1
|
Giertz M, Aarnivala H, Wilk Michelsen S, Björklund C, Englund A, Grönroos M, Hjalgrim LL, Huttunen P, Niinimäki T, Penno E, Pöyhönen T, Raittinen P, Ranta S, Svahn JE, Törnudd L, Niinimäki R, Harila A. Symptomatic osteonecrosis in children treated for Hodgkin lymphoma: A population-based study in Sweden, Finland, and Denmark. Pediatr Blood Cancer 2024:e31250. [PMID: 39140964 DOI: 10.1002/pbc.31250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Osteonecrosis (ON) is a potentially disabling skeletal complication of cancer treatment. Although symptomatic osteonecrosis (sON) is well-known in acute lymphoblastic leukemia (ALL), with an incidence around 6%, studies on sON in pediatric Hodgkin lymphoma (HL) are scarce. The aim of this study was to examine the incidence, risk factors, and outcome of sON in children treated for HL. PROCEDURE A total of 490 children under 18, diagnosed with HL between 2005 and 2019 in Sweden, Finland, and Denmark were eligible for the study. Data on patient characteristics, HL treatment, and development of sON were collected from patients' medical records. Magnetic resonance imaging scans were used to establish ON diagnosis and grade ON according to the Niinimäki grading system. RESULTS Cumulative 2-year incidence of sON among the 489 included patients was 5.5% (n = 30). The risk for developing sON was higher for those with older age (odds ratio [OR] 1.25, 95% confidence interval [CI]: 1.05-1.49, p < .010), female sex (OR 4.45, CI 1.87-10.58, p < .001), high total cumulative glucocorticoid (GC) doses (OR 1.76, 95% CI: 1.21-2.56, p = 0.003), and advanced HL (OR 2.19, 95% CI: 1.03-4.65, p = .042). Four (13.3%) patients underwent major surgical procedures and 13 (43.3%) had persistent symptoms due to ON at follow-up. CONCLUSIONS This study shows that sON is as common in pediatric HL as in pediatric ALL, with risk factors such as older age, female sex, high cumulative GC doses, and advanced HL. Future HL protocol development should aim to reduce the burden of ON by modifying GC treatment.
Collapse
Affiliation(s)
- Mia Giertz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Henri Aarnivala
- Department of Paediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Sascha Wilk Michelsen
- Department of Pediatric Hematology and Oncology, Department of Pediatric and Adolescence Medicine, Juliane Marie Centret, University Hospital Copenhagen, Copenhagen, Denmark
| | - Caroline Björklund
- Department of Pediatric Hematology and Oncology, Umeå University Hospital, Umeå, Sweden
| | - Annika Englund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Marika Grönroos
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatric Hematology and Oncology, Department of Pediatric and Adolescence Medicine, Juliane Marie Centret, University Hospital Copenhagen, Copenhagen, Denmark
| | - Pasi Huttunen
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Tuukka Niinimäki
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Eva Penno
- Department of Surgical Sciences, Unit of Radiology, Uppsala University, Uppsala, Sweden
| | - Tuuli Pöyhönen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Päivi Raittinen
- Centre for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Johan E Svahn
- Department of Paediatric Oncology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lisa Törnudd
- Division of Children's and Women's Health, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Pediatrics, H.R.H Crown Princess Victoria's Children's and Youth Hospital, Linköping, Sweden
| | - Riitta Niinimäki
- Department of Paediatrics, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology and Hematology, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
2
|
Elhennawy MG, Akl Y, Abbassi M, Sabry NA. The effectiveness and pharmacoeconomic study of using different corticosteroids in the treatment of hypersensitivity pneumonitis. BMC Pulm Med 2024; 24:87. [PMID: 38360614 PMCID: PMC10870560 DOI: 10.1186/s12890-024-02896-z] [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: 08/20/2023] [Accepted: 02/03/2024] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Interstitial lung diseases (ILDs) are caused by inflammation and/or fibrosis of alveolar walls resulting in impaired gas exchange. Hypersensitivity pneumonitis (HP) is the third most common type of ILDs. Corticosteroids are the mainstay treatment for HP. The use of intramuscular (IM) betamethasone or intravenous (IV) dexamethasone as weekly pulse doses has shown higher benefit than daily oral prednisolone for HP patients. The aim of this study is to directly compare different corticosteroids in terms of effectiveness and in monetary values and perform an economic evaluation. METHODS One hundred and seven patients were tested for pulmonary function tests (PFTs) and inflammatory markers to assess the treatment effectiveness. A cost-effectiveness analysis (CEA) was performed. ICERs between 3 treatment groups were calculated. RESULTS Post treatment, Krebs von den Lungen-6 (KL-6) levels significantly improved in betamethasone group from 723.22 ± 218.18 U/ml to 554.48 ± 129.69 U/ml (p = 0.001). A significant improvement in erythrocyte sedimentation rate (ESR) occurred in the dexamethasone group from 56.12 ± 27.97 mm to 30.06 ± 16.04 mm (p = 0.048). A significant improvement in forced expiratory volume (FEV1), forced vital capacity (FVC) and six-minute walk distance (6MWD) was observed within the three treatment groups. A significant improvement in oxygen desaturation percentage (SpO2) occurred within dexamethasone and betamethasone groups. Betamethasone and dexamethasone were found more cost-effective than prednisolone as their ICERs fell in quadrant C. Furthermore, ICER between betamethasone and dexamethasone was performed; a small difference in cost was found compared to the higher benefit of betamethasone. CONCLUSION Betamethasone and dexamethasone were found to be more effective than prednisolone in improving the inflammatory reaction and the clinical features of HP patients. Betamethasone was found to be the best intervention in terms of cost against the effect.
Collapse
Affiliation(s)
- Marwa G Elhennawy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt.
| | - Yosri Akl
- Department of Pulmonology, Faculty of Medicine, Cairo University, 11562, Cairo, Egypt
| | - Maggie Abbassi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt
| | - Nirmeen A Sabry
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt
| |
Collapse
|
3
|
Kyler KE, Szefler SJ. Fifty Years of Unraveling the Clinical Pharmacology of Corticosteroids. J Pharm Sci 2024; 113:47-54. [PMID: 37844761 DOI: 10.1016/j.xphs.2023.10.016] [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: 08/15/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
This review will highlight portions of Dr. William Jusko's and colleagues' work that affected the clinical use and study of corticosteroids in acute and chronic disease management. Selected publications related to corticosteroid pharmacokinetics and pharmacodynamics from the 1970s through today were included in this review, with a focus on the foundational human-based studies conducted in the 1970s-1990s. Dr. Jusko contributed significantly to early corticosteroid pharmacology across several domains including: 1) foundational corticosteroid pharmacokinetic methods and parameter development, 2) disease state-variation in corticosteroid pharmacokinetics, 3) drug interaction effects on corticosteroid pharmacokinetics, and 4) early corticosteroid pharmacodynamic studies. In an era where little was known about the pharmacokinetics and pharmacodynamics of corticosteroids, Dr. Jusko's work opened the eyes of researchers and clinicians to the potential for disease and drug interactions that could reduce or enhance the effects of corticosteroids. This significant body of work paved the way for alternative routes of administration that would be useful in concentrating the activity at the site of action and markedly reduced systemic drug exposure, minimizing the risk of adverse effects through application of the dose-sparing pharmacokinetic and pharmacodynamic principles.
Collapse
Affiliation(s)
- Kathryn E Kyler
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, MO, United States; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Stanley J Szefler
- University of Colorado School of Medicine, Department of Pediatrics Pediatric Pulmonary and Sleep Medicine Section, United States; Children's Hospital Colorado, Breathing Institute, United States.
| |
Collapse
|
4
|
Mager DE, Straubinger RM. Contributions of William Jusko to Development of Pharmacokinetic and Pharmacodynamic Models and Methods. J Pharm Sci 2024; 113:2-10. [PMID: 37778439 DOI: 10.1016/j.xphs.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Enhanced Pharmacodynamics, LLC, Buffalo, New York, USA.
| | - Robert M Straubinger
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| |
Collapse
|
5
|
He Q, Wang C, Wang Y, Chen G, Zhou Y, Wu Y, Zhong M. Efficacy and safety of glucocorticoids use in patients with COVID-19: a systematic review and network meta‑analysis. BMC Infect Dis 2023; 23:896. [PMID: 38124031 PMCID: PMC10734118 DOI: 10.1186/s12879-023-08874-w] [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: 05/24/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Currently, some meta-analyses on COVID-19 have suggested that glucocorticoids use can reduce the mortality rate of COVID-19 patients, utilization rate of invasive ventilation, and improve the prognosis of patients. However, optimal regimen and dosages of glucocorticoid remain unclear. Therefore, the purpose of this network meta-analysis is to analyze the efficacy and safety of glucocorticoids in treating COVID-19 at regimens. METHODS This meta-analysis retrieved randomized controlled trials from the earliest records to December 30, 2022, published in PubMed, Embase, Cochrane Library, CNKI Database and Wanfang Database, which compared glucocorticoids with placebos for their efficacy and safety in the treatment of COVID-19, Effects of different treatment regimens, types and dosages (high-dose methylprednisolone, very high-dose methylprednisolone, Pulse therapy methylprednisolone, medium-dose hydrocortisone, high-dose hydrocortisone, high-dose dexamethasone, very high-dose dexamethasone and placebo) on 28-day all-caused hospitalization mortality, hospitalization duration, mechanical ventilation requirement, ICU admission and safety outcome were compared. RESULTS In this network meta-analysis, a total of 10,544 patients from 19 randomized controlled trials were finally included, involving a total of 9 glucocorticoid treatment regimens of different types and dosages. According to the analysis results, the 28-day all-cause mortality rate was the lowest in the treatment with pulse therapy methylprednisolone (OR 0.08, 95% CI 0.02, 0.42), but the use of high-dose methylprednisolone (OR 0.85, 95% CI 0.59, 1.22), very high-dose dexamethasone (OR 0.95, 95% CI 0.67, 1.35), high-dose hydrocortisone (OR 0.64, 95% CI 0.34, 1.22), medium-dose hydrocortisone (OR 0.80, 95% CI 0.49, 1.31) showed no benefit in prolonging the 28-day survival of patient. Compared with placebo, the treatment with very high-dose methylprednisolone (MD = -3.09;95%CI: -4.10, -2.08) had the shortest length of hospital stay, while high-dose dexamethasone (MD = -1.55;95%CI: -3.13,0.03) and very high-dose dexamethasone (MD = -1.06;95%CI: -2.78,0.67) did not benefit patients in terms of length of stay. CONCLUSIONS Considering the available evidence, this network meta‑analysis suggests that the prognostic impact of glucocorticoids in patients with COVID-19 may depend on the regimens of glucocorticoids. It is suggested that pulse therapy methylprednisolone is associated with lower 28-day all-cause mortality, very high-dose methylprednisolone had the shortest length of hospital stay in patients with COVID-19. TRIAL REGISTRATION PROSPERO CRD42022350407 (22/08/2022).
Collapse
Affiliation(s)
- Qiaolan He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Chen Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yingqin Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Guannan Chen
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yue Zhou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Yuanyuan Wu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200030, China.
- Shanghai Key Laboratory of Lung Inflammation and Injury, 180 Fenglin Road, Shanghai, 200030, China.
- Shanghai Institute of Infectious Disease and Biosecurity, School of Public Health, Fudan University, Shanghai, 200030, China.
| |
Collapse
|
6
|
Świerczek A, Jusko WJ. Anti-inflammatory effects of dexamethasone in COVID-19 patients: Translational population PK/PD modeling and simulation. Clin Transl Sci 2023; 16:1667-1679. [PMID: 37386717 PMCID: PMC10499420 DOI: 10.1111/cts.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/24/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
Dexamethasone (DEX) given at a dose of 6 mg once-daily for 10 days is a recommended dosing regimen in patients with coronavirus disease 2019 (COVID-19) requiring oxygen therapy. We developed a population pharmacokinetic and pharmacodynamic (PopPK/PD) model of DEX anti-inflammatory effects in COVID-19 and provide simulations comparing the expected efficacy of four dosing regimens of DEX. Nonlinear mixed-effects modeling and simulations were performed using Monolix Suite version 2021R1 (Lixoft, France). Published data for DEX PK in patients with COVID-19 exhibited moderate variability with a clearance of about half that in healthy adults. No accumulation of the drug was expected even with daily oral doses of 12 mg. Indirect effect models of DEX inhibition of TNFα, IL-6, and CRP plasma concentrations were enacted and simulations performed for DEX given at 1.5, 3, 6, and 12 mg daily for 10 days. The numbers of individuals that achieved specified reductions in inflammatory biomarkers were compared among the treatment groups. The simulations indicate the need for 6 or 12 mg daily doses of DEX for 10 days for simultaneous reductions in TNFα, IL-6, and CRP. Possibly beneficial is DEX given at a dose of 12 mg compared to 6 mg. The PopPK/PD model may be useful in the assessment of other anti-inflammatory compounds as well as drug combinations in the treatment of cytokine storms.
Collapse
Affiliation(s)
- Artur Świerczek
- Department of Pharmacokinetics and Physical Pharmacy, Faculty of PharmacyJagiellonian University Medical CollegeKrakówPoland
| | - William J. Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical SciencesState University of New York at BuffaloBuffaloNew YorkUSA
| |
Collapse
|
7
|
Zhou Y, Zhou A, Philip AM, Margolis M, Babiker F, Chang PY, Anesi SD, Foster CS. Vision Outcomes of Long-Term Immunomodulatory and Steroid Therapy in Sympathetic Ophthalmia. Am J Ophthalmol 2023; 253:152-159. [PMID: 37150338 DOI: 10.1016/j.ajo.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE To compare vision acuity outcomes of long-term steroid therapy compared with immunomodulatory therapy for treatment of sympathetic ophthalmia. DESIGN Single-center, retrospective, comparative clinical study. METHODS Patients with sympathetic ophthalmia treated from March 2005 to October 2022 with at least 1 year of follow-up were included. Visual acuity outcomes were compared by steroid and immunomodulatory treatment modality. RESULTS Thirty-five patients with sympathetic ophthalmia were included in the study, with follow-up ranging from 1 to 17 years. Higher rates of vision loss correlated with longer periods of active uveitis and steroid treatment. Lower rates of vision loss correlated with longer periods of uveitis remission on immunomodulatory therapy alone and drug-free remission. Treatment with alkylating agents or combination therapy with an antimetabolite, a biologic-response modifier, and cyclosporine are more likely to result in sympathetic ophthalmia remission. CONCLUSION Immunomodulatory therapy leads to superior vision outcomes in cases of steroid-resistant or recurrent sympathetic ophthalmia. Steroid therapy may be useful for acute or recalcitrant sympathetic uveitis but is insufficient for long-term inflammatory control. PRéCIS: This manuscript describes a retrospective analysis of vision outcomes in patients with sympathetic ophthalmia. Results indicate that long-term immunomodulatory therapy is associated with better vision outcomes than long-term steroid therapy for sympathetic ophthalmia treatment.
Collapse
Affiliation(s)
- Yujia Zhou
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Avery Zhou
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Andrew M Philip
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Michael Margolis
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Fatima Babiker
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Peter Y Chang
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Stephen D Anesi
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - C Stephen Foster
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); Department of Ophthalmology, Harvard Medical School, Boston, MA, USA (C.S.F).
| |
Collapse
|
8
|
Ferrer M, Mourikis N, Davidson EE, Kleeman SO, Zaccaria M, Habel J, Rubino R, Gao Q, Flint TR, Young L, Connell CM, Lukey MJ, Goncalves MD, White EP, Venkitaraman AR, Janowitz T. Ketogenic diet promotes tumor ferroptosis but induces relative corticosterone deficiency that accelerates cachexia. Cell Metab 2023; 35:1147-1162.e7. [PMID: 37311455 PMCID: PMC11037504 DOI: 10.1016/j.cmet.2023.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/03/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023]
Abstract
Glucose dependency of cancer cells can be targeted with a high-fat, low-carbohydrate ketogenic diet (KD). However, in IL-6-producing cancers, suppression of the hepatic ketogenic potential hinders the utilization of KD as energy for the organism. In IL-6-associated murine models of cancer cachexia, we describe delayed tumor growth but accelerated cachexia onset and shortened survival in mice fed KD. Mechanistically, this uncoupling is a consequence of the biochemical interaction of two NADPH-dependent pathways. Within the tumor, increased lipid peroxidation and, consequently, saturation of the glutathione (GSH) system lead to the ferroptotic death of cancer cells. Systemically, redox imbalance and NADPH depletion impair corticosterone biosynthesis. Administration of dexamethasone, a potent glucocorticoid, increases food intake, normalizes glucose levels and utilization of nutritional substrates, delays cachexia onset, and extends the survival of tumor-bearing mice fed KD while preserving reduced tumor growth. Our study emphasizes the need to investigate the effects of systemic interventions on both the tumor and the host to accurately assess therapeutic potential. These findings may be relevant to clinical research efforts that investigate nutritional interventions such as KD in patients with cancer.
Collapse
Affiliation(s)
- Miriam Ferrer
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA; MRC Cancer Unit, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0XZ, UK
| | | | - Emma E Davidson
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Sam O Kleeman
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | | | - Jill Habel
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Rachel Rubino
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Qing Gao
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Thomas R Flint
- Department of Oncology, CRUK Cambridge Institute, Cambridge Biomedical Campus, Cambridge CB2 0RE, UK
| | - Lisa Young
- Department of Oncology, CRUK Cambridge Institute, Cambridge Biomedical Campus, Cambridge CB2 0RE, UK
| | - Claire M Connell
- Department of Oncology, CRUK Cambridge Institute, Cambridge Biomedical Campus, Cambridge CB2 0RE, UK
| | - Michael J Lukey
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Marcus D Goncalves
- Division of Endocrinology, Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Eileen P White
- Department of Molecular Biology and Biochemistry, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA; Ludwig Princeton Branch, Ludwig Institute for Cancer Research, Princeton University, Princeton, NJ 08544, USA
| | - Ashok R Venkitaraman
- MRC Cancer Unit, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0XZ, UK; Cancer Science Institute of Singapore, National University of Singapore, Singapore 117599, Singapore; Institute for Molecular & Cell Biology, Agency for Science, Technology and Research (A∗STAR), Singapore 138648, Singapore
| | - Tobias Janowitz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA; Northwell Health Cancer Institute, Northwell Health, New Hyde Park, NY 11042, USA.
| |
Collapse
|
9
|
Świerczek A, Jusko WJ. Pharmacokinetic/Pharmacodynamic Modeling of Dexamethasone Anti-Inflammatory and Immunomodulatory Effects in LPS-Challenged Rats: A Model for Cytokine Release Syndrome. J Pharmacol Exp Ther 2023; 384:455-472. [PMID: 36631280 PMCID: PMC9976795 DOI: 10.1124/jpet.122.001477] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/01/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023] Open
Abstract
Dexamethasone (DEX) is a potent synthetic glucocorticoid used for the treatment of variety of inflammatory and immune-mediated disorders. The RECOVERY clinical trial revealed benefits of DEX therapy in COVID-19 patients. Severe SARS-CoV-2 infection leads to an excessive inflammatory reaction commonly known as a cytokine release syndrome that is associated with activation of the toll like receptor 4 (TLR4) signaling pathway. The possible mechanism of action of DEX in the treatment of COVID-19 is related to its anti-inflammatory activity arising from inhibition of cytokine production but may be also attributed to its influence on immune cell trafficking and turnover. This study, by means of pharmacokinetic/pharmacodynamic modeling, aimed at the comprehensive quantitative assessment of DEX effects in lipopolysaccharide-challenged rats and to describe interrelations among relevant signaling molecules in this animal model of cytokine release syndrome induced by activation of TLR4 pathway. DEX was administered in a range of doses from 0.005 to 2.25 mg·kg-1 in LPS-challenged rats. Serum DEX, corticosterone (CST), tumor necrosis factor α, interleukin-6, and nitric oxide as well as lymphocyte and granulocyte counts in peripheral blood were quantified at different time points. A minimal physiologically based pharmacokinetic/pharmacodynamic (mPBPK/PD) model was proposed characterizing the time courses of plasma DEX and the investigated biomarkers. A high but not complete inhibition of production of inflammatory mediators and CST was produced in vivo by DEX. The mPBPK/PD model, upon translation to humans, may help to optimize DEX therapy in patients with diseases associated with excessive production of inflammatory mediators, such as COVID-19. SIGNIFICANCE STATEMENT: A mPBPK/PD model was developed to describe concentration-time profiles of plasma DEX, mediators of inflammation, and immune cell trafficking and turnover in LPS-challenged rats. Interrelations among DEX and relevant biomarkers were reflected in the mechanistic model structure. The mPBPK/PD model enabled quantitative assessment of in vivo potency of DEX and, upon translation to humans, may help optimize dosing regimens of DEX for the treatment of immune-related conditions associated with exaggerated immune response.
Collapse
Affiliation(s)
- Artur Świerczek
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - William J Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
| |
Collapse
|
10
|
Kellogg D, Gutierrez GC, Small CE, Stephens B, Sanchez P, Beg M, Keyt HL, Restrepo MI, Attridge RL, Maselli DJ. Safety and efficacy of methylprednisolone versus dexamethasone in critically ill patients with COVID-19 acute respiratory distress syndrome: a retrospective study. Ther Adv Infect Dis 2023; 10:20499361231153546. [PMID: 36818803 PMCID: PMC9936170 DOI: 10.1177/20499361231153546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/11/2023] [Indexed: 02/18/2023] Open
Abstract
Background Corticosteroids (CSs), specifically dexamethasone (DEX), are the treatment of choice for severe acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia (CARDS). However, data from both ARDS and relatively small CARDS clinical trials have suggested improved outcomes with methylprednisolone (MP) versus DEX. The objective of this retrospective cohort study was to compare the safety and effectiveness of MP and DEX in critically ill CARDS patients. Methods The study cohort included CARDS patients admitted to a tertiary referral intensive care unit (ICU) between April and September 2020 who received at least 5 days of CSs for CARDS. Results The cohort was notable for a high severity of illness (overall, 88.5% of patients required mechanical ventilation and 16% required vasopressors on admission). The DEX group (n = 62) was significantly older with a higher illness severity [Sequential Organ Failure Assessment (SOFA) 6 (4.75-8) versus 4.5 (3-7), p = 0.008], while the MP group (n = 51) received significantly more loading doses [19 (37.3%) versus 4 (6.5%), p < 0.0001]. MP was associated with a shorter time to intubation and more rapid progression to mortality [days to death: 18 (15-23) versus 27 (15-34), p = 0.026]. After correction for baseline imbalances in age and SOFA score, DEX was associated with improved mortality at 90 days compared with MP [hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.23-0.80, p = 0.008]. However, there were no differences between rates of secondary infections during hospitalization or insulin requirements at 7 and 14 days. Conclusion In this cohort of critically ill CARDS, choice of CS was associated with mortality but not adverse event profile, and thus warrants further investigation.
Collapse
Affiliation(s)
- Dean Kellogg
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - G. Christina Gutierrez
- Department of Pharmacotherapy & Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Clay E. Small
- Department of Pharmacotherapy & Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Benjamin Stephens
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Paloma Sanchez
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Moezzullah Beg
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Holly L. Keyt
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Marcos I. Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX, USA
| | - Rebecca L. Attridge
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
- Agilum Healthcare Intelligence, Inc., Deerfield Beach, FL, USA
| | | |
Collapse
|
11
|
Tsai HJ, Wu MJ, Chen CH, Yang SS, Huang YH, Chang YZ, Chang HR, Lee TY. Risk Stratification for Hepatitis B Virus Reactivation in Kidney Transplant Recipients With Resolved HBV Infection. Transpl Int 2023; 36:11122. [PMID: 37125384 PMCID: PMC10134034 DOI: 10.3389/ti.2023.11122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 03/31/2023] [Indexed: 05/02/2023]
Abstract
The prophylaxis strategy for hepatitis B virus (HBV) reactivation in kidney transplant recipients (KTRs) with resolved HBV infection remains unclear. In this hospital-based retrospective cohort study, consecutive KTRs with resolved HBV infection were screened from the years 2000 through 2020. After excluding confounding conditions, 212 and 45 patients were respectively recruited into Anti-HBs positive and Anti-HBs negative groups. Cumulative incidences of, and subdistribution hazard ratios (SHRs) for HBV reactivation were analyzed after adjusting the competing risk. During a median 8.3 (mean 8.4 ± 4.9) years of follow-up, the 10-year cumulative incidence of HBV reactivation was significantly higher in Anti-HBs negative group when compared to that in Anti-HBs positive group (15.2%, 95% CI: 3.6-26.7 vs. 1.3%, 95% CI: 0.0-3.0; p < 0.001). In multivariable regression analysis, absence of anti-HBs (SHR 14.2, 95% CI: 3.09-65.2; p < 0.001) and use of high-dose steroids, i.e., steroid dose ≥20 mg/day of prednisolone equivalent over 4 weeks (SHR 8.96, 95% CI: 1.05-76.2; p = 0.045) were independent risk factors related to HBV reactivation. Accordingly, the 10-year cumulative incidence of HBV reactivation occurring in patients with two, one and zero risk factors was 42.7% (95% CI: 0.0-87.1), 7.9% (95% CI: 1.2-14.7) and 0%, respectively (p < 0.001). In conclusion, the strategy of HBV antiviral prophylaxis may be defined according to the risk stratification.
Collapse
Affiliation(s)
- Hsin-Ju Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Ju Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Sheng-Shun Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yan-Zin Chang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Clinical Laboratory, Drug Testing Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Horng-Rong Chang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- *Correspondence: Horng-Rong Chang, ; Teng-Yu Lee,
| | - Teng-Yu Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- *Correspondence: Horng-Rong Chang, ; Teng-Yu Lee,
| |
Collapse
|
12
|
Effects of Different Corticosteroid Doses in Elderly Unvaccinated Patients with Severe to Critical COVID-19. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111924. [PMID: 36431059 PMCID: PMC9697502 DOI: 10.3390/life12111924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/04/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
SARS-CoV-2 infection can induce a broad range of clinical symptoms, and the most severe cases are characterized by an uncontrolled inflammatory response with the overproduction of proinflammatory cytokines. Elevated levels of C-reactive protein, interleukin-1B, and interleukin-6 have become key signatures of severe COVID-19. For this reason, the use of 6 mg of dexamethasone has become a standard of care, although this regime may not be optimal. Even though various glucocorticoid doses have been proposed, it is still unclear which dose should be used to prevent adverse effects while at the same time reducing the inflammatory response. Here, we compared two different doses of corticosteroids in 52 elderly hospitalized patients with severe to critical COVID-19 to assess efficacy and safety. We showed that in patients receiving a higher dose of prednisone, the time to negative swab was significantly longer. Furthermore, although neither dose was correlated with the risk of death, patients receiving the high dose were more likely to have adverse events such as hyperglycemia, leukocytosis, an increase in systemic blood pressure, and others. Finally, the BMI, WBC number, and NLR value were directly related to death. In conclusion, although the optimal glucocorticoid dose is still undefined, our retrospective study supports the absence of beneficial effects in the utilization of higher doses of corticosteroids in elderly patients with severe to critical COVID-19.
Collapse
|
13
|
Patel NJ, Tozzo V, Higgins JM, Stone JH. The Effects of Daily Prednisone and Tocilizumab on Hemoglobin A 1c During the Treatment of Giant Cell Arteritis. Arthritis Rheumatol 2022; 75:586-594. [PMID: 36383175 DOI: 10.1002/art.42405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the longitudinal effects of both glucocorticoids and tocilizumab, an interleukin-6 receptor inhibitor, on hemoglobin A1c (HbA1c ) levels during glucocorticoid tapering. METHODS We analyzed patients with complete data from the Tocilizumab in Giant Cell Arteritis (GiACTA) trial to investigate the impact of both glycemic and nonglycemic factors on changes in HbA1c levels over the 52-week trial. Giant cell arteritis (GCA) patients were randomized to receive either tocilizumab or placebo in addition to glucocorticoids. We used a multivariable mixed-effects model to evaluate associations of HbA1c level with daily glucocorticoid dose, randomization to receive tocilizumab, and red blood cell count in patients with and those without diabetes mellitus at baseline, over 52 weeks. RESULTS In 209 patients, the median HbA1c level decreased by 0.50% (P < 0.01) in the group that received both tocilizumab and glucocorticoids (tocilizumab/glucocorticoid) and by 0.10% (P < 0.01) in the glucocorticoid-only group. Randomization to tocilizumab/glucocorticoid was associated with lower HbA1c (β = -0.209% in those without diabetes, P < 0.01; β = -0.290% in those with diabetes, P = 0.23). These changes had a sizable impact on glucose tolerance classification: 42.5% of patients in the tocilizumab/glucocorticoid group improved from prediabetes status to normal, compared to only 12.5% of patients treated with glucocorticoids alone. Daily glucocorticoid dose was associated with HbA1c level in patients with baseline diabetes (β = 0.018%/mg, P < 0.01) and those without baseline diabetes (β = 0.005%/mg, P < 0.01). CONCLUSION Tocilizumab treatment was associated with a substantial reduction in HbA1c level, independent of glucocorticoid exposure, which may be achieved through a combination of glycemic and nonglycemic effects.
Collapse
Affiliation(s)
- Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Veronica Tozzo
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, and Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
| | - John M Higgins
- Department of Pathology and Center for Systems Biology, Massachusetts General Hospital, and Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| |
Collapse
|
14
|
Wiencke JK, Molinaro AM, Warrier G, Rice T, Clarke J, Taylor JW, Wrensch M, Hansen H, McCoy L, Tang E, Tamaki SJ, Tamaki CM, Nissen E, Bracci P, Salas LA, Koestler DC, Christensen BC, Zhang Z, Kelsey KT. DNA methylation as a pharmacodynamic marker of glucocorticoid response and glioma survival. Nat Commun 2022; 13:5505. [PMID: 36127421 PMCID: PMC9486797 DOI: 10.1038/s41467-022-33215-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/08/2022] [Indexed: 12/15/2022] Open
Abstract
Assessing individual responses to glucocorticoid drug therapies that compromise immune status and affect survival outcomes in neuro-oncology is a great challenge. Here we introduce a blood-based neutrophil dexamethasone methylation index (NDMI) that provides a measure of the epigenetic response of subjects to dexamethasone. This marker outperforms conventional approaches based on leukocyte composition as a marker of glucocorticoid response. The NDMI is associated with low CD4 T cells and the accumulation of monocytic myeloid-derived suppressor cells and also serves as prognostic factor in glioma survival. In a non-glioma population, the NDMI increases with a history of prednisone use. Therefore, it may also be informative in other conditions where glucocorticoids are employed. We conclude that DNA methylation remodeling within the peripheral immune compartment is a rich source of clinically relevant markers of glucocorticoid response.
Collapse
Affiliation(s)
- J K Wiencke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Gayathri Warrier
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Terri Rice
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Clarke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Jennie W Taylor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Margaret Wrensch
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Helen Hansen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Lucie McCoy
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Emily Tang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Stan J Tamaki
- Parnassus Flow Cytometry CoLab, University of California San Francisco, San Francisco, CA, USA
| | - Courtney M Tamaki
- Parnassus Flow Cytometry CoLab, University of California San Francisco, San Francisco, CA, USA
| | - Emily Nissen
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Paige Bracci
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Lucas A Salas
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Devin C Koestler
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brock C Christensen
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
- Department of Molecular and Systems Biology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
- Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Ze Zhang
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Karl T Kelsey
- Department of Epidemiology, Brown University, Providence, RI, USA
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| |
Collapse
|
15
|
Davis GE, Zeiger RS, Emmanuel B, Chung Y, Tran TN, Evans KA, Chen S, Katial R, Kreindler JL, Tkacz J. Systemic Corticosteroid–related Adverse Outcomes and Health Care Resource Utilization and Costs Among Patients with Chronic Rhinosinusitis with Nasal Polyposis. Clin Ther 2022; 44:1187-1202. [DOI: 10.1016/j.clinthera.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 11/03/2022]
|
16
|
Lamberink H, Wagemakers A, Sigaloff KCE, van Houdt R, de Jonge NA, van Dijk K. The impact of the updated EORTC/MSG criteria on the classification of hematological patients with suspected invasive pulmonary aspergillosis. Clin Microbiol Infect 2022; 28:1120-1125. [PMID: 35248746 DOI: 10.1016/j.cmi.2022.02.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 02/13/2022] [Accepted: 02/19/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Our aim was to evaluate the effect of the updated European Organization for Research and Treatment of Cancer (EORTC) and Mycoses Study Group 2019 definitions for invasive pulmonary aspergillosis (IPA) on patient classification and the related all-cause 12-week mortality. METHODS In this retrospective cohort study from our tertiary care centre, we reclassified patients with haematological malignancy who underwent bronchoalveolar lavage between 2014 and 2019 for suspected IPA using the novel EORTC 2019 criteria. We performed receiver operating characteristic curve analysis to define the optimal cut-off for positive PCR and galactomannan and present survival analyses and their possible association with these diagnostic criteria through post hoc comparisons with log rank and Cox regression. RESULTS From 323 episodes of suspected IPA in 282 patients, 73 were reclassified: 31 (42.5%) from possible to probable IPA, 5 (6.8%) from EORTC criteria not met to probable IPA, and 37 (50.7%) from EORTC criteria not met to possible IPA. Probable IPA increased therefore 11.1% (64/323, 19.8% to 100/323, 30.9%), mostly due to positive PCR (31/36, 86.1%). There was no difference in mortality between newly defined possible and probable IPA (log rank p = 0.950). Mortality was higher in probable cases with lower cycle thresholds (Ct values) versus higher Ct values (p = 0.004). Receiver operating characteristic curve analysis showed an optimal Ct value cut-off of 36.8 with a sensitivity of 75% (95% CI 64.9%-85.1%) and a specificity of 61.7% (95% CI 53.5-69.9) for 12-week mortality. DISCUSSION The new EORTC criteria led to 11.1% more probable IPA diagnoses, mostly due to Aspergillus PCR. Restricting positive PCR to below a certain threshold might improve the discrimination of the new EORTC IPA categories for mortality.
Collapse
Affiliation(s)
- Hanne Lamberink
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Alex Wagemakers
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Robin van Houdt
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nick A de Jonge
- Department of Hematology, Amsterdam UMC Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
17
|
Whelan G, Sim J, Smith B, Moffatt M, Littlewood C. Are Corticosteroid Injections Associated With Secondary Adrenal Insufficiency in Adults With Musculoskeletal Pain? A Systematic Review and Meta-analysis of Prospective Studies. Clin Orthop Relat Res 2022; 480:1061-1074. [PMID: 35302533 PMCID: PMC9263464 DOI: 10.1097/corr.0000000000002145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, and it is part of the management of numerous orthopaedic conditions. However, there is concern about offering corticosteroid injections for musculoskeletal pain because of the possibility of secondary adrenal insufficiency. QUESTIONS/PURPOSES In this systematic review and meta-analysis of prospective studies, we asked: (1) Are corticosteroid injections associated with secondary adrenal insufficiency as measured by 7-day morning serum cortisol? (2) Does this association differ depending on whether the shot was administered in the spine or the appendicular skeleton? METHODS We searched the Allied and Complementary Medicine (AMED), Embase, EmCare, MEDLINE, CINAHL, and Web of Science from inception to January 22, 2021. We retrieved 4303 unique records, of which 17 were eventually included. Study appraisal was via the Downs and Black tool, with an average quality rating of fair. A Grading of Recommendations, Assessment, Development, and Evaluations assessment was conducted with the overall certainty of evidence being low to moderate. Reflecting heterogeneity in the study estimates, a pooled random-effects estimate of cortisol levels 7 days after corticosteroid injection was calculated. Fifteen studies or subgroups (254 participants) provided appropriate estimates for statistical pooling. A total of 106 participants received a spine injection, and 148 participants received an appendicular skeleton injection, including the glenohumeral joint, subacromial bursa, trochanteric bursa, and knee. RESULTS Seven days after corticosteroid injection, the mean morning serum cortisol was 212 nmol/L (95% confidence interval 133 to 290), suggesting that secondary adrenal insufficiency was a possible outcome. There is a difference in the secondary adrenal insufficiency risk depending on whether the injection was in the spine or the appendicular skeleton. For spinal injection, the mean cortisol was 98 nmol/L (95% CI 48 to 149), suggesting secondary adrenal insufficiency was likely. For appendicular skeleton injection the mean cortisol was 311 nmol/L (95% CI 213 to 409) suggesting hypothalamic-pituitary-adrenal axis integrity was likely. CONCLUSION Clinicians offering spinal injections should discuss the possibility of short-term secondary adrenal insufficiency with patients, and together, they can decide whether the treatment remains appropriate and whether mitigation strategies are needed. Clinicians offering appendicular skeleton injections should not limit care because of concerns about secondary adrenal insufficiency based on the best available evidence, and clinical guidelines could be reviewed accordingly. Further research is needed to understand whether age and/or sex determine risk of secondary adrenal insufficiency and what clinical impact secondary adrenal insufficiency has on patients undergoing spinal injection. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
Affiliation(s)
- Gareth Whelan
- Musculoskeletal Department, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Julius Sim
- School of Medicine, Keele University, Keele, UK
| | - Benjamin Smith
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK; Rehabilitation & Ageing Research Group, Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, UK
| | - Maria Moffatt
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Chris Littlewood
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| |
Collapse
|
18
|
Stam SP, Vulto A, Vos MJ, Kerstens MN, Rutgers A, Kema I, Touw DJ, Bakker SJ, van Beek AP. Rationale and design of the CORE (COrticosteroids REvised) study: protocol. BMJ Open 2022; 12:e061678. [PMID: 35473729 PMCID: PMC9045047 DOI: 10.1136/bmjopen-2022-061678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Corticosteroids are an important pillar in many anti-inflammatory and immunosuppressive treatment regimens and are available in natural and synthetic forms, which are considered equipotent if clinical bioequivalence data are used. Current clinical bioequivalence data are however based on animal studies or studies with subjective endpoints. Furthermore, advancement in steroid physiology with regard to metabolism, intracellular handling and receptor activation have not yet been incorporated. Therefore, this study aims to re-examine the clinical bioequivalence and dose effects of the most widely used synthetic corticosteroids, prednisolone and dexamethasone. METHODS AND ANALYSIS In this double-blind, randomised cross-over clinical trial, 24 healthy male and female volunteers aged 18-75 years, will be included. All volunteers will randomly receive either first a daily dose of 7.5 mg prednisolone for 1 week, immediately followed by a daily dose of 30 mg prednisolone for 1 week, or first a presumed clinical bioequivalent dose of 1.125 mg dexamethasone per day, immediately followed by 4.5 mg of dexamethasone per day for 1 week. After a wash-out period of 4-8 weeks, the other treatment will be applied. The primary study endpoint is the difference in free cortisol excretion in 24 hours urine. Secondary endpoints will include differences in immunological parameters, blood pressure and metabolic measurements. ETHICS AND DISSEMINATION This study has been approved by the Medical Ethics Committee of the University Medical Center Groningen (METC 2020.398). The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (Identifier: NCT04733144), and in the Dutch trial registry (NL9138).
Collapse
Affiliation(s)
- Suzanne P Stam
- Internal Medicine, Division of Nephrology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Annet Vulto
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michel J Vos
- Laboratory Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ido Kema
- Laboratory Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Clincal Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan Jl Bakker
- Internal Medicine, Division of Nephrology, University Medical Centre Groningen, Groningen, The Netherlands
| | - André P van Beek
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
19
|
Mehta J, Rolta R, Mehta BB, Kaushik N, Choi EH, Kaushik NK. Role of Dexamethasone and Methylprednisolone Corticosteroids in Coronavirus Disease 2019 Hospitalized Patients: A Review. Front Microbiol 2022; 13:813358. [PMID: 35242118 PMCID: PMC8886296 DOI: 10.3389/fmicb.2022.813358] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
The WHO announced coronavirus disease 2019 (COVID-19) as a pandemic disease globally on March 11, 2020, after it emerged in China. The emergence of COVID-19 has lasted over a year, and despite promising vaccine reports that have been produced, we still have a long way to go until such remedies are accessible to everyone. The immunomodulatory strategy has been kept at the top priority for the research agenda for COVID-19. Corticosteroids have been used to modulate the immune response in a wide range of diseases for the last 70 years. These drugs have been shown to avoid and reduce inflammation in tissues and the bloodstream through non-genomic and genomic effects. Now, the use of corticosteroids increased the chance of survival and relief by combating the viral strong inflammatory impacts and has moved to the forefront in the management of patients seeking supplemental oxygen. The goal of this review is to illuminate dexamethasone and methylprednisolone, i.e., in terms of their chemical and physical properties, role in COVID-19 patients suffering from pneumonia, the proposed mode of action in COVID-19, pharmacokinetics, pharmacodynamics, clinical outcomes in immunocompromised populations with COVID-19, interaction with other drugs, and contradiction to explore the trends and perspectives for future research. Literature was searched from scientific databases such as Science Direct, Wiley, Springer, PubMed, and books for the preparation of this review. The RECOVERY trial, a massive, multidisciplinary, randomized, and open-label trial, is mainly accountable for recommendations over the usage of corticosteroids in COVID-19 patients. The corticosteroids such as dexamethasone and methylprednisolone in the form of medication have anti-inflammatory, analgesic, and anti-allergic characteristics, including the ability to inhibit the immune system. These drugs are also recommended for treating symptoms of multiple ailments such as rheumatic and autoimmune diseases, leukemia, multiple myeloma, and Hodgkin’s and non-Hodgkin’s lymphoma along with other drugs. Toxicology studies proved them safe usually at low dosage via oral or other routes.
Collapse
Affiliation(s)
- Jyoti Mehta
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Solan, India
| | - Rajan Rolta
- Faculty of Applied Sciences and Biotechnology, Shoolini University of Biotechnology and Management Sciences, Solan, India
| | | | - Neha Kaushik
- Department of Biotechnology, The University of Suwon, Hwaseong, South Korea
| | - Eun Ha Choi
- Department of Electrical and Biological Physics, Plasma Bioscience Research Center, Kwangwoon University, Seoul, South Korea
| | - Nagendra Kumar Kaushik
- Department of Electrical and Biological Physics, Plasma Bioscience Research Center, Kwangwoon University, Seoul, South Korea
| |
Collapse
|
20
|
Pitfalls of Early Systemic Corticosteroids Home Therapy in Older Patients with COVID-19 Pneumonia. Geriatrics (Basel) 2022; 7:geriatrics7010021. [PMID: 35200526 PMCID: PMC8871955 DOI: 10.3390/geriatrics7010021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/15/2022] Open
Abstract
Corticosteroids have been widely used for acute respiratory distress syndrome (ARDS), but their role in the early phase of SARS-CoV-2 infection is controversial. Our study aimed to determine the effectiveness of early corticosteroid therapy (ECT) in preventing the progression of disease, reducing the escalation of care and improving clinical outcome in older patients hospitalized for COVID-19 pneumonia. A total of 90 subjects (47.7% women; mean age = 82.3 ± 6.7 years) were enrolled. ECT was administered to 33 out of 90 patients before the hospitalization. At admission, no difference was detected in median SOFA score (2, IQR:2 vs. 2, IQR: 2). We found a significant difference in mean PaO2/FiO2 ratio during the first week of hospitalization between ECT patients and controls (F = 5.49, p = 0.002) and in mean PaO2/FiO2 ratio over time (F = 6.94, p < 0.0001). We detected no-significant differences in terms of in-hospital mortality and transfer to ICU between ECT patients and controls (27.1% vs. 22.8%, respectively, p = 0.63). ECT was associated with worse clinical outcomes, showing no benefit in attenuating the progression of the disease or reducing the escalation of care. These findings are crucial given the current pandemic, and further studies are needed to provide additional data on the optimal timing of initiating corticosteroid treatment.
Collapse
|
21
|
Saeed MAM, Mohamed AH, Owaynat AH. Comparison between methylprednisolone infusion and dexamethasone in COVID-19 ARDS mechanically ventilated patients. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022; 34:19. [PMID: 35194371 PMCID: PMC8853130 DOI: 10.1186/s43162-022-00113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/29/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) causing severe acute respiratory distress syndrome caused by coronavirus 2 (SARS-CoV-2) still has no solid effective therapy.From previous studies, dexamethasone has led to a decrease in mortality in patients who required oxygen supplementation mainly invasive mechanical ventilation; at the same time, it is unknown if another corticosteroid can be effective when used and what is the optimal dose and its duration, to achieve improvement in clinical outcome.The cornerstone of the study was to compare the differences in clinical outcome and laboratory results in intensive care patients with SARS-CoV-2 pneumonia treated with dexamethasone 6 mg/day: doses versus those treated with methylprednisolone 2 mg/kg/day infusion. MATERIALS AND METHODS A prospective cohort study with a survival analysis of 414 patients diagnosed with severe COVID-19 pneumonia confirmed by polymerase chain reaction, for SARS-CoV-2 according to the Berlin definition of ARDS, who were admitted in the intensive care unit in the Helwan University Hospitals; the duration is from June 2020 till October 2021.Patients included in the study were mechanically ventilated with radiological confirmation of pneumonia by chest tomography; patients were included in the study according to the Berlin definition of ARDS and met the inclusion criteria of the study; 222 patients were treated with methylprednisolone infusion with a dose of 2 mg/kg/day versus 192 patients treated with dexamethasone 6 mg/day; both groups were treated for 10 days and were mechanically ventilated; the clinical out come and differences in the laboratory results were evaluated during the 10-day course for each group. RESULTS Four hundred fourteen patients had COVID-19 pneumonia, diagnosed and confirmed by ground glass opacities in chest tomography and arterial partial pressure of oxygen/inspired oxygen and fraction of inspired oxygen (P/F ratio) less than 300.Two hundred twenty-two patients received methylprednisolone infusion at a dose of 2 mg/kg/day, and 192 patients received dexamethasone 6 mg daily; both groups were treated for 10 days.Inflammatory markers for cytokine storm were improved in the methylprednisolone group in comparison to the patients who were given dexamethasone when comparing the on-admission markers to the results of the inflammatory markers after 10 days, like ferritin after 10 days in methylprednisolone group 292.26 ± 330.10 versus the dexa group 648.10 ± 329.09 (p value < 0.001).D-dimer in the methylprednisolone group was 1301.75 ± 1515.51 versus 2523.78 ± 843.18 in the dexa group (p value < 0.001); CRP was 49.65 ± 19.91 in the methylprednisolone group versus 100.54 ± 36.75 (p value < 0.001) in the dexa group; LDH after 10 days in methylprednisolone group was 345.09 ± 128.31, and in the dexa group, it was 731.87 ± 195.09 (p value < 0.001); neutrophil to lymphocyte ratio (N:L ratio) after 10 days of treatment in the methylprednisolone group was 17.27 ± 5.09 versus 26.68 ± 7.19 (p value < 0.001) in the dexa group; also, the length of stay was shorter in the methylprednisolone group (7.33 ± 1.71) versus in the dexa group (19.43 ± 5.42) (p value < 0.001), together with mechanical ventilation MV days which are 3.82 ± 1.14 in the methyl group versus 16.57 ± 4.71 in the dexa group (p value < 0.001).Also, the radiological findings are improved in the methyl group (20.3%) versus the dexa group (73.4%) with p value < 0.001, and discharge from ICU in the methyl group was 79.7% versus 26.6% in the dexa group with p value < 0.001. CONCLUSIONS Treatment of severe COVID-19 pneumonia, Patients who were mechanically ventilated with methylprednisolone infusion 2 mg/kg/day for 10 days versus dexamethasone 6 mg for 10 days showed a statistically significant improvement in the MV days and length of stay in the intensive care unit, together with the overall mortality and severity inflammatory markers of cytokine storm c-reactive protein (CRP), D-dimer, ferritin, LDH, and N:L ratio.
Collapse
|
22
|
Buso R, Cinetto F, Dell’Edera A, Veneran N, Facchini C, Biscaro V, Schiavon S, Vian E, Grossi U, Zanus G, Giobbia M, Scarpa R, Agostini C, Rattazzi M, Felice C. Comparison between Dexamethasone and Methylprednisolone Therapy in Patients with COVID-19 Pneumonia Admitted to Non-Intensive Medical Units. J Clin Med 2021; 10:jcm10245812. [PMID: 34945108 PMCID: PMC8703463 DOI: 10.3390/jcm10245812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Data on different steroid compounds for the treatment of hospitalized COVID-19 (coronavirus disease 2019) patients are still limited. The aim of this study was to compare COVID-19 patients admitted to non-intensive units and treated with methylprednisolone or dexamethasone. (2) Methods: This was a single-center retrospective study that included consecutive patients with COVID-19 hospitalized in medical wards during the second wave of the pandemic. Thirty-day mortality and the need for intensive or semi-intensive care were the main clinical outcomes analyzed in patients receiving methylprednisolone (60 mg/day) compared with dexamethasone (6 mg/day). Secondary outcomes included complication rates, length of hospital stay, and time to viral clearance. (3) Results: Two-hundred-forty-six patients were included in the analysis, 110 treated with dexamethasone and 136 with methylprednisolone. No statistically significant differences were found between the two groups of patients regarding 30-day mortality (OR 1.35, CI95% 0.71-2.56, p = 0.351) and the need for intensive or semi-intensive care (OR 1.94, CI95% 0.81-4.66, p = 0.136). The complication rates, length of hospital stay, and time to viral clearance did not significantly differ between the two groups. (4) Conclusions: In patients hospitalized for COVID-19 in non-intensive units, the choice of different steroid compounds, such as dexamethasone or methylprednisolone, did not affect the main clinical outcomes.
Collapse
Affiliation(s)
- Roberta Buso
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| | - Francesco Cinetto
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
- Department of Medicine, DIMED, University of Padova, 35122 Padova, Italy
| | - Alessandro Dell’Edera
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| | - Nicola Veneran
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| | - Cesarina Facchini
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| | - Valeria Biscaro
- Microbiology Unit, Department of Specialist and Laboratory Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (V.B.); (S.S.); (E.V.)
| | - Stefania Schiavon
- Microbiology Unit, Department of Specialist and Laboratory Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (V.B.); (S.S.); (E.V.)
| | - Elisa Vian
- Microbiology Unit, Department of Specialist and Laboratory Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (V.B.); (S.S.); (E.V.)
| | - Ugo Grossi
- Surgery 2 Unit, DISCOG, Ca’ Foncello University Hospital, University of Padua, 31100 Treviso, Italy; (U.G.); (G.Z.)
| | - Giacomo Zanus
- Surgery 2 Unit, DISCOG, Ca’ Foncello University Hospital, University of Padua, 31100 Treviso, Italy; (U.G.); (G.Z.)
| | - Mario Giobbia
- Infective Disease Unit, Department of Specialist and Laboratory Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy;
| | - Riccardo Scarpa
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| | - Carlo Agostini
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
- Department of Medicine, DIMED, University of Padova, 35122 Padova, Italy
| | - Marcello Rattazzi
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
- Department of Medicine, DIMED, University of Padova, 35122 Padova, Italy
- Correspondence: or ; Tel.: +39-0498211867 or +39-0422322207; Fax: +39-0498754179
| | - Carla Felice
- Medicine 1 Unit, Department of Medicine, Ca’ Foncello University Hospital, 31100 Treviso, Italy; (R.B.); (F.C.); (A.D.); (N.V.); (C.F.); (R.S.); (C.A.); (C.F.)
| |
Collapse
|
23
|
Thee S, Basu Roy R, Blázquez-Gamero D, Falcón-Neyra L, Neth O, Noguera-Julian A, Lillo C, Galli L, Venturini E, Buonsenso D, Götzinger F, Martinez-Alier N, Velizarova S, Brinkmann F, Welch SB, Tsolia M, Santiago-Garcia B, Schilling R, Tebruegge M, Krüger R. Treatment and outcome in children with tuberculous meningitis - a multi-centre Paediatric Tuberculosis Network European Trials Group study. Clin Infect Dis 2021; 75:372-381. [PMID: 34849642 DOI: 10.1093/cid/ciab982] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Currently, data on treatment, outcome, and prognostic factors in children with tuberculous meningitis (TBM) in Europe are limited. To date, most existing data on TBM originate from adult studies, or studies conducted in low-resource settings. METHODS Multicentre, retrospective study involving 27 paediatric healthcare institutions in nine European countries via an established paediatric TB research network, before and after the 2014 revision of WHO dosing recommendations. RESULTS Of 118 children, 39 (33.1%) had TBM grade 1, 68 (57.6%) grade 2 and 11 (9.3%) grade 3. Fifty-eight (49.1%) children received a standard four-drug treatment regimen; other commonly used drugs included streptomycin, prothionamide, and amikacin. Almost half of the patients (48.3%; 56/116) were admitted to intensive care unit, with a median stay of 10 (IQR 4.5-21.0) days. Of 104 children with complete outcome data, 9.6% (10/104) died, and only 47.1% (49/104) recovered fully. Main long-term sequelae included spasticity of one or more limbs and developmental delay both in 19.2% (20/104), and seizure disorder in 17.3% (18/104). Multivariate regression analyses identified microbiological confirmation of TBM, the need for neurosurgical intervention and mechanical ventilation as risk factors for unfavourable outcome. DISCUSSION There was considerable heterogeneity in the use of TB drugs in this cohort. Despite few children presenting with advanced disease and the study being conducted in a high-resource setting, morbidity and mortality were high. Several risk factors for poor outcome were identified, which may aid prognostic predictions in children with TBM in the future.
Collapse
Affiliation(s)
- Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel Blázquez-Gamero
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Lola Falcón-Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Cristina Lillo
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Luisa Galli
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Elisabetta Venturini
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Florian Götzinger
- Department of Paediatrics and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Klinik Ottakring, Vienna, Austria
| | - Nuria Martinez-Alier
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Svetlana Velizarova
- Department of Pulmonary Diseases, Medical University, Hospital for Lung Diseases 'St. Sofia', Sofia, Bulgaria
| | - Folke Brinkmann
- Department of Paediatric Pulmonology, Ruhr University Bochum, Bochum, Germany
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Maria Tsolia
- Second Department or Paediatrics, National and Kapodistrian University of Athens, School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Begoña Santiago-Garcia
- Department of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. Red de Investigación Translacional en Infectología Pediátrica (RITIP)
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany.,Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Germany
| | - Marc Tebruegge
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia.,Department of Infection, Immunity & Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | |
Collapse
|
24
|
Carlson TJ, Gonzales-Luna AJ, Wilcox MF, Theriault SG, Alnezary FS, Patel P, Ahn BK, Zasowski EJ, Garey KW. Corticosteroids Do Not Increase the Likelihood of Primary Clostridioides difficile Infection in the Setting of Broad-Spectrum Antibiotic Use. Open Forum Infect Dis 2021; 8:ofab419. [PMID: 34646906 PMCID: PMC8501294 DOI: 10.1093/ofid/ofab419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/09/2021] [Indexed: 11/21/2022] Open
Abstract
Background The pathogenesis of Clostridioides difficile infection (CDI) involves a significant host immune response. Generally, corticosteroids act by suppressing the host inflammatory response, and their anti-inflammatory effects are used to treat gastrointestinal disorders. Although previous investigations have demonstrated mixed results regarding the effect of corticosteroids on CDI, we hypothesized that the anti-inflammatory effect of corticosteroids would decrease the risk of CDI in hospitalized patients. Methods This was a case–control study of hospitalized adults. The case population included patients diagnosed with primary CDI who received at least 1 dose of a high-risk antibiotic (cefepime, meropenem, or piperacillin-tazobactam) in the 90 days before CDI diagnosis. The control population included patients who received at least 1 dose of the same high-risk antibiotic but did not develop CDI in the 90 days following their first dose of antibiotic. The primary study outcome was the development of CDI based on receipt of corticosteroids. Results The final study cohort consisted of 104 cases and 153 controls. Those who received corticosteroids had a lower odds of CDI after adjusting for age, proton pump inhibitor use, and antibiotic days of therapy (odds ratio, 0.54; 95% CI, 0.30–0.97; P = .04). We did not observe an association between corticosteroid dose or duration and CDI. Conclusions We demonstrated a 46% relative reduction in the odds of developing CDI in patients who received corticosteroids in the past 90 days. We believe that our results provide the best clinical evidence to further support mechanistic studies underlying this phenomenon.
Collapse
Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| | - Melissa F Wilcox
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| | - Sarah G Theriault
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| | - Faris S Alnezary
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA.,Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Medina,Kingdom of Saudi Arabia
| | - Pankaj Patel
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| | - Bumhee K Ahn
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| | - Evan J Zasowski
- Department of Clinical Sciences, Touro University College of Pharmacy, Vallejo, California, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas,USA
| |
Collapse
|
25
|
Vrouwe JPM, Kamerling IMC, van Esdonk MJ, Metselaar JM, Stuurman FE, van der Pluijm G, Burggraaf J, Osanto S. An exploratory first-in-man study to investigate the pharmacokinetics and safety of liposomal dexamethasone at a 2- and 1-week interval in patients with metastatic castration resistant prostate cancer. Pharmacol Res Perspect 2021; 9:e00845. [PMID: 34414692 PMCID: PMC8377443 DOI: 10.1002/prp2.845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
Dexamethasone has antitumor activity in metastatic castration resistant prostate cancer (mCRPC). We aimed to investigate intravenous liposome-encapsulated dexamethasone disodium phosphate (liposomal dexamethasone) administration in mCRPC patients. In this exploratory first-in-man study, patients in part A received a starting dose of 10 mg followed by five doses of 20 mg liposomal dexamethasone at 2-week intervals. Upon review of part A safety, patients in part B received 10 weekly doses of 18.5 mg. Primary outcomes were safety and pharmacokinetic profile, secondary outcome was antitumor efficacy. Nine mCRPC patients (5 part A, 4 part B) were enrolled. All patients experienced grade 1-2 toxicity, one (part B) patient experienced grade 3 toxicity (permanent bladder catheter-related urosepsis). No infusion-related adverse events occurred. One patient had upsloping glucose levels ≤9.1 mmol/L. Trough plasma concentrations of liposomal- and free dexamethasone were below the lower limit of quantification (LLOQ) in part A, and above LLOQ in three patients in part B (t1/2 ~50 h for liposomal dexamethasone), trough concentrations of liposomal- and free dexamethasone increased toward the end of the study. In seven of nine patients (78%) patients, stable disease was observed in bone and/or CT scans at follow-up, and in one (part B) of these seven patients a >50% PSA biochemical response was observed. Bi- and once weekly administrations of IV liposomal dexamethasone were well-tolerated. Weekly dosing enabled trough concentrations of liposomal- and free dexamethasone >LLOQ. The data presented support further clinical investigation in well-powered studies. Clinical trial registration: ISRCTN 10011715.
Collapse
Affiliation(s)
- Josephina P. M. Vrouwe
- Centre for Human Drug ResearchLeidenThe Netherlands
- Department of Medical OncologyLeiden University Medical CentreLeidenThe Netherlands
| | - Ingrid M. C. Kamerling
- Centre for Human Drug ResearchLeidenThe Netherlands
- Department of Infectious DiseasesLeiden University Medical CentreLeidenThe Netherlands
| | | | - Josbert M. Metselaar
- Enceladus PharmaceuticalsNaardenThe Netherlands
- Rheinisch‐Westfälische Technische Hochschule Aachen University ClinicAachenGermany
| | - Frederik E. Stuurman
- Centre for Human Drug ResearchLeidenThe Netherlands
- Department of Clinical Pharmacology and ToxicologyLeiden University Medical CentreLeidenThe Netherlands
| | | | - Jacobus Burggraaf
- Centre for Human Drug ResearchLeidenThe Netherlands
- Leiden Academic Centre for Drug ResearchLeidenThe Netherlands
| | - Susanne Osanto
- Department of Medical OncologyLeiden University Medical CentreLeidenThe Netherlands
| |
Collapse
|
26
|
Ye Q, Wang G, Lu J, Huang Y, Zhang J, Zhu L, Zhu Y, Lan J, Li Z, Liu Y, Xu H, Li Z. Exposure levels of mycophenolic acid are associated with comorbidities in children with systemic lupus erythematosus. Lupus 2021; 30:1808-1818. [PMID: 34304630 DOI: 10.1177/09612033211034555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Little is known about the relationship between exposure levels of mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), and comorbidities of systemic lupus erythematosus (SLE) in children. This study aims to explore this association. METHODS Longitudinal data from SLE children, who were taking MMF for immunosuppression and under therapeutic drug monitoring (TDM), were retrospectively collected. Area under the concentration-time curve of mycophenolic acid (MPA) over 24 hours (AUC0-24h) was estimated with Bayesian methods. Logistic regression and random forest models were used to explore the association between comorbidities and MPA exposure levels. RESULTS This study included 107 children with 358 times of follow-up (median age 169.02 months). The incidence of diabetes, acute kidney injury (AKI), or pneumonia was significantly associated with AUC0-24h (odds ratio [OR] 0.991, 95% confidence interval [CI] 0.982-0.999), SLE duration (OR 1.012, 95% CI 1.002-1.022), lymphocyte percentage (OR 0.959, 95% CI 0.925-0.991), plasma albumin levels (OR 0.891, 95% CI 0.843-0.940), use of aspirin (OR 0.292, 95% CI 0.126-0.633) and hydroxychloroquine (OR 0.407, 95% CI 0.184-0.906). The random forest model showed that albumin and AUC0-24h were two important predictors. The case group (with the three comorbidities) had a mean AUC0-24h of 73.63 mg · h/L, while the control group had a mean AUC0-24h of 100.39 mg · h/L. CONCLUSIONS Increased levels of MPA exposure are associated with decreased incidence odds of diabetes, AKI or pneumonia in SLE children. An AUC0-24h of 100.39 mg · h/L or an AUC0-12h of 50.20 mg · h/L could be used as the targeted exposure level for clinical practice.
Collapse
Affiliation(s)
- Qiaofeng Ye
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Guangfei Wang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jinmiao Lu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Junqi Zhang
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Lin Zhu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yiqing Zhu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jianger Lan
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Ziwei Li
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yubing Liu
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| |
Collapse
|
27
|
Thangaraju P, B AK, Venkatesan S. Vigilance in selection of low-dose versus high-dose steroids in COVID-19. Int J Infect Dis 2021; 109:54-55. [PMID: 34139368 PMCID: PMC8277292 DOI: 10.1016/j.ijid.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India.
| | - Aravind Kumar B
- Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Sajitha Venkatesan
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| |
Collapse
|
28
|
Ye Q, Wang G, Huang Y, Lu J, Zhang J, Zhu L, Zhu Y, Li X, Lan J, Li Z, Liu Y, Xu H, Li Z. Mycophenolic Acid Exposure Optimization Based on Vitamin D Status in Children with Systemic Lupus Erythematosus: A Single-Center Retrospective Study. Rheumatol Ther 2021; 8:1143-1157. [PMID: 34142344 PMCID: PMC8380596 DOI: 10.1007/s40744-021-00324-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/15/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction Systemic lupus erythematosus (SLE) can affect bone metabolism and homeostasis of serum electrolytes that are associated with abnormal levels of vitamin D. Mycophenolate mofetil (MMF) is a commonly used immunosuppressant with the active metabolite mycophenolic acid (MPA). The area under the plasma concentration–time curve (AUC) of MPA is often monitored during the treatment to assess the exposure levels. This study aims to explore the association between exposure levels of MPA and 25-hydroxyvitamin D [25(OH)D] levels in children with SLE. Methods Repeated measured data of children with SLE who were treated with MMF and under therapeutic drug monitoring (TDM) were retrospectively collected from the electronic medical records. MPA exposure levels were reflected by the area under the concentration–time curve over 24 h (AUC0–24h). Univariate and multivariate linear regression models were employed to analyze factors associated with 25(OH)D levels. Hierarchical linear models were developed to analyze the intra- and inter-individual effects of AUC0–24h on the variance of 25(OH)D levels. Results Data from 184 children with SLE (142 female and 42 male) with 518 follow-ups were collected. The median age was 14 years (range 3–18 years) at TDM. Children with normal 25(OH)D levels had significantly higher AUC0–24h than children with low 25(OH)D levels (98.71 vs. 84.05 mg·h/L, P = 0.004). Intra- and inter-individual effects of AUC0–24h on 25(OH)D levels were similar (\documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$${\gamma }_{10}$$\end{document}γ10 = 0.034 vs. \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$${\gamma }_{01}$$\end{document}γ01 = 0.037) but only the intra-individual effect was significant (P = 0.001) in hierarchical models. Other associated factors include age, sex, season at measurement, glucocorticoid daily dose, and external vitamin D3 supplements. Conclusion 25(OH)D levels are associated with MPA exposure levels, and may serve as a potential indicator to optimize the exposure level of MPA during treatment. AUC0–24h of 98.71 mg·h/L or AUC0–12h of 49.36 mg·h/L could be the targeted exposure level for children with SLE.
Collapse
Affiliation(s)
- Qiaofeng Ye
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Guangfei Wang
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yidie Huang
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Jinmiao Lu
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Junqi Zhang
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Lin Zhu
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yiqing Zhu
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xiaoxia Li
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Jianger Lan
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Ziwei Li
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yubing Liu
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China.
| | - Zhiping Li
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Shanghai, 201102, China.
| |
Collapse
|
29
|
Presti M, Westergaard MCW, Draghi A, Chamberlain CA, Gokuldass A, Svane IM, Donia M. The effects of targeted immune-regulatory strategies on tumor-specific T-cell responses in vitro. Cancer Immunol Immunother 2021; 70:1771-1776. [PMID: 33165629 DOI: 10.1007/s00262-020-02760-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Immune-related adverse events (IrAEs) are auto-immune reactions associated with immune checkpoint inhibitor-based therapy (ICI). Steroids are currently the first-line option for irAE management; however, recent studies have raised concerns regarding their potential impairment of tumor-specific immune responses. In this study, we investigated the in vitro effects of commonly used irAE treatment drugs on the anti-tumor activity of tumor-infiltrating lymphocytes (TILs). METHODS Impairment of anti-tumor immune responses by four drugs (antibodies: vedolizumab and tocilizumab; small molecules: mycophenolate mofetil and tacrolimus) reported to be effective in treating irAEs was tested at clinically relevant doses in vitro and compared to a standard moderate dose of corticosteroids (small molecules) or infliximab (antibodies). TIL responses against autologous tumor cell lines, in the presence or absence of irAE drugs, were determined by flow cytometry (short-term tumor-specific T-cell activation) or xCELLigence (T-cell-mediated tumor killing). RESULTS None of the tested antibodies influenced T-cell activation or T-cell-mediated tumor killing. Low-dose mycophenolate and tacrolimus did not influence T-cell activation, whereas higher doses of tacrolimus (> 1 ng/ml) impaired T-cell activation comparably to dexamethasone. All tested small molecules impaired T-cell-mediated tumor killing, with high-dose tacrolimus reducing killing at levels comparable to dexamethasone-mediated inhibition. In addition, mycophenolate and tacrolimus alone also demonstrated anti-proliferative effects on tumor cells. CONCLUSIONS These data support clinical testing of targeted immune-regulatory strategies in the initial phase of irAE management, as a potential replacement for corticosteroids.
Collapse
Affiliation(s)
- Mario Presti
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Marie Christine Wulff Westergaard
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Arianna Draghi
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Christopher Aled Chamberlain
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Aishwarya Gokuldass
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Inge Marie Svane
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark
| | - Marco Donia
- Department of Oncology, Copenhagen University Hospital, National Center for Cancer Immune Therapy (CCIT-DK), Borgmester Ib Juuls Vej 25C, 5th floor, 2730, Herlev, Denmark.
| |
Collapse
|
30
|
Gálvez‐Romero JL, Palmeros‐Rojas O, Real‐Ramírez FA, Sánchez‐Romero S, Tome‐Maxil R, Ramírez‐Sandoval MP, Olivos‐Rodríguez R, Flores‐Encarnación SE, Cabrera‐Estrada AA, Ávila‐Morales J, Cortés‐Sánchez V, Sarmiento‐Padilla G, Tezmol‐Ramírez SE, Aparicio‐Hernández D, Urbina‐Sánchez MI, Gómez‐Pluma MÁ, Cisneros‐Méndez S, Rodríguez‐Rivas DI, Reyes‐Inurrigarro S, Cortés‐Díaz G, Cruz‐Delgado C, Navarro‐González J, Deveaux‐Homs J, Pedraza‐Sánchez S. Cyclosporine A plus low-dose steroid treatment in COVID-19 improves clinical outcomes in patients with moderate to severe disease: A pilot study. J Intern Med 2021; 289:906-920. [PMID: 33274479 PMCID: PMC7753398 DOI: 10.1111/joim.13223] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/29/2020] [Accepted: 11/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND COVID-19 pandemic causes high global morbidity and mortality and better medical treatments to reduce mortality are needed. OBJECTIVE To determine the added benefit of cyclosporine A (CsA), to low-dose steroid treatment, in patients with COVID-19. METHODS Open-label, non randomized pilot study of patients with confirmed infection of SARS-CoV-2 hospitalized from April to May 2020 at a single centre in Puebla, Mexico. Patients were assigned to receive either steroids or CsA plus steroids. Pneumonia severity was assessed by clinical, laboratory, and lung tomography. The death rate was evaluated at 28 days. RESULTS A total of 209 adult patients were studied, 105 received CsA plus steroids (age 55.3 ± 13.3; 69% men), and 104 steroids alone (age 54.06 ± 13.8; 61% men). All patients received clarithromycin, enoxaparin and methylprednisolone or prednisone up to 10 days. Patient's death was associated with hypertension (RR = 3.5) and diabetes (RR = 2.3). Mortality was 22 and 35% for CsA and control groups (P = 0.02), respectively, for all patients, and 24 and 48.5% for patients with moderate to severe disease (P = 0.001). Higher cumulative clinical improvement was seen for the CsA group (Nelson Aalen curve, P = 0.001, log-rank test) in moderate to severe patients. The Cox proportional hazard analysis showed the highest HR improvement value of 2.15 (1.39-3.34, 95%CI, P = 0.0005) for CsA treatment in moderate to severe patients, and HR = 1.95 (1.35-2.83, 95%CI, P = 0.0003) for all patients. CONCLUSION CsA used as an adjuvant to steroid treatment for COVID-19 patients showed to improve outcomes and reduce mortality, mainly in those with moderate to severe disease. Further investigation through controlled clinical trials is warranted.
Collapse
Affiliation(s)
| | - O. Palmeros‐Rojas
- Área de MatemáticasDepartamento de Preparatoria AgrícolaUniversidad Autónoma ChapingoTexcocoMéxico
| | | | | | - R. Tome‐Maxil
- Departamento de Medicina InternaHospital RegionalISSSTEPueblaMéxico
| | | | | | | | | | - J. Ávila‐Morales
- Departamento de Medicina InternaHospital RegionalISSSTEPueblaMéxico
| | | | | | | | | | | | | | | | | | - S. Reyes‐Inurrigarro
- Departamento del Servicio de Urgencias y Terapia IntensivaHospital RegionalISSSTEPueblaMéxico
| | - G. Cortés‐Díaz
- Departamento del Servicio de Urgencias y Terapia IntensivaHospital RegionalISSSTEPueblaMéxico
| | - C. Cruz‐Delgado
- Departamento del Servicio de Urgencias y Terapia IntensivaHospital RegionalISSSTEPueblaMéxico
| | - J. Navarro‐González
- Departamento del Servicio de EpidemiologíaHospital RegionalISSSTEPueblaMéxico
| | - J. Deveaux‐Homs
- Director MédicoHospital RegionalHospital Regional ISSSTEPueblaMéxico
| | - S. Pedraza‐Sánchez
- Unidad de BioquímicaInstituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), and Facultad de Ciencias, Universidad Nacional Autónoma de México (UNAM)Ciudad de MéxicoMéxico
| |
Collapse
|
31
|
Wu K, Michalski A, Cortes D, Rozenberg D, Mathur S. Glucocorticoid-induced myopathy in people with asthma: a systematic review. J Asthma 2021; 59:1396-1409. [PMID: 33951991 DOI: 10.1080/02770903.2021.1926488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To review the current literature on the evidence and the underlying characteristics of glucocorticoids (type, dosage, and duration) associated with myopathy in asthma. DATA SOURCES Four electronic databases were searched to October 19, 2020. STUDY SELECTION Inclusion criteria: adults or adolescents with asthma, taking systemic glucocorticoids, and measures of muscle impairments. RESULTS Nine studies met the eligibility criteria. The methodologic quality of most studies was fair or good. Two studies reported significantly lower inspiratory muscle function in outpatients taking daily oral glucocorticoids (≥10 mg), but one study reported no such difference. No differences was found in limb muscle strength in one study. Only 11-36% patients with acute exacerbation taking glucocorticoids intravenously suffered from limb muscle weakness during/after critical care admissions. Two studies reported significant associations between dosage of oral glucocorticoid use and inspiratory and limb muscle function, whereas seven studies did not find any significant correlations among the characteristics of systemic glucocorticoids and myopathy. Two studies comparing people with non-glucocorticoid dependent asthma taking inhaled glucocorticoid and healthy people did not find any significant differences in their inspiratory muscle strength and endurance. CONCLUSIONS There were limited studies and inconsistent results on glucocorticoid-induced myopathy in people with asthma, and its association with the characteristics of glucocorticoids use. We recommended future studies should use a commonly accepted operational definition of myopathy, utilize a cohort study design, measure the cumulative dosage of glucocorticoids, and integrate possible confounding factors in the analysis.
Collapse
Affiliation(s)
- Kenneth Wu
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Respirology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anna Michalski
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Heart, Lung, and Vascular Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Daniel Cortes
- Department of Pharmacy, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Dmitry Rozenberg
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sunita Mathur
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
32
|
Population pharmacodynamic modeling of intramuscular and oral dexamethasone and betamethasone effects on six biomarkers with circadian complexities in Indian women. J Pharmacokinet Pharmacodyn 2021; 48:411-438. [PMID: 33954911 PMCID: PMC8099395 DOI: 10.1007/s10928-021-09755-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/03/2021] [Indexed: 11/07/2022]
Abstract
Population pharmacokinetic/pharmacodynamic (PK/PD) analysis was performed for extensive data for differing dosage forms and routes for dexamethasone (DEX) and betamethasone (BET) in 48 healthy nonpregnant Indian women in a partial and complex cross-over design. Single doses of 6 mg dexamethasone phosphate (DEX-P), betamethasone phosphate (BET-P), or 1:1 mixture of betamethasone phosphate and acetate (BET-PA) were administered orally (PO) or intramuscularly (IM) where each woman enrolled in a two-period cross-over study. Plasma concentrations collected over 96 h were described with a two-compartment model with differing PO and IM first-order absorption inputs. Overall, BET exhibited slower clearance, similar volume of distribution, faster absorption, and longer persistence than DEX with BET acetate producing extremely slow absorption but full bioavailability of BET. Six biomarkers were assessed over a 24-h baseline period with four showing circadian rhythms with complex baselines. These baselines and the strong responses seen after drug dosing were fitted with various indirect response models using the Laplace estimation methods in NONMEM 7.4. Both the PK and six biomarker responses were well-described with modest variability likely due to the homogeneous ages, weights, and ethnicities of the women. The drugs either inhibited or stimulated the influx processes with some models requiring joint inclusion of drug effects on circadian cortisol suppression. The biomarkers and order of sensitivity (lowest IC50/SC50 to highest) were: cortisol, T-helper cells, basophils, glucose, neutrophils, and T-cytotoxic cells. DEX sensitivities were generally greater than BET with corresponding mean ratios for these biomarkers of 2.86, 1.27, 1.72, 1.27, 2.69, and 1.06. Overall, the longer PK (e.g. half-life) of BET, but lesser PD activity (e.g. higher IC50), produces single-dose response profiles that appear quite similar, except for the extended effects from BET-PA. This comprehensive population modeling effort provides the first detailed comparison of the PK profiles and six biomarker responses of five commonly used dosage forms of DEX and BET in healthy women.
Collapse
|
33
|
Valenzuela B, Pérez-Ruixo JJ, Leirens Q, Ouwerkerk-Mahadevan S, Poggesi I. Effect of Ponesimod Exposure on Total Lymphocyte Dynamics in Patients with Multiple Sclerosis. Clin Pharmacokinet 2021; 60:1239-1250. [PMID: 33914285 DOI: 10.1007/s40262-021-01019-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the relationship between ponesimod plasma concentrations and the temporal evolution of lymphocyte counts in multiple sclerosis (MS) patients. METHODS Population pharmacokinetic (PK) and PK/pharmacodynamic (PD) models were developed using data from phase I, II, and III trials, and the impact of clinically relevant covariates on PK and PD parameters was assessed. Simulations were conducted to evaluate the maximal lymphocyte count reduction after ponesimod treatment, and the time required for total lymphocyte counts to return to normal values after treatment interruption. RESULTS In MS patients, ponesimod PK were characterized by a low mean apparent plasma clearance (5.52 L/h) and a moderate mean apparent volume of distribution at steady state (239 L). The model developed indicated that none of the evaluated covariates (age, sex, formulation, food, body weight, clinical condition, and renal impairment) had a clinically relevant impact on the PK/PD parameters. In MS patients, total lymphocyte counts were characterized by a maximum reduction of 88.0% and a half maximal inhibitory concentration (IC50) of 54.9 ng/mL. Simulations indicated that in patients with normal hepatic function treated with ponesimod 20 mg daily, total lymphocyte counts were reduced to 41% of baseline at trough. After stopping treatment, lymphocyte counts were restored to normal levels within one week. CONCLUSIONS The population PK/PD model well-characterized the PK of ponesimod and the time course of total lymphocyte counts in MS patients. Additionally, none of the evaluated covariates had a clinically relevant impact. This should be taken into consideration when assessing the risk of infection, administration of live-attenuated vaccines, and concomitant use of immunosuppressants.
Collapse
Affiliation(s)
- Belén Valenzuela
- Janssen-Cilag Spain, Part of Janssen Pharmaceutical Companies of Johnson and Johnson, Madrid, Spain.
| | - Juan-José Pérez-Ruixo
- Janssen-Cilag Spain, Part of Janssen Pharmaceutical Companies of Johnson and Johnson, Madrid, Spain
| | - Quentin Leirens
- SGS Exprimo, part of SGS Belgium NV, Mechelen, Belgium.,Pharmetheus AB, Uppsala, Sweden
| | | | - Italo Poggesi
- Janssen-Cilag Italy, part of the Janssen Pharmaceutical Companies of Johnson and Johnson, Cologno Monzese, Italy
| |
Collapse
|
34
|
Assal M, Lambert J, Chow-Chine L, Bisbal M, Servan L, Gonzalez F, de Guibert JM, Faucher M, Vey N, Sannini A, Mokart D. Prognostic impact of early adjunctive corticosteroid therapy in non-HIV oncology or haematology patients with Pneumocystis jirovecii pneumonia: A propensity score analysis. PLoS One 2021; 16:e0250611. [PMID: 33886692 PMCID: PMC8061944 DOI: 10.1371/journal.pone.0250611] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/10/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose While early adjunctive corticosteroid therapy (EACST) has been proven effective in HIV patients with Pneumocystis Jirovecii Pneumonia (PJP), data remains controversial concerning non-HIV oncology or haematology patients. Methods This retrospective study included cancer patients without HIV and with diagnosis of PJP admitted in a cancer referral centre, from January-1-2010 to March-31-2017. We compared 30-day and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score(SOFA-resp worsening), use of tracheal intubation between day-1 and day-5 of anti-pneumocystis therapy and occurrence of coinfections between patients with EACST and those with no or late corticosteroid therapy, using an inverse probability weighting propensity score-based (IPW) analysis. Results 133 non-HIV oncology or haematology PJP patients were included (EACST n = 58, others n = 75). The main underlying conditions were haematological malignancies (n = 107, 80,5%), solid tumour (n = 27, 20,3%) and allogeneic stem cell transplantation (n = 17, 12,8%). Overall 30-day and 1-year mortality rate was 24,1% and 56,4%, respectively. IPW analysis found no difference on 30-day (HR = 1.45, 95% CI [0.7–3.04], p = 0.321) and 1-year (HR = 1.25, CI 95% [0.75–2.09], p = 0.39) mortality rate between groups. Conclusion No difference in SOFA-resp worsening, tracheal intubation and coinfections was found between groups. Combination of EACST with anti-pneumocystis therapy in non-HIV onco-haematology PJP-patients was not associated with clinical improvement.
Collapse
Affiliation(s)
- Mehdi Assal
- Intensive Care Unit, Hôpital La Timone, Marseille, France
| | - Jérôme Lambert
- Biostatistics Department, Saint Louis Teaching Hospital, Paris, France
| | | | - Magali Bisbal
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Luca Servan
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Marion Faucher
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Norbert Vey
- Department of Haematology, Institut Paoli-Calmettes, Marseille, France
| | - Antoine Sannini
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
- * E-mail:
| |
Collapse
|
35
|
Ranjbar K, Moghadami M, Mirahmadizadeh A, Fallahi MJ, Khaloo V, Shahriarirad R, Erfani A, Khodamoradi Z, Gholampoor Saadi MH. Methylprednisolone or dexamethasone, which one is superior corticosteroid in the treatment of hospitalized COVID-19 patients: a triple-blinded randomized controlled trial. BMC Infect Dis 2021; 21:337. [PMID: 33838657 PMCID: PMC8035859 DOI: 10.1186/s12879-021-06045-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients. METHODS In this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8). RESULTS There were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040). CONCLUSION In hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone. TRIAL REGISTRATION The trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1 ).
Collapse
Affiliation(s)
- Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Moghadami
- Health Policy research center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Alireza Mirahmadizadeh
- Health Policy research center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Non-communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Javad Fallahi
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Khaloo
- Ali Asghar hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zohre Khodamoradi
- Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Shiraz Geriatric Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | |
Collapse
|
36
|
Janowitz T, Kleeman S, Vonderheide RH. Reconsidering Dexamethasone for Antiemesis when Combining Chemotherapy and Immunotherapy. Oncologist 2021; 26:269-273. [PMID: 33465258 PMCID: PMC8018330 DOI: 10.1002/onco.13680] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022] Open
Abstract
Whether the immune suppressive action of glucocorticoid steroids, such as dexamethasone, might reduce the benefits of cancer immunotherapy has long been a concern. Observations that established tumor regressions in response to immune checkpoint inhibitors (ICIs) often persist, despite the use of steroids to mitigate ICI-related autoimmune breakthrough, are not sufficiently reassuring, because these observations do not address the potential blunting of immune priming at the initiation of ICI therapy. With increasing indications for ICI in combination with chemotherapy, this issue merits reconsideration. Professional society guidance advises that dexamethasone should be used as first-line prophylaxis for nausea and vomiting in patients receiving ICI and highly emetogenic chemotherapy combination regimens. Here, we review the availability of data on this subject and propose an alternative approach focused on the adoption of steroid minimization or sparing for prophylaxis of nausea until the underlying immune biology is better understood.
Collapse
Affiliation(s)
- Tobias Janowitz
- Cold Spring Harbor LaboratoryNew YorkCold Spring HarborUSA
- Cancer InstituteNorthwell Health, New YorkUSA
| | - Sam Kleeman
- Cold Spring Harbor LaboratoryNew YorkCold Spring HarborUSA
| | | |
Collapse
|
37
|
Applications of cosinor rhythmometry in pharmacology. J Pharmacokinet Pharmacodyn 2021; 48:339-359. [PMID: 33755872 DOI: 10.1007/s10928-021-09748-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
Study design and data analysis are two important aspects relevant to chronopharmacometrics. Blunders can be avoided by recognizing that most physiological variables are circadian periodic. Both ill health and treatment can affect the amplitude, phase, and/or period of circadian (and other) rhythms, in addition to their mean. The involvement of clock genes in molecular pathways related to important physiological systems underlies the bidirectional relationship often seen between circadian rhythm disruption and disease risk. Circadian rhythm characteristics of marker rhythms interpreted in the light of chronobiologic reference values represent important diagnostic tools. A set of cosinor-related programs is presented. They include the least squares fit of multiple-frequency cosine functions to model the time structure of individual records; a cosinor-based spectral analysis to detect periodic signals; the population-mean cosinor to generalize inferences; the chronobiologic serial section to follow the time course of changing rhythm parameters over time; and parameter tests to assess differences among populations. Relative merits of other available cosinor and non-parametric algorithms are reviewed. Parameter tests to compare individual records and a self-starting cumulative sum (CUSUM) make personalized chronotherapy possible, where the treatment of each patient relies on an N-of-1 design. Methods are illustrated in a few examples relevant to endocrinology, cancer and cardiology. New sensing technology yielding large personal data sets is likely to change the healthcare system. Chronobiologic concepts and methods should become an integral part of these evolving systems.
Collapse
|
38
|
Orsi FA, Lijfering WM, Geersing GJ, Rosendaal FR, Dekkers OM, le Cessie S, Cannegieter SC. Glucocorticoid use and risk of first and recurrent venous thromboembolism: self-controlled case-series and cohort study. Br J Haematol 2021; 193:1194-1202. [PMID: 33748963 PMCID: PMC8251551 DOI: 10.1111/bjh.17388] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/11/2021] [Indexed: 12/21/2022]
Abstract
Glucocorticoid treatment increases venous thromboembolism (VTE) risk. Whether this is due to the medication or the underlying disease, or affects the risk of VTE recurrence, has been difficult to determine. The aim of our present study was to quantify the risk for first and recurrent VTE associated with oral glucocorticoids use, considering the underlying disease. A total of 2547 patients with VTE from the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study were linked to the Dutch Pharmaceutical Statistics register. The risk of first VTE during periods of exposure with oral glucocorticoids was estimated by the self‐controlled case series method and that of recurrent VTE was examined in a cohort design. The incidence rate ratio (IRR) of first VTE in the period of glucocorticoid treatment was 3·51 [95% confidence interval (CI) 2·55–4·80]. This IRR was 2·53 (95% CI 1·10–5·72) in the week before treatment started, 5·28 (95% CI 2·89–9·53) in the first 7 days of treatment, remained elevated afterwards and decreased to 1·55 (95% CI 0·85–3·12) after 6 months, as compared to unexposed periods. The hazard ratio for recurrence was 2·72 (95% CI 1·64–4·78) in treatment periods as compared with no treatment. The increased risk of VTE associated with oral glucocorticoid treatment is due to a combined effect of the treatment and the underlying disease, remaining high during the first months of prescription.
Collapse
Affiliation(s)
- Fernanda A Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Internal Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
39
|
Song D, Jusko WJ. Across‐species meta‐analysis of dexamethasone pharmacokinetics utilizing allometric and scaling modeling approaches. Biopharm Drug Dispos 2021; 42:191-203. [DOI: 10.1002/bdd.2266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/15/2021] [Accepted: 01/27/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Dawei Song
- Department of Pharmaceutical Sciences School of Pharmacy and Pharmaceutical Sciences State University of New York at Buffalo Buffalo New York USA
| | - William J Jusko
- Department of Pharmaceutical Sciences School of Pharmacy and Pharmaceutical Sciences State University of New York at Buffalo Buffalo New York USA
| |
Collapse
|
40
|
Palomäki A, Kerola AM, Malmberg M, Rautava P, Kytö V. Patients with rheumatoid arthritis have impaired long-term outcomes after myocardial infarction - a nationwide case-control registry study. Rheumatology (Oxford) 2021; 60:5205-5215. [PMID: 33667301 PMCID: PMC8566209 DOI: 10.1093/rheumatology/keab204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/14/2021] [Indexed: 01/06/2023] Open
Abstract
Objective To investigate the long-term outcomes of patients with RA after myocardial infarction (MI). Methods All-comer, real-life MI patients with RA (n = 1614, mean age 74 years) were retrospectively compared with propensity score (1:5) matched MI patients without RA (n = 8070) in a multicentre, nationwide, cohort register study in Finland. The impact of RA duration and the usage of corticosteroids and antirheumatic drugs on RA patients’ outcomes were also studied. The median follow-up was 7.3 years. Results RA was associated with an increased 14-year mortality risk after MI compared with patients without RA [80.4% vs 72.3%; hazard ratio (HR) 1.25; CI: 1.16, 1.35; P <0.0001]. Patients with RA were at higher risk of new MI (HR 1.22; CI: 1.09, 1.36; P =0.0001) and revascularization (HR 1.28; CI: 1.10, 1.49; P =0.002) after discharge from index MI. Cumulative stroke rate after MI did not differ between RA and non-RA patients (P =0.322). RA duration and corticosteroid usage before MI, but not use of methotrexate or biologic antirheumatic drugs, were independently associated with higher mortality (P <0.001) and new MI (P =0.009). A higher dosage of corticosteroids prior to MI was independently associated with higher long-term mortality (P =0.002) and methotrexate usage with lower stroke rate (P =0.034). Serological status of RA was not associated with outcomes. Conclusion RA is independently associated with poorer prognosis after MI. RA duration and corticosteroid usage and dosage were independent predictors of mortality after MI in RA. Special attention is needed for improvement of outcomes after MI in this vulnerable population.
Collapse
Affiliation(s)
- Antti Palomäki
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, Turku University Hospital, Turku, Finland.,Department of Medicine, University of Turku, Turku, Finland.,Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Anne M Kerola
- Preventive Cardio-Rheuma Clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Department of Rheumatology, Päijät-Häme Joint Authority for Health and Wellbeing, Lahti, Finland
| | - Markus Malmberg
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland.,Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Centre, Hospital District of Southwest Finland, Turku, Finland
| |
Collapse
|
41
|
Drakaki A, Dhillon PK, Wakelee H, Chui SY, Shim J, Kent M, Degaonkar V, Hoang T, McNally V, Luhn P, Gutzmer R. Association of baseline systemic corticosteroid use with overall survival and time to next treatment in patients receiving immune checkpoint inhibitor therapy in real-world US oncology practice for advanced non-small cell lung cancer, melanoma, or urothelial carcinoma. Oncoimmunology 2020; 9:1824645. [PMID: 33101774 PMCID: PMC7553559 DOI: 10.1080/2162402x.2020.1824645] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint inhibitors (CPIs) have expanded treatment options for patients with solid tumors. Systemic corticosteroids (CSs) have an indispensable role in cancer care, but CS-related immunosuppression may counteract the CPI-driven antitumor immune response. This retrospective study investigated the association between baseline CS use (bCS; ≤14 days before, ≤30 days after CPI initiation) and clinical outcomes in patients with advanced non-small cell lung cancer (aNSCLC), melanoma (aMel), or urothelial carcinoma (aUC). We analyzed data from the Flatiron Health electronic health record-derived de-identified database for adults diagnosed with aNSCLC, aMel, or aUC between January 2011 and June 2017 who received ≥1 CPI monotherapy in any treatment line. Associations of bCS use with overall survival (OS) and time to next treatment (TTNT) were estimated using multivariable Cox proportional hazards models adjusting for demographic and clinical characteristics (i.e., ECOG performance status, site of metastases). In total, 2,213 patients were diagnosed with aNSCLC (n = 862), aMel (n = 742), or aUC (n = 609) and received ≥1 CPI administration. Most patients (67%-95%) received CSs, many during the baseline period (19%-30%). Patients with bCS use had shorter median OS than those with no bCS use for aNSCLC (6.6 vs 10.6 months; P= .00018), aMel (16.4 vs 21.5; P= .095), and aUC (4.1 vs 7.7; P= .0012). bCS use was associated with shorter OS (not significant for aMel) and TTNT in adjusted multivariable analyses, and clinical outcomes were not explained by prior CS use or other measured confounders. These findings suggest a potential association between bCS use and decreased CPI effectiveness, warranting further investigation.
Collapse
Affiliation(s)
- Alexandra Drakaki
- Division of Hematology/Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Preet K Dhillon
- Personalized Healthcare, Product Developmen, Genentech, Inc, South San Francisco, CA, USA
| | - Heather Wakelee
- Thoracic Oncology, Stanford Medical School, Stanford, CA, USA
| | - Stephen Y Chui
- Product Development Oncology, Genentech, Inc, South San Francisco, CA, USA
| | - Jinjoo Shim
- Personalized Healthcare, Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Matthew Kent
- Real World Evidence Solutions, Genesis Research, Hoboken, NJ, USA
| | - Viraj Degaonkar
- Product Development Oncology, Genentech, Inc, South San Francisco, CA, USA
| | - Tien Hoang
- Product Development Oncology, Genentech, Inc, South San Francisco, CA, USA
| | - Virginia McNally
- Clinical Development, Roche Products Ltd, Welwyn Garden City, UK
| | - Patricia Luhn
- Personalized Healthcare, Product Developmen, Genentech, Inc, South San Francisco, CA, USA
| | - Ralf Gutzmer
- Clinic for Dermatology, Allergology und Venerology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
42
|
Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The Historical Role and Contemporary Use of Corticosteroids in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:1316-1329. [PMID: 32170314 DOI: 10.1093/ecco-jcc/jjaa053] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of corticosteroids to treat patients with inflammatory bowel disease [IBD] has been the bedrock of IBD therapeutics since the pioneering work of Truelove and Witts in the UK in the 1950s and subsequent large cohort studies in the USA and Europe. Nevertheless, although effective for induction of remission, these agents do not maintain remission and are associated with a long list of recognised side effects, including a risk of increased mortality. With the arrival of an increasing number of therapies for patients with IBD, the question arises as to whether we are using these agents appropriately in contemporary practice. This review discusses the historical background to steroid usage in IBD, and also provides a brief review of the literature on side effects of corticosteroid treatment as relevant to IBD patients. Data on licensed medications are presented with specific reference to the achievement of corticosteroid-free remission. We review available international data on the incidence of corticosteroid exposure and excess, and discuss some of the observations we and others have made concerning health care and patient-level factors associated with the risk of corticosteroid exposure, including identification of 'at-risk' populations.
Collapse
Affiliation(s)
- Alexander M Dorrington
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Gareth C Parkes
- Department of Gastroenterology, Royal London Hospital, Barts Health, London, UK
| | - Melissa Smith
- Department of Gastroenterology, Brighton and Sussex University Hospitals, Brighton, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
43
|
Turmel-Roy J, Bédard MA, Millette M, Simonyan D, Proulx-Gauthier JP, Rousseau-Nepton I. Risk of adrenal insufficiency following intra-articular or periarticular corticosteroid injections among children with chronic arthritis. J Pediatr Endocrinol Metab 2020; 33:1257-1263. [PMID: 32845867 DOI: 10.1515/jpem-2020-0219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/13/2020] [Indexed: 11/15/2022]
Abstract
Objectives Intra-articular and/or periarticular corticosteroid injection (IACI) is a common procedure in pediatric rheumatology. Despite many adult studies demonstrating a significant risk of adrenal insufficiency (AI) following the procedure, very little evidence is available in the pediatric literature regarding this risk. The main goal of this study is to evaluate the prevalence of AI in children with chronic arthritis following IACI. Methods This is a retrospective study including children aged 0-18 years who had an IACI from June 2017 to July 2019. An 8:00 morning cortisol (8MC) sample was drawn around two weeks after the injection, and an ACTH 1mcg stimulation test was performed if morning cortisol level was low. AI was defined as an 8MC under 50 nmol/L or an abnormal ACTH stimulation test. Risks factors for AI and its duration were assessed. Results Sixty patients were included in this study. AI prevalence was 30% with 18 of 60 affected patients. The corticosteroid dose injected was statistically associated with the development of AI. Median duration of AI was 181 days for the nine patients who were followed up until resolution of AI. Four patients developed symptoms of AI, namely fatigue (2 of 4), nausea (2 of 4) and abdominal pain (3 of 4). None were hospitalized or died. Conclusions In this cohort of children with chronic arthritis who had an IACI, we found a high prevalence of AI. Monitoring and counseling of such complication is warranted until further evidence is available.
Collapse
Affiliation(s)
- Justine Turmel-Roy
- Department of Pediatrics, CHU de Québec - Université Laval, Québec, Canada
| | - Marc-Antoine Bédard
- Department of Pediatrics, Division of Pediatric Immunology, CHU Sainte-Justine, Montréal University, Quebec, Canada
| | - Maude Millette
- Department of Pediatrics, Division of Pediatric Endocrinology, CHU de Québec - Université Laval, Québec, Canada
| | | | | | - Isabelle Rousseau-Nepton
- Department of Pediatrics, Division of Pediatric Endocrinology, CHU de Québec - Université Laval, Québec, Canada
| |
Collapse
|
44
|
Ora J, Calzetta L, Matera MG, Cazzola M, Rogliani P. Advances with glucocorticoids in the treatment of asthma: state of the art. Expert Opin Pharmacother 2020; 21:2305-2316. [PMID: 32808828 DOI: 10.1080/14656566.2020.1807514] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Asthma is one of the most frequent chronic diseases all over the world. Glucocorticoids (GCs), both inhaled (ICSs) and oral (OCSs), are the most effective treatment in asthma because they control symptoms and prevent exacerbations. AREAS COVERED The present article reviews the new therapeutic indications of GCs for the treatment of asthma and focuses on new molecules and safety issues. EXPERT OPINION Most patients with asthma benefit from corticosteroid-based treatments. Side effects are mainly due to prolonged use of oral GCs, while they are minor with inhaled GCs. Interesting insights come from the new ICSs, which are characterized by lower oral bioavailability and higher lipophilicity and are more effective with less side effects. Recent trials have shown the efficacy of early use of ICSs in mild asthma. Furthermore, the possibility to prescribe targeted therapies using specific biomarkers in steroid-sensitive asthma can reduce doses and duration of treatment, while biological agents should be reserved for non-responding patients. All this evidence confirm the need to continue on the path toward precision medicine, in which the treatments are based on clinical and molecular traits.
Collapse
Affiliation(s)
- Josuel Ora
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata" , Rome, Italy
| | - Luigino Calzetta
- Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli , Naples, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
| | - Paola Rogliani
- Division of Respiratory Medicine, University Hospital "Policlinico Tor Vergata" , Rome, Italy.,Department of Experimental Medicine, University of Rome Tor Vergata , Rome, Italy
| |
Collapse
|
45
|
Ayyar VS, Jusko WJ. Transitioning from Basic toward Systems Pharmacodynamic Models: Lessons from Corticosteroids. Pharmacol Rev 2020; 72:414-438. [PMID: 32123034 DOI: 10.1124/pr.119.018101] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Technology in bioanalysis, -omics, and computation have evolved over the past half century to allow for comprehensive assessments of the molecular to whole body pharmacology of diverse corticosteroids. Such studies have advanced pharmacokinetic and pharmacodynamic (PK/PD) concepts and models that often generalize across various classes of drugs. These models encompass the "pillars" of pharmacology, namely PK and target drug exposure, the mass-law interactions of drugs with receptors/targets, and the consequent turnover and homeostatic control of genes, biomarkers, physiologic responses, and disease symptoms. Pharmacokinetic methodology utilizes noncompartmental, compartmental, reversible, physiologic [full physiologically based pharmacokinetic (PBPK) and minimal PBPK], and target-mediated drug disposition models using a growing array of pharmacometric considerations and software. Basic PK/PD models have emerged (simple direct, biophase, slow receptor binding, indirect response, irreversible, turnover with inactivation, and transduction models) that place emphasis on parsimony, are mechanistic in nature, and serve as highly useful "top-down" methods of quantitating the actions of diverse drugs. These are often components of more complex quantitative systems pharmacology (QSP) models that explain the array of responses to various drugs, including corticosteroids. Progressively deeper mechanistic appreciation of PBPK, drug-target interactions, and systems physiology from the molecular (genomic, proteomic, metabolomic) to cellular to whole body levels provides the foundation for enhanced PK/PD to comprehensive QSP models. Our research based on cell, animal, clinical, and theoretical studies with corticosteroids have provided ideas and quantitative methods that have broadly advanced the fields of PK/PD and QSP modeling and illustrates the transition toward a global, systems understanding of actions of diverse drugs. SIGNIFICANCE STATEMENT: Over the past half century, pharmacokinetics (PK) and pharmacokinetics/pharmacodynamics (PK/PD) have evolved to provide an array of mechanism-based models that help quantitate the disposition and actions of most drugs. We describe how many basic PK and PK/PD model components were identified and often applied to the diverse properties of corticosteroids (CS). The CS have complications in disposition and a wide array of simple receptor-to complex gene-mediated actions in multiple organs. Continued assessments of such complexities have offered opportunities to develop models ranging from simple PK to enhanced PK/PD to quantitative systems pharmacology (QSP) that help explain therapeutic and adverse CS effects. Concurrent development of state-of-the-art PK, PK/PD, and QSP models are described alongside experimental studies that revealed diverse CS actions.
Collapse
Affiliation(s)
- Vivaswath S Ayyar
- Department of Pharmaceutical Sciences University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York
| | - William J Jusko
- Department of Pharmaceutical Sciences University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York
| |
Collapse
|
46
|
Almquist J, Sadiq MW, Eriksson UG, Hegelund Myrbäck T, Prothon S, Leander J. Estimation of Equipotent Doses for Anti-Inflammatory Effects of Prednisolone and AZD9567, an Oral Selective Nonsteroidal Glucocorticoid Receptor Modulator. CPT Pharmacometrics Syst Pharmacol 2020; 9:444-455. [PMID: 32501650 PMCID: PMC7438818 DOI: 10.1002/psp4.12536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/05/2020] [Indexed: 01/08/2023] Open
Abstract
AZD9567 is a potent and selective nonsteroidal oral glucocorticoid receptor modulator. It is developed as an anti-inflammatory drug with improved safety profile compared with steroids like prednisolone. Throughout the clinical development of AZD9567, dose selection and data interpretation require a method for determining doses with the same anti-inflammatory effect as prednisolone. Equipotent doses of AZD9567 and prednisolone were defined by the same average inhibition of TNFα release, a biomarker of anti-inflammatory effect, measured in a lipopolysaccharide-stimulated whole blood ex vivo assay. Based on pharmacokinetic-pharmacodynamic models, TNFα dose-response relationships for AZD9567 and prednisolone were established. A comparison of the dose-response curves enabled estimation of an equipotency relationship. Specifically, 20 mg prednisolone was estimated to be equipotent to 40 mg AZD9567 (95% confidence interval: 29-54 mg). Static concentration-response analyses showed that the relative potencies for inhibition of TNFα release of AZD9567 and prednisolone were well aligned with several other pro-inflammatory cytokines.
Collapse
Affiliation(s)
- Joachim Almquist
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Muhammad Waqas Sadiq
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Ulf G. Eriksson
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Tove Hegelund Myrbäck
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Susanne Prothon
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| | - Jacob Leander
- Clinical Pharmacology and Quantitative PharmacologyClinical Pharmacology and Safety SciencesR&D, AstraZenecaGothenburgSweden
| |
Collapse
|
47
|
Cardenas-Mori J, Lewis-Ramos V. Corticosteroids for Common Palliative Care Symptoms #395. J Palliat Med 2020; 23:987-989. [DOI: 10.1089/jpm.2020.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
48
|
Mohammed AG, Mansour AA, Ahmed JH. Effect of exogenous glucocorticoids on male hypogonadism. Biomed Rep 2020; 13:12. [PMID: 32765851 PMCID: PMC7391295 DOI: 10.3892/br.2020.1319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/06/2020] [Indexed: 12/23/2022] Open
Abstract
The aim of the present study was to investigate the effects of exogenous glucocorticoids (GCs), a potent cause of male hypogonadism, on the function of the hypothalamic-pituitary-gonadal axis, and to determine their secondary effects in male patients. The present study was a case-controlled study conducted in Basrah, Iraq. Of the 152 participants who met the inclusion criteria, 100 patients used different types of GCs. Of these 100 patients, 57 patients (57%) were current GC users, and 43 patients (43%) were not currently using GCs (had not used GCs in the past 30 days). The control group was comprised of 52 men (34.21%), considered as healthy participants, although 7 men (13.65%) were biochemically diagnosed with hypogonadism. Current GC exposure significantly decreased the total and free testosterone levels, whereas previous GC exposure increased estradiol (E2) levels, with the 31 patients on oral dexamethasone (cumulative dose, 18.9 mg) exhibiting a 7.5-fold increased risk of being diagnosed with hypogonadism. For previous GC users, a significant increase in the E2 level was observed, whereas all other gonadal hormonal levels were within normal reference ranges, including the total and free testosterone levels. The total cumulative dose of equivalent GCs was 240 mg, which resulted in a decrease in total testosterone levels, and subsequent hypogonadism. Oral dexamethasone at a lower total cumulative dose resulted in hypogonadism.
Collapse
Affiliation(s)
- Adel Gassab Mohammed
- Thi-Qar Specialized Diabetes, Endocrine and Metabolism Center, Endocrine and Metabolism Division, Department of Medicine, College of Medicine, University of Thi-Qar, Nasiriyah, Thi-Qar 64001, Iraq
| | - Abbas Ali Mansour
- Faiha Specialized Diabetes, Endocrine and Metabolism Center, Endocrine and Metabolism Division, Department of Pharmacology, College of Medicine, University of Basrah, Basrah 61013, Iraq
| | - Jawad Hassan Ahmed
- Faiha Specialized Diabetes, Endocrine and Metabolism Center, Endocrine and Metabolism Division, Department of Pharmacology, College of Medicine, University of Basrah, Basrah 61013, Iraq
| |
Collapse
|
49
|
Daley-Yates P, Brealey N, Thomas S, Austin D, Shabbir S, Harrison T, Singh D, Barnes N. Therapeutic index of inhaled corticosteroids in asthma: A dose-response comparison on airway hyperresponsiveness and adrenal axis suppression. Br J Clin Pharmacol 2020; 87:483-493. [PMID: 32484940 PMCID: PMC9328361 DOI: 10.1111/bcp.14406] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/14/2020] [Accepted: 05/24/2020] [Indexed: 12/01/2022] Open
Abstract
Aims To compare the airway potency, systemic activity and therapeutic index of three inhaled corticosteroids that differ in glucocorticoid receptor binding affinity, physicochemical and pharmacokinetic properties. Methods This escalating‐dose, placebo‐controlled, cross‐over study randomised adults with asthma to 1 or 2 treatment periods with ≥25 days washout in‐between. Each treatment period comprised five 7‐day dose escalations (μg/d): fluticasone furoate (FF; 25 → 100 → 200 → 400 → 800), fluticasone propionate (FP; 50 → 200 → 500 → 1000 → 2000), budesonide (BUD; 100 → 400 → 800 → 1600 → 3200) or placebo. Airway hyperresponsiveness to adenosine‐5'‐monophosphate (AMP PC20) was assessed on day 8. Plasma cortisol was assessed on day 1 (predose baseline) and from pre‐PM dose on day 6 to pre‐PM dose day 7 (24‐h weighted mean). Results Fifty‐four subjects were randomised. FF showed greater airway potency than FP and BUD (AMP PC20 dose at which 50% of the maximum effect is achieved [ED50] values: 48.52, 1081.27 and 1467.36 μg/d, respectively). Systemic activity (cortisol suppression) ED50 values were 899.99, 1986.05 and 1927.42 μg/d, respectively. The therapeutic index (ED50 cortisol suppression/ED50 AMP PC20) was wider for FF (18.55) than FP (1.84) and BUD (1.31). FF 100 μg/d and 200 μg/d were both comparable in terms of airway potency with high doses of FP (≥1000 μg twice daily [BID]) and BUD (≥1500 μg/BID). The systemic activity of FF 100 μg/d and 200 μg/d (cortisol suppression: 7.41% and 14.28%, respectively) was comparable with low doses of FP (100 μg/BID and 250 μg/BID) and BUD (100 μg/BID and 200 μg/BID). Conclusion This study provides evidence that FF can provide more protection against airway hyperresponsiveness, with less systemic activity, than FP or BUD. This suggests that all inhaled corticosteroids are not therapeutically similar and may differ in their therapeutic index. (203162; NCT02991859).
Collapse
Affiliation(s)
- Peter Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GlaxoSmithKline plc, Uxbridge, UK
| | - Noushin Brealey
- Clinical Pharmacology and Experimental Medicine, GlaxoSmithKline plc, Uxbridge, UK
| | - Sebin Thomas
- Biostatistics and Programming, GlaxoSmithKline plc, Bangalore, India
| | - Daren Austin
- Clinical Pharmacology and Experimental Medicine, GlaxoSmithKline plc, Uxbridge, UK
| | - Shaila Shabbir
- Medicines Research Centre, GlaxoSmithKline plc, Stevenage, UK
| | - Tim Harrison
- Respiratory Research Unit, Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Neil Barnes
- Global Medical Franchise, GlaxoSmithKline plc, Brentford, UK.,William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
50
|
Thevis M, Kuuranne T, Dib J, Thomas A, Geyer H. Do dried blood spots (DBS) have the potential to support result management processes in routine sports drug testing? Drug Test Anal 2020; 12:704-710. [PMID: 32180361 DOI: 10.1002/dta.2790] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
Abstract
Dried blood spots (DBS) have been considered as complementary matrix in sports drug testing for many years. Especially concerning substances prohibited in-competition only, the added value of DBS collected concomitantly with routine doping control urine samples has been debated, and an increasing potential of DBS has been discussed in the scientific literature. To which extent and under which prerequisites DBS can contribute to enhanced anti-doping efforts is currently evaluated. As a proof-of-principle, two analytical applications, one targeting cocaine/benzoyl ecgonine and the other prednisone/prednisolone, are presented in this perspective to indicate potential added value but also presently existing limitations of the DBS approach.
Collapse
Affiliation(s)
- Mario Thevis
- Center for Preventive Doping Research - Institute of Biochemistry, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany.,European Monitoring Center for Emerging Doping Agents, Cologne, Germany
| | - Tiia Kuuranne
- Swiss Laboratory for Doping Analyses, University Center of Legal Medicine, Genève and Lausanne, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Epalinges, Switzerland
| | - Josef Dib
- Center for Preventive Doping Research - Institute of Biochemistry, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany
| | - Andreas Thomas
- Center for Preventive Doping Research - Institute of Biochemistry, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany
| | - Hans Geyer
- Center for Preventive Doping Research - Institute of Biochemistry, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany.,European Monitoring Center for Emerging Doping Agents, Cologne, Germany
| |
Collapse
|