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Lee H, Yoon HY. Inhaled corticosteroid increased the risk of adrenal insufficiency in patients with chronic airway diseases: a nationwide population-based study. Sci Rep 2024; 14:28831. [PMID: 39572602 PMCID: PMC11582715 DOI: 10.1038/s41598-024-78298-2] [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: 06/17/2024] [Accepted: 10/29/2024] [Indexed: 11/24/2024] Open
Abstract
Inhaled corticosteroids (ICS) are commonly used for airway disease, but concerns about adrenal insufficiency (AI) have arisen. This retrospective observational study investigated the link between ICS use and AI risk using data from the National Health Insurance Service-National Sample Cohort, analyzing 66,631 patients with COPD (Korean Standard Classification of Diseases [KCD] codes J42-J44) or asthma (KCD codes J45-J46). ICS use, daily dosage, and AI cases (hospitalization or ≥ 2 outpatient visits with KCD code E27) were identified via diagnostic codes. Cox proportional hazard survival analysis and inverse probability of treatment weighting (IPTW) addressed baseline differences between ICS and non-ICS users. In total 66,631 patients, the mean age was 57.3 years, 42.6% were male, and 42.2% had a Charlson comorbidity index (CCI) of 2 or higher. Among the patients, 15.5% used ICS, with a mean daily dose of 404.2 µg/day. The incidence of AI was higher in ICS users (1.69 per 1000) than in non-users (0.54 per 1000). ICS use independently increased AI risk (HR: 3.06, 95% CI: 1.82-5.14, p < 0.001). Each 100 µg/day increase in ICS was associated with a 3% increase in AI incidence (HR: 1.03, 95% CI: 1.02-1.04, p < 0.001). Quartile analysis indicated a significant AI risk increase across all ICS dosage quartiles compared with non-users. Subgroup analysis showed consistent associations with age, sex, and smoking, with stronger links in systemic steroid users (HR: 3.54, 95% CI: 2.10-5.96, p < 0.001) and those with higher CCI (HR: 2.61, 95% CI: 1.64-4.12, p < 0.001). ICS may use increases AI risk in chronic airway disease patients, particularly among systemic steroid users and those with higher CCI. Close monitoring of high-risk patients is advised, and further research is needed to clarify mechanisms and optimize safe ICS use.
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Affiliation(s)
- Hyewon Lee
- Department of Health Administration and Management, College of Medical Sciences, Soonchunhyang University, Asan, Republic of Korea
- Department of Software Convergence, Soonchunhyang University Graduate School, Asan, Republic of Korea
| | - Hee-Young Yoon
- Division of Allergy and Respiratory Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, 59 Daesagwanro, Yongsan-gu, Seoul, 04401, Republic of Korea.
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2
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De Vleeschhauwer F, Casteels K, Hoffman I, Proesmans M, Rochtus A. Systemic Adverse Events Associated with Locally Administered Corticosteroids. CHILDREN (BASEL, SWITZERLAND) 2024; 11:951. [PMID: 39201886 PMCID: PMC11353265 DOI: 10.3390/children11080951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/23/2024] [Accepted: 08/02/2024] [Indexed: 09/03/2024]
Abstract
Topical corticosteroids are a mainstay in the treatment of many pediatric disorders. While they have proven beneficial therapeutic effects and are generally considered safe, systemic adverse events may occur. This study presents four cases of children who experienced systemic adverse events after using inhaled and intranasal topical corticosteroids, as well as topical corticosteroids in other forms. A comprehensive literature review was performed to explore the existing evidence on this topic. The aim of this study is to raise awareness among healthcare providers about the possibility of systemic adverse events associated with the use of locally administered corticosteroids in pediatric patients. This information underscores the importance of careful monitoring, individualized treatment plans, and further research to better understand and mitigate the risks associated with corticosteroids, even those not given systemically.
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Affiliation(s)
| | - Kristina Casteels
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Ilse Hoffman
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Marijke Proesmans
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Anne Rochtus
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
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3
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Tran DT, Chen Y, Zheng Y, Hecker J, Hawcutt DB, Pirmohamed M, Lasky‐Su J, Wu AC, Tantisira KG, McGeachie MJ, Weiss ST, Dahlin A. Urine metabolomics signature reveals novel determinants of adrenal suppression in children taking inhaled corticosteroids to control asthma symptoms. Immun Inflamm Dis 2024; 12:e1315. [PMID: 39031511 PMCID: PMC11259003 DOI: 10.1002/iid3.1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Asthma is routinely treated with inhaled corticosteroids (ICS). Asthma patients on ICS are at increased risk of adrenal suppression, a potentially serious effect of long-term glucocorticoid exposure; however, this relationship is poorly understood. Therefore, this study aims to identify metabolite biomarkers related to adrenal suppression in asthma patients taking ICS. METHODS A total of 571 urine metabolites from 200 children with asthma on ICS in the Pharmacogenetics of Adrenal Suppression with Inhaled Steroids (PASS) cohort were profiled. Samples were grouped by peak plasma cortisol measurement as adrenal sufficient (>350 nmol/L) or insufficient (≤350 nmol/L) (outcome). Regression and discriminant-based statistical models combined with network analyses were utilized to assess relationships between metabolites and the outcome. Finally, prioritized metabolites were validated using data from an ancillary study of the Childhood Asthma Management (CAMP) cohort with similar characteristics to PASS. RESULTS Ninety metabolites were significantly associated with adrenal suppression, of which 57 also could discriminate adrenal status. While 26 metabolites (primarily steroids) were present at lower levels in the adrenal insufficient patients, 14 were significantly elevated in this group; the top metabolite, mannitol/sorbitol, was previously associated with asthma exacerbations. Network analyses identified unique clusters of metabolites related to steroids, fatty acid oxidation, and nucleoside metabolism, respectively. Four metabolites including urocanic acid, acetylcarnitine, uracil, and sorbitol were validated in CAMP cohort for adrenal suppression. CONCLUSIONS Urinary metabolites differ among asthma patients on ICS, by adrenal status. While steroid metabolites were reduced in patients with poor adrenal function, our findings also implicate previously unreported metabolites involved in amino acid, lipid, and nucleoside metabolism.
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Affiliation(s)
- Dung T. Tran
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yulu Chen
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Yi Zheng
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Julian Hecker
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Jessica Lasky‐Su
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Ann C. Wu
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMassachusettsUSA
| | - Kelan G. Tantisira
- Division of Pediatric Respiratory MedicineUniversity of California San Diego and Rady Children's HospitalSan DiegoCaliforniaUSA
| | - Michael J. McGeachie
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Scott T. Weiss
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Amber Dahlin
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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4
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Gans MD, Gavrilova T. Understanding the immunology of asthma: Pathophysiology, biomarkers, and treatments for asthma endotypes. Paediatr Respir Rev 2020; 36:118-127. [PMID: 31678040 DOI: 10.1016/j.prrv.2019.08.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
Asthma is a common disease in paediatrics and adults with a significant morbidity, mortality, and financial burden worldwide. Asthma is now recognized as a heterogeneous disease and emerging clinical and laboratory research has elucidated understanding of asthma's underlying immunology. The future of asthma is classifying asthma by endotype through connecting discernible characteristics with immunological mechanisms. This comprehensive review of the immunology of asthma details the currently known pathophysiology and clinical practice biomarkers in addition to forefront biologic and targeted therapies for all of the asthma endotypes. By understanding the immunology of asthma, practitioners will be able to diagnose patients by asthma endotype and provide personalized, biomarker-driven treatments to effectively control patients' asthma.
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Affiliation(s)
- Melissa D Gans
- Division of Allergy and Immunology, Montefiore Medical Center, 1525 Blondell Ave, Bronx, NY 10461, USA.
| | - Tatyana Gavrilova
- Division of Allergy and Immunology, Montefiore Medical Center, 1525 Blondell Ave, Bronx, NY 10461, USA.
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Alreshidi NM, Livesley J, Al-Kalaldeh M, Long T. The Impact of a School-based, Nurse-delivered Asthma Health Education Program on Quality of Life, Knowledge, and Attitudes of Saudi Children with Asthma. Compr Child Adolesc Nurs 2020; 45:43-57. [PMID: 33021848 DOI: 10.1080/24694193.2020.1824033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
More than two million people have asthma in Saudi Arabia: 13% aged 6-10 years. Asthma is one of the most common childhood illnesses. Little has been explored about children's ability to learn more about their own asthma in Saudi Arabia. The study was designed to assess the impact of a school-based, nurse-delivered asthma health education program on asthmatic children's knowledge and attitude toward asthma, quality of life, anxiety level, and school absenteeism. A quasi-experimental, non-equivalent group, pretest-posttest design was used. The education program was developed from existing evidence. The Pediatric Asthma Quality of Life Questionnaire, Spence Anxiety Tool, Asthma Knowledge Questionnaire, and Asthma Attitude Questionnaire were employed for data collection. Intervention (n = 130) and control (n = 98) groups were drawn from 10 schools in Ha'il region, Saudi Arabia. Descriptive and inferential statistics were used to examine differences within and between groups. Knowledge of asthma increased significantly more in the intervention group than in the control group. Attitude toward asthma was not changed by the intervention. Anxiety scores reverted to pretest level by posttest II. The intervention group had significantly better total quality of life scores than the control group, and school absenteeism reduced significantly after the delivery of the program. It was concluded that the asthma education program impacted positively on students' knowledge, quality of life, and school attendance. However, asthma education did not change attitudes toward the condition, and the impact on anxiety was not persistent. The results emphasize the benefits of the provision of health education directly to children. Asthma education should be integrated into the Saudi national child health program.
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Affiliation(s)
- Nashi Masnad Alreshidi
- Department of Continuing Education, Nursing Administration in Hail Region, Hail City, Saudi Arabia
| | - Joan Livesley
- School of Health & Society, University of Salford, Salford, UK
| | | | - Tony Long
- Department of Continuing Education, Nursing Administration in Hail Region, Hail City, Saudi Arabia
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6
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Comer GM, Bush MA, Dellon ES, Marino MT. Effect of Food Intake and Body Position on the Pharmacokinetics of Swallowed APT-1011, a Fluticasone Orally Disintegrating Tablet, in Healthy Adult Volunteers. J Clin Pharmacol 2020; 60:734-743. [PMID: 31943257 DOI: 10.1002/jcph.1572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/02/2019] [Indexed: 12/20/2022]
Abstract
Eosinophilic esophagitis is a common atopic disease of the esophagus. APT-1011 is an orally disintegrating tablet formulation of fluticasone propionate under development for the treatment of eosinophilic esophagitis. The objective of this study was to evaluate the pharmacokinetics, safety, and tolerability of APT-1011 under fed or fasted conditions in the morning (am) or at bedtime (hs) in the supine position. The study was a randomized, single-dose, 3-way, crossover design in healthy adult volunteers. In each study period participants received 2 3-mg orally disintegrating APT-1011 tablets. Serial plasma samples were collected before dosing and up to 72 hours after each dose. Twenty-two participants completed the study. The fluticasone propionate peak concentration (Cmax ) ranged from 5.97 to 200 pg/mL. Compared with am-fasted dosing, am-fed dosing was associated with a modestly higher Cmax (∼21%) but lower net exposure (area under the concentration-time curve ∼56% difference) and shorter time to reach Cmax (Tmax ) (Tmax fasted = 10 hours, fed = 5 hours). Dosing at hs resulted in an 18% and 32% decrease in Cmax relative to am-fasted and am-fed conditions, respectively. Dosing at hs led to an exposure that was higher than am-fed but lower than am-fasted dosing. Tmax with hs dosing (14 hours) was later than that with am dosing (Tmax fasted = 10 hours, fed = 5 hours). Adverse events were mild. There is low systemic exposure of fluticasone propionate with APT-1011. The rate of absorption was increased with a high-fat meal but decreased with hs dosing, suggesting the potential for longer dwell times in the esophagus.
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Affiliation(s)
- Gail M Comer
- Adare Pharmaceuticals, Lawrence Township, New Jersey, USA
| | - Mark A Bush
- Nuventra Pharma Sciences, Durham, North Carolina, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark T Marino
- Mark T. Marino, Consulting, LLC, Carlsbad, California, USA
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7
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Akcan N, Bahceciler NN. Headliner in Physiology and Management of Childhood Asthma: Hypothalamic-Pituitary-Adrenal Axis. Curr Pediatr Rev 2020; 16:43-52. [PMID: 31738144 DOI: 10.2174/1573396315666191026100643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/23/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023]
Abstract
Asthma is the most common chronic inflammatory disease of children. Inhaled corticosteroids (ICS) are the cornerstone of asthma therapy which are the most effective, commonly used treatment of persistent asthma. Mostly, studies on the relationship between asthma and cortisol have focused on side effects of treatment. Recently, asthmatic patients not treated with ICS have been reported to have an attenuated activity and/or responsiveness of their Hypothalamic-Pituitary- Adrenal (HPA) axis. Moreover, it has been proposed that asthma worsening with stress may be due to a dysfunctional HPA axis, or cortisol insensitivity due to chronic psychological stress through impaired glucocorticoid receptor expression or function. Although long-term ICS treatment might produce adrenal suppression or iatrogenic Cushing syndrome, improvement of adrenal function has also been detected in some of asthmatic cases. Thus, the response scheme of HPA axis still contains undiscovered features in asthma. The management of asthma can be improved by increasing knowledge on the role of HPA axis in asthma pathophysiology. The risk for side effects of ICS can be minimized through increased awareness, early recognition of at-risk patients and regular patient follow-up. This review was written to draw attention to the role of HPA axis in both asthma and its treatment and to illustrate a follow up algorithm of HPA axis in the management of asthma.
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Affiliation(s)
- Nese Akcan
- Department of Pediatric Endocrinology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Nerin N Bahceciler
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Near East University, Nicosia, Cyprus
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8
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Kwda A, Gldc P, Baui B, Kasr K, Us H, S W, Kantha L, Ksh DS. Effect of long term inhaled corticosteroid therapy on adrenal suppression, growth and bone health in children with asthma. BMC Pediatr 2019; 19:411. [PMID: 31684902 PMCID: PMC6829958 DOI: 10.1186/s12887-019-1760-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are the most effective treatment for children with persistent asthma. However adverse effects of ICS on Hypothalamo Pituitary Adrenal (HPA) axis, growth and bone metabolism are a concern. Hence the primary objective of this study was to describe the effects of long term inhaled corticosteroid therapy (ICS) on adrenal function, growth and bone health in children with asthma in comparison to an age and sex matched group of children with asthma who were not on long term ICS. Describing the association between the dose of ICS and duration of therapy on the above parameters were secondary objectives. METHOD Seventy children with asthma on ICS and 70 controls were studied. Diagnosis of asthma in selected patients was reviewed according to the criteria laid down by GINA 2018 guidelines. The estimated adult heights were interpreted relative to their Mid Parental Height (MPH) range. Serum calcium, alkaline phosphatase and vitamin D levels were analyzed in both groups and cortisol value at 30 min following a low dose short synacthen test was obtained from the study group. The average daily dose of ICS (Beclamethasone) was categorized as low, medium and high (100-200, 200-400, > 400 μg /day) respectively according to published literature. RESULTS Heights of all children were within the MPH range. There was no statistically significant difference in the bone profiles and vitamin D levels between the two groups (Ca: p = 0.554, vitamin D: p = 0.187) but vitamin D levels were insufficient (< 50 nmol/l) in 34% of cases and 41% of controls. Suppressed cortisol levels were seen in 24%. Doses of ICS were low, medium and high in 56, 32 and 12% of children respectively. The association between adrenal suppression with longer duration of therapy (p < 0.01) and with increasing dose of ICS (p < 0.001) were statistically significant. CONCLUSION ICS had no impact on the growth and bone profiles but its dose and duration were significantly associated with adrenal suppression.
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Affiliation(s)
- Anuradha Kwda
- Lecturer Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
- Acting paediatric pulmonologist, University paediatric unit, Lady Ridgeway Hospital for children, Colombo, Sri Lanka.
| | - Prematilake Gldc
- Acting paediatric endocrinologist, Lady Ridgeway Hospital for children, Colombo, Sri Lanka
| | - Batuwita Baui
- Research Assistant, University paediatrc unit, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Kannangoda Kasr
- Medical Officer, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Hewagamage Us
- Medical Officer, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Wijeratne S
- Laboratory Director, Vindana Reproductive Health Centre, Colombo, Sri Lanka
| | - Lankatilake Kantha
- Associate Professor, Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - de Silva Ksh
- Professor in paeditrics ,Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
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Goldbloom EB, Ahmet A. Screening practices for paediatric asymptomatic adrenal suppression in Canada: Are we addressing this important risk? Paediatr Child Health 2019; 25:389-393. [PMID: 34163543 DOI: 10.1093/pch/pxy174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background Children with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable. Objective To assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases. Methods Before and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013. Results Response rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year. Conclusion Frequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
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10
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Kaplan A, Hardjojo A, Yu S, Price D. Asthma Across Age: Insights From Primary Care. Front Pediatr 2019; 7:162. [PMID: 31131265 PMCID: PMC6510260 DOI: 10.3389/fped.2019.00162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/08/2019] [Indexed: 11/16/2022] Open
Abstract
Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from childhood up to old age. In this review, we summarize the current knowledge on the similarities and differences in asthma across different age-groups, with emphasis on the perspective from primary care. Despite the similar disease presentation, phenotyping studies showed that there are differences in the distribution of phenotypes of asthma presenting in childhood compared to that in adulthood. Whereas, asthma with early age of onset tends to be of the atopic phenotype, the disease shifts toward the non-atopic phenotypes at later ages. Studies within primary care patients aiming to elucidate risk factors for future asthma exacerbation have shown pediatric and elderly patients to be at higher risk for future asthma attacks compared to other adult patients. Regardless, both pediatric and adult studies demonstrated previous asthma episodes and severity, along with high blood eosinophil to predict subsequent asthma attacks. Differences in childhood and adult asthma are not limited to the underlying phenotypes but also extends to the challenges in the diagnosis, treatment, and management of the disease. Diagnosis of asthma is complicated by age-specific differential diagnoses such as infectious wheezing and nasal obstruction in children, and aging-related problems such as heart disease and obesity in the elderly. There are also age-related issues leading to decreased disease control such as non-adherence, tobacco use, difficulty in using inhalers and corticosteroid-related side effects which hinder asthma control at different patient age-groups. Several clinical guidelines are available to guide the diagnosis and drug prescription of asthma in pediatric patients. However, there are conflicting recommendations for the diagnostic tools and treatment for pediatric patients, posing additional challenges for primary care physicians in working with multiple guidelines. While tools such as spirometry and peak flow variability are often available in primary care, their usage in preschool patients is not consistently recommended. FeNO measurement may be a valuable non-invasive tool which can be adopted by primary physicians to assist asthma diagnosis in preschool-age patients.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Shaylynn Yu
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.,Optimum Patient Care, Cambridge, United Kingdom
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11
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Wood Heickman LK, Davallow Ghajar L, Conaway M, Rogol AD. Evaluation of Hypothalamic-Pituitary-Adrenal Axis Suppression following Cutaneous Use of Topical Corticosteroids in Children: A Meta-Analysis. Horm Res Paediatr 2018; 89:389-396. [PMID: 29898449 DOI: 10.1159/000489125] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS A meta-analysis was performed to determine the likelihood of hypothalamic-pituitary-adrenal (HPA) axis suppression following short-term cutaneous treatment of atopic dermatitis with topical corticosteroids (TCS) in pediatric patients. METHODS All published pediatric clinical trials evaluating TCS use with pre- and post-treatment HPA axis assessment by cosyntropin stimulation testing were included. RESULTS Of 128 eligible trials, 12 were selected for meta-analysis with a total of 522 participants. There were 20 observed cases of HPA axis suppression (3.8%, 95% CI 2.4-5.8). The percentage of HPA axis suppression with low- (classes 6-7), medium- (classes 3-5) and high-potency (classes 1-2) TCS use was 2% (3 of 148 patients, 95% CI 0.7-5.8), 3.1% (7 of 223 patients, 95% CI 1.5-6.3), and 6.6% (10 of 151 patients, 95% CI 3.6-11.8), respectively. CONCLUSION There is a low rate of reversible HPA axis suppression with the use of mid- to low-potency TCS compared to more potent formulations. In pediatric clinical practice, the limited use of mid- to low-potency TCS is rarely associated with clinically significant adrenal insufficiency or adrenal crisis. In the absence of signs and symptoms of adrenal insufficiency, there is little need to test the HPA axis of these patients.
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Affiliation(s)
- Lauren K Wood Heickman
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
| | - Ladan Davallow Ghajar
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Alan D Rogol
- Department of Pediatrics, Division of Endocrinology, University of Virginia, Charlottesville, Virginia, USA
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12
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Abstract
Asthma is the most common respiratory disorder in Canada. Despite significant improvement in the diagnosis and management of this disorder, the majority of Canadians with asthma remain poorly controlled. In most patients, however, control can be achieved through the use of avoidance measures and appropriate pharmacological interventions. Inhaled corticosteroids (ICS) represent the standard of care for the majority of patients. Combination ICS/long-acting beta2-agonist inhalers are preferred for most adults who fail to achieve control with ICS therapy. Biologic therapies targeting immunoglobulin E or interleukin-5 are recent additions to the asthma treatment armamentarium and may be useful in select cases of difficult to control asthma. Allergen-specific immunotherapy represents a potentially disease-modifying therapy for many patients with asthma, but should only be prescribed by physicians with appropriate training in allergy. In addition to avoidance measures and pharmacotherapy, essential components of asthma management include: regular monitoring of asthma control using objective testing measures such as spirometry, whenever feasible; creation of written asthma action plans; assessing barriers to treatment and adherence to therapy; and reviewing inhaler device technique. This article provides a review of current literature and guidelines for the appropriate diagnosis and management of asthma in adults and children.
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Affiliation(s)
| | | | | | | | - Harold Kim
- 1McMaster University, Hamilton, ON Canada.,3Western University, London, ON Canada
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13
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Kaur S, Singh V. Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration. Indian J Pediatr 2018; 85:748-756. [PMID: 29306991 DOI: 10.1007/s12098-017-2553-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/22/2017] [Indexed: 01/30/2023]
Abstract
Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.
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Affiliation(s)
- Satnam Kaur
- Department of Pediatrics, Vardhman Mahavir Medical College and Associated Safdarjung Hospital, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India.
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Barra CB, Fontes MJF, Cintra MTG, Cruz RC, Rocha JAG, Guimarães MCC, Silva IN. Oral corticosteroids for asthma exacerbations might be associated with adrenal suppression: Are physicians aware of that? ACTA ACUST UNITED AC 2018; 63:899-903. [PMID: 29267492 DOI: 10.1590/1806-9282.63.10.899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/05/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Oral corticosteroids (OCS) are a mainstay of treatment for asthma exacerbations, and short-term OCS courses were generally considered to be safe. Nevertheless, frequent short-term OCS courses could lead to hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Our study aimed at investigating the integrity of the HPA axis in children with persistent asthma or recurrent wheezing at the beginning of an inhaled corticosteroids (ICS) trial. METHOD Morning basal cortisol was assessed just before the beginning of ICS, and 30, 60, and 90 days later, using Immulite® Siemens Medical Solutions Diagnostic chemiluminescent enzyme immunoassay (Los Angeles, USA; 2006). RESULTS In all, 140 children (0.3-15 years old) with persistent asthma or recurrent wheezing have been evaluated and 40% of them reported short-term OCS courses for up to 30 days before evaluation. Out of these, 12.5% had biochemical adrenal suppression but showed adrenal recovery during a three-month ICS trial treatment. No significant differences were observed among children with or without adrenal suppression, neither in the number of days free of OCS treatment before cortisol evaluation (p=0.29) nor in the last OCS course duration (p=0.20). The number of short-term OCS courses reported in the year preceding the cortisol evaluation was also not different (p=0.89). CONCLUSION Short-term systemic courses of corticosteroids at conventional doses can put children at risk of HPA axis dysfunction. ICS treatment does not impair adrenal recovery from occurring. Health practitioners should be aware of the risk of a blunted cortisol response upon exposure to stress during the follow-up of patients with persistent asthma or recurrent wheezing.
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Affiliation(s)
- Cristina B Barra
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
| | - Maria Jussara F Fontes
- Professor of the Department of Pediatrics, Pediatric Pneumology Division, HC-FM-UFMG, Belo Horizonte, MG, Brazil
| | | | - Renata C Cruz
- Medical Student, FM-UFMG, Belo Horizonte, MG, Brazil
| | | | | | - Ivani Novato Silva
- Professor of the Department of Pediatrics, Pediatric Endocrinology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas Gerais (HC-FM-UFMG), Belo Horizonte, MG, Brazil
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Abstract
Secondary adrenal insufficiency can result from insufficient stimulation of the adrenal glands due to inadequate secretion or synthesis of adrenocorticotropic hormone (ACTH). This can be caused by hypopituitarism, central nervous system injury (tumors, radiation, and surgery) or long-term glucocorticoid therapy. Glucocorticoids were introduced in the 1950s, and have been used for their anti-inflammatory and other pharmacological effects, and also as replacement therapy for adrenal insufficiency. However, chronic glucocorticoid use may lead to suppression of the hypothalamic pituitary adrenal axis through negative feedback. This may lead to secondary adrenal insufficiency. Typically, the hypothalamic pituitary adrenal axis recovers after cessation of glucocorticoids, but the timing of recovery can be variable and can take anywhere from 6-12 months. Understanding the effect of exogenous glucocorticoids on the hypothalamic pituitary adrenal axis, recovery of the axis, and tests used to assess the recovery, are crucial to avoid prescribing unnecessary steroid replacement or missing a critical diagnosis with detrimental consequences.
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Affiliation(s)
- Areej K Younes
- Section of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Noor K Younes
- Division of Pediatrics, King Hussein Cancer Center, Amman, Jordan
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Smit MP, van Leer EH, Noppe G, de Rijke YB, Kramer van Driel D, van den Akker EL. Long-Term Cortisol Concentration in Scalp Hair of Asthmatic Children Using Inhaled Corticosteroids: A Case-Control Study. Horm Res Paediatr 2017; 88:231-236. [PMID: 28715822 PMCID: PMC6050635 DOI: 10.1159/000478526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 06/09/2017] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) can interfere with the hypothalamic-pituitary-adrenal (HPA) axis and may lead to adrenal insufficiency, resulting in a decrease of cortisol production. Cortisol levels measured in scalp hair provide a marker for long-term cortisol exposure. Data regarding hair cortisol concentration (HCC) in asthmatic children with ICS therapy are scarce. The aim of this study is to compare HCC in asthmatic children under ICS treatment with a healthy control group. METHODS We set up a case-control study measuring the cortisol concentration in scalp hair in asthmatic children (N = 80) treated with ICS and healthy controls (N = 252) aged 4-18 years. Anthropometric characteristics and hair samples from the posterior vertex were obtained. At least 5 mg of the most proximal 3 cm of hair was used for each hair sample. HCC was analyzed by liquid chromatography-tandem mass spectrometry. RESULTS HCC did not significantly differ between asthmatic children using ICS and healthy controls (p = 0.950) after adjustment for age, gender, height, body mass index, and socioeconomic status. No correlation was found between budesonide dosage and HCC levels (r = -0.031, p = 0.78). CONCLUSION There was no evidence of suppression of basal cortisol production, as measured in scalp hair, in asthmatic children using ICS, compared to healthy controls. No conclusions can be drawn on the HPA-axis stress response in these children.
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Affiliation(s)
- Maaike P. Smit
- Department of Paediatrics, Groene Hart Hospital, Gouda, The Netherlands
| | - Ed H.G. van Leer
- Department of Paediatrics, Groene Hart Hospital, Gouda, The Netherlands
| | - Gerard Noppe
- Department of Paediatrics and Internal Medicine, Sophia Children's Hospital-Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Erica L.T. van den Akker
- Department of Paediatrics, Sophia Children's Hospital-Erasmus MC, Rotterdam, The Netherlands,*Erica L.T. van den Akker, MD, PhD, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC - SP1536, PO Box 2060, NL-3000 CB Rotterdam (The Netherlands), E-Mail
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Leung JS, Johnson DW, Sperou AJ, Crotts J, Saude E, Hartling L, Stang A. A systematic review of adverse drug events associated with administration of common asthma medications in children. PLoS One 2017; 12:e0182738. [PMID: 28793336 PMCID: PMC5549998 DOI: 10.1371/journal.pone.0182738] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/24/2017] [Indexed: 12/16/2022] Open
Abstract
Objective To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications. Methods Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency. Findings Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments. Conclusion The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.
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Affiliation(s)
- James S. Leung
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - David W. Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | - Arissa J. Sperou
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Crotts
- Departments of Pediatrics, Emergency Medicine, Pediatric Emergency Research Institute, Calgary, Alberta, Canada
| | - Erik Saude
- Departments of Emergency Medicine and Pediatric Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Center for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Antonia Stang
- Departments of Pediatrics, Emergency Medicine, and Community Health Sciences, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
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Vitale C, Maglio A, Pelaia C, Vatrella A. Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy. Expert Opin Pharmacother 2017; 18:667-676. [PMID: 28387160 DOI: 10.1080/14656566.2017.1317747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.
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Affiliation(s)
- Carolina Vitale
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Angelantonio Maglio
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Corrado Pelaia
- b Department of Medical and Surgical Sciences, Section of Respiratory Diseases , University "Magna Graecia" of Catanzaro , Catanzaro , Italy
| | - Alessandro Vatrella
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
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Goldbloom EB, Mokashi A, Cummings EA, Abish S, Benseler SM, Huynh HQ, Watson W, Ahmet A. Symptomatic adrenal suppression among children in Canada. Arch Dis Child 2017; 102:338-339. [PMID: 28320817 DOI: 10.1136/archdischild-2016-311223] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Adrenal suppression (AS) is an under-recognised side effect of glucocorticoid (GC) use. AS may go undetected until a physiological stress precipitates an adrenal crisis. The incidence of AS has not been established. We sought to estimate the minimum national incidence and presenting features of paediatric symptomatic AS. METHODS Through the established methodology of the Canadian Paediatric Surveillance Program, over 2500 paediatricians were surveyed monthly for 2 years (April 2010-March 2012) to report new cases of symptomatic AS. RESULTS Forty-six cases of symptomatic AS were confirmed. The estimated annual incidence is 0.35/100 000 children aged 0-18 years (95% CI 0.26 to 0.47). The most common presentations were growth failure (35%), non-specific symptoms (28%) or both (13%). Adrenal crisis occurred in six cases (13%). Thirty-seven children (80%) had received inhaled corticosteroid (ICS) alone or in combination with other GC forms. Many children received high but commonly prescribed doses of ICS. CONCLUSIONS AS is responsible for significant morbidity in children, including susceptibility to adrenal crisis. The minimal estimated incidence reported is for the entire paediatric population and would be much higher in the at-risk group (ie, children treated with GCs). Close monitoring of growth and possible symptoms of AS, which may be non-specific, are important in children on all forms of GC therapy including ICS. To reduce the risk of AS, physicians must be aware of the risk of AS, revisit GC doses frequently and use the lowest effective dose.
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Affiliation(s)
- Ellen B Goldbloom
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elizabeth A Cummings
- Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sharon Abish
- Department of Pediatrics (Hematology Oncology), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Susanne M Benseler
- Department of Pediatrics (Rheumatology), Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Hien Q Huynh
- Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Wade Watson
- Department of Pediatrics (Allergy), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandra Ahmet
- Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Ahmet A, Benchimol EI, Goldbloom EB, Barkey JL. Adrenal suppression in children treated with swallowed fluticasone and oral viscous budesonide for eosinophilic esophagitis. Allergy Asthma Clin Immunol 2016; 12:49. [PMID: 27766109 PMCID: PMC5057375 DOI: 10.1186/s13223-016-0154-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/22/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Adrenal suppression (AS), a glucocorticoid (GC) side effect associated with significant morbidity, is well described related to inhaled corticosteroid therapy for asthma. Swallowed topical glucocorticoid therapy is the main pharmacotherapy treatment for eosinophilic esophagitis (EoE) and therefore children with EoE are potentially at increased risk of AS. METHODS In this prospective cohort study, we included children and youth <18 years diagnosed with EoE and treated with swallowed fluticasone or oral viscous budesonide for more than 1 month. First morning cortisol and low dose adrenocorticotropic hormone stimulation test (LDST) were performed 2 weeks following GC discontinuation. AS was defined as an abnormal LDST result (cortisol peak <500 nmol/L). We determined the prevalence and duration of AS related to swallowed topical GC therapy in EoE by LDST, as well as the diagnostic accuracy of first morning cortisol compared to LDST. RESULTS Of 29 participants enrolled, 26 (89.7 %) received oral viscous budesonide and 3 (10.3 %) received swallowed fluticasone. Nineteen (65.5 %) participants had AS. Median duration of AS was 43 weeks. Five (17.2 %) participants had persistent AS at 12 months. There were no identifiable risk factors for the development of AS. First morning cortisol was highly specific but had poor sensitivity for detection of AS. CONCLUSIONS The majority of children with EoE had AS after discontinuation of swallowed topical GC therapy. Stress steroids should be considered in children treated with swallowed topical GC therapy for EoE, even after GC discontinuation, to prevent possible adrenal crisis.
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Affiliation(s)
- Alexandra Ahmet
- Division of Endocrinology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada ; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada ; Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON Canada ; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada ; Department of Pediatrics, University of Ottawa, Ottawa, ON Canada ; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON Canada
| | - Ellen B Goldbloom
- Division of Endocrinology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada ; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada ; Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
| | - Janice L Barkey
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON Canada ; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada ; Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
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Hossny E, Rosario N, Lee BW, Singh M, El-Ghoneimy D, SOH JY, Le Souef P. The use of inhaled corticosteroids in pediatric asthma: update. World Allergy Organ J 2016; 9:26. [PMID: 27551328 PMCID: PMC4982274 DOI: 10.1186/s40413-016-0117-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023] Open
Abstract
Despite the availability of several formulations of inhaled corticosteroids (ICS) and delivery devices for treatment of childhood asthma and despite the development of evidence-based guidelines, childhood asthma control remains suboptimal. Improving uptake of asthma management plans, both by families and practitioners, is needed. Adherence to daily ICS therapy is a key determinant of asthma control and this mandates that asthma education follow a repetitive pattern and involve literal explanation and physical demonstration of the optimal use of inhaler devices. The potential adverse effects of ICS need to be weighed against the benefit of these drugs to control persistent asthma especially that its safety profile is markedly better than oral glucocorticoids. This article reviews the key mechanisms of inhaled corticosteroid action; recommendations on dosage and therapeutic regimens; potential optimization of effectiveness by addressing inhaler technique and adherence to therapy; and updated knowledge on the real magnitude of adverse events.
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Affiliation(s)
- Elham Hossny
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Cairo, 11566 Egypt
| | | | - Bee Wah Lee
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Meenu Singh
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dalia El-Ghoneimy
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Cairo, 11566 Egypt
| | - Jian Yi SOH
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Peter Le Souef
- Winthrop Professor of Paediatrics & Child Health, School of Paediatrics & Child Health, University of Western Australia, Crawley, Australia
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