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Kulkarni S, Durham H, Glover L, Ather O, Phillips V, Nemes S, Cousens L, Blomgran P, Ambery P. Metabolic adverse events associated with systemic corticosteroid therapy-a systematic review and meta-analysis. BMJ Open 2022; 12:e061476. [PMID: 36549729 PMCID: PMC9772659 DOI: 10.1136/bmjopen-2022-061476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To assess the risk of new-onset or worsening hyperglycaemia, hypertension, weight gain and hyperlipidaemia with systemic corticosteroid therapy (CST) as reported in published randomised control trial (RCT) studies. DATA SOURCES Literature search using MEDLINE, EMBASE, Cochrane library, Web of Science and Scopus STUDY ELIGIBILITY CRITERIA: Published articles on results of RCT with a systemic CST arm with numerical data presented on adverse effect (AE). PARTICIPANTS AND INTERVENTIONS Reports of hyperglycaemia, hypertension, weight gain and hyperlipidaemia associated with systemic CST in patients or healthy volunteer's ≥17 years of age. STUDY APPRAISAL METHODS Risk of bias tool, assessment at the level of AE and key study characteristics. RESULTS A total of 5446 articles were screened to include 118 studies with 152 systemic CST arms (total participants=17 113 among which 8569 participants treated with CST). Pooled prevalence of hyperglycaemia in the CST arms within the studies was 10% (95% CI 7% to 14%), with the highest prevalence in respiratory illnesses at 22% (95% CI 9% to 35%). Pooled prevalence of severe hyperglycaemia, hypertension, weight gain and hyperlipidaemia within the corticosteroid arms was 5% (95% CI 2% to 9%), 6% (95% CI 4% to 8%), 13% (95% CI 8% to 18%), 8% (95% CI 4% to 17%), respectively. CST was significantly associated hyperglycaemia, hypertension and weight gain as noted in double-blinded placebo-controlled parallel-arms studies: OR of 2.13 (95% CI 1.66 to 2.72), 1.68 (95% CI 0.96 to 2.95) and 5.20 (95% CI 2.10 to 12.90), respectively. Intravenous therapy posed higher risk than oral therapy: OR of 2.39 (95% CI 1.16 to 4.91). LIMITATIONS There was significant heterogeneity in the AE definitions and quality of AE reporting in the primary studies and patient populations in the studies. The impact of cumulative dose effect on incidental AE could not be calculated. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Systemic CST use is associated with increased risk of metabolic AEs, which differs for each disease group and route of administration. PROSPERO REGISTRATION NUMBER CRD42020161270.
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Affiliation(s)
- Spoorthy Kulkarni
- Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hannah Durham
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Glover
- Department of Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Osaid Ather
- Structural & Chemical Biology, The Francis Crick Institute, London, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Szilard Nemes
- Data Science & AI, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Leslie Cousens
- Respiratory & Immunology, AstraZeneca R&D Boston, Waltham, Massachusetts, USA
| | - Parmis Blomgran
- Early Respiratory & Immunology, AstraZeneca R&D Gothenburg, Mölndal, Sweden
| | - Philip Ambery
- Late CVRM Research, AstraZeneca R&D Gothenburg, Mölndal, Sweden
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Nowak KM, Rdzanek-Pikus M, Romanowska-Próchnicka K, Nowakowska-Płaza A, Papierska L. High prevalence of steroid-induced glucose intolerance with normal fasting glycaemia during low-dose glucocorticoid therapy: an oral glucose tolerance test screening study. Rheumatology (Oxford) 2021; 60:2842-2851. [PMID: 33254223 DOI: 10.1093/rheumatology/keaa724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/24/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To evaluate the prevalence and risk factors of new-onset glucose metabolism impairment using an oral glucose tolerance test (OGTT) in patients with normal fasting glycaemia on long-term glucocorticoid (GC) treatment. METHODS An OGTT was performed in 150 patients without a previous history of pre-diabetes or diabetes who were diagnosed with inflammatory rheumatic diseases and treated with GCs >3 months. All participants underwent clinical and biochemical evaluation for risk factors of diabetes: age, sex, current and cumulative dose of steroids, treatment duration, waist circumference, BMI, Homeostatic Model Assessment for Insulin Resistance, fasting insulin concentration, family history of diabetes, CRP, 28-joint DAS with CRP, type of connective tissue disease and trunk fat percentage measured by DXA. Logistic regression analysis was conducted to evaluate the association between the presence of impaired glucose tolerance (IGT) in the OGTT and analysed risk factors. RESULTS A total of 102 patients (68%) had fully normal glucose tolerance. Diabetes, isolated impaired fasting glucose, isolated IGT and combined impaired fasting glucose + IGT was diagnosed in 3.3, 4.67, 19.33 and 4.67% of patients, respectively; 20% of participants had IGT or diabetes despite normal fasting glucose concentration. The median cumulative dose and current dose (5 mg) of GCs and treatment duration were similar compared with the normal glucose tolerance group. In a multivariate logistic regression model, only older age (particularly ≥50 years of age) and trunk fat percentage remained significant factors predicting IGT or diabetes in the OGTT. CONCLUSION New-onset GC-induced glucose intolerance, even in patients on long-term low-dose treatment, is prevalent despite normal fasting glucose concentration and patients should be screened with an OGTT despite the absence of classic risk factors of diabetes.
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Affiliation(s)
- Karolina M Nowak
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Monika Rdzanek-Pikus
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Katarzyna Romanowska-Próchnicka
- Department of General and Experimental Pathology, 2nd Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland.,Department of Systemic Connective Tissue Diseases , Warsaw, Poland
| | - Anna Nowakowska-Płaza
- Department of Rheumatology, Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Lucyna Papierska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
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Shi Y, Xie C, He Y, Liu H, Zhu B, Zhu J. Efficacy and adverse reactions of methotrexate in the treatment of ocular cicatricial pemphigoid: A case series study. Medicine (Baltimore) 2018; 97:e12338. [PMID: 30235689 PMCID: PMC6160102 DOI: 10.1097/md.0000000000012338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The application of methotrexate (MTX) in the treatment of autoimmune diseases has been gradually increasing, but reports of MTX treatment for advanced ocular cicatricial pemphigoid (OCP) are extremely rare. This study investigated the efficacy and adverse reactions of low-dose MTX in patients with OCP.This was a retrospective, noncontrolled, case series study. Eleven patients diagnosed with advanced OCP (4 cases in stage III and 7 cases in stage IV) were enrolled. Treatment by oral administration of MTX (7.5 ± 2.5 mg) alone was performed. Visual acuity of the patients, conjunctival inflammation, cicatrization, ocular surface keratinization, and toxic side effects of drugs were evaluated.All patients enrolled in this study were females aged 32 to 83 years. Patients were followed up for 4 to 33 months. Low-dose MTX improved visual acuity of 3 cases (6 eyes, 27.3%). Conjunctival inflammation of 5 patients (10 eyes) rested after treatment, and conjunctival inflammation of 3 cases (6 eyes, 27.3%) was decreased with an effective rate of 72.7%. Cicatrices of 8 cases (15 eyes) showed degeneration after treatment with an effective rate of 71.4% (15/21). Ocular surface keratinization receded in 4 cases with an effective rate of 66.7%. None of the patients discontinued the treatment due to severe toxic side effects. All patients tolerated mild drug-induced gastrointestinal reactions. Three patients terminated the treatment in advance after 4 to 6 months due to no improvement in the disease condition.Observation of clinical efficacy and safety findings demonstrated that low-dose MTX can be used to treat patients with advanced OCP.
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Affiliation(s)
- Yewen Shi
- Department of Otorhinolaryngology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an
- Department of Ophthalmology, The Affiliated Guangren Hospital of Xi’an Jiaotong University
| | - Chen Xie
- The Fourth Clinical College, School of Medicine, Nanchang University, Nanchang
| | - Yuan He
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Huifeng Liu
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Binliang Zhu
- Department of Ophthalmology, The Second Affiliated Hospital of Xi’an Medicine University, Xi’an, China
| | - Jiang Zhu
- Department of Ophthalmology, The Affiliated Guangren Hospital of Xi’an Jiaotong University
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Dănescu AS, Bâldea I, Leucuţa DC, Lupan I, Samaşca G, Sitaru C, Chiorean R, Baican A. Immunological markers as predictors of developing steroid-induced diabetes mellitus in pemphigus vulgaris patients: An observational study. Medicine (Baltimore) 2018; 97:e0463. [PMID: 29702999 PMCID: PMC5944517 DOI: 10.1097/md.0000000000010463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to evaluate the clinical importance of autoantibodies in pemphigus vulgaris patients who developed steroid-induced diabetes mellitus (SID) because of the glucocorticoid therapy of pemphigus.A total of 137 patients with pemphigus vulgaris were studied. Patients with SID and pemphigus were compared with those that had only pemphigus. The variables recorded were: age at diagnosis, sex, body mass index, presence of diabetes mellitus (DM), cumulative cortisone dose, treatment duration, value of anti-desmoglein 1 and 3, and anti-glutamic acid decarboxylase autoantibodies.A total of 31 patients (22.62%) that developed steroid-induced DM were identified. Anti-glutamic acid decarboxylase autoantibodies were positive in 20.75% of patients with pemphigus vulgaris and in 25.75% of patients with pemphigus vulgaris and SID.The overall anti-glutamic acid decarboxylase autoantibodies prevalence in pemphigus patients was high, and the risk of developing DM in patients with pemphigus remains a serious problem, being associated with increased risk of mortality.
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Affiliation(s)
| | | | - Daniel Corneliu Leucuţa
- Department of Medical Informatics and Biostatistics, Iuliu Hatieganu University of Medicine and Pharmacy
| | - Iulia Lupan
- Department of Molecular Biology, Babes-Bolyai University
| | - Gabriel Samaşca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cassian Sitaru
- Department of Dermatology, University Medical Center Freiburg, Center for Biological Signalling Studies (BIOSS), University of Freiburg, Freiburg, Germany
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Di Zenzo G, Amber KT, Sayar BS, Müller EJ, Borradori L. Immune response in pemphigus and beyond: progresses and emerging concepts. Semin Immunopathol 2015; 38:57-74. [DOI: 10.1007/s00281-015-0541-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/30/2015] [Indexed: 12/18/2022]
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González-Serrano J, Paredes VM, López-Pintor RM, de Arriba L, Hernández G. Successful treatment of oral pemphigus vulgaris in an insulin-dependant geriatric patient. Gerodontology 2015; 33:569-572. [PMID: 26108158 DOI: 10.1111/ger.12201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To present a clinical report of a patient treated with corticosteroids for oral pemphigus vulgaris (PV) lesions. BACKGROUND PV is the type of pemphigus that most often affects the oral mucosa and tends not to appear in elderly people. METHODS Two biopsies were needed for diagnosis. She was treated with oral prednisone and topically with 0.05% clobetasol propionate. CONCLUSION An early diagnosis and treatment is needed for a good prognosis, especially in elderly patients with multiple systemic pathology.
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Affiliation(s)
- José González-Serrano
- Faculty of Odontology, Department of Stomatology III, Complutense University, Madrid, Spain
| | - Víctor Manuel Paredes
- Faculty of Odontology, Department of Stomatology III, Complutense University, Madrid, Spain
| | | | - Lorenzo de Arriba
- Faculty of Odontology, Department of Stomatology III, Complutense University, Madrid, Spain
| | - Gonzalo Hernández
- Faculty of Odontology, Department of Stomatology III, Complutense University, Madrid, Spain.
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Heelan K, Mahar AL, Walsh S, Shear NH. Pemphigus and associated comorbidities: a cross-sectional study. Clin Exp Dermatol 2015; 40:593-9. [PMID: 25786337 DOI: 10.1111/ced.12634] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pemphigus is a rare autoimmune blistering disease, reported to be associated with other coexisting and autoimmune diseases, including thyroid diseases, rheumatoid arthritis, alopecia areata, vitiligo, systemic lupus erythematosus, scleroderma and rare entities such as myasthenia gravis. AIM To identify and describe patients with pemphigus with a diagnosed comorbidity, and to quantify the risk of additional comorbidities. METHODS This was a cross-sectional study of patients with pemphigus treated at a tertiary referral centre. Prevalence rates of 15 comorbid diseases were calculated. Age-standardized prevalence ratio (SPR) and 95% CI were calculated in comparison with prevalence rates in the general Canadian population using data from the Canadian Community Health Survey. Data were analysed using SAS software. RESULTS In total, 295 patients were identified. An increased risk of hypothyroidism (n = 38, SPR = 1.53, 95% CI 1.08-2.10) and inflammatory bowel disease (IBD) (SPR = 1.48, 95% CI 0.40-3.80), and a two-fold increased risk of diabetes (SPR = 2.20, 95% CI 1.64-2.87) were observed. CONCLUSIONS Patients with pemphigus have a higher incidence of hypothyroidism, IBD and diabetes compared with the general population. As part of pemphigus investigations and surveillance, investigating for these conditions may be considered.
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Affiliation(s)
- K Heelan
- Division of Dermatology, ON, Canada
| | - A L Mahar
- Department of Public Health Sciences, Queen's University , Kingston, ON, Canada
| | - S Walsh
- Division of Dermatology, ON, Canada
| | - N H Shear
- Division of Dermatology, ON, Canada.,Division of Clinical Pharmacology and Toxicology at Sunnybrook, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
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Liu XX, Zhu XM, Miao Q, Ye HY, Zhang ZY, Li YM. Hyperglycemia induced by glucocorticoids in nondiabetic patients: a meta-analysis. ANNALS OF NUTRITION AND METABOLISM 2014; 65:324-32. [PMID: 25402408 DOI: 10.1159/000365892] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/13/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND/AIMS Glucocorticoids are associated with a number of side effects including the development of new-onset hyperglycemia or diabetes. The diagnosis and treatment of glucocorticoid-induced hyperglycemia are surprisingly undervalued by many health-care professionals, probably due to the lack of quality studies that assess specific reasons for and prevention of hyperglycemia. The aim of this meta-analysis was to evaluate the long-term incidence of glucocorticoid-induced hyperglycemia and diabetes in nondiabetic patients who received glucocorticoid treatment. METHODS We searched Medline, Embase, and the Cochrane Library (Central) until January 2014 for studies in which subjects received systematic glucocorticoid treatment and which evaluated whether subjects developed hyperglycemia or were diagnosed with diabetes following treatment. The primary outcome for this analysis was the incidence of hyperglycemia and the secondary outcome was the frequency of diabetes. RESULTS We identified 13 studies that met our inclusion criteria; 12 of the studies were retrospective or observational in design. We found that the rate at which patients developed glucocorticoid-induced hyperglycemia or diabetes was 32.3% (p = 0.003) and 18.6% (p = 0.002), respectively. CONCLUSIONS Our meta-analysis indicated that glucocorticoid-induced hyperglycemia occurs fairly frequently and points to the need for the design of prospective, randomized, controlled studies to further investigate and better understand this medical problem.
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Affiliation(s)
- Xiao-xia Liu
- Department of Endocrinology and Metabolism, Northern Branch of Huashan Hospital, Shanghai, China
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Masjedi M, Asilian A, Shahmoradi Z, Rajabi Dehnavi P, Abtahi Naeini B. Successful treatment of pemphigus vulgaris with the extensive mucocutaneous lesions in an elderly patient. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13967. [PMID: 25068042 PMCID: PMC4102975 DOI: 10.5812/ircmj.13967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 10/31/2013] [Accepted: 01/28/2014] [Indexed: 11/16/2022]
Abstract
Introduction: Pemphigus vulgaris (PV) is a chronic and infrequent autoimmune mucocutaneous disease that is characterized by the loose blisters and erosions on the skin and mucous membrane. Middle-aged adults are affect most frequently and the elderly and juvenile cases are infrequent. Herein, we reported a case of pemphigus vulgaris in an elderly patient. Case Presentation: We reported a case of pemphigus vulgaris in a 79-year-old patient with the extensive mucocutaneous lesions. We also reviewed the literature in MEDLINE with keywords such as pemphigus vulgaris, elderly, mucocutaneous lesions, oral lesions, and treatment. Discussion: We have to stress that the importance of this case report is its presentation in an elderly patient, as the frequent age of presentation in the Iranian patients is the middle age. On the other hand, PV occurs rarely, thus, the reporting of any rare case with some exceptions is important.
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Affiliation(s)
- Mohsen Masjedi
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
- Corresponding Author: Mohsen Masjedi, Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran. Tel: +98-9132705806, Fax: +98-3117922431, E-mail:
| | - Ali Asilian
- Department of Dermatology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Zabihollah Shahmoradi
- Department of Dermatology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Parvin Rajabi Dehnavi
- Department of Dermatology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Bahareh Abtahi Naeini
- Department of Dermatology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
- Medicine Students’ Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
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