A Randomized Controlled Trial to Determine the Effect of Inhaled Corticosteroid on Intraocular Pressure in Open-Angle Glaucoma and Ocular Hypertension: The ICOUGH Study

Impact of Inhaled and Intranasal Corticosteroids Exposure on the Risk of Ocular Hypertension and Glaucoma: A Systematic Review and Meta-Analysis

Purpose

Starting in 2019, the Global Initiative for Asthma recommended the use of inhaled corticosteroids (ICS) as part of reliever combination therapy in patients 12 years of age and older, thus dramatically increasing the population exposure to ICS. ICS and intranasal corticosteroids (INS) are commonly used for a variety of respiratory diseases. Chronic steroid use is a well-known risk factor for elevated intraocular pressure (IOP) and glaucoma regardless of route of administration. This study aimed to determine the reported risk of glaucoma, ocular hypertension (OHT) and IOP elevation associated with ICS and INS use.

Materials and Methods

Systematic literature search in MEDLINE, EMBASE, Cochrane, CINAHL, BIOSIS, and Web of Science databases from the date of inception identified studies that assess ocular outcomes related to glaucoma in ICS and INS users. Study selection, risk of bias assessment and data extraction were done independently in duplicate. Meta-analysis assessed glaucoma incidence, OHT incidence and IOP changes in patients using ICS and INS. Study adhered to PRISMA guidelines. Study protocol was registered with PROSPERO: CRD42020190241.

Results

Qualitative and quantitative analyses included 65 and 41 studies, respectively. Incidence of glaucoma was not significantly different in either ICS or INS users compared to control over 45,457 person-years of follow-up. Similarly, no significant difference in OHT incidence over 4431 person-years was detected. In studies reporting IOP, a significantly higher IOP was observed (0.69 mmHg) in 857 ICS or INS users compared to 615 controls. However, no significant increase in IOP was observed within ICS or INS users when compared to pre-treatment baseline.

Conclusion

Overall, use of ICS or INS does not significantly increase the incidence of glaucoma or OHT. However, ICS and INS patients had significantly higher IOPs compared to untreated patients. Awareness of these findings is significant in care of patients with additional risk factors for glaucoma.

The Effects of Intranasal, Inhaled and Systemic Glucocorticoids on Intraocular Pressure: A Literature Review

Topical glucocorticoids are a well-known risk factor of intraocular pressure (IOP) elevation in one third of the general population and in up to 90% of glaucomatous patients. Whether this steroid response is caused by intranasal, inhaled or systemic glucocorticoids, is less known. This study presents an overview of the current literature on the topic, thereby providing guidance on when ophthalmological follow-up is indicated. A literature study was performed in Medline, and 31 studies were included for analysis. Twelve out of fourteen studies discussing intranasal glucocorticoids show no significant association with an elevated IOP. Regarding inhaled glucocorticoids, only three out of twelve studies show a significant association. The observed increase was either small or was only observed in patients treated with high inhaled doses or in patients with a family history of glaucoma. An elevated IOP caused by systemic glucocorticoids is reported by four out of the five included studies, with one study reporting a clear dose–response relationship. This review concludes that a steroid response can be triggered in patients treated with systemic glucocorticoids. Inhaled glucocorticoids may cause a significant IOP elevation when administered in high doses or in patients with a family history of glaucoma. At present, there is no evidence for a clinically significant steroid response caused by intranasally administered glucocorticoids.

Inhaled Corticosteroid and Secondary Glaucoma: A Meta-analysis of 18 Studies

Purpose

Guidelines and systematic reviews frequently warn of inhaled corticosteroid (ICS)-induced glaucoma. However, most of the published studies deny it.

Methods

We performed a systematic review of randomized, cohort, nested-case control, cross-sectional studies by using Meta-analyses of Observational Studies in Epidemiology statement. Four major databases, PubMed, EMBASE, Cochrane Search Manager, and the Web of Science Core Collection as well as meta-analysis were used. Studies comparing incidence, prevalence and intraocular pressure (IOP) between patients who were treated with and without ICSs were included. A random-model meta-analysis was performed using the inverse variance method.

Results

Out of 623 studies screened, 18 with 31,665 subjects were finally included. No significant difference between the 2 groups was observed for crude glaucoma incidence (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.86–1.04; P = 0.26; I² = 0%; P for heterogeneity = 0.57) as a primary endpoint, adjusted glaucoma incidence (OR, 0.90; 95% CI, 0.65–1.24; P = 0.64), crude prevalence (OR, 1.82; 95% CI, 0.23–14.19; P = 0.57), adjusted prevalence (OR, 1.22; 95% CI, 0.50–2.96; P = 0.66), IOP change during ICS treatment (mean difference [MD] +0.01 mmHg; 95% CI, −0.19–0.20; P = 0.95), and single measurement IOP (MD +0.37 mmHg; 95% CI, −0.24–0.97; P = 0.23). Time-to-event analysis for glaucoma development as one of the secondary endpoints (adjusted hazard ratio, 0.52; 95% CI, 0.28–0.96) suggested a reverse association between ICS and glaucoma.

Conclusions

The ophthalmological side effects of ICSs, such as glaucoma and intraocular hypertension, should not be exaggerated.

Trial Registration

University Hospital Medical Information Network Center Clinical Trial Registry Identifier: UMIN000040351

Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management

Glucocorticoids are a class of anti-inflammatory drugs commonly used to treat various ocular and systemic conditions. Although the role of glucocorticoids in the treatment of numerous serious inflammatory diseases is pivotal, their prolonged use may increase intraocular pressure resulting in steroid-induced glaucoma. We provide a detailed update on steroid-induced glaucoma as a preventable cause of blindness in the adult and pediatric population and describe its epidemiology, social impact, and risk factors. Furthermore, we explore the propensity of different steroids to increase the intraocular pressure, the role of different routes of steroid administration, dosage and duration of treatment, as well as the clinical features, genetics, and management of steroid-induced glaucoma.

A review of systemic medications that may modulate the risk of glaucoma

With increasing longevity, patients are developing more and more chronic diseases that require treatment with medications. Yet, it is not fully understood the extent by which these systemic medications affect ocular structures and whether they may increase or decrease the risk of sight-threatening ocular diseases. This review provides a summary of reported associations between different systemic medications and the risk of developing glaucoma or experiencing disease progression. Medication classes covered in this review that are known to or may modulate the risk of open-angle glaucoma include corticosteroids, beta blockers, calcium channel blockers, metformin, statins, selective serotonin reuptake inhibitors, bupropion, postmenopausal hormones, and cannabinoids. Medication classes addressed in this review that may increase the risk of angle closure glaucoma include anticholinergics, adrenergic agonists, certain classes of antidepressants, sulfonamides, and topiramate.

Bioequivalence Study Methods with Pharmacokinetic Endpoints for Topical Ophthalmic Corticosteroid Suspensions and Effects of Subject Demographics

PURPOSE

To establish bioequivalence for topical ophthalmic corticosteroid suspensions, some of U.S. product-specific guidances (PSGs) for generic drug products recommend evaluation of aqueous humor (AH) pharmacokinetics (PK). However, the AH PK study is complex because the relationships among AH PK, subject demographics, ocular anatomy, physiology and the compounds' physicochemical characteristics are not well understood. The objective of this research is to provide an overview of the in vivo human AH studies submitted to the U.S. Food and Drug Administration (FDA) for ophthalmic corticosteroid suspensions and to investigate the impact of subject demographics on the human AH PK.

METHODS

We summarized demographic data, sampling time points, sample size per time point and PK parameters to investigate correlations in the studies submitted to the FDA.

RESULTS

In the evaluation of subject-specific covariates, the area under the concentration-time curves (AUC) and maximum concentrations (C_max) were significantly different among ethnicities and age groups. Gender was not primarily associated with differences in AH PK.

CONCLUSIONS

Our results suggest that the difference in ethnicity and age of the study population play an important role in the AH PK profiles of topical ophthalmic corticosteroid suspensions. Considering the subject-specific covariate effects in designing bioequivalence studies with AH PK endpoints could reduce bias from covariate imbalance and help identify true effects of formulation differences.

The effect of inhaled steroids on the intraocular pressure

Background

Steroids are known to play a role in the pathogenesis of glaucoma, but little is known about the effect of inhaled corticosteroids (ICS). The purpose of this study was to investigate whether there is a clinically significant association between inhalational steroids and intraocular pressure (IOP).

Methods

This was a cross-sectional, case-control study performed at St John's Medical College, Bengaluru, India, from October 2013 to July 2015 of 200 patients using 800 mcg of budesonide or its equivalent dose of ICS and 200 healthy controls not using any form of steroids. Patients using ICS for a period of at least 6 months with no usage of oral or topical steroids within the last 3 months were included as cases. Age- and sex-matched controls were recruited from among the general patient population of the ophthalmological department. IOP and central corneal thickness (CCT) were analyzed. Cases were divided into two subgroups. Group 1 had IOP of <21 mm Hg and cup-to-disc ratio of <0.5. Group 2 had IOP of ≥21 mm Hg or cup-to-disc ratio of ≥0.5 or cup-disc asymmetry ≥0.2. These two subgroups were analyzed to determine whether there was an increased risk of developing ocular hypertension or glaucoma with extended use of ICS.

Results

A total of 400 subjects participated, with 200 in each group. The mean IOP of cases was 15.31 ± 3.27 mm Hg, statistically significantly higher than the mean of 13.39 mm Hg ± 1.95 in controls (P < 0.001). The mean CCT in cases was 522.02 ± 30.47 μm, lower than the mean of 528.73 ± 29.09 μm of the control group (P > 0.001). Of the 200 cases, 11 (5.5%) had ocular hypertension and 2 (1%) had open-angle glaucoma. There was no statistically significant correlation between duration of inhaled steroids usage and increase in IOP (P = 0.62). There was no development of ocular hypertension or glaucoma among the controls.

Conclusions

Our findings suggest a probable association between ICS and IOP and that it may be advisable to measure baseline IOPs and CCT and to follow patients on ICS at regular intervals.