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Lockett J, Inder WJ, Clifton VL. The Glucocorticoid Receptor: Isoforms, Functions, and Contribution to Glucocorticoid Sensitivity. Endocr Rev 2024; 45:593-624. [PMID: 38551091 PMCID: PMC11244253 DOI: 10.1210/endrev/bnae008] [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] [Received: 11/15/2023] [Indexed: 07/13/2024]
Abstract
Glucocorticoids exert pleiotropic effects on all tissues to regulate cellular and metabolic homeostasis. Synthetic forms are used therapeutically in a wide range of conditions for their anti-inflammatory benefits, at the cost of dose and duration-dependent side effects. Significant variability occurs between tissues, disease states, and individuals with regard to both the beneficial and deleterious effects. The glucocorticoid receptor (GR) is the site of action for these hormones and a vast body of work has been conducted understanding its function. Traditionally, it was thought that the anti-inflammatory benefits of glucocorticoids were mediated by transrepression of pro-inflammatory transcription factors, while the adverse metabolic effects resulted from direct transactivation. This canonical understanding of the GR function has been brought into question over the past 2 decades with advances in the resolution of scientific techniques, and the discovery of multiple isoforms of the receptor present in most tissues. Here we review the structure and function of the GR, the nature of the receptor isoforms, and the contribution of the receptor to glucocorticoid sensitivity, or resistance in health and disease.
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Affiliation(s)
- Jack Lockett
- Mater Research Institute, The University of Queensland, Translational Research Institute, Woolloongabba, QLD 4101, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD 4006, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Metro South Health, Woolloongabba, QLD 4102, Australia
| | - Warrick J Inder
- Faculty of Medicine, The University of Queensland, Herston, QLD 4006, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Metro South Health, Woolloongabba, QLD 4102, Australia
| | - Vicki L Clifton
- Mater Research Institute, The University of Queensland, Translational Research Institute, Woolloongabba, QLD 4101, Australia
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2
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Brennan V, Martin-Grace J, Greene G, Heverin K, Mulvey C, McCartan T, Lombard L, Walsh J, Hale EM, Srinivasan S, O'Reilly MW, Thompson CJ, Costello RW, Sherlock M. The Contribution of Oral and Inhaled Glucocorticoids to Adrenal Insufficiency in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2614-2623. [PMID: 35697207 DOI: 10.1016/j.jaip.2022.05.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Exposure to any form of glucocorticoid preparation is associated with a risk of adrenal insufficiency (AI). OBJECTIVE To establish the contribution of oral corticosteroid (OCS) and inhaled corticosteroid (ICS) exposure to the risk of AI in a cohort of patients (n = 80) with severe, uncontrolled asthma. METHODS We compiled individualized cumulative OCS and ICS exposure data using a combination of health care records and electronic inhaler monitoring using an Inhaler Compliance Assessment device and estimated the risk of AI for each participant using a morning serum cortisol concentration. RESULTS The predicted prevalence of AI based on morning cortisol concentrations was 25% (20 of 80). Participants on maintenance OCS therapy had the highest risk of AI at 60% (6 of 10) compared with 17% (11 of 65) in those with no recent OCS exposure. Morning serum cortisol correlated negatively with both OCS exposure (mg/kg prednisolone) (r = -0.4; P < .0002) and ICS exposure (mg/kg fluticasone propionate) (r = -0.26; P = .019). Logistic regression of risk of AI against the number of standard treatment courses of OCS demonstrated a positive relationship although this did not reach statistical significance (odds ratio, 1.41; 95% CI, 0.97-2.05; P = .073). Logistic regression analysis, categorizing patients as high-risk AI (cortisol <130 nmol/L) or not (cortisol >130 nmol/L), showed that cumulative ICS exposure remained a significant predictor of AI, even when exposure to OCS was controlled for (odds ratio, 2.17 per 1 mg/kg increase in cumulative fluticasone propionate exposure; 95% CI, 1.06-4.42; P = .033). CONCLUSIONS Our data suggest that AI is common among patients with asthma and highlights that the risk of AI is associated with both high-dose ICS therapy and intermittent treatment courses of OCS.
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Affiliation(s)
- Vincent Brennan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Julie Martin-Grace
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Garrett Greene
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Karen Heverin
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Christopher Mulvey
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Tom McCartan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Lorna Lombard
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Joanne Walsh
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Elaine Mac Hale
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Shari Srinivasan
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Chris J Thompson
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma Strategy 2021. Executive Summary and Rationale for Key Changes. Arch Bronconeumol 2022; 58:35-51. [DOI: 10.1016/j.arbres.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022]
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Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S1-S18. [PMID: 34718211 DOI: 10.1016/j.jaip.2021.10.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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5
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Eur Respir J 2021; 59:13993003.02730-2021. [PMID: 34667060 PMCID: PMC8719459 DOI: 10.1183/13993003.02730-2021] [Citation(s) in RCA: 231] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes.GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA.Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4.Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia.
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Respirology 2021; 27:14-35. [PMID: 34668278 DOI: 10.1111/resp.14174] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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7
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive Summary and Rationale for Key Changes. Am J Respir Crit Care Med 2021; 205:17-35. [PMID: 34658302 PMCID: PMC8865583 DOI: 10.1164/rccm.202109-2205pp] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults/adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The University of Sydney, 4334, Woolcock Institute of Medical Research,, Sydney, New South Wales, Australia;
| | - Leonard B Bacharier
- Vanderbilt University Medical Center, 12328, Monroe Carell Jr Children's Hospital , Nashville, Tennessee, United States
| | - Eric D Bateman
- University of Cape Town Department of Medicine, 71984, Observatory, Western Cape, South Africa
| | - Christopher E Brightling
- NIHR Leicester Biomedical Research Centre, 573772, Leicester, United Kingdom of Great Britain and Northern Ireland
| | - Guy G Brusselle
- University Hospital Ghent, 60200, Ghent, Belgium and Erasmus MC University Medical Center, Rotterdam, Belgium
| | - Roland Buhl
- Mainz University Hospital, Pulmonary Department, Mainz, Germany
| | - Alvaro A Cruz
- Universidade Federal da Bahia, 28111, ProAR-Center of Excellence in Asthma, Salvador, Brazil
| | - Liesbeth Duijts
- Erasmus MC, 6993, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - J Mark FitzGerald
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Louise J Fleming
- Imperial College London, 4615, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Fanny W Ko
- The Chinese University of Hong Kong, 26451, Hong Kong, Hong Kong
| | - Jerry A Krishnan
- University of Illinois at Chicago, 14681, Breathe Chicago Center, Chicago, Illinois, United States
| | - Mark L Levy
- Locum GP, London, United Kingdom of Great Britain and Northern Ireland
| | - Jiangtao Lin
- Peking University, 12465, China-Japan Friendship Hospital, Beijing, China
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, 9655, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Paulo M Pitrez
- Hospital Moinhos de Vento, 156417, Porto Alegre, Rio Grande do Sul, Brazil
| | - Aziz Sheikh
- The University of Edinburgh, 3124, Usher Institute, Edinburgh, United Kingdom of Great Britain and Northern Ireland
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Trends in oral corticosteroids use in severe asthma: a 14-year population-based study. Respir Res 2021; 22:103. [PMID: 33836765 PMCID: PMC8034163 DOI: 10.1186/s12931-021-01696-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral corticosteroids are important components of pharmacotherapy in severe asthma. Our objective was to describe the extent, trends, and factors associated with exposure to oral corticosteroids (OCS) in a severe asthma cohort. METHODS We used administrative health databases of British Columbia, Canada (2000-2014) and validated algorithms to retrospectively create a cohort of severe asthma patients. Exposure to OCS within each year of follow-up was measured in two ways: maintenance use as receiving on average ≥ 2.5 mg/day (prednisone-equivalent) OCS, and episodic use as the number of distinct episodes of OCS exposure for up to 14 days. Trends and factors associated with exposure on three time axes (calendar year, age, and time since diagnosis) were evaluated using Poisson regression. RESULTS 21,144 patients (55.4% female; mean entry age 28.7) contributed 40,803 follow-up years, in 8.2% of which OCS was used as maintenance therapy. Maintenance OCS use declined by 3.8%/calendar year (p < 0.001). The average number of episodes of OCS use was 0.89/year, which increased by 1.1%/calendar year (p < 0.001). Trends remained significant for both exposure types in adjusted analyses. Both maintenance and episodic use increased by age and time since diagnosis. CONCLUSIONS This population-based study documented a secular downward trend in maintenance OCS use in a period before widespread use of biologics. This might have been responsible for a higher rate of exacerbations that required episodic OCS therapy. Such trends in OCS use might be due to changes in the epidemiology of severe asthma, or changes in patient and provider preferences over time.
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Alahmadi FH, Simpson AJ, Gomez C, Ericsson M, Thörngren JO, Wheelock CE, Shaw DE, Fleming LJ, Roberts G, Riley J, Bates S, Sousa AR, Knowles R, Bansal AT, Corfield J, Pandis I, Sun K, Bakke PS, Caruso M, Chanez P, Dahlén B, Horvath I, Krug N, Montuschi P, Singer F, Wagers S, Adcock IM, Djukanovic R, Chung KF, Sterk PJ, Dahlen SE, Fowler SJ. Medication Adherence in Patients With Severe Asthma Prescribed Oral Corticosteroids in the U-BIOPRED Cohort. Chest 2021; 160:53-64. [PMID: 33610577 DOI: 10.1016/j.chest.2021.02.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high. RESEARCH QUESTIONS What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity? STUDY DESIGN AND METHODS Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry. RESULTS Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV1, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels. INTERPRETATION Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.
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Affiliation(s)
- Fahad H Alahmadi
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England; Respiratory Therapy Department, College of Medical Rehabilitation Sciences, Taibah University, Medina, Saudi Arabia
| | - Andrew J Simpson
- Division of Sport, Health and Exercise Science, University of Hull, Hull, England
| | - Cristina Gomez
- The Centre for Allergy Research, The Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Ericsson
- The Doping Laboratory, The Department of Laboratory Medicine at the Karolinska University Hospital Huddinge, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - John-Olof Thörngren
- The Doping Laboratory, The Department of Laboratory Medicine at the Karolinska University Hospital Huddinge, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Craig E Wheelock
- Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden; Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Dominic E Shaw
- Respiratory Research Unit, University of Nottingham, Nottingham, England
| | - Louise J Fleming
- National Heart and Lung Institute, Imperial College London, London, England
| | - Graham Roberts
- NIHR Southampton Respiratory Biomedical Research Unit, Clinical and Experimental Sciences and Human Development and Health, Southampton, England
| | - John Riley
- Respiratory Therapeutic Unit, GlaxoSmithKline, Stockley Park, London, England
| | - Stewart Bates
- Respiratory Therapeutic Unit, GlaxoSmithKline, Stockley Park, London, England
| | - Ana R Sousa
- Respiratory Therapeutic Unit, GlaxoSmithKline, Stockley Park, London, England
| | | | - Aruna T Bansal
- Acclarogen Ltd, St John's Innovation Centre, Cambridge, England
| | | | - Ioannis Pandis
- Data Science Institute, South Kensington Campus, Imperial College London, London, England
| | - Kai Sun
- Data Science Institute, South Kensington Campus, Imperial College London, London, England
| | - Per S Bakke
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Massimo Caruso
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pascal Chanez
- Assistance Publique-Hôpitaux de Marseille, Clinique des Bronches, de l'Allergie et du Sommeil CIC Nord, Aix-Marseille Université, Marseille, France
| | - Barbro Dahlén
- Division of Respiratory Medicine and Allergy, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ildiko Horvath
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Norbert Krug
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | | | - Florian Singer
- Division of Respiratory Medicine, Department of Pediatrics, Inselspital University Hospital Bern, University of Bern, Switzerland
| | | | - Ian M Adcock
- National Heart and Lung Institute, Imperial College London, London, England
| | - Ratko Djukanovic
- NIHR Southampton Respiratory Biomedical Research Unit, Clinical and Experimental Sciences and Human Development and Health, Southampton, England
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London, England
| | - Peter J Sterk
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sven-Erik Dahlen
- The Centre for Allergy Research, The Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, and Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England.
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Busby J, Khoo E, Pfeffer PE, Mansur AH, Heaney LG. The effects of oral corticosteroids on lung function, type-2 biomarkers and patient-reported outcomes in stable asthma: A systematic review and meta-analysis. Respir Med 2020; 173:106156. [PMID: 32979621 DOI: 10.1016/j.rmed.2020.106156] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Several studies have investigated the physiological effect of OCS in stable asthma, however these have included heterogeneous populations and outcomes. This paper is the first to combine their results. METHODS We searched Medline, Embase and Web of Science databases for studies reporting the impact of OCS on FEV1, FVC, blood eosinophils, fractional exhaled nitric oxide (FeNO), Asthma Control Questionnaire (ACQ) score or Asthma Quality Of Life Questionnaire (AQLQ) score in stable asthma. We extracted data on the correlates of OCS response. RESULTS 61 studies, comprising 1608 patients, were included. FEV1 was improved by 9% (95% CI: 7, 11). There were stronger increases in FEV1 among those with a mean baseline FEV1<60% predicted (19%, 95% CI: 13, 24). Despite these improvements, substantial residual impairment remained after treatment. Blood eosinophils were reduced by 76% (95% CI: 63, 88) with larger decreases in studies of corticosteroid-naïve patients (93%, 95% CI: 73,100). Sputum eosinophils were reduced by 89% (95% CI: 79, 98) while FeNO was decreased by 35% (95% CI: 28, 41). ACQ scores were reduced by 20% (95% CI: 11, 29). Patients with higher baseline lung function impairment, sputum eosinophils, blood eosinophils and FeNO had improved OCS response. INTERPRETATION OCS consistently improves lung function, reduces markers of type-2 inflammation, and alleviates asthma symptoms. However, substantial residual impairment remained following treatment and mean improvements were below the minimally important clinically difference. Patients with increased markers of type-2 inflammation are more responsive to treatment, suggesting these should be used to better target OCS use.
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Affiliation(s)
| | | | | | - Adel H Mansur
- University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
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11
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Lipworth B, Chan R, Kuo CR. Systemic effects of fluticasone on blood eosinophils in bronchiectasis. Eur Respir J 2020; 56:56/3/2002005. [PMID: 32883758 DOI: 10.1183/13993003.02005-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School Dundee, Dundee, Scotland UK
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12
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Lipworth B, Chan R, Kuo CR. Diagnosing adrenal insufficiency using ACTH stimulation test. Eur Respir J 2020; 56:56/2/2001478. [PMID: 32763962 DOI: 10.1183/13993003.01478-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/19/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee Scotland, UK
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13
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Lipworth B, Kuo CR, Chan R. Systemic potency of fluticasone in asthma. Eur Respir J 2020; 55:55/3/2000104. [PMID: 32139592 DOI: 10.1183/13993003.00104-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Rory Chan
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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14
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Berthon BS, Gibson PG, McElduff P, MacDonald-Wicks LK, Wood LG. Effects of short-term oral corticosteroid intake on dietary intake, body weight and body composition in adults with asthma - a randomized controlled trial. Clin Exp Allergy 2016; 45:908-919. [PMID: 25640664 DOI: 10.1111/cea.12505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/02/2014] [Accepted: 11/12/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral corticosteroids (OCS) are an efficacious treatment for asthma exacerbations, yet risk of adverse effects may decrease patient adherence to therapy. In particular, changes in appetite and dietary intake, which lead to weight gain and changes in body composition, are considered undesirable. OBJECTIVE To determine whether 10-day OCS therapy in adults with asthma causes changes in leptin, appetite, dietary intake, body weight and body composition. METHODS Double-blinded, placebo-controlled randomized cross-over trial of 10 days prednisolone (50 mg) in adults with stable asthma (n = 55) (ACTRN12611000562976). Pre- and post-assessment included spirometry, body weight, body composition measured by dual-energy X-ray absorptiometry and bioelectrical impedance analysis, appetite measured using a validated visual analogue scale (VAS) and dietary intake assessed using 4-day food records. Leptin was measured as a biomarker of appetite and eosinophils as an adherence biomarker. Outcomes were analysed by generalized linear mixed models. RESULTS Subject adherence was confirmed by a significant decrease in blood eosinophils (× 10(9) /L) following prednisolone compared to placebo [Coef. -0.29, 95% CI: (-0.39, -0.19) P < 0.001]. There was no difference in serum leptin (ng/mL) [Coef. 0.13, 95% CI: (-3.47, 3.72) P = 0.945] or appetite measured by VAS (mm) [Coef. -4.93, 95% CI: (-13.64, 3.79) P = 0.267] following prednisolone vs. placebo. There was no difference in dietary intake (kJ/day) [Coef. 255, 95% CI: (-380, 891) P = 0.431], body weight (kg) [Coef. -0.38, 95% CI: (-0.81, 0.05) P = 0.083] or body fat (%) [Coef. -0.31, 95% CI: (-0.81, 0.20) P = 0.230]. Symptoms including sleep and gastrointestinal disturbance were reported significantly more often during prednisolone vs. placebo. CONCLUSIONS AND CLINICAL RELEVANCE Short-term OCS in stable asthma did not induce significant changes in appetite, dietary intake, body weight or composition, although other adverse effects may require medical management. This evidence may assist in increasing medication adherence of asthmatics prescribed OCS for exacerbations.
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Affiliation(s)
- B S Berthon
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P G Gibson
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - L K MacDonald-Wicks
- School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - L G Wood
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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15
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Lipworth BJ. Biomarkers to predict inhaled corticosteroid response. J Allergy Clin Immunol 2015; 136:515. [PMID: 26070882 DOI: 10.1016/j.jaci.2015.04.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom.
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16
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Downing HE, Carroll F, Brookes ST, Hollinghurst S, Timmins D, Orton E, Wang K, Kendrick D, Little P, Moore MV, Harnden A, Thompson M, May MT, Hay AD. Can oral corticosteroids reduce the severity or duration of an acute cough, and the associated National Health Service and societal costs, in adults presenting to primary care? Study protocol for a randomised controlled trial. Trials 2015; 16:78. [PMID: 25885677 PMCID: PMC4358709 DOI: 10.1186/s13063-015-0569-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute lower respiratory tract infection (LRTI) is one of the most common conditions managed internationally and is costly to health services and patients. Despite good evidence that antibiotics are not effective for improving the symptoms of uncomplicated LRTI, they are widely prescribed, contributing to antimicrobial resistance. Many of the symptoms observed in LRTI are mediated by inflammatory processes also observed in exacerbations of asthma, for which there is strong evidence of corticosteroid effectiveness. The primary aim of the OSAC (Oral Steroids for Acute Cough) Trial is to determine whether oral prednisolone (40 mg daily for 5 days) can reduce the duration of moderately bad (or worse) cough and the severity of all its associated symptoms on days 2 to 4 post-randomisation (day 1 is trial entry) by at least 20% in adults ≥18 years with acute LRTI presenting to primary care. METHODS/DESIGN OSAC is a two-arm, multi-centre, placebo-controlled, randomised superiority trial. The target sample size is 436 patients, which allows for a 20% dropout rate. Patients will be recruited from primary care sites (General Practitioner surgeries) across England and followed up until symptom resolution. The two primary clinical outcomes are the duration of moderately bad (or worse) cough, and the severity of all its associated symptoms on days 2 to 4 post-randomisation. Secondary outcomes include: antibiotic consumption; symptom burden; adverse events; participant satisfaction with treatment and intention to consult for future similar illnesses. A parallel economic evaluation will investigate the cost-effectiveness of the intervention. DISCUSSION Results from the OSAC trial will increase knowledge regarding the clinical and cost-effectiveness of corticosteroids for LRTI, and will establish the potential of a new treatment option that could substantially improve patient health. We have chosen a relatively high 'efficacy dose' as this will enable us to decide on the potential for further research into lower dose oral and/or inhaled corticosteroids. This trial will also contribute to a growing body of research investigating the natural course of this very common illness, as well as the effects of steroids on the undesirable inflammatory symptoms associated with infection. TRIAL REGISTRATION Current Controlled Trials ISRCTN57309858 (31 January 2013).
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Affiliation(s)
- Harriet E Downing
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Fran Carroll
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Sara T Brookes
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - David Timmins
- Nuffield Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Elizabeth Orton
- Division of Primary Care, University of Nottingham, Floor 13, Tower Building, University Park, Nottingham, NG7 2RD, UK.
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Denise Kendrick
- Division of Primary Care, University of Nottingham, Floor 13, Tower Building, University Park, Nottingham, NG7 2RD, UK.
| | - Paul Little
- University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO15 5ST, UK.
| | - Mike V Moore
- University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO15 5ST, UK.
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Matthew Thompson
- Nuffield Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Margaret T May
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
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Stokes FJ, Bailey LM, Ganguli A, Davison AS. Assessment of endogenous, oral and inhaled steroid cross-reactivity in the Roche cortisol immunoassay. Ann Clin Biochem 2013; 51:503-6. [PMID: 24150482 DOI: 10.1177/0004563213509793] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Inhaled steroids are widely used for the treatment of asthma. Concerns over adrenal suppression when used at high doses or in combination with drugs such as ritonavir exist, requiring the measurement of serum cortisol. Herein, we investigate the cross-reactivity of the inhaled steroids betamethasone, fluticasone and beclomethasone in the Roche cortisol immunoassay, in addition to five other steroids. METHODS Five replicates were produced from a serum pool for each of the eight steroids at a final concentration of 0.1 and 1 µg/mL. Each steroid was dissolved in 50% methanol, with 50% methanol of the same volume added to the control sample. The cross-reactivity of each steroid in the cortisol assay was calculated. RESULTS There was no statistically or clinically significant cross-reactivity in the measurement of cortisol when fluticasone, beclomethasone or betamethasone were spiked at 0.1 and 1.0 µg/mL, except for beclomethasone at a concentration of 1 µg/mL (1490 nmol/L) with a cross-reactivity of 1.6%, which is unlikely to be clinically significant. At both steroid concentrations investigated, prednisolone, 17-hydroxyprogesterone and 11-deoxycortisol exhibited statistically significant cross-reactivities that were greater than the least significant change of the assay (13.1%), whereas dexamethasone and metyrapone did not. Mean inter-assay precision was 1.5% (405-1586 nmol/L). CONCLUSION The cross-reactivity of the inhaled steroids; betamethasone, fluticasone and beclomethasone in the Roche cortisol immunoassay are unlikely to be clinically significant at the concentrations found in patients on therapeutic doses. This will enable confident assessment of adrenal status in patients at risk of adrenal suppression.
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Affiliation(s)
- F J Stokes
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - L M Bailey
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - A Ganguli
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - A S Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
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18
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Colice G, Martin RJ, Israel E, Roche N, Barnes N, Burden A, Polos P, Dorinsky P, Hillyer EV, Lee AJ, Chisholm A, von Ziegenweidt J, Barion F, Price D. Asthma outcomes and costs of therapy with extrafine beclomethasone and fluticasone. J Allergy Clin Immunol 2013; 132:45-54. [PMID: 23591272 DOI: 10.1016/j.jaci.2013.02.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 02/06/2013] [Accepted: 02/11/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Characteristics of inhaled corticosteroids (ICSs) differ, but data comparing the real-life effectiveness of various ICSs for asthma are lacking. OBJECTIVE We sought to compare real-life asthma outcomes and costs of extrafine hydrofluoroalkane (HFA)-beclomethasone and fluticasone administered through a pressurized metered-dose inhaler. METHODS This retrospective matched cohort study examined database markers of asthma control from a large US longitudinal health care claims database over 1 baseline and 1 outcome year for 10,312 patients with asthma aged 12 to 80 years receiving their first ICS as HFA-beclomethasone or fluticasone and matched on baseline demographic characteristics and asthma severity. RESULTS Patients started on HFA-beclomethasone had significantly higher odds (adjusted odds ratio, 1.19; 95% CI; 1.08-1.31) of achieving overall control (risk and impairment), which was defined as no hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory tract infection and less than 2 puffs per day of short-acting β-agonist; they also experienced a lower rate of respiratory-related hospitalizations or referrals (adjusted rate ratio, 0.82; 95% CI, 0.73-0.93) than patients started on fluticasone. Other database outcome measures were similar in the 2 cohorts. Prescribed HFA-beclomethasone doses were lower (P < .001) than fluticasone doses (median, 320 μg/d [interquartile range, 160-320 μg/d] vs 440 μg/d [interquartile range, 176-440 μg/d]). Adjusted respiratory-related health care costs were significantly lower for HFA-beclomethasone than fluticasone (mean, $1869 [95% CI, $1727-$2032] vs $2259 [95% CI, $2111-$2404]), representing a mean annual savings of $390 (95% CI, $165-$620) per patient prescribed HFA-beclomethasone rather than fluticasone. CONCLUSIONS Asthma treatment outcomes were similar or better with HFA-beclomethasone prescribed at significantly lower doses and with lower costs than fluticasone.
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Affiliation(s)
- Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
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Gamble J, Stevenson M, McClean E, Heaney LG. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med 2009; 180:817-22. [PMID: 19644048 DOI: 10.1164/rccm.200902-0166oc] [Citation(s) in RCA: 295] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE With the advent of new and expensive therapies for severe refractory asthma, targeting the appropriate patients is important. An important issue is identifying nonadherence with current therapies. The extent of nonadherence in a population with difficult asthma has not been previously reported. OBJECTIVES To examine the prevalence of nonadherence to corticosteroid medication in a population with difficult asthma referred to a Specialist Clinic and to examine the relationship of poor adherence to asthma outcome. METHODS General practitioner prescription refill records for the previous 6 months for inhaled combination therapy and short-acting beta-agonists were compared with initial prescriptions and expressed as a percentage. Blood plasma prednisolone and cortisol assay levels were used to examine the utility of these measures in assessing adherence to oral prednisolone. Patient demographics, hospital admissions, lung function, oral prednisolone courses, and quality of life data were analyzed to indentify the variables associated with reduced medication adherence. MEASUREMENTS AND MAIN RESULTS A total of 182 patients were assessed. Sixty-three patients (35%) filled 50% or fewer inhaled medication prescriptions; 88% admitted poor adherence with inhaled therapy after initial denial. Twenty-one percent of patients filled more than 100% of presciptions, and 45% of subjects filled between 51 and 100% of prescriptions. Twenty-three of 51 patients (45%) prescribed oral steroids were found to be nonadherent. CONCLUSIONS A significant proportion of patients with difficult-to-control asthma remained nonadherent to corticosteroid therapy. Objective surrogate and direct measures of adherence should be performed as part of a difficult asthma assessment and are important before prescibing expensive novel biological therapies.
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Affiliation(s)
- Jacqueline Gamble
- Centre for Infection and Immunity, Queen's University of Belfast, Northern Ireland, UK
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20
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van den Berge M, Arshad SH, Ind PW, Magnussen H, Hamelmann E, Kanniess F, Postma DS. Similar efficacy of ciclesonide versus prednisolone to treat asthma worsening after steroid tapering. Respir Med 2009; 103:1216-23. [PMID: 19297141 DOI: 10.1016/j.rmed.2009.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 01/27/2009] [Accepted: 01/27/2009] [Indexed: 11/25/2022]
Abstract
RATIONALE Oral corticosteroids effectively treat asthma exacerbations but are associated with well-described side effects. OBJECTIVE This study compared the efficacy and safety of a high dose of an inhaled corticosteroid with oral prednisolone in patients with worsening of their asthma after medication withdrawal. METHODS Patients tapered off their inhaled corticosteroids until they reached predefined criteria of "worsening asthma". Randomized patients (n=130) were treated double blind with either ciclesonide 800mug twice daily (starting with 800mug hourly for 3h after randomization) or prednisolone 40mg once daily for 2 weeks. Spirometry, daily asthma symptoms, morning and evening peak expiratory flow and blood parameters were assessed in all, methacholine challenge and inflammatory measures were determined in induced sputum in a subset of patients. RESULTS Ciclesonide was as effective as prednisolone in improving forced expiratory flow in 1s, morning peak expiratory flow and symptoms, the latter improving more rapidly with ciclesonide. No differences were found in methacholine responsiveness or inflammatory measures in sputum or blood. Ciclesonide caused significantly less reduction in morning plasma cortisol levels (p<0.0001). CONCLUSION This study shows that inhaled ciclesonide (800mug twice daily) has comparable efficacy to oral prednisolone (40mg once daily) to regain asthma control in patients with asthma worsening. The more rapid onset and smaller effect on cortisol suppression suggest a better safety profile of ciclesonide.
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Affiliation(s)
- M van den Berge
- Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands.
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21
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Role of Prednisolone Pharmacokinetics in Postchallenge Glycemia After Renal Transplantation. Ther Drug Monit 2008; 30:583-90. [DOI: 10.1097/ftd.0b013e318187bb2f] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Suzuki M, Otake R, Kashio A. Effect of Corticosteroids or Diuretics in Low-Tone Sensorineural Hearing Loss. ORL J Otorhinolaryngol Relat Spec 2006; 68:170-6. [PMID: 16465072 DOI: 10.1159/000091343] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Accepted: 09/30/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We retrospectively analyzed 225 patients with acute low-tone sensorineural hearing loss (ALSHL), comparing the effectiveness of corticosteroid and diuretic therapy, and also determining the factors affecting hearing recovery. DESIGN Retrospective clinical record review. METHODS Multivariate logistic regression analysis. RESULTS Analyses identified unfavorable factors such as aging, late initiation of treatment, and pretreatment pure-tone hearing thresholds at three lower frequencies adding up to 95 dB and more. Multivariate logistic regression analysis indicated a significantly greater improvement in hearing in patients treated with corticosteroids at high initial and total doses than in those treated with vitamin B12 and ATP without adding corticosteroids. In 145 patients treated with corticosteroids, multivariate logistic regression analysis showed a trend toward greater improvement with high initial and total doses than with low doses. CONCLUSION Corticosteroids should be changed from low to high doses within 7 days after onset of ALSHL, if low doses are failing.
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Affiliation(s)
- Mitsuya Suzuki
- Department of Otolaryngology, Tokyo Metropolitan Police Hospital, Fujimi, Tokyo, Japan.
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Mortimer KJ, Tattersfield AE. Benefit versus risk for oral, inhaled, and nasal glucocorticosteroids. Immunol Allergy Clin North Am 2006; 25:523-39. [PMID: 16054541 DOI: 10.1016/j.iac.2005.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many factors affect the benefit-to-risk analysis of the use of the glucocorticosteroids in the treatment of allergic inflammation. For most patients the benefit-to-risk ratio favors topical over oral administration, but in severe disease oral administration may be required. It is clear from pharmacokinetic and pharmacodynamic studies that inhaled glucocorticosteroids in particular are absorbed into the systemic circulation and that they can have clinical adverse effects when given in high doses. Therefore, with inhaled and nasal glucocorticosteroids, the dose that will achieve the optimal benefit/risk ratio is the lowest dose that controls symptoms and prevents exacerbations requiring treatment with oral glucocorticosteroids. This optimal dose needs to be determined on an individual basis and is likely to vary as disease severity changes over time.
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Affiliation(s)
- Kevin J Mortimer
- Division of Respiratory Medicine, Clinical Sciences Building, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
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Di Franco A, Bacci E, Bartoli ML, Cianchetti S, Dente FL, Taccola M, Vagaggini B, Zingoni M, Paggiaro PL. Inhaled fluticasone propionate is effective as well as oral prednisone in reducing sputum eosinophilia during exacerbations of asthma which do not require hospitalization. Pulm Pharmacol Ther 2005; 19:353-60. [PMID: 16289980 DOI: 10.1016/j.pupt.2005.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 09/16/2005] [Accepted: 09/19/2005] [Indexed: 11/15/2022]
Abstract
The aim of this study was to evaluate whether fluticasone propionate (FP) is effective as well as prednisone (P) in reducing sputum eosinophilia and in improving airway obstruction due to asthma exacerbations not requiring hospitalization. We measured, in a parallel-group, double-blind double-dummy, randomized study, sputum and blood inflammatory cell counts and soluble mediators in 37 asthmatic subjects during a spontaneous exacerbation of asthma (Visit 1) and after a 2 week (Visit 2) treatment with inhaled FP (1000microg bid) (Group A, n=18) or a reducing course of oral P (Group B, n=19). Asthma exacerbation was accompanied by sputum eosinophilia (eosinophils >2%) in almost all patients (95%). FP improved FEV(1) (from 53.9%+/-16.8 at Visit 1 to 76.4%+/-21.2 at Visit 2, p=0.0001) and reduced the percentage of sputum eosinophils (from 38%[0-78] to 3%[1-31, p=0.0008) as well as oral P (FEV(1): from 51.5%+/-14.4 to 83.6%+/-21.1, p=0.0001; sputum eosinophils: from 52%[1-96] to 11%[0-64], p=0.0003). At Visit 2, sputum eosinophils were significantly lower in Group A than in Group B. P but not FP induced significant decrease in blood and sputum ECP. Oxygen saturation, PEF variability, symptom score and use of rescue medication similarly improved in both groups. We conclude that FP is effective at least as well as P in reducing sputum eosinophilia and in improving airway obstruction due to asthma exacerbation. However, the cost/effectiveness ratio of this option should be further evaluated.
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Affiliation(s)
- Antonella Di Franco
- Respiratory Phatophysiology, Cardio-Thoracic Department, University of Pisa, via Paradisa 2, 56214 Pisa, Italy.
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Girodet PO, Molimard M. Pharmacological Approach to Evaluate Aerosol Pulmonary Deposition. ACTA ACUST UNITED AC 2005; 18:183-92. [PMID: 15966772 DOI: 10.1089/jam.2005.18.183] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Drug delivery to the lung in vivo may be assessed using pharmacokinetic or pharmacodynamic techniques. The choice of method depends on drug class specificities. Pharmacokinetic determination of deposition to the lung for drugs without hepatic first-pass effect, such as short acting beta2-agonists, has to be done shortly after inhalation to minimize the effect of gastrointestinal absorption. For medication undergoing important hepatic first-pass metabolisation, such as inhaled corticosteroid, plasma concentration indirectly reflects bronchial deposition. The pharmacodynamic profile should be assessed through clinical effects and adverse events induced by inhaled drugs. Dose ranking of lung deposition for bronchodilators requires patient selection with sufficient bronchial obstruction to maintain room for improvement after the first dose. To assess dose effect relationship between inhaled corticosteroid, the Finney parallel line bioassay is the reference method with a study period of at least 6 weeks. Analysis of side effects with high doses of beta2-agonists or inhaled corticosteroids may also be used to compare lung deposition. Finally, pharmacological evaluation of lung deposition provides complementary information to scintigraphic studies, based on their clinical relevance.
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Lipworth BJ, Kaliner MA, LaForce CF, Baker JW, Kaiser HB, Amin D, Kundu S, Williams JE, Engelstaetter R, Banerji DD. Effect of ciclesonide and fluticasone on hypothalamic-pituitary-adrenal axis function in adults with mild-to-moderate persistent asthma. Ann Allergy Asthma Immunol 2005; 94:465-72. [PMID: 15875528 DOI: 10.1016/s1081-1206(10)61117-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite their proven efficacy in the treatment and prevention of asthma exacerbations, current inhaled corticosteroids carry safety concerns, especially adrenal suppression. Ciclesonide (hydrofluoroalkane propellant) is a novel inhaled corticosteroid with few, if any, clinical adverse events. OBJECTIVE To evaluate the potential effects of ciclesonide therapy on the dynamic cortisol response to sequential low- and high-dose cosyntropin stimulation in adults with mild-to-moderate persistent asthma. METHODS This was a double-blind, randomized, placebo-controlled, 12-week study in adults with mild-to-moderate asthma. One hundred sixty-four patients were randomized and treated; 148 patients completed the study. Fluticasone propionate (chlorofluorocarbon propellant) was used as an active comparator. The doses administered were 320 microg of ciclesonide once daily, 320 microg of ciclesonide twice daily, and 440 microg of fluticasone propionate twice daily, all doses ex-actuator. RESULTS For both ciclesonide groups, changes in mean low- and high-dose peak serum cortisol levels and in 24-hour urinary free cortisol levels corrected for creatinine were small vs baseline and comparable with placebo. For the fluticasone propionate group, significant reductions vs placebo in serum cortisol levels in response to high-dose cosyntropin stimulation and in 24-hour urinary free cortisol levels were observed. Oral candidiasis rates were 2.5% for 320-microg/d ciclesonide, 2.4% for 640-microg/d ciclesonide, and 22.0% for 880-microg/d fluticasone propionate. CONCLUSIONS These findings confirm the safety of ciclesonide therapy, demonstrating that at doses up to 640 microg/d, the drug does not affect sensitive markers of adrenal function.
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Affiliation(s)
- Brian J Lipworth
- Allergy Research Group, Department of Medicine and Therapeutics, University of Dundee, Dundee, Scotland.
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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: 557] [Impact Index Per Article: 29.3] [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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Mortimer KJ, Harrison TW, Tattersfield AE. Effects of inhaled corticosteroids on bone. Ann Allergy Asthma Immunol 2005; 94:15-21; quiz 22-3, 79. [PMID: 15702810 DOI: 10.1016/s1081-1206(10)61280-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To discuss the effects of inhaled corticosteroids on bone and their potential public health implications. DATA SOURCES The MEDLINE and EMBASE databases were searched to identify articles published between 1966 and January 2004 with the following keywords in the title: inhaled corticosteroid, beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone plus bone, fracture, osteoporosis, osteocalcin, growth, or height. STUDY SELECTION Key studies of adequate size and duration that allowed for potential confounding factors where required were selected. RESULTS Inhaled corticosteroids are absorbed into the systemic circulation and therefore have the potential to cause adverse effects on bone. Several of the larger studies showed that inhaled corticosteroids cause a dose-related reduction in bone mineral density. Three cross-sectional studies found a dose-related increase in fractures in people taking an inhaled corticosteroid compared with controls. Prospective studies found a short-term reduction in growth velocity in children taking an inhaled corticosteroid, although target adult height is usually achieved. CONCLUSION Since osteoporotic fracture is common in elderly patients and up to 5% of the population in more developed countries take an inhaled corticosteroid, these findings have public health implications. Strategies are needed to reduce the systemic effects of inhaled corticosteroids.
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Affiliation(s)
- K J Mortimer
- Division of Respiratory Medicine, Nottingham University City Hospital, Nottingham, England.
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Kankaanranta H, Lahdensuo A, Moilanen E, Barnes PJ. Add-on therapy options in asthma not adequately controlled by inhaled corticosteroids: a comprehensive review. Respir Res 2004; 5:17. [PMID: 15509300 PMCID: PMC528858 DOI: 10.1186/1465-9921-5-17] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 10/27/2004] [Indexed: 11/19/2022] Open
Abstract
Many patients with persistent asthma can be controlled with inhaled corticosteroids (ICS). However, a considerable proportion of patients remain symptomatic, despite the use of ICS. We present systematically evidence that supports the different treatment options. A literature search was made of Medline/PubMed to identify randomised and blinded trials. To demonstrate the benefit that can be obtained by increasing the dose of ICS, dose-response studies with at least three different ICS doses were identified. To demonstrate whether more benefit can be obtained by adding long-acting beta2-agonist (LABA), leukotriene antagonist (LTRA) or theophylline than by increasing the dose of ICS, studies comparing these options were identified. Thirdly, studies comparing the different "add-on" options were identified. The addition of a LABA is more effective than increasing the dose of ICS in improving asthma control. By increasing the dose of ICS, clinical improvement is likely to be of small magnitude. Addition of a LTRA or theophylline to the treatment regimen appears to be equivalent to doubling the dose of ICS. Addition of a LABA seems to be superior to an LTRA in improving lung function. However, addition of LABA and LTRA may be equal with respect to asthma exacerbations. However, more and longer studies are needed to better clarify the role of LTRAs and theophylline as add-on therapies.
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Affiliation(s)
- Hannu Kankaanranta
- The Immunopharmacological Research Group, Medical School, University of Tampere, Tampere, Finland
- Department of Pulmonary Diseases, Tampere University Hospital, Tampere, Finland
| | - Aarne Lahdensuo
- Department of Pulmonary Diseases, Tampere University Hospital, Tampere, Finland
| | - Eeva Moilanen
- The Immunopharmacological Research Group, Medical School, University of Tampere, Tampere, Finland
- Department of Clinical Chemistry, Tampere University Hospital, Tampere, Finland
| | - Peter J Barnes
- Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College, London, UK
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Raissy HH, Wright H, Crowley M, Marshik P, Colon-Semidy A, Kelly HW. Comparison of the Systemic Effects of Fluticasone Propionate and Triamcinolone Acetonide Administered in Equipotent Doses in Children with Asthma. ACTA ACUST UNITED AC 2003. [DOI: 10.1089/088318703322751336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Roumestan C, Henriquet C, Bousquet J, Mathieu M. Fluticasone propionate and mometasone furoate have equivalent transcriptional potencies. Clin Exp Allergy 2003; 33:895-901. [PMID: 12859444 DOI: 10.1046/j.1365-2222.2003.01709.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Glucocorticoids exert their anti-inflammatory effects mainly through transrepression of the transcription factors activator protein-1 (AP-1) and nuclear factor-kappa B (NF-kappaB). Certain adverse effects of glucocorticoids are mediated through gene transactivation. Fluticasone propionate (FP) and mometasone furoate (MF) are the most recently developed topical glucocorticoids for the treatment of airway disorders. Their relative capacities to repress AP-1 and NF-kappaB activities are not known and comparison of their transactivation potencies has given unclear results. OBJECTIVE To determine the relative transactivation and transrepression potencies of FP and MF. METHODS Transactivation assays were performed in HeLa cells carrying a glucocorticoid-inducible luciferase gene. To measure transrepressive potencies of FP and MF, A549 lung epithelial cells were transiently transfected with an AP-1- or NF-kappaB-dependent luciferase gene. Using an immunoassay, we also evaluated the ability of MF and FP to inhibit the production of Regulated upon Activation, Normal T-cell Expressed and Secreted (RANTES), a pro-inflammatory cytokine, whose gene is controlled by AP-1 and NF-kappaB. Areas under the dose-response curve were calculated to determine relative potencies. RESULTS FP and MF are equipotent for transactivation. Both molecules show globally the same potency to inhibit AP-1 and NF-kappaB activities and RANTES production. MF and FP have very significant transcriptional effects at 2x10(-10) M, which is the peak concentration reached in the plasma after inhalation of high dosages. Indeed, they produce a 17-fold induction of luciferase in the transactivation assay, and inhibit AP-1 activity, NF-kappaB activity and RANTES release by approximately 40%. CONCLUSION FP and MF have the same ability to trigger gene activation and also the same potency to inhibit AP-1 and NF-kappaB activities. Their strong transcriptional effects at 2x10(-10) M suggest that these compounds act not only topically but also systemically, with the risk of provoking concomitant adverse effects at high dosages.
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Affiliation(s)
- C Roumestan
- Institut National de la Santé et de la Recherche Médicale U454-IFR3, Hôpital Arnaud de Villeneuve, Montpellier, France
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Wilson AM, Coutie WJR, Sims EJ, Lipworth BJ. The skin vasoconstrictor assay does not correlate significantly to airway or systemic responsiveness to inhaled budesonide in asthmatic patients. Eur J Clin Pharmacol 2003; 58:643-7. [PMID: 12610738 DOI: 10.1007/s00228-002-0547-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2002] [Accepted: 11/23/2002] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The responsiveness to inhaled corticosteroid varies among individual asthmatic patients. It is not known, however, whether the effects of corticosteroids on one bodily tissue reflect the response in another in a given individual. The aim was to a assess whether skin vasoconstrictor assay might predict airway and systemic tissue responsiveness to inhaled budesonide in patients with asthma. METHODS Twenty-two patients with mild to moderate persistent asthma previously enrolled in a dose-response study assessing the effects of inhaled budesonide on airway bronchial challenge testing, exhaled nitric oxide and blood cortisol and eosinophil count were recalled for assessment of vasoconstrictor response to topical budesonide. The MacKenzie vasoconstrictor assay was performed by applying tenfold dilutions from 10(-2) g/ml to 10(-8) g/ml budesonide and visually assessing the degree of skin blanching after 18 h at each concentration. RESULTS There was a significant overall dose-response effect for the degree of skin blanching at each concentration. There was no significant correlation between the effects on the skin and measures of anti-asthmatic efficacy or systemic effect after 3 weeks of 400 microg/day inhaled budesonide. There was a significant correlation with the overall dose-cutaneous response effect versus the overall dose-response effect with adenosine monophosphate (r=-0.53) but not methacholine bronchial challenge testing or serum cortisol. CONCLUSION It may not be possible to use the McKenzie vasoconstrictor assay to predict which patients are most or least susceptible to inhaled corticosteroids for anti-asthmatic efficacy or systemic adverse effects.
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Affiliation(s)
- Andrew M Wilson
- Asthma and Allergy Research Group, Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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Uhl A, Czock D, Boehm BO, Zellner D, Mertz A, Keller F. Pharmacokinetics and pharmacodynamics of methylprednisolone after one bolus dose compared with two dose fractions. J Clin Pharm Ther 2002; 27:281-7. [PMID: 12174030 DOI: 10.1046/j.1365-2710.2002.00422.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Although the elimination half-life of most glucocorticoids is short, they are usually administered once daily, or even on alternate days. Our hypothesis was that this practice might compromise the immunosuppressive effect of those drugs during the second part of the administration interval. METHODS Eight healthy male volunteers were randomly assigned to receive intravenous methylprednisolone either 32 mg in the morning, or 16 mg in the morning and 16 mg in the evening in a cross-over design. Methylprednisolone concentrations were determined in plasma by high-pressure liquid chromatography. The total number of CD3+ lymphocytes, and CD4+ and CD8+ T-cell subpopulations was measured in blood. The suppression of these cells was used as a surrogate parameter for the immunosuppressive response, and expressed as reduction of the area under the effect time curve (AUETC). Possible adverse effects on blood pressure, glucose, insulin, and endogenous cortisol levels were monitored. RESULTS There were no significant differences in methylprednisolone half-life (2.2 +/- 0.4 h), clearance (575 +/- 113 mL/min), volume of distribution (106 +/- 22 l), concentration producing the half-maximum effect on CD4+ T-cells (1.5 +/- 0.7 ng/mL), and Hill-coefficient (1.2 +/- 0.1), after single or divided dose. However, the total 24 h effect area (AUETC) of lymphocytes, and mainly CD4+ T-cells was significantly more suppressed (P = 0.008) with the divided dosage regimen than after the single dose (8422 +/- 2163 vs. 11,545 +/- 3020 h cells/microL). The surrogate markers for adverse events were not different, except for cortisol. CONCLUSION Within a 24-h interval, two dose fractions of methylprednisolone produce a stronger and more sustained immunosuppressive response than one single bolus dose.
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Affiliation(s)
- A Uhl
- Division of Nephrology, University Hospital, Ulm, Germany
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Casale TB, Nelson HS, Stricker WE, Raff H, Newman KB. Suppression of hypothalamic-pituitary-adrenal axis activity with inhaled flunisolide and fluticasone propionate in adult asthma patients. Ann Allergy Asthma Immunol 2001; 87:379-85. [PMID: 11730179 DOI: 10.1016/s1081-1206(10)62918-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Suppression of the hypothalamic-pituitary-adrenal (HPA) axis, a potential systemic effect of inhaled corticosteroid therapy, can be quantified by monitoring serum, urinary, and salivary cortisol levels. OBJECTIVES 1) Compare the effects on HPA axis of the inhaled corticosteroids flunisolide and fluticasone propionate versus placebo and oral prednisone. 2) Estimate dose-potency ratio for HPA-axis suppression. METHODS Multicenter, randomized, placebo-controlled, open-label, 21-day trial. Active regimens were flunisolide 500 and 1,000 microg, twice daily; fluticasone propionate 110, 220, 330, and 440 microg, twice daily; and prednisone, 7.5 mg daily. Enrolled patients were nonsmokers, 18 to 50 years of age, with persistent mild-to-moderate asthma and had not used oral, nasal, or inhaled corticosteroids for 6 months before study. Main outcome measures were area under serum cortisol concentration curve for 22 hours (AUC(0-22h)); 24-hour urinary cortisol level; and 8 AM salivary cortisol level. RESULTS One hundred fifty-three patients were randomly assigned to active treatment or placebo; 125 patients completed the study and were at least 80% compliant with their regimens. Both fluticasone propionate and flunisolide caused dose-dependent suppression of HPA axis, which was statistically greater for fluticasone propionate (P = 0.0003). Dose-potency ratio showed 4.4 times more serum-cortisol suppression/microgram increase in dose with fluticasone propionate than with flunisolide. Diurnal pattern of serum cortisol suppression was persistent with fluticasone propionate and "remitting" with flunisolide. Salivary and urinary cortisol data were qualitatively similar to serum cortisol results. CONCLUSIONS Fluticasone caused significantly more suppression of HPA axis than flunisolide. Flunisolide may provide a safe option for patients with asthma requiring long-term inhaled corticosteroid therapy.
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Affiliation(s)
- T B Casale
- Department of Medicine. Creighton University, Omaha, Nebraska 68131, USA.
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Harrison TW, Wisniewski A, Honour J, Tattersfield AE. Comparison of the systemic effects of fluticasone propionate and budesonide given by dry powder inhaler in healthy and asthmatic subjects. Thorax 2001; 56:186-91. [PMID: 11182010 PMCID: PMC1758787 DOI: 10.1136/thorax.56.3.186] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The potential for long term adverse effects from inhaled corticosteroids relates to their systemic absorption, usually assessed from proxy markers in short term studies. When fluticasone propionate and budesonide have been compared in this way the results have been inconsistent. To determine whether this is because of the subjects studied or the sensitivity of the systemic marker used, we have compared the effects of fluticasone propionate and budesonide in healthy and asthmatic subjects and investigated the effect of treatment on three systemic markers. METHODS Forty six healthy subjects were randomised to receive inhaled fluticasone propionate 1500 microg/day (via an Accuhaler), budesonide 1600 microg/day (via a Turbuhaler), or placebo; 31 subjects with moderately severe asthma were randomised to receive the same doses of fluticasone propionate or budesonide but not placebo. Systemic effects in healthy and asthmatic subjects were compared after 7 days. Treatment was continued for another 21 days in the subjects with asthma when systemic effects and asthma control were assessed. RESULTS At baseline healthy subjects had higher urinary levels of total cortisol metabolites (TCM) than subjects with asthma. After 7 days of treatment with fluticasone propionate urinary TCM levels in the healthy subjects were significantly lower than in the subjects with asthma (mean difference between groups 1663 microg/day, 95% CI 328 to 2938). This was not the case with budesonide, however, where urinary TCM levels in the healthy subjects remained above those in the asthmatic subjects (mean difference between groups 1210 microg/day, 95% CI -484 to 2904). Urinary TCM levels were considerably more sensitive to the effects of inhaled corticosteroids than morning serum cortisol or osteocalcin concentrations. Only budesonide reduced the serum level of osteocalcin. CONCLUSIONS When given by dry powder inhaler for 7 days, fluticasone propionate 1500 microg/day has a greater effect on the hypothalamic-pituitary-adrenal axis in healthy subjects than in subjects with asthma, but this is not the case for budesonide 1600 microg/day. These findings, together with the differences in sensitivity between systemic markers, explain many of the discrepancies in the literature.
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Affiliation(s)
- T W Harrison
- Division of Respiratory Medicine, Nottingham City Hospital, Nottingham NG5 1PB, UK.
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