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Kim HJ, Lee JH, Kwon SY, Kwon YJ, Park MS, Kim KH, Shin CH, Joo JC, Park SJ. Effect of a Combination of Lactiplantibacillus plantarum KC3 and Leonurus japonicus Extracts in Respiratory Discomfort: A Randomized, Double-Blind, Placebo-Controlled Trial. Nutrients 2024; 16:2128. [PMID: 38999876 PMCID: PMC11243513 DOI: 10.3390/nu16132128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
The increased global prevalence of chronic respiratory diseases in recent years has caused a substantial public health burden. Lactiplantibacillus plantarum KC3 and Leonurus japonicus Houtt. (LJH) extracts can alleviate respiratory symptoms and improve lung function in vitro and in vivo. However, the clinical efficacy and safety profile of this combination in patients with respiratory diseases remain unclear. Therefore, this multicenter, randomized, double-blind, placebo-controlled clinical trial aimed to evaluate the efficacy and safety of L. plantarum KC3 and LJH extracts in adults with respiratory discomfort. This mixture was termed 'CKDB-315'. Participants, randomly assigned to the CKDB-315 or placebo groups, were treated for 12 weeks. Assessments included the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Obstructive Pulmonary Disease Assessment Test (CAT). The CKDB-315 group showed considerably improved SGRQ and CAT scores compared with the placebo group. Secondary outcomes, including dyspnea, pulmonary function, total antioxidant status, and inflammatory cytokine levels, were consistent with the primary outcomes. Exploratory analyses of the gut microbiota and short-chain fatty acid contents revealed the potential mechanisms underlying the effects of CKDB-315. Finally, safety analysis indicated that CKDB-315 was well tolerated and caused few adverse events. Our findings indicate that CKDB-315 is a promising therapeutic option for respiratory discomfort in adults.
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Affiliation(s)
- Hyung-Jin Kim
- College of Korean Medicine, Woosuk University, Jeonju-si 54986, Jeollabuk-do, Republic of Korea
| | - Jun-Ho Lee
- College of Korean Medicine, Woosuk University, Jeonju-si 54986, Jeollabuk-do, Republic of Korea
| | - So-Young Kwon
- CKD BiO Research Institute, 8 Chungjeong-ro, Seodaemun-gu, Seoul 03742, Republic of Korea
| | - Yoo Jin Kwon
- CKD BiO Research Institute, 8 Chungjeong-ro, Seodaemun-gu, Seoul 03742, Republic of Korea
| | - Mi-Sun Park
- CKD BiO Research Institute, 8 Chungjeong-ro, Seodaemun-gu, Seoul 03742, Republic of Korea
| | - Kyung Hwan Kim
- CKD BiO Research Institute, 8 Chungjeong-ro, Seodaemun-gu, Seoul 03742, Republic of Korea
| | - Chang Hun Shin
- CKD BiO Research Institute, 8 Chungjeong-ro, Seodaemun-gu, Seoul 03742, Republic of Korea
| | - Jong-Cheon Joo
- Department of Constitutional Medicine, College of Korean Medicine, Wonkwang University, Iksan-si 54538, Jeollabuk-do, Republic of Korea
| | - Soo-Jung Park
- Department of Sasang Constitutional Medicine, College of Korean Medicine, Woosuk University, Jeonju-si 55338, Jeollabuk-do, Republic of Korea
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2
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Tran DT, Chen Y, Zheng Y, Hecker J, Hawcutt DB, Pirmohamed M, Lasky‐Su J, Wu AC, Tantisira KG, McGeachie MJ, Weiss ST, Dahlin A. Urine metabolomics signature reveals novel determinants of adrenal suppression in children taking inhaled corticosteroids to control asthma symptoms. Immun Inflamm Dis 2024; 12:e1315. [PMID: 39031511 PMCID: PMC11259003 DOI: 10.1002/iid3.1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Asthma is routinely treated with inhaled corticosteroids (ICS). Asthma patients on ICS are at increased risk of adrenal suppression, a potentially serious effect of long-term glucocorticoid exposure; however, this relationship is poorly understood. Therefore, this study aims to identify metabolite biomarkers related to adrenal suppression in asthma patients taking ICS. METHODS A total of 571 urine metabolites from 200 children with asthma on ICS in the Pharmacogenetics of Adrenal Suppression with Inhaled Steroids (PASS) cohort were profiled. Samples were grouped by peak plasma cortisol measurement as adrenal sufficient (>350 nmol/L) or insufficient (≤350 nmol/L) (outcome). Regression and discriminant-based statistical models combined with network analyses were utilized to assess relationships between metabolites and the outcome. Finally, prioritized metabolites were validated using data from an ancillary study of the Childhood Asthma Management (CAMP) cohort with similar characteristics to PASS. RESULTS Ninety metabolites were significantly associated with adrenal suppression, of which 57 also could discriminate adrenal status. While 26 metabolites (primarily steroids) were present at lower levels in the adrenal insufficient patients, 14 were significantly elevated in this group; the top metabolite, mannitol/sorbitol, was previously associated with asthma exacerbations. Network analyses identified unique clusters of metabolites related to steroids, fatty acid oxidation, and nucleoside metabolism, respectively. Four metabolites including urocanic acid, acetylcarnitine, uracil, and sorbitol were validated in CAMP cohort for adrenal suppression. CONCLUSIONS Urinary metabolites differ among asthma patients on ICS, by adrenal status. While steroid metabolites were reduced in patients with poor adrenal function, our findings also implicate previously unreported metabolites involved in amino acid, lipid, and nucleoside metabolism.
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Affiliation(s)
- Dung T. Tran
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yulu Chen
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yi Zheng
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Julian Hecker
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Jessica Lasky‐Su
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Ann C. Wu
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMassachusettsUSA
| | - Kelan G. Tantisira
- Division of Pediatric Respiratory MedicineUniversity of California San Diego and Rady Children's HospitalSan DiegoCaliforniaUSA
| | - Michael J. McGeachie
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Scott T. Weiss
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Amber Dahlin
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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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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7
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Kawahara T, Tsuji M, Tominaga N, Toyama N, Toda M. Frequency of adrenal insufficiency in patients with hypoglycemia in an emergency department: A cross-sectional study. J Endocr Soc 2022; 6:bvac119. [PMID: 36042975 PMCID: PMC9419498 DOI: 10.1210/jendso/bvac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.
Objective
We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.
Methods
In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level <70 mg/dL [3.9 mmol/L]) between April 1, 2016, and March 31, 2021, using a rapid adrenocorticotropic hormone (ACTH) test.
Results
There were 528 cases with hypoglycemia included (52.1% male; median age 62 years [range 19 to 92]). The majority (389 [73.7%]) of patients were using anti-diabetes drugs. Additionally, 33 (6.3%) consumed alcohol, 17 (3.2%) suffered from malnutrition, 13 (2.5%) liver dysfunction, 12 (2.3%) severe infectious disease, 11 (2.1%) malignancy, 9 (1.7%) heart failure, 4 (0.8%) insulin autoimmune syndrome, 3 (0.6%) insulinoma, 2 (0.4%) were using hypoglycemia-relevant drugs, and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs. 139 mEq/L, P<0.01), eosinophil counts were higher (14 vs. 8%, P<0.01), and systolic blood pressure was lower (120 vs. 128 mmHg, P<0.05) at baseline than in patients with the other etiologies, respectively.
Conclusion
The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.
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Affiliation(s)
- Tetsuya Kawahara
- Department of Endocrinology and Diabetes, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Maiko Tsuji
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Naoki Tominaga
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Nagahiro Toyama
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Mikio Toda
- Department of Internal Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
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8
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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9
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Borresen SW, Klose M, Glintborg D, Watt T, Andersen MS, Feldt-Rasmussen U. Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2022; 107:2065-2076. [PMID: 35302603 DOI: 10.1210/clinem/dgac151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 11/19/2022]
Abstract
Glucocorticoid-induced adrenal insufficiency is caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis and is the most prevalent form of adrenal insufficiency. The condition is important to diagnose given the risk of life-threatening adrenal crisis and impact on patients' quality of life. The diagnosis is made with a stimulation test such as the ACTH test. Until now, testing for glucocorticoid-induced adrenal insufficiency has often been based on clinical suspicion rather than routinely but accumulating evidence indicates that a significant number of cases will remain unrecognized. During ongoing oral glucocorticoid treatment or initially after withdrawal, ~50% of patients have adrenal insufficiency, but, outside clinical studies, ≤ 1% of patients have adrenal testing recorded. More than 70% of cases are identified during acute hospital admission, where the diagnosis can easily be missed because symptoms of adrenal insufficiency are nonspecific and overlap those of the underlying and intercurrent conditions. Treatment of severe glucocorticoid-induced adrenal insufficiency should follow the principles for treatment of central adrenal insufficiency. The clinical implications and thus indication to treat mild-moderate adrenal deficiency after glucocorticoid withdrawal has not been established. Also, the indication of adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear. In patients with established glucocorticoid-induced adrenal insufficiency, high rates of poor confidence in self-management and delayed glucocorticoid administration in the acute setting with an imminent adrenal crisis call for improved awareness and education of clinicians and patients. This article reviews different facets of glucocorticoid-induced adrenal insufficiency and discusses approaches to the condition in common clinical situations.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Torquil Watt
- Department of Endocrinology and Internal Medicine, Herlev and Gentofte Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marianne Skovsager Andersen
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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10
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Park J, Titman A, Lancaster G, Selvarajah B, Collingwood C, Powell D, Das U, Dharmaraj P, Didi M, Senniappan S, Blair J. Baseline and peak cortisol response to the low dose short Synacthen test relates to indication for testing, age and sex. J Endocr Soc 2022; 6:bvac043. [DOI: 10.1210/jendso/bvac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective
To review the outcomes of a simplified low dose Synacthen test (LDSST) performed in a tertiary endocrine service over seven years, and to examine for relationships between cortisol measurements and indication for testing, age and sex.
Design
Retrospective, observational study of LDSST performed in 2008 – 2014 (N=335) and 2016-2020 (N=160).
Methods
LDSST were performed by endocrine nurses. Synacthen 500ng/1.73m 2 administered as IV bolus, sampling at 0, 15, 25 and 35 minutes.
Results
Mean (± 1SD) baseline cortisol was 221 ± 120 nmol/L, peak 510 ± 166nmol/L and increment 210 ± 116 nmol/L. 336 (70%) of patients had a normal response (baseline cortisol >100nmol/L, peak >450nmol/L), 78 (16%) a suboptimal response (peak cortisol 350-450nmol/L) and were prescribed hydrocortisone to during periods of stress only, 67 (14%) an abnormal response (baseline <100nmol/L or peak <350nmol/L) and were prescribed daily hydrocortisone. Basal, peak and incremental increases in cortisol were higher in females (p=0.03, p<0.001, p=0.03 respectively). Abnormal results occurred most frequently in patients treated previously with pharmacological doses of glucocorticoids or structural brain abnormalities (p<0.0001).
Discussion
There are concerns that the specificity of the LDSST is poor. The low prevalence and strong association of abnormal results with indication for testing, suggests that over diagnosis occurred infrequently in this clinical setting.
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Affiliation(s)
- Julie Park
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Andrew Titman
- Department of Mathematics and Statistics, Lancaster University
| | - Gillian Lancaster
- School of Primary, Social and Community Care & Keele Clinical Trials Unit, Keele University
| | | | | | - Darren Powell
- Department of Biochemistry, Alder Hey Children’s NHS Foundation Trust
| | - Urmi Das
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Poonam Dharmaraj
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | | | - Joanne Blair
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
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11
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Bush A. Severe and Difficult Asthma: Diagnosis and Management-Challenges for a Low-Resource Environment. Indian J Pediatr 2022; 89:156-162. [PMID: 34677803 PMCID: PMC8741654 DOI: 10.1007/s12098-021-03952-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/03/2021] [Indexed: 01/28/2023]
Abstract
Severe and difficult asthma in a low- and middle-income country (LMIC) can relate to (a) lack of availability of basic medications; (b) potentially reversible factors such as poor adherence or comorbidities such as obesity inhibiting a good response to treatment; and (c) (rarely) true severe, therapy-resistant asthma. However, definitions of severity should encompass not merely doses of prescribed medication, but also underlying risk. The nature of asthmatic airway disease shows geographical variation, and LMIC asthma should not be assumed to be phenotypically the same as that in high-income countries (HICs). The first assessment step is to ensure another diagnosis is not being missed. Largely, political action is needed if children with asthma are to get access to basic medications. If a child is apparently not responding to low dose, simple medications, the next step is not to increase the dose but perform a detailed assessment of what factors (for example co-morbidities such as obesity, or social factors like poor adherence) are inhibiting a treatment response; in most cases, an underlying reason can be found. An assessment of risk of future severe asthma attacks, side-effects of medication and impaired lung development is also important. True severe, therapy-resistant asthma is rare and there are multiple underlying molecular pathologies. In HICs, steroid-resistant eosinophilia would be treated with omalizumab or mepolizumab, but the cost of these is prohibitive in LMICs, the biomarkers of successful therapy are likely only relevant to HICs. In LMICs, a raised blood eosinophil count may be due to parasites, so treating asthma based on the blood eosinophil count may not be appropriate in these settings.
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Affiliation(s)
- Andrew Bush
- Department of Pediatrics and Pediatric Respirology, National Heart and Lung Institute, Imperial College, London, UK. .,Imperial Center for Pediatrics and Child Health, Imperial College, London, UK. .,Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK.
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12
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Laulhé M, Dumaine C, Chevenne D, Leye F, Faye A, Dozières B, Strullu M, Viala J, Hogan J, Houdouin V, Léger J, Simon D, Carel JC, Storey C, Guilmin-Crépon S, Martinerie L. Glucocorticoid induced adrenal insufficiency in children: Morning cortisol values to avoid LDSST. Front Pediatr 2022; 10:981765. [PMID: 36589156 PMCID: PMC9798323 DOI: 10.3389/fped.2022.981765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Glucocorticoid-induced adrenal insufficiency (GI-AI) is a common side effect of glucocorticoid therapy. However, its diagnosis currently relies on the realization of a Low Dose Short Synacthen Test (LD-SST) that requires an outpatient hospital and several blood samples. Our goal was to evaluate whether morning cortisol values could predict the response to LD-SST, in children, to avoid useless dynamic tests and facilitate diagnosis of glucocorticoid induced adrenal insufficiency. STUDY DESIGN We recorded data of 91 pediatric patients who underwent a LD-SST in our center between 2016 and 2020 in a retrospective observational study. We selected LD-SST realized following administration of supra-physiologic doses of glucocorticoids during more than 3 weeks and performed at least four weeks after treatment was stopped. Adrenal deficiency was defined as a plasma cortisol concentration inferior to 500 nmol/l at LD-SST. RESULTS Glucocorticoid-induced adrenal insufficiency was diagnosed in 60% of our cohort. Morning cortisol values were predictive of the response to the LD-SST (AUC ROC 0.78). A plasma cortisol concentration of less than 144 nmol/l predicted glucocorticoid induced adrenal insufficiency with a specificity of 94% and a value over 317 nmol/l predicted recovery of the HPA axis with a sensitivity of 95%. We did not find any other predictive factor for glucocorticoid-induced adrenal insufficiency. CONCLUSIONS Morning cortisol values can safely assess recovery of the HPA axis in children treated chronically with glucocorticoids. Using these thresholds, more than 50% of LD-SST could be avoided in children.
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Affiliation(s)
- Margaux Laulhé
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Cécile Dumaine
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Didier Chevenne
- Biochemistry Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Fallou Leye
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Albert Faye
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Blandine Dozières
- Pediatric Neurology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Marion Strullu
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Hematology and Immunology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Jérome Viala
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Gastroenterology and Hepatology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Julien Hogan
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Nephrology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Véronique Houdouin
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Pulmonology and Allergology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Juliane Léger
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Dominique Simon
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Jean-Claude Carel
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France.,Université Paris Cité, Inserm 1141, NeuroDiderot, Paris, France
| | - Caroline Storey
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Sophie Guilmin-Crépon
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Laetitia Martinerie
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.,UFR Médecine, Université Paris Cité, Paris, France
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13
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Laquer V, Nguyen A, Squittieri N, Nguyen T. Halobetasol propionate lotion 0.05% in patients 12 to 16 years 11 months of age with plaque psoriasis: Results of an open-label study evaluating adrenal suppression potential. JAAD Int 2021; 6:13-19. [PMID: 34870246 PMCID: PMC8626834 DOI: 10.1016/j.jdin.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background The effects of halobetasol propionate (HBP) lotion 0.05% on the hypothalamic-pituitary-adrenal (HPA) axis have not been previously evaluated in adolescents. Objective To examine the effect of HBP on HPA axis suppression in patients aged <17 years with plaque psoriasis. Methods In this phase 4, open-label, multicenter study, patients aged 12 to 16 years 11 months with stable plaque psoriasis covering ≥10% of their body surface area were enrolled. The patients applied an HBP lotion twice daily for up to 2 weeks. The cosyntropin stimulation test was used to determine cortisol levels at the time of screening and at the end of the study to evaluate HPA axis response. The additional endpoints included adverse events, disease severity (measured using Investigator Global Assessment score), and percent body surface area affected. Results Sixteen patients were enrolled and included in the safety population; 14 were included in the evaluable population. One patient exhibited an abnormal HPA axis response (16.2 μg/dL) at the end of the study; the response returned to normal at the 6-month follow-up visit. By the end of the study, the Investigator Global Assessment score improved by ≥1 point in most patients; moreover, the percent body surface area affected decreased from 11.5% to 2.8%. One mild adverse event was possibly related to the HBP lotion; however, it resolved and did not cause study discontinuation. Limitations Small sample size. Conclusion The HBP lotion 0.05% appeared efficacious and well tolerated in patients as young as 12 years old.
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Key Words
- AE, adverse event
- BSA, body surface area
- CST, cosyntropin stimulation test
- EOS, end of study
- HBP, halobetasol propionate
- HPA, hypothalamic-pituitary-adrenal
- IGA, Investigator Global Assessment
- LSR, local skin reaction
- PK, pharmacokinetics
- adolescent
- adrenal suppression
- corticosteroids
- halobetasol propionate
- max, Maximum
- min, Minimum
- pharmacology
- psoriasis
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Affiliation(s)
| | | | - Nicholas Squittieri
- Department of Medical Affairs, Sun Pharmaceutical Industries, Inc, Princeton, New Jersey
| | - Tien Nguyen
- First OC Dermatology, Fountain Valley, California
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14
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Ahmet A, Rowan-Legg A, Pancer L. Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity. Paediatr Child Health 2021; 26:242-254. [PMID: 34630779 DOI: 10.1093/pch/pxab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.
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Affiliation(s)
- Alexandra Ahmet
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Anne Rowan-Legg
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Larry Pancer
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
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15
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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16
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Ahmet A, Rowan-Legg A, Pancer L. La suppression surrénalienne causée par les glucocorticoïdes exogènes : en reconnaître les facteurs de risque et en prévenir les effets. Paediatr Child Health 2021; 26:248-254. [PMID: 34136054 DOI: 10.1093/pch/pxab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Résumé
La suppression surrénalienne, un effet secondaire potentiel du traitement aux glucocorticoïdes (y compris les corticostéroïdes inhalés), peut avoir des conséquences graves et même fatales. Au Canada, on continue de déclarer des poussées d’insuffisance corticosurrénalienne consécutives à une suppression surrénalienne chez les enfants. Avant de prescrire des glucocorticoïdes, le clinicien doit absolument connaître les symptômes de suppression surrénalienne, comprendre les facteurs de risque de cette affection et être au courant des stratégies susceptibles d’en réduire les risques.
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Affiliation(s)
- Alexandra Ahmet
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Anne Rowan-Legg
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Larry Pancer
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
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17
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Kanthagnany SK, Lane LC, Wood C, Sachdev P, Drake AJ, Cheetham T. Fifteen-minute consultation: An approach to the child receiving glucocorticoids. Arch Dis Child Educ Pract Ed 2021; 106:130-135. [PMID: 32769084 DOI: 10.1136/archdischild-2019-317812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 11/03/2022]
Abstract
Glucocorticoids (GC) are used in paediatric practice for a broad range of conditions and all paediatricians will prescribe GC, in some form, during their career. A wide variety of GC formulations, doses and administration routes are used for periods of time ranging from days to years. Exposure to exogenous GC can result in hypothalamic-pituitary-adrenal axis suppression-otherwise known as adrenal suppression (AS). Patients with AS may be well most of the time but if GC therapy is reduced or stopped or if additional endogenous GC cannot be generated during illness, then an absolute or relative lack of GC can result in severe illness or death. Here, we highlight the relevance of AS to all paediatricians by providing an overview of the background and discussing the presentation and approaches to the management of this clinical entity.
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Affiliation(s)
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire Wood
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Pooja Sachdev
- Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Jane Drake
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK .,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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18
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Chang AB, Fortescue R, Grimwood K, Alexopoulou E, Bell L, Boyd J, Bush A, Chalmers JD, Hill AT, Karadag B, Midulla F, McCallum GB, Powell Z, Snijders D, Song WJ, Tonia T, Wilson C, Zacharasiewicz A, Kantar A. Task Force report: European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis. Eur Respir J 2021; 58:13993003.02990-2020. [PMID: 33542057 DOI: 10.1183/13993003.02990-2020] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/21/2020] [Indexed: 11/05/2022]
Abstract
There is increasing awareness of bronchiectasis in children and adolescents, a chronic pulmonary disorder associated with poor quality-of-life for the child/adolescent and their parents, recurrent exacerbations and costs to the family and health systems. Optimal treatment improves clinical outcomes. Several national guidelines exist, but there are no international guidelines.The European Respiratory Society (ERS) Task Force for the management of paediatric bronchiectasis sought to identify evidence-based management (investigation and treatment) strategies. It used the ERS standardised process that included a systematic review of the literature and application of the GRADE approach to define the quality of the evidence and level of recommendations.A multidisciplinary team of specialists in paediatric and adult respiratory medicine, infectious disease, physiotherapy, primary care, nursing, radiology, immunology, methodology, patient advocacy and parents of children/adolescents with bronchiectasis considered the most relevant clinical questions (for both clinicians and patients) related to managing paediatric bronchiectasis. Fourteen key clinical questions (7 "Patient, Intervention, Comparison, Outcome" [PICO] and 7 narrative) were generated. The outcomes for each PICO were decided by voting by the panel and parent advisory group.This guideline addresses the definition, diagnostic approach and antibiotic treatment of exacerbations, pathogen eradication, long-term antibiotic therapy, asthma-type therapies (inhaled corticosteroids, bronchodilators), mucoactive drugs, airway clearance, investigation of underlying causes of bronchiectasis, disease monitoring, factors to consider before surgical treatment and the reversibility and prevention of bronchiectasis in children/adolescents. Benchmarking quality of care for children/adolescents with bronchiectasis to improve clinical outcomes and evidence gaps for future research could be based on these recommendations.
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Affiliation(s)
- Anne B Chang
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Rebecca Fortescue
- Population Health Research Institute, St George's University of London, London, United Kingdom
| | - Keith Grimwood
- Departments of Infectious Disease and Paediatrics, Gold Coast Health, Southport, Queensland, Australia.,School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast campus, Southport, Queensland, Australia
| | - Efthymia Alexopoulou
- 2nd Radiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Leanne Bell
- European Lung Foundation bronchiectasis paediatric patient advisory group, Alnwick, United Kingdom
| | | | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial School of Medicine, London, UK
| | - James D Chalmers
- College of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Adam T Hill
- Dept of Respiratory Medicine, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Bulent Karadag
- Division of Pediatric Pulmonology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Fabio Midulla
- Department of Maternal Science, Sapienza University of Rome, Rome, Italy
| | - Gabrielle B McCallum
- Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Zena Powell
- European Lung Foundation bronchiectasis paediatric patient advisory group, Alnwick, United Kingdom
| | - Deborah Snijders
- Dipartimento Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christine Wilson
- Department of Physiotherapy, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Angela Zacharasiewicz
- Department of Pediatrics, and Adolescent Medicine, Teaching Hospital of the University of Vienna, Wilhelminen Hospital, Klinikum Ottakring Vienna, Wien, Austria
| | - Ahmad Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Ponte San Pietro-Bergamo, Bergamo, Italy
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Akurugu WA, Van Heerden CJ, Mulder N, Zöllner EW. Hypothalamic-pituitary-adrenal axis suppression in asthma: A glucocorticoid receptor polymorphism may protect. Pediatr Allergy Immunol 2021; 32:273-279. [PMID: 32969491 DOI: 10.1111/pai.13379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Asthmatic children on corticosteroids can develop hypothalamic-pituitary-adrenal axis suppression (HPAS). Single nucleotide polymorphisms (SNPs) rs242941 and rs1876828 of the corticotrophin-releasing hormone receptor 1 (CRHR1) gene were associated with lower stimulated cortisol (F) levels, whereas rs41423247 of the glucocorticoid receptor (NR3C1) gene was associated with higher basal F levels. The objective of the current study was to confirm whether these three SNPs are associated with HPAS in asthmatic children. METHODS DNA was extracted from saliva obtained from 95 asthmatic children, who had previously undergone basal F and metyrapone testing. Thirty-six children were classified as suppressed. Non-suppressed children were subclassified according to their post-metyrapone adrenocorticotropin (PMTP ACTH) level into a middle (106-319 pg/mL) and a high (>319 pg/mL) ACTH response group. TaqMan® polymerase chain reaction assays were utilized. RESULTS Only rs41423247 was inversely associated with HPAS (OR = 0.27 [95% CI 0.06-0.90]). Its GC genotype was inversely associated with HPAS (log odds = -1.28, P = .021). √PMTP ACTH was associated with CC (effect size = 10.85, P = .005) and GC genotypes (effect size = 4.06, P = .023). The C allele is inherited as a dominant trait (effect size = -1.31 (95% CI -2.39--0.33; P = .012). In the high ACTH response group, both genotypes affected the PMTP ACTH (effect sizes 1.41 and 15.46; P-values .023 and <2 × 10-26 for GC and CC, respectively). CONCLUSIONS The C allele of rs41423247 was found to be protective against HPAS. CC genotype is associated with the highest PMTP ACTH response.
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Affiliation(s)
- Wisdom Alemya Akurugu
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Nicola Mulder
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Ekkehard Werner Zöllner
- Paediatric Endocrine & Diabetes Unit, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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20
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Seo KH. Perioperative glucocorticoid management based on current evidence. Anesth Pain Med (Seoul) 2021; 16:8-15. [PMID: 33445232 DOI: 10.17085/apm.20089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023] Open
Abstract
Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.
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Affiliation(s)
- Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Korea
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21
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Rayas MS, Kelly A, Hughan KS, Daley T, Zangen D. Adrenal function in cystic fibrosis. J Cyst Fibros 2020; 18 Suppl 2:S74-S81. [PMID: 31679732 DOI: 10.1016/j.jcf.2019.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Cystic fibrosis (CF) is not known to directly affect the adrenal gland, but commonly used CF therapies do impact the function of the hypothalamic-pituitary-adrenal (HPA) axis. By binding to the glucocorticoid receptor, medications such as inhaled and oral corticosteroids can enhance the systemic effects of cortisol and result in iatrogenic Cushing syndrome. Prolonged use suppresses the body's ability to make cortisol, resulting in iatrogenic adrenal insufficiency upon medication discontinuation. Chronic use of inhaled and oral corticosteroids can negatively affect bone health, growth, and glucose metabolism. This chapter provides practical guidelines regarding the screening, diagnosis, and treatment of iatrogenic adrenal insufficiency. As the guidelines are mainly derived from the asthma literature, this chapter also highlights the need for studies to evaluate the impact of CF therapies on adrenal function and other CF-endocrinopathies.
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Affiliation(s)
- Maria Socorro Rayas
- Division of Pediatric Endocrinology and Diabetes, University of Texas Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA.
| | - Andrea Kelly
- Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine of University of Pennsylvania, 2716 South Street, Philadelphia, PA 19146, USA.
| | - Kara S Hughan
- Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tanicia Daley
- Division of Pediatric Endocrinology and Metabolism, Emory Children's Center/Emory Pediatric Institute, Emory University School of Medicine, 1400 Tullie Road, Atlanta, GA 30329, USA.
| | - David Zangen
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem 91240, Israel.
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22
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Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review. ENDOCRINES 2020. [DOI: 10.3390/endocrines1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.
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Abstract
Asthma is the most common chronic inflammatory disease of children, and inhaled corticosteroids (ICSs) are the most effective and commonly used treatment of persistent asthma. ICSs currently approved for and commonly used by children with asthma include beclomethasone dipropionate, budesonide, fluticasone propionate, mometasone furoate, ciclesonide, and triamcinolone acetonide. This article reviews 4 areas critical to understanding potential adverse endocrine outcomes of ICSs and placing them in proper perspective: (1) influence of drug/delivery device properties on systemic steroid burden; (2) adrenal insufficiency during ICS treatment; (3) growth effects of ICS and asthma itself; and (4) bone mineral accretion during ICS therapy.
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Affiliation(s)
- David B Allen
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, H4/448 CSC - Pediatrics, 600 Highland Avenue, Madison, WI 53792-4108, USA.
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24
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Lee DDH, Cardinale D, Terakosolphan W, Sornsute A, Radhakrishnan P, Coppel J, Smith CM, Satyanarayana S, Forbes B, O'Callaghan C. Fluticasone Particles Bind to Motile Respiratory Cilia: A Mechanism for Enhanced Lung and Systemic Exposure? J Aerosol Med Pulm Drug Deliv 2020; 34:181-188. [PMID: 32960118 DOI: 10.1089/jamp.2020.1598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Inhaled corticosteroids (ICSs) are the main prophylactic treatment for asthma and are used in other diseases, including chronic pulmonary obstructive disease, yet the interaction of ICS particles with the ciliated epithelium remains unclear. The aim of this study was to investigate the earliest interaction of aerosolized fluticasone propionate (FP) particles with human ciliated respiratory epithelium. Methods: A bespoke system was developed to allow aerosolized FP particles to be delivered to ciliated epithelial cultures by nebulization and from a pressurized metered-dose inhaler (pMDI) through a spacer with interactions observed in real time using high-speed video microscopy. Interaction with nonrespiratory cilia was investigated using steroids on brain ependymal ciliary cultures. The dissolution rate of steroid particles was determined. Results: FP particles delivered by aerosol attached to the tips of rapidly beating cilia. Within 2 hours, 8.7% ± 1.8% (nebulization) and 12.1% ± 2.1% (pMDI through spacer) of ciliated cells had one or more particles attached to motile cilia. These levels decreased to 5.8% ± 1.6% (p = 0.59; nebulization) and 5.3% ± 2.2% (p = 0.14; pMDI through spacer) at 24 hours. Particle attachment did not affect ciliary beat frequency (p > 0.05) but significantly (p < 0.001) reduced ciliary beat amplitude. Steroid particles also attached to the tips of motile ependymal brain cilia and also reduced beat amplitude (24 hours: >2 particles bound p < 0.001). Dissolution of FP particles was slow with only 22.8% ± 1.3% of nebulized and 12.8% ± 0.5% of pMDI-delivered drug dissolving by 24 hours. Conclusions: FP particles adhere to the tips of rapidly moving cilia with significant numbers remaining bound at 24 hours, resisting the shear stress generated by ciliary beating. In vivo, this mechanism may predispose to high local drug concentrations and enhance respiratory and systemic corticosteroid exposure.
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Affiliation(s)
- Dani Do Hyang Lee
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Daniela Cardinale
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | | | - Acom Sornsute
- Pharmaceutics, UCL School of Pharmacy, London, United Kingdom
| | - Priya Radhakrishnan
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Jonathan Coppel
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | - Claire M Smith
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
| | | | - Ben Forbes
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Christopher O'Callaghan
- Respiratory, Critical Care, and Anesthesia, UCL Great Ormond Street Children's Hospital Institute of Child Health & NIHR GOSH BRC, London, United Kingdom
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25
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Elder CJ, Vilela R, Johnson TN, Taylor RN, Kemp EH, Keevil BG, Cross AS, Ross RJ, Wright NP. Pharmacodynamic studies of nasal tetracosactide with salivary glucocorticoids for a noninvasive Short Synacthen Test. J Clin Endocrinol Metab 2020; 105:5850507. [PMID: 32593173 DOI: 10.1210/clinem/dgaa323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/27/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The Short Synacthen Test (SST) is the gold standard for diagnosing adrenal insufficiency. It requires invasive administration of Synacthen, venous sampling, and is resource-intensive. OBJECTIVE To develop a nasally administered SST, with salivary glucocorticoids measurement, to assess the adrenal response. DESIGN We conducted 5 studies: 4 open-label, sequence-randomized, crossover, pharmacodynamic studies testing 6 doses/formulations and a repeatability study. Additionally, pharmacokinetic analysis was undertaken using our chosen formulation, 500 µg tetracosactide with mucoadhesive chitosan, Nasacthin003, in our pediatric study. SETTING Adult and children's clinical research facilities. PARTICIPANTS A total of 36 healthy adult males and 24 healthy children. INTERVENTION We administered all 6 nasal formulations using an European regulator endorsed atomization device. The IV comparators were 250 µg or 1 µg SST. MAIN OUTCOME MEASURES We analyzed paired blood and saliva samples for plasma cortisol and salivary cortisol and cortisone. RESULTS The addition of chitosan to tetracosactide and dose escalation increased peak cortisol response (P = 0.01 and 0.001, respectively). The bioavailability of Nasacthin003 was 14.3%. There was no significant difference in plasma cortisol at 60 minutes between 500 µg Nasacthin003 and 250 µg IV Synacthen (P = 0.17). The repeatability coefficient at 60 minutes was 105 nmol/L for IV Synacthen and salivary cortisol and cortisone was 10.3 and 21.1 nmol/L, respectively. The glucocorticoid response in children was indistinguishable from that of adults. CONCLUSIONS Nasal administration of Nasacthin003 generates equivalent plasma cortisol values to the 250-µg IV SST and, with measurement at 60 minutes of salivary cortisol or cortisone, provides a noninvasive test for adrenal insufficiency.
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Affiliation(s)
- Charlotte J Elder
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
- Department of Endocrinology, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ruben Vilela
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | | | - Rosie N Taylor
- Statistical Services Unit, The University of Sheffield, Sheffield, United Kingdom
| | - E Helen Kemp
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Brian G Keevil
- Department of Clinical Biology, Manchester University NHS Trust, Manchester, United Kingdom
| | - Alexandra S Cross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Neil P Wright
- Department of Endocrinology, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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26
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Bareille P, Tomkins S, Imber V, Tayob M, Dunn K, Mehta R, Khindri S. A randomized, double-blind, placebo-controlled, parallel-group study of once-daily inhaled fluticasone furoate on the hypothalamic-pituitary-adrenocortical axis of children with asthma. Allergy Asthma Clin Immunol 2020; 16:11. [PMID: 32042286 PMCID: PMC7001316 DOI: 10.1186/s13223-020-0406-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/17/2020] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate the effects of fluticasone furoate on the hypothalamic–pituitary–adrenocortical axis, and the safety and tolerability of fluticasone furoate treatment in children with asthma. Methods This was a randomized, double-blind, placebo-controlled, multicenter, stratified, parallel-group, non-inferiority study of fluticasone furoate 50 µg inhalation powder administered once daily. The study enrolled children (aged 5–11 years inclusive) with a documented diagnosis of asthma for ≥ 6 months and a Childhood Asthma Control Test score of > 19. After a 7–14-day run-in period, eligible subjects were stratified by age and randomized to fluticasone furoate 50 µg once daily or placebo once daily via ELLIPTA for 6 weeks. The primary endpoint was the change from baseline (expressed as a ratio) in 0–24-h weighted mean serum cortisol at the end of the treatment period. Results Fifty-six randomized subjects received fluticasone furoate 50 µg once daily and 55 received placebo. The primary analysis was performed in the serum cortisol population (n = 104) and demonstrated that fluticasone furoate 50 µg once daily was non-inferior to placebo (ratio = 0.93; 95% confidence interval 0.8096, 1.0620), as the lower limit of the 95% confidence interval for the geometric mean treatment ratio of fluticasone furoate 50 µg once daily versus placebo was greater than 0.80. Findings from the intent-to-treat population (n = 111) were similar. Conclusions Six weeks of treatment with inhaled fluticasone furoate 50 µg once daily had no clinically relevant effect on the hypothalamic–pituitary–adrenocortical axis function of children, as measured by 24-h serum cortisol profiles. The primary analysis showed that fluticasone furoate 50 µg once daily was non-inferior to placebo. Fluticasone furoate 50 µg once daily was well tolerated and no new safety concerns emerged during the study. Trial registration This study is registered in ClinicalTrials.gov (NCT02483975). Date of submission: 25 June 2015.
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Affiliation(s)
- Philippe Bareille
- 1Medicines Research Centre, GlaxoSmithKline, Gunnels Wood Rd, Stevenage, SG1 2NY Hertfordshire UK
| | | | | | | | - Karen Dunn
- 4North Carolina Clinical Research, Raleigh, NC USA
| | - Rashmi Mehta
- 5GlaxoSmithKline Research Triangle Park, Durham, NC USA
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27
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Inhaled corticosteroid-phobia and childhood asthma: Current understanding and management implications. Paediatr Respir Rev 2020; 33:62-66. [PMID: 31053357 DOI: 10.1016/j.prrv.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 02/04/2023]
Abstract
Asthma is the most prevalent chronic disease in children. Inhaled corticosteroids (ICS) is the first-line controller therapy for children with persistent asthma, however, suboptimal compliance to ICS therapy remains as a major obstacle in paediatric asthma management. Steroid-phobia, the fear of side-effects and subsequent aversion of ICS, has been widely reported in parents of asthmatic children. The reported prevalence of steroid-phobia varies widely from 19% to 67% in different populations. The concerns about ICS frequently raised by parents include growth suppression, weight gain, bone weakness, addiction and psychiatric disturbances. Outside of growth suppression, which is statistically significant yet mild in clinical studies, the other concerns are not evidence-based and are misconceptions. Conflicting results have been reported regarding the impact of steroid-phobia on ICS compliance. In contrast, steroid-phobia has consistent and negative effects on asthma control in children. While asthma educational programmes have demonstrable benefits in general paediatric populations, the generalisability of such programmes to steroid-phobic parents remains undetermined. There is a paucity of data on specific educational programmes to clear misconceptions and reduce steroid-phobia. Given the continually raising prevalence of paediatric asthma, high-quality studies are warranted to investigate the prevalence and impact of steroid-phobia, with an ultimate goal of developing effective strategies to tackle steroid-phobia and improve asthma care in children.
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28
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Khanimov I, Shimonov M, Wainstein J, Leibovitz E. Hypoglycemia, Malnutrition and Body Composition. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:71-84. [PMID: 32329027 DOI: 10.1007/5584_2020_526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypoglycemia is one of the most significant factors to affect prognosis, and is detrimental to patients regardless of diabetes mellitus (DM) status. The classical paradigms dictate that hypoglycemia is a result of overtreatment with glucose lowering agents (iatrogenic hypoglycemia), or, as among patients without DM, this condition is attributed to disease severity. New information shows that hypoglycemia occurs among patients that have a tendency for it. Incident hypoglycemia is very prevalent in the hospital setting, occurring in 1:6 patients with DM and in 1:17 patients without DM (Leibovitz E, Khanimov I, Wainstein J, Boaz M; Diabetes Metab Syndr Clin Res Rev. 13:222-226, 2019).One of the major factors associated with incidence of hypoglycemia is the nutritional status on hospital admission and during the hospitalization. Assessment of nutritional status using questionnaires and biomarkers might be helpful in determining risk of hypoglycemia. Moreover, administration of oral nutritional supplements was shown to decrease this risk.It is also well known that a high burden of comorbidities is associated with an increased risk of hypoglycemia. For example, kidney disease, whether acute or chronic, was shown to increase the risk for hypoglycemia, as well as some endocrine disorders.In this review we elaborate on specific findings that are characteristic of patients at risk for developing hypoglycemia, as well as treatment aimed at preventing its occurrence.
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Affiliation(s)
- I Khanimov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Shimonov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Diabetes Unit, Edith Wolfson Medical Center, Holon, Israel
| | - J Wainstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery "A", Edith Wolfson Medical Center, Holon, Israel
| | - Eyal Leibovitz
- Department of Internal Medicine "A", Yoseftal Hospital, Eilat, Israel.
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29
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Co-Occurrence of Exogenous and Endogenous Cushing’s Syndromes—Dilemma in Diagnosis. Case Rep Endocrinol 2019; 2019:2986312. [PMID: 31737375 PMCID: PMC6815529 DOI: 10.1155/2019/2986312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/16/2019] [Indexed: 11/18/2022] Open
Abstract
Approach to patients who manifest with features of Cushing's syndrome often begin with exclusion of exposure to excessive exogenous source of glucocorticoids (GC). Most guidelines advocate no further assessment if excessive exogenous GC use is present. We present a case of a 66-year-old lady who was noted to have typical features of Cushing's syndrome. As she gave a very clear history of ingesting exogenous GC for a year, no further work up was undertaken. Despite cessation of GC for a year, she continued to have thin skin and easy bruising. Upon admission for hypertensive emergency, her clinician took note of her changes and investigated her for endogenous Cushing's syndrome. Her cortisol post overnight dexamethasone suppression test was 707 nmol/l. Post low dose dexamethasone suppression test yielded a cortisol of 1133.2 nmol/l. 24 hours urine cortisol was 432.2 nmol/l. Plasma ACTH was 1.1 pmol/l, indicating an ACTH independent Cushing's syndrome. We proceeded with Computed tomography scan (CT scan) of adrenals which revealed a right adrenal adenoma measuring 4.4 × 3.4 × 4.0 cm. Right retroperiteneoscopic adrenalectomy was done. Histopathology examination was consistent with adrenal cortical adenoma with foci of myelolipoma. Post adrenalectomy she developed hypocortisolism secondary to contralateral adrenal suppression which lasted up to the present date. Her cutaneous and musculoskeletal manifestations improved substantially. Co-occurrence of endogenous and exogenous Cushing's syndromes is uncommon but should be considered in patients whose Cushingnoid features do not resolve after cessation of exogenous GC.
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30
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Kalayci O, Abdelateef H, Pozo Beltrán CF, El-Sayed ZA, Gómez RM, Hossny E, Morais-Almeida M, Nieto A, Phipatanakul W, Pitrez P, Wong GW, Xepapadaki P, Papadopoulos NG. Challenges and choices in the pharmacological treatment of non-severe pediatric asthma: A commentary for the practicing physician. World Allergy Organ J 2019; 12:100054. [PMID: 31641403 PMCID: PMC6796770 DOI: 10.1016/j.waojou.2019.100054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022] Open
Abstract
In recent years, asthma research has focused intensely on the severe part of the disease spectrum, leading to new treatments, mostly therapeutic monoclonal antibodies. However, severe asthma accounts for not more than 2% of asthma in the pediatric population. Therefore, non-severe asthma remains a major health problem in children, not only for patients and parents but also for healthcare professionals such as general practitioners, pediatricians and allergists who take care of these patients. It is thus essential to identify and put in context novel concepts, applicable to the treatment of these patients. Recent evidence suggests benefits from using anti-inflammatory treatment even for the mildest cases, for whom until now only symptomatic bronchodilation was recommended. Likewise, “reliever” medication may be better combined with an inhaled corticosteroid (ICS). Among “new” treatments (for children), ICS formulation in ultrafine particles has showed promise and tiotropium is gaining access to the pediatric population. Maintenance and reliever therapy (MART) is an option for moderate disease. Most importantly, personalized response to medications appears to be considerable, therefore, it may need to be taken into account. Overall, these new options provide opportunities for multiple new management strategies. The deployment of such strategies in different populations remains to be evaluated.
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Affiliation(s)
- Omer Kalayci
- Pediatric Allergy and Asthma, Hacettepe University, School of Medicine, Ankara, Turkey
- Corresponding author.
| | - Hanan Abdelateef
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Zeinab A. El-Sayed
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Antonio Nieto
- Pediatric Pulmonology & Allergy Unit Children's Hospital la Fe, 46026, Valencia, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo Pitrez
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Gary Wk. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, China
| | | | - Nikolaos G. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
- Corresponding author. Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK
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Abstract
BACKGROUND The reduction of lung inflammation is one of the goals of cystic fibrosis therapy. Inhaled corticosteroids are often used in this respect to treat children and adults with cystic fibrosis. The rationale for this is their potential to reduce lung damage arising from inflammation, as well as their effect on symptomatic wheezing. It is important to establish the current level of evidence for the risks and benefits of inhaled corticosteroids, especially in the light of their known adverse effects on growth. This is an update of a previously published review; however, due to the lack of research in this area, we do not envisage undertaking any further updates. OBJECTIVES To assess the effectiveness of taking regular inhaled corticosteroids compared to not taking them in children and adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We requested information from pharmaceutical companies manufacturing inhaled corticosteroids and authors of identified trials.Date of most recent search of the Group's Trials Register: 19 November 2018. SELECTION CRITERIA Randomised or quasi-randomised trials, published and unpublished, comparing inhaled corticosteroids to placebo or standard treatment in individuals with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two independent authors assessed methodological quality and risk of bias in trials using established criteria and extracted data using standard pro formas. The quality of the evidence was assessed using the GRADE criteria. MAIN RESULTS The searches identified 35 citations, of which 27 (representing 13 trials) were eligible for inclusion. These 13 trials reported the use of inhaled corticosteroids in 525 people with cystic fibrosis aged between 6 and 55 years. One was a withdrawal trial in 171 individuals who were already taking inhaled corticosteroids. Methodological quality and risk of bias were difficult to assess from published information.Objective measures of airway function were reported in most trials but were often incomplete and reported at different time points. We found no difference in forced expiratory volume in one second (FEV1) or forced vital capacity (FVC) % predicted in any of the trials, although the quality of the evidence was low due to risks of bias within the included trials and low participant numbers. We are uncertain whether inhaled corticosteroids result in an improvement in exercise tolerance, bronchial hyperreactivity or exacerbations as the quality of the evidence was very low. Data from one trial suggested that inhaled corticosteroids may make little or no difference to quality of life (low-quality evidence).Three trials reported adverse effects, but the quality of the evidence is low and so we are uncertain whether inhaled corticosteroids increase the risk of adverse effects. However, one study did show that growth was adversely affected by high doses of inhaled corticosteroids. AUTHORS' CONCLUSIONS Evidence from these trials is of low to very low quality and insufficient to establish whether inhaled corticosteroids are beneficial in cystic fibrosis, but withdrawal in those already taking them has been shown to be safe. There is some evidence they may cause harm in terms of growth. It has not been established whether long-term use is beneficial in reducing lung inflammation, which should improve survival, but it is unlikely this will be proven conclusively in a randomised controlled trial.
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Affiliation(s)
- Ian M Balfour-Lynn
- Dept. Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London, UK, SW3 6NP
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Goldbloom EB, Ahmet A. Screening practices for paediatric asymptomatic adrenal suppression in Canada: Are we addressing this important risk? Paediatr Child Health 2019; 25:389-393. [PMID: 34163543 DOI: 10.1093/pch/pxy174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background Children with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable. Objective To assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases. Methods Before and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013. Results Response rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year. Conclusion Frequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
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Miller BS, Spencer SP, Geffner ME, Gourgari E, Lahoti A, Kamboj MK, Stanley TL, Uli NK, Wicklow BA, Sarafoglou K. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med 2019; 68:16-25. [PMID: 30819831 PMCID: PMC6996103 DOI: 10.1136/jim-2019-000999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 01/01/2023]
Abstract
Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient's HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient's home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.
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Affiliation(s)
- Bradley S Miller
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Sandra P Spencer
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mitchell E Geffner
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Evgenia Gourgari
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amit Lahoti
- Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Manmohan K Kamboj
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Takara L Stanley
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Naveen K Uli
- Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Brandy A Wicklow
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kyriakie Sarafoglou
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
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Ahmet A, Mokashi A, Goldbloom EB, Huot C, Jurencak R, Krishnamoorthy P, Rowan-Legg A, Kim H, Pancer L, Kovesi T. Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children. BMJ Paediatr Open 2019; 3:e000569. [PMID: 31750407 PMCID: PMC6830460 DOI: 10.1136/bmjpo-2019-000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022] Open
Abstract
Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.
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Affiliation(s)
- Alexandra Ahmet
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Pediatrics, Division of Endocrinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ellen B Goldbloom
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Celine Huot
- Pediatrics, Division of Endocrinology, University of Montreal, Montreal, Quebec, Canada.,Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Roman Jurencak
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Preetha Krishnamoorthy
- Pediatrics, Division of Endocrinology, Montreal Childrens Hospital, Montreal, Quebec, Canada.,Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Anne Rowan-Legg
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Joseph's Hospital, London, Ontario, Canada
| | - Larry Pancer
- Pediatrics, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Tom Kovesi
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab 2019; 10:2042018819848218. [PMID: 31223468 PMCID: PMC6566489 DOI: 10.1177/2042018819848218] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/04/2019] [Indexed: 12/24/2022] Open
Abstract
Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. An adrenal crisis may be the first presentation of adrenal insufficiency or can occur in patients who have been established on glucocorticoid replacement therapy. Infections are the major precipitating factor, but other causes include physical stress such as a surgical procedure or trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress. The emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration and management of electrolyte abnormalities. Prevention is centred around patient education. All patients should be educated on stress dosing and parenteral glucocorticoid administration. They should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification. Despite many improvements in the management of patients with adrenal insufficiency, adrenal crisis continues to occur and represents a major source of morbidity, mortality and distress for patients. Improved patient and clinician education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are central to the management of this life-threatening event.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Chino K, Ganzberg S, Mendoza K. Office-Based Sedation/General Anesthesia for COPD Patients, Part II. Anesth Prog 2019; 66:44-51. [PMID: 30883229 PMCID: PMC6424168 DOI: 10.2344/anpr-66-02-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/10/2018] [Indexed: 11/11/2022] Open
Abstract
The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.
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Affiliation(s)
- Kristin Chino
- Private Practice, Anesthesia for Dentistry, Las Vegas, Nevada
| | - Steven Ganzberg
- Clinical Professor of Anesthesiology, UCLA School of Dentistry, Los Angeles, California
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Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
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Spera K, Rubin D, Gupta T, Fantaneanu T, Henderson GV. Clinical Reasoning: An 87-year-old man with chronic obstructive pulmonary disease and acute encephalopathy. Neurology 2018; 87:e135-9. [PMID: 27672171 DOI: 10.1212/wnl.0000000000003149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Kristyn Spera
- From the Department of Neurology (K.S., D.R.), Massachusetts General Hospital and Brigham and Women's Hospital and Harvard Medical School; and Departments of Endocrinology (T.G.) and Neurology (T.F., G.V.H.), Brigham and Women's Hospital, Boston, MA.
| | - Daniel Rubin
- From the Department of Neurology (K.S., D.R.), Massachusetts General Hospital and Brigham and Women's Hospital and Harvard Medical School; and Departments of Endocrinology (T.G.) and Neurology (T.F., G.V.H.), Brigham and Women's Hospital, Boston, MA
| | - Tina Gupta
- From the Department of Neurology (K.S., D.R.), Massachusetts General Hospital and Brigham and Women's Hospital and Harvard Medical School; and Departments of Endocrinology (T.G.) and Neurology (T.F., G.V.H.), Brigham and Women's Hospital, Boston, MA
| | - Tadeu Fantaneanu
- From the Department of Neurology (K.S., D.R.), Massachusetts General Hospital and Brigham and Women's Hospital and Harvard Medical School; and Departments of Endocrinology (T.G.) and Neurology (T.F., G.V.H.), Brigham and Women's Hospital, Boston, MA
| | - Galen V Henderson
- From the Department of Neurology (K.S., D.R.), Massachusetts General Hospital and Brigham and Women's Hospital and Harvard Medical School; and Departments of Endocrinology (T.G.) and Neurology (T.F., G.V.H.), Brigham and Women's Hospital, Boston, MA
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Lefebvre H, Goichot B. Controversy: Pros and cons screening of corticotropic deficiency after exogenous glucocorticoid therapy. ANNALES D'ENDOCRINOLOGIE 2018; 79:182-183. [PMID: 29656921 DOI: 10.1016/j.ando.2018.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- H Lefebvre
- Service d'endocrinologie, diabète et maladies métaboliques, CHU de Rouen, 76031 Rouen, France.
| | - B Goichot
- Service de médecine interne, endocrinologie et nutrition, hôpitaux universitaires de Strasbourg, 67091 Strasbourg, France
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40
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Smy L, Shaw K, Amstutz U, Staub M, Chaudhry S, Smith A, Carleton B, Koren G. Assessment of hair cortisol as a potential biomarker for possible adrenal suppression due to inhaled corticosteroid use in children with asthma: A retrospective observational study. Clin Biochem 2018; 56:26-32. [PMID: 29673814 DOI: 10.1016/j.clinbiochem.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/10/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are the recommended long-term control therapy for asthma in children. However, concern exists regarding potential adrenal suppression with chronic ICS use. Our pilot study reported that hair cortisol in children was 50% lower during ICS therapy than prior to therapy, suggestive of adrenal suppression. OBJECTIVE To evaluate hair cortisol concentration (HCC) as a potential biomarker for possible adrenal suppression from ICS use in children with asthma. METHODS A retrospective observational study was performed at asthma clinics in Vancouver, Winnipeg, and Toronto, Canada. Children (n = 586) were recruited from July 2012 to December 2014 inclusive of those without asthma, with asthma not using ICS, and with asthma using ICS. The most recent three-month HCC was measured by enzyme immunoassay and compared among the groups. Quantile regression analysis was performed to identify factors potentially affecting HCC. RESULTS The median HCC was not significantly different among the children: No ICS (n = 47, 6.7 ng/g, interquartile range (IQR) 3.7-9.8 ng/g), ICS Treated (n = 360, 6.5 ng/g, IQR 3.8-14.3 ng/g), and Controls (n = 53, 5.8 ng/g, IQR 4.6-16.7 ng/g). 5.6% of the children using ICS had hair cortisol <2.0 ng/g compared to none in the control groups (P < .05, comparing ICS Treated (20/360) to all Controls combined (0/100)) and only half had been exposed to systemic corticosteroids. Age, sex, BMI, and intranasal corticosteroid use were significantly associated with HCC. CONCLUSIONS Results suggest HCC may be a potential biomarker for adrenal suppression as a population of children using ICS with HCC < 2.0 ng/g was identified compared to none in the control groups. Further research is needed to determine if those children have or are at risk of adrenal suppression or insufficiency.
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Affiliation(s)
- Laura Smy
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada; Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kaitlyn Shaw
- Child & Family Research Institute, Vancouver, BC, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ursula Amstutz
- Child & Family Research Institute, Vancouver, BC, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; University Institute of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, Switzerland
| | - Michelle Staub
- Winnipeg Regional Health Authority, Pharmacy Department, Winnipeg, Manitoba, Canada
| | - Shahnaz Chaudhry
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne Smith
- Child & Family Research Institute, Vancouver, BC, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Bruce Carleton
- Child & Family Research Institute, Vancouver, BC, Canada; Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, BC, Canada.
| | - Gideon Koren
- Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Maccabi-Kahn Research Institute, Tel Aviv, Israel
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Barra CB, Fontes MJF, Cintra MTG, Cruz RC, Rocha JAG, Guimarães MCC, Silva IN. Oral corticosteroids for asthma exacerbations might be associated with adrenal suppression: Are physicians aware of that? ACTA ACUST UNITED AC 2018; 63:899-903. [PMID: 29267492 DOI: 10.1590/1806-9282.63.10.899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/05/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Oral corticosteroids (OCS) are a mainstay of treatment for asthma exacerbations, and short-term OCS courses were generally considered to be safe. Nevertheless, frequent short-term OCS courses could lead to hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Our study aimed at investigating the integrity of the HPA axis in children with persistent asthma or recurrent wheezing at the beginning of an inhaled corticosteroids (ICS) trial. METHOD Morning basal cortisol was assessed just before the beginning of ICS, and 30, 60, and 90 days later, using Immulite® Siemens Medical Solutions Diagnostic chemiluminescent enzyme immunoassay (Los Angeles, USA; 2006). RESULTS In all, 140 children (0.3-15 years old) with persistent asthma or recurrent wheezing have been evaluated and 40% of them reported short-term OCS courses for up to 30 days before evaluation. Out of these, 12.5% had biochemical adrenal suppression but showed adrenal recovery during a three-month ICS trial treatment. No significant differences were observed among children with or without adrenal suppression, neither in the number of days free of OCS treatment before cortisol evaluation (p=0.29) nor in the last OCS course duration (p=0.20). The number of short-term OCS courses reported in the year preceding the cortisol evaluation was also not different (p=0.89). CONCLUSION Short-term systemic courses of corticosteroids at conventional doses can put children at risk of HPA axis dysfunction. ICS treatment does not impair adrenal recovery from occurring. Health practitioners should be aware of the risk of a blunted cortisol response upon exposure to stress during the follow-up of patients with persistent asthma or recurrent wheezing.
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Affiliation(s)
- Cristina B Barra
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
| | - Maria Jussara F Fontes
- Professor of the Department of Pediatrics, Pediatric Pneumology Division, HC-FM-UFMG, Belo Horizonte, MG, Brazil
| | | | - Renata C Cruz
- Medical Student, FM-UFMG, Belo Horizonte, MG, Brazil
| | | | | | - Ivani Novato Silva
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
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Chanson P, Guignat L, Goichot B, Chabre O, Boustani DS, Reynaud R, Simon D, Tabarin A, Gruson D, Reznik Y, Raffin Sanson ML. Group 2: Adrenal insufficiency: screening methods and confirmation of diagnosis. ANNALES D'ENDOCRINOLOGIE 2017; 78:495-511. [DOI: 10.1016/j.ando.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smit MP, van Leer EH, Noppe G, de Rijke YB, Kramer van Driel D, van den Akker EL. Long-Term Cortisol Concentration in Scalp Hair of Asthmatic Children Using Inhaled Corticosteroids: A Case-Control Study. Horm Res Paediatr 2017; 88:231-236. [PMID: 28715822 PMCID: PMC6050635 DOI: 10.1159/000478526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 06/09/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) can interfere with the hypothalamic-pituitary-adrenal (HPA) axis and may lead to adrenal insufficiency, resulting in a decrease of cortisol production. Cortisol levels measured in scalp hair provide a marker for long-term cortisol exposure. Data regarding hair cortisol concentration (HCC) in asthmatic children with ICS therapy are scarce. The aim of this study is to compare HCC in asthmatic children under ICS treatment with a healthy control group. METHODS We set up a case-control study measuring the cortisol concentration in scalp hair in asthmatic children (N = 80) treated with ICS and healthy controls (N = 252) aged 4-18 years. Anthropometric characteristics and hair samples from the posterior vertex were obtained. At least 5 mg of the most proximal 3 cm of hair was used for each hair sample. HCC was analyzed by liquid chromatography-tandem mass spectrometry. RESULTS HCC did not significantly differ between asthmatic children using ICS and healthy controls (p = 0.950) after adjustment for age, gender, height, body mass index, and socioeconomic status. No correlation was found between budesonide dosage and HCC levels (r = -0.031, p = 0.78). CONCLUSION There was no evidence of suppression of basal cortisol production, as measured in scalp hair, in asthmatic children using ICS, compared to healthy controls. No conclusions can be drawn on the HPA-axis stress response in these children.
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Affiliation(s)
- Maaike P. Smit
- Department of Paediatrics, Groene Hart Hospital, Gouda, The Netherlands
| | - Ed H.G. van Leer
- Department of Paediatrics, Groene Hart Hospital, Gouda, The Netherlands
| | - Gerard Noppe
- Department of Paediatrics and Internal Medicine, Sophia Children's Hospital-Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Erica L.T. van den Akker
- Department of Paediatrics, Sophia Children's Hospital-Erasmus MC, Rotterdam, The Netherlands,*Erica L.T. van den Akker, MD, PhD, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC - SP1536, PO Box 2060, NL-3000 CB Rotterdam (The Netherlands), E-Mail
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Duong TN, Zeki AA, Louie S. Medical Management of Hospitalized Patients with Asthma or Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2017; 6:437-455. [PMID: 30547000 PMCID: PMC6289537 DOI: 10.1016/j.ehmc.2017.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Theresa N Duong
- Section of Hospital Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, 4150 V Street, Suite 3100, Sacramento, CA 95817, USA
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, 4150 V Street, Suite 3400, Sacramento, CA 35817, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Northern California Veteran's Administration, 10535 Hospital Way, Mather, CA 95655, USA
| | - Samuel Louie
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, 4150 V Street, Suite 3400, Sacramento, CA 35817, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Northern California Veteran's Administration, 10535 Hospital Way, Mather, CA 95655, USA
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Ye Q, He XO, D’Urzo A. A Review on the Safety and Efficacy of Inhaled Corticosteroids in the Management of Asthma. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0043-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Bayman E, Drake AJ. Adrenal suppression with glucocorticoid therapy: still a problem after all these years? Arch Dis Child 2017; 102:338-339. [PMID: 27879240 DOI: 10.1136/archdischild-2016-311601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 10/10/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Elizabeth Bayman
- Department of Paediatric Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Amanda J Drake
- Department of Paediatric Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK.,University/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
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Goldbloom EB, Mokashi A, Cummings EA, Abish S, Benseler SM, Huynh HQ, Watson W, Ahmet A. Symptomatic adrenal suppression among children in Canada. Arch Dis Child 2017; 102:338-339. [PMID: 28320817 DOI: 10.1136/archdischild-2016-311223] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Adrenal suppression (AS) is an under-recognised side effect of glucocorticoid (GC) use. AS may go undetected until a physiological stress precipitates an adrenal crisis. The incidence of AS has not been established. We sought to estimate the minimum national incidence and presenting features of paediatric symptomatic AS. METHODS Through the established methodology of the Canadian Paediatric Surveillance Program, over 2500 paediatricians were surveyed monthly for 2 years (April 2010-March 2012) to report new cases of symptomatic AS. RESULTS Forty-six cases of symptomatic AS were confirmed. The estimated annual incidence is 0.35/100 000 children aged 0-18 years (95% CI 0.26 to 0.47). The most common presentations were growth failure (35%), non-specific symptoms (28%) or both (13%). Adrenal crisis occurred in six cases (13%). Thirty-seven children (80%) had received inhaled corticosteroid (ICS) alone or in combination with other GC forms. Many children received high but commonly prescribed doses of ICS. CONCLUSIONS AS is responsible for significant morbidity in children, including susceptibility to adrenal crisis. The minimal estimated incidence reported is for the entire paediatric population and would be much higher in the at-risk group (ie, children treated with GCs). Close monitoring of growth and possible symptoms of AS, which may be non-specific, are important in children on all forms of GC therapy including ICS. To reduce the risk of AS, physicians must be aware of the risk of AS, revisit GC doses frequently and use the lowest effective dose.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elizabeth A Cummings
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sharon Abish
- Department of Pediatrics (Hematology Oncology), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Susanne M Benseler
- Department of Pediatrics (Rheumatology), Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Hien Q Huynh
- Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Wade Watson
- Department of Pediatrics (Allergy), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Choi IS, Sim DW, Kim SH, Wui JW. Adrenal insufficiency associated with long-term use of inhaled steroid in asthma. Ann Allergy Asthma Immunol 2016; 118:66-72.e1. [PMID: 27839667 DOI: 10.1016/j.anai.2016.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We previously reported that as many as one third of hospitalized patients with asthma treated with a low to medium daily dose of inhaled steroids (ICSs) for an average of 4.5 years showed adrenal insufficiency (AI). OBJECTIVE To re-examine this issue in consecutive outpatients with asthma because of possible subject selection bias. METHODS One hundred twenty-one consecutive adult patients with asthma under ICS treatment for at least 6 months underwent a rapid adrenocorticotrophic hormone stimulation test. AI was defined as a morning serum cortisol level no higher than 3 μg/dL or lower than 18 μg/dL before and after administration of 250 μg of adrenocorticotrophic hormone. RESULTS The mean durations of ICS use in the short-term (less than the median) and long-term (at least the median) users were 3.8 and 11.5 years, respectively. The proportion of subjects affected by AI tended to increase with the increasing cumulative dose of ICS (short-term users at a low to medium daily dose: mean cumulative dose 502 mg [15 of 34, 44.1%]; short-term users at a high dose of 941 mg [16 of 26, 61.5%]; long-term users at a low to medium dose of 1,077 mg [25 of 41, 61.0%]; long-term users at a high dose of 2,805 mg [13 of 20, 65.0%]), although not significantly. In short-term users, daily and cumulative ICS doses were significantly related to serum cortisol levels 60 minutes after taking adrenocorticotrophic hormone (r = -0.300 and -0.287, respectively; P < .05). CONCLUSION A large number of patients with asthma might have AI even with low- to medium-dose ICS treatment when ICSs are administered over a long period. Thus, it is essential that patients with asthma under ICS treatment be checked for AI much more frequently.
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Affiliation(s)
- Inseon S Choi
- Department of Allergy, Chonnam National University Medical School, Gwangju, Korea; Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea.
| | - Da-Woon Sim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seung-Hoon Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jin-Woo Wui
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
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Yanase T, Tajima T, Katabami T, Iwasaki Y, Tanahashi Y, Sugawara A, Hasegawa T, Mune T, Oki Y, Nakagawa Y, Miyamura N, Shimizu C, Otsuki M, Nomura M, Akehi Y, Tanabe M, Kasayama S. Diagnosis and treatment of adrenal insufficiency including adrenal crisis: a Japan Endocrine Society clinical practice guideline [Opinion]. Endocr J 2016; 63:765-784. [PMID: 27350721 DOI: 10.1507/endocrj.ej16-0242] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This clinical practice guideline of the diagnosis and treatment of adrenal insufficiency (AI) including adrenal crisis was produced on behalf of the Japan Endocrine Society. This evidence-based guideline was developed by a committee including all authors, and was reviewed by a subcommittee of the Japan Endocrine Society. The Japanese version has already been published, and the essential points have been summarized in this English language version. We recommend diagnostic tests, including measurement of basal cortisol and ACTH levels in combination with a rapid ACTH (250 μg corticotropin) test, the CRH test, and for particular situations the insulin tolerance test. Cut-off values in basal and peak cortisol levels after the rapid ACTH or CRH tests are proposed based on the assumption that a peak cortisol level ≥18 μg/dL in the insulin tolerance test indicates normal adrenal function. In adult AI patients, 15-25 mg hydrocortisone (HC) in 2-3 daily doses, depending on adrenal reserve and body weight, is a basic replacement regime for AI. In special situations such as sickness, operations, pregnancy and drug interactions, cautious HC dosing or the correct choice of glucocorticoids is necessary. From long-term treatment, optimal diurnal rhythm and concentration of serum cortisol are important for the prevention of cardiovascular disease and osteoporosis. In maintenance therapy during the growth period of patients with 21-hydroxylase deficiency, proper doses of HC should be used, and long-acting glucocorticoids should not be used. Education and carrying an emergency card are essential for the prevention and rapid treatment of adrenal crisis.
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Affiliation(s)
- Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoa 814-0180, Japan
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Abstract
BACKGROUND Reduction of lung inflammation is one of the goals of cystic fibrosis therapy. Inhaled corticosteroids are often used to treat children and adults with cystic fibrosis. The rationale for this is their potential to reduce lung damage arising from inflammation, as well as their effect on symptomatic wheezing. It is important to establish the current level of evidence for the risks and benefits of inhaled corticosteroids, especially in the light of their known adverse effects on growth. This is an update of a previously published review. OBJECTIVES To assess the effectiveness of taking regular inhaled corticosteroids, compared to not taking them, in children and adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We requested information from pharmaceutical companies manufacturing inhaled corticosteroids and authors of identified trials.Date of most recent search of the Group's Trials Register: 15 August 2016. SELECTION CRITERIA Randomised or quasi-randomised trials, published and unpublished, comparing inhaled corticosteroids to placebo or standard treatment in individuals with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two independent authors assessed methodological quality and risk of bias in trials using established criteria and extracted data using standard pro formas. MAIN RESULTS The searches identified 34 citations, of which 26 (representing 13 trials) were eligible for inclusion. These 13 trials reported the use of inhaled corticosteroids in 506 people with cystic fibrosis aged between six and 55 years. One was a withdrawal trial in individuals who were already taking inhaled corticosteroids. Methodological quality and risk of bias were difficult to assess from published information. Many of the risk of bias judgements were unclear due to a lack of available information. Only two trials specified how participants were randomised and less than half of the included trials gave details on how allocation was concealed. Trials were generally judged to have a low risk of bias from blinding, except for two which were open label or did not use a placebo. There were some concerns that a number of trials had not been published in peer-reviewed journals, but the risk of bias from this was unclear. Inclusion criteria varied between trials, as did type and duration of treatment and timing of outcome assessments. Objective measures of airway function were reported in most trials but were often incomplete. Significant benefit has not been conclusively demonstrated. Four trials systematically documented adverse effects and growth was significantly affected in one study using high doses. AUTHORS' CONCLUSIONS Evidence from these trials is insufficient to establish whether inhaled corticosteroids are beneficial in cystic fibrosis, but withdrawal in those already taking them has been shown to be safe. There is some evidence they may cause harm in terms of growth. It has not been established whether long-term use is beneficial in reducing lung inflammation, which should improve survival, but it is unlikely this will be proven conclusively in a randomised controlled trial.
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Affiliation(s)
- Ian M Balfour-Lynn
- Dept. Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London, UK, SW3 6NP
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