I will also overview the molecular mechanisms and genetic bases for cellular and clinical resistance to immunosuppressive drugs. Lastly, the future clinical prospects for the application of in vitro drug sensitivity tests for "patient-tailored" immunosuppressive therapies are discussed.
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Affiliation(s)
- Toshihiko Hirano
- Department of Clinical Pharmacology, School of Pharmacy, Tokyo University of Pharmacy and Life Science, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan.
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Abstract
Acute exacerbations of asthma may represent reactions to airway irritants or failures of chronic treatment. The costs to both the patient and society are high. Exacerbations often are frightening episodes that can cause significant morbidity and sometimes death. The emergency department (ED) visits and hospitalizations often required lead to significant health care expenses. Thus, preventing and optimizing management of acute exacerbations is critical. Corticosteroids are a cornerstone of asthma therapy. They have been shown to lower admission rates and reduce risk of relapse. This article provides an overview of the role of corticosteroids (including betamethasone, dexamethasone, methylprednisolone, and prednisolone) in the management of acute asthma exacerbations, with an aim toward effective decision making about the choice of therapy.
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Affiliation(s)
- Stanley B Fiel
- Department of Medicine, Morristown Memorial Hospital, Morristown, New Jersey, USA.
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Czock D, Keller F, Rasche FM, Häussler U. Pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids. Clin Pharmacokinet 2005; 44:61-98. [PMID: 15634032 DOI: 10.2165/00003088-200544010-00003] [Citation(s) in RCA: 569] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glucocorticoids have pleiotropic effects that are used to treat diverse diseases such as asthma, rheumatoid arthritis, systemic lupus erythematosus and acute kidney transplant rejection. The most commonly used systemic glucocorticoids are hydrocortisone, prednisolone, methylprednisolone and dexamethasone. These glucocorticoids have good oral bioavailability and are eliminated mainly by hepatic metabolism and renal excretion of the metabolites. Plasma concentrations follow a biexponential pattern. Two-compartment models are used after intravenous administration, but one-compartment models are sufficient after oral administration.The effects of glucocorticoids are mediated by genomic and possibly nongenomic mechanisms. Genomic mechanisms include activation of the cytosolic glucocorticoid receptor that leads to activation or repression of protein synthesis, including cytokines, chemokines, inflammatory enzymes and adhesion molecules. Thus, inflammation and immune response mechanisms may be modified. Nongenomic mechanisms might play an additional role in glucocorticoid pulse therapy. Clinical efficacy depends on glucocorticoid pharmacokinetics and pharmacodynamics. Pharmacokinetic parameters such as the elimination half-life, and pharmacodynamic parameters such as the concentration producing the half-maximal effect, determine the duration and intensity of glucocorticoid effects. The special contribution of either of these can be distinguished with pharmacokinetic/pharmacodynamic analysis. We performed simulations with a pharmacokinetic/pharmacodynamic model using T helper cell counts and endogenous cortisol as biomarkers for the effects of methylprednisolone. These simulations suggest that the clinical efficacy of low-dose glucocorticoid regimens might be increased with twice-daily glucocorticoid administration.
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Affiliation(s)
- David Czock
- Division of Nephrology, University Hospital Ulm, Robert-Koch-Str. 8, Ulm 89081, Germany
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Sekido H, Matsuo K, Takeda K, Morioka D, Kubota T, Tanaka K, Endo I, Togo S, Inayama Y, Nakatani Y, Hirano T, Shimada H. Successful conversion from prednisolone to methylprednisolone for immunosuppression: a case report. Transplant Proc 2003; 35:223-4. [PMID: 12591373 DOI: 10.1016/s0041-1345(02)03988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- H Sekido
- Department of Surgery II, Yokohama City University, School of Medicine, Yokohama, Japan
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Hirano T, Akashi T, Kido T, Oka K, Shiratori T, Miyaoka M. Immunosuppressant pharmacodynamics on peripheral-blood mononuclear cells from patients with ulcerative colitis. Int Immunopharmacol 2002; 2:1055-63. [PMID: 12349943 DOI: 10.1016/s1567-5769(02)00077-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We investigated peripheral-blood mononuclear cell (PBMC) response to immunosuppressive drugs and its influence on glucocorticoid therapy in ulcerative colitis (UC). IC50s of immunosuppressive drugs on in vitro blastogenesis of PBMCs stimulated with concanavalin A were estimated in 76 UC and 146 healthy subjects. Individual differences in IC50s for prednisolone, methylprednisolone, cyclosporine, and tacrolimus on blastogenesis of PBMCs from UC patients were spread from 11.0 to 1000, 0.6 to 1000, 0.01 to 1000, and 0.001 to 4.6 ng/ml, respectively. Normal upper thresholds for IC50s of these drugs were estimated from the mean + 2 S.D. of the IC50s of healthy PBMCs, and the patients exhibiting IC50s over these levels were arbitrarily considered as resistant. The incidences of resistance to glucocorticoids and cyclosporine in UC were significantly higher than those in healthy subjects (p < 0.0005). In 14 UC patients, there was a significant correlation between amounts of prednisolone (p < 0.05) or period of prednisolone administration (p < 0.05) for UC treatment and prednisolone IC50. The results showed that large individual deviations in PBMC response to the drugs were observed in UC, and UC patients exhibiting low PBMC sensitivity to prednisolone required a high prednisolone amount as well as long period of prednisolone administration for treatment. Thus, the drug sensitivity tests could be informative to single out refractory patients to the immunosuppressive therapy.
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Affiliation(s)
- Toshihiko Hirano
- Department of Clinical Pharmacology, School of Pharmacy, Tokyo University of Pharmacy and Life Science, Japan.
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