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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.
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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
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Daniels GA, Guerrera AD, Katz D, Viets-Upchurch J. Challenge of immune-mediated adverse reactions in the emergency department. Emerg Med J 2019; 36:369-377. [PMID: 31113799 PMCID: PMC6582806 DOI: 10.1136/emermed-2018-208206] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/01/2019] [Accepted: 04/06/2019] [Indexed: 12/15/2022]
Abstract
Multiple drugs of a new class of cancer treatments called immune checkpoint inhibitors, which work by enabling the immune system to attack tumour cells, have been approved for a variety of indications in recent years. Immune checkpoints, such as cytotoxic T-lymphocyte antigen-4 and programmed death-1, are part of the normal immune system and regulate immune activation. Treatment with inhibitors of these checkpoints can significantly improve response rates, progression-free survival and overall survival of patients with cancer; it can also result in adverse reactions that present similarly to other conditions. These immune-mediated adverse reactions (IMARs) are most commonly gastrointestinal, respiratory, endocrine or dermatologic. Although patients’ presentations may appear similar to other types of cancer therapy, the underlying causes, and consequently their management, may differ. Prompt recognition is critical because, with appropriate management, most IMARs resolve and patients can continue receiving immune checkpoint inhibitor treatment. Rarely, these IMARs may be life-threatening and escape detection from the usual evaluations in the emergency environment. Given the unusual spectrum and mechanism of IMARs arising from immune checkpoint inhibitors, emergency departmentED staff require a clear understanding of the evaluation of IMARs to enable them to appropriately assess and treat these patients. Treatment of IMARs, most often with high-dose steroids, differs from chemotherapy-related adverse events and when possible should be coordinated with the treating oncologist. This review summarises the ED presentation and management of IMARs arising from immune checkpoint inhibitors and includes recommendations for tools and resources for ED healthcare professionals.
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Affiliation(s)
- Gregory A Daniels
- Department of Medicine, Moores UCSD Cancer Center, La Jolla, California, USA
| | - Angela D Guerrera
- Department of Emergency Medicine, Cooper University Health Care, Camden, New Jersey, USA
| | - Donna Katz
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA
| | - Jayne Viets-Upchurch
- Department of Emergency Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Kirkland SW, Vandermeer B, Campbell S, Villa-Roel C, Newton A, Ducharme FM, Rowe BH. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018; 56:522-533. [PMID: 29693459 DOI: 10.1080/02770903.2018.1467444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this systematic review was to explore the effectiveness of various systemic corticosteroid (SCS) regimens to mitigate relapse in children with asthma discharged from an acute care setting. DATA SOURCES Medline, EMBASE, Global Health, International Pharmaceutical Abstracts, EMB ALL, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS were searched using controlled vocabulary and key words. Additional citations were searched via clinical trial registries, Google Scholar, bibliographies, a SCOPUS forward search of a sentinel paper, and hand searching conference abstracts. STUDY SELECTION No limitations based on language, publication status, or year of publication were applied. Two independent reviewers searched to identify randomized controlled trials comparing the effectiveness of SCS regimens to prevent relapse in children following treatment for acute asthma. RESULTS Fifteen studies were included. In 3 studies comparing SCS to placebo, asthma relapse was significantly reduced (RR = 0.10; 95% CI: 0.01, 0.77; I2 = 0%). A network analysis identified a significant reduction in relapse in children treated with intramuscular corticosteroids (OR = 0.038; 95% CrI: 0.001, 0.397), short-course oral prednisone (OR = 0.054; 95% CrI: 0.002, 0.451), and oral dexamethasone (OR = 0.071; 95% CrI: 0.002, 0.733) compared to placebo. CONCLUSION This review found evidence that SCS reduces relapse in children following treatment for acute asthma, albeit based on a limited number of studies. Additional studies are required to assess the differential effect of SCS doses and treatment duration to prevent relapse in children following discharge for acute asthma.
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Affiliation(s)
- Scott W Kirkland
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Ben Vandermeer
- b Department of Pediatrics, Alberta Research Centre for Health Evidence , University of Alberta, Edmonton Clinic Health Academy , Edmonton , AB , Canada
| | - Sandy Campbell
- c J.W. Scott Health Sciences Library , University of Alberta , Walter C. Mackenzie Health Sciences Centre, Edmonton , AB , Canada
| | - Cristina Villa-Roel
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Amanda Newton
- d Department of Pediatrics , University of Alberta , Edmonton , AB , Canada
| | - Francine M Ducharme
- e Departments of Pediatrics and of Social and Preventive Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Brian H Rowe
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada.,f School of Public Health, University of Alberta , Edmonton Clinic Health Academy , Edmonton , AB , Canada
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Kirkland SW, Cross E, Campbell S, Villa‐Roel C, Rowe BH. Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma. Cochrane Database Syst Rev 2018; 6:CD012629. [PMID: 29859017 PMCID: PMC6513614 DOI: 10.1002/14651858.cd012629.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute asthma is a common cause of presentations to acute care centres, such as the emergency department (ED), and while the majority of patients can be discharged, relapse requiring additional medical care is common. Systemic corticosteroids are a major part in the treatment of moderate to severe acute asthma; however, there is no clear evidence regarding the most effective route of administration for improving outcomes in patients discharged from acute care. OBJECTIVES To examine the effectiveness and safety of a single dose of intramuscular (IM) corticosteroids provided prior to discharge compared to a short course of oral corticosteroids in the treatment of acute asthma patients discharged from an ED or equivalent acute care setting. SEARCH METHODS The Cochrane Airways Group conducted searches of the Cochrane Airways Group Register of Trials, most recently on 14 March 2018. In addition in April 2017 we completed an extensive search of nine electronic databases including Medline, Embase, EBM ALL, Global Health, International Pharmaceutical Abstracts, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS. Furthermore, we searched the grey literature to identify any additional studies. SELECTION CRITERIA We included randomized controlled trials or controlled clinical trials if they compared the effectiveness of intramuscular (IM) versus oral corticosteroids to treat paediatric or adult patients presenting with acute asthma to an ED or equivalent acute care setting. Two independent reviewers assessed study eligibility and study quality. We resolved disagreements via a third party and assessed risk of bias using the Cochrane 'Risk of bias' tool. We assessed the quality of the evidence using GRADE. DATA COLLECTION AND ANALYSIS For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RRs) with 95% confidence intervals (CIs) using a random-effects model. We reported continuous outcomes using mean difference (MD) or standardised mean difference (SMD) with 95% CIs using a random-effects model. We reported heterogeneity using I² and Cochran Q statistics. We used standard procedures recommended by Cochrane. MAIN RESULTS Nine studies involving 804 participants (IM = 402 participants; oral = 402 participants) met our review inclusion criteria. Four studies enrolled children (n = 245 participants), while five studies enrolled adults (n = 559 participants). All of the studies recruited participants presenting to an ED, except one study which recruited participants attending a primary care clinic. All of the paediatric studies compared intramuscular (IM) dexamethasone to oral prednisone/prednisolone. In the adult studies, the IM corticosteroid provided ranged from methylprednisolone, betamethasone, dexamethasone, or triamcinolone, while the regimen of oral corticosteroids provided consisted of prednisone, methylprednisolone, or dexamethasone. Only five studies were placebo controlled. For the purposes of this review, we did not take corticosteroid dose equivalency into account in the analysis. The most common co-intervention provided to participants during the acute care visit included short-acting beta₂-agonists (SABA), methylxanthines, and ipratropium bromide. In some instances, some studies reported providing some participants with supplemental oral or IV corticosteroids during their stay in the ED. Co-interventions provided to participants at discharge consisted primarily of SABA, methylxanthine, long-acting beta₂-agonists (LABA), and ipratropium bromide. The risk of bias of the included studies ranged from unclear to high across various domains. The primary outcome of interest was relapse to additional care defined as an unscheduled visit to a health practitioner for worsening asthma symptoms, or requiring subsequent treatment with corticosteroids which may have occurred at any time point after discharge from the ED.We found intramuscular and oral corticosteroids to be similarly effective in reducing the risk for relapse (RR 0.94, 95% CI 0.72 to 1.24; 9 studies, 804 participants; I² = 0%; low-quality evidence). We found no subgroup differences in relapse rates between paediatric and adult participants (P = 0.71), relapse occurring within or after 10 days post-discharge (P = 0.22), or participants with mild/moderate or severe exacerbations (P = 0.35). While we found no statistical difference between participants receiving IM versus oral corticosteroids regarding the risk for adverse events (RR 0.83, 95% CI 0.64 to 1.07; 5 studies, 404 participants; I² = 0%; moderate-quality evidence), an estimated 50 fewer patients per 1000 receiving IM corticosteroids reported experiencing adverse events (95% from 106 fewer to 21 more). We found inconsistent reporting of specific adverse events across the studies. There were no differences in the frequency of specific adverse events including nausea and vomiting, pain, swelling, redness, insomnia, or personality changes. We did not seek additional adverse events data.Participants receiving IM corticosteroids or oral corticosteroids both reported decreases in peak expiratory flow (MD -7.78 L/min, 95% CI -38.83 L/min to 23.28 L/min; 4 studies, 272 participants; I² = 33%; moderate-quality evidence), similar symptom persistence (RR 0.41, 95% CI 0.14 to 1.20; 3 studies, 80 participants; I² = 44%; low-quality evidence), and 24-hour beta-agonist use (RR 0.54, 95% CI 0.21 to 1.37; 2 studies, 48 participants; I² = 0%; low-quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to identify whether IM corticosteroids are more effective in reducing relapse compared to oral corticosteroids among children or adults discharged from an ED or equivalent acute care setting for acute asthma. While we found no statistical differences, patients receiving IM corticosteroids reported fewer adverse events. Additional studies comparing the effectiveness of IM versus oral corticosteroids could provide further evidence clarity. Furthermore, there is a need for studies comparing different IM corticosteroids (e.g. IM dexamethasone versus IM methylprednisone) and different oral corticosteroids (e.g. oral dexamethasone versus oral prednisone), with consideration for dosing and pharmacokinetic properties, to better identify the optimal IM or oral corticosteroid regimens to improve patient outcomes. Other factors, such as patient preference and potential issues with adherence, may dictate practitioner prescribing.
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Affiliation(s)
- Scott W Kirkland
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Elfriede Cross
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Sandra Campbell
- University of AlbertaJohn W. Scott Health Sciences LibraryEdmontonABCanada
| | | | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
- University of AlbertaSchool of Public HeathEdmontonCanada
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Carroll P, Wachs JE. Managing Asthma in the Workplace: An Overview for Occupational Health Nurses. ACTA ACUST UNITED AC 2017. [DOI: 10.1177/216507990405201108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Patricia Carroll
- Nurse's Notebook, LLC, and Community Health Care Consultant, Connecticut Resource Development Corporation, Meriden, CT
| | - Joy E. Wachs
- East Tennessee State University, Johnson City, TN
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Marsh B, Drake MG. Outpatient Management for Acute Exacerbations of Obstructive Lung Diseases. Med Clin North Am 2017; 101:537-551. [PMID: 28372712 DOI: 10.1016/j.mcna.2016.12.008] [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] [Indexed: 10/20/2022]
Abstract
Primary care providers tasked with treating acute exacerbations of asthma and chronic obstructive pulmonary disease must be able to recognize exacerbation of symptoms and triage patients based on exacerbation severity to the appropriate level of care. Early treatment with bronchodilators and corticosteroids should be followed by repeated assessments of treatment efficacy. Primary care providers should also provide symptom-guided action plans to empower patients to manage their disease.
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Affiliation(s)
- Brenda Marsh
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Matthew G Drake
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Kirkland SW, Cross E, Campbell S, Villa-Roel C, Rowe BH. Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma. Hippokratia 2017. [DOI: 10.1002/14651858.cd012629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Scott W Kirkland
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
| | - Elfriede Cross
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
| | - Sandra Campbell
- University of Alberta; John W. Scott Health Sciences Library; Edmonton AB Canada
| | | | - Brian H Rowe
- University of Alberta; Department of Emergency Medicine; Edmonton AB Canada
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Rowe BH, Kirkland SW, Vandermeer B, Campbell S, Newton A, Ducharme FM, Villa‐Roel C. Prioritizing Systemic Corticosteroid Treatments to Mitigate Relapse in Adults With Acute Asthma: A Systematic Review and Network Meta-analysis. Acad Emerg Med 2017; 24:371-381. [PMID: 27664401 DOI: 10.1111/acem.13107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/14/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES While systemic corticosteroids (SCS) are widely used to prevent relapse in adults with acute asthma discharged from the emergency department, the most effective route of administration is unclear. The objective of this review was to examine the effectiveness of SCS in adults and to identify the most effective route of SCS to preventing relapse. METHODS A search was conducted to identify randomized controlled trials comparing the effectiveness of intramuscular (IM) or oral (PO) short-course or long-course corticosteroids to prevent relapse in adults with acute asthma. Two independent reviewers judged study relevance, inclusion, and risk of bias. Pooled statistics were calculated as risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (CI) and credibility intervals (CrI) using a random-effects model. A Bayesian network meta-analysis was performed for indirect comparisons of SCS to placebo. Probability of best (PB) analysis was reported for comparisons between the routes of administration. RESULTS Thirteen studies of moderate quality were included. Four studies compared SCS to placebo, in which SCS significantly reduced relapse (RR = 0.43; 95% CI = 0.25 to 0.74). In the network meta-analysis, a significant reduction in relapse within 10 days of discharge was found in adults receiving IM (OR = 0.21; 95% CrI = 0.05 to 0.73) and PO long-course (OR = 0.31; 95% CrI = 0.09 to 0.95) corticosteroids. Relapse rates between PO short-course corticosteroids and placebo were not statistically significantly different (OR = 0.37; 95% CrI = 0.04 to 3.38). PB analysis favored IM corticosteroids (62%) followed by PO short-course (20.3%) and PO long-course (14.1%) corticosteroids. CONCLUSIONS The network analysis identified IM corticosteroids and PO long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to PO short-course corticosteroids. The lack of significant findings with PO short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer PO SCS treatment options in adults.
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Affiliation(s)
- Brian H. Rowe
- Department of Emergency Medicine University of Alberta Edmonton Alberta
- School of Public Health University of Alberta Edmonton Alberta
| | - Scott W. Kirkland
- Department of Emergency Medicine University of Alberta Edmonton Alberta
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence University of Alberta Edmonton Alberta
| | - Sandy Campbell
- J.W. Scott Health Sciences Library University of Alberta Walter C. Mackenzie Health Sciences Centre Edmonton Alberta
| | - Amanda Newton
- Department of Pediatrics University of Alberta Edmonton Clinic Health Academy Edmonton Alberta
| | - Francine M. Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine University of Montreal Montreal Quebec Canada
| | - Cristina Villa‐Roel
- Department of Emergency Medicine University of Alberta Edmonton Alberta
- School of Public Health University of Alberta Edmonton Alberta
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Abstract
BACKGROUND Asthma is a common long-term breathing condition that affects approximately 300 million people worldwide. People with asthma may experience short-term worsening of their asthma symptoms; these episodes are often known as 'exacerbations', 'flare-ups', 'attacks' or 'acute asthma'. Oral steroids, which have a potent anti-inflammatory effect, are recommended for all but the most mild asthma exacerbations; they should be initiated promptly. The most often prescribed oral steroids are prednisolone and dexamethasone, but current guidelines on dosing vary between countries, and often among different guideline producers within the same country. Despite their proven efficacy, use of steroids needs to be balanced against their potential to cause important adverse events. Evidence is somewhat limited regarding optimal dosing of oral steroids for asthma exacerbations to maximise recovery while minimising potential side effects, which is the topic of this review. OBJECTIVES To assess the efficacy and safety of any dose or duration of oral steroids versus any other dose or duration of oral steroids for adults and children with an asthma exacerbation. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/) and reference lists of all primary studies and review articles. This search was up to date as of April 2016. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), irrespective of blinding or duration, that evaluated one dose or duration of oral steroid versus any other dose or duration, for management of asthma exacerbations. We included studies involving both adults and children with asthma of any severity, in which investigators analysed adults and children separately. We allowed any other co-intervention in the management of an asthma exacerbation, provided it was not part of the randomised treatment. We included studies reported as full text, those published as abstract only and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data and assessed risk of bias; all data were cross-checked for accuracy. We resolved disagreements by discussion with the third review author or with an external advisor.We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs). We used a random-effects model, and we carried out a fixed-effect analysis if we detected statistical heterogeneity. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We included 18 studies that randomised a total of 2438 participants - both adults and children - and performed comparisons of interest. Included studies assessed higher versus lower doses of prednisolone (n = 4); longer versus shorter courses of prednisolone (n = 3) or dexamethasone (n = 1); tapered versus non-tapered courses of prednisolone (n = 4); and prednisolone versus dexamethasone (n = 6). Follow-up duration ranged from seven days to six months. The smallest study randomised just 15 participants, and the largest 638 (median 93). The varied interventions and outcomes reported limited the number of meaningful meta-analyses that we could perform.For two of our primary outcomes - hospital admission and serious adverse events - events were too infrequent to permit conclusions about the superiority of one treatment over the other, or their equivalence. Researchers in the included studies reported asthma symptoms in different ways and rarely used validated scales, again limiting our conclusions. Secondary outcome meta-analysis was similarly hampered by heterogeneity among interventions and outcome measures used. Overall, we found no convincing evidence of differences in outcomes between a higher dose or longer course and a lower dose or shorter course of prednisolone or dexamethasone, or between prednisolone and dexamethasone.Included studies were generally of reasonable methodological quality. Review authors assessed most outcomes in the review as having low or very low quality, meaning we are not confident in the effect estimates. The predominant reason for downgrading was imprecision, but indirectness and risk of bias also reduced our confidence in some estimates. AUTHORS' CONCLUSIONS Evidence is not strong enough to reveal whether shorter or lower-dose regimens are generally less effective than longer or higher-dose regimens, or indeed that the latter are associated with more adverse events. Any changes recommended for current practice should be supported by data from larger, well-designed trials. Varied study design and outcome measures limited the number of meta-analyses that we could perform. Greater emphasis on palatability and on whether some regimens might be easier to adhere to than others could better inform clinical decisions for individual patients.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
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Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma. Ann Emerg Med 2016; 68:608-613. [PMID: 27117874 DOI: 10.1016/j.annemergmed.2016.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 02/24/2016] [Accepted: 03/03/2016] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Oral dexamethasone demonstrates bioavailability similar to that of oral prednisone but has a longer half-life. We evaluate whether a single dose of oral dexamethasone plus 4 days of placebo is not inferior to 5 days of oral prednisone in treatment of adults with mild to moderate asthma exacerbations to prevent relapse defined as an unscheduled return visit for additional treatment for persistent or worsening asthma within 14 days. METHODS Adult emergency department patients (aged 18 to 55 years) were randomized to receive either a single dose of 12 mg of oral dexamethasone with 4 days of placebo or a 5-day course of oral prednisone 60 mg a day. Outcomes including relapse were assessed by a follow-up telephone interview at 2 weeks. RESULTS One hundred seventy-three dexamethasone and 203 prednisone subjects completed the study regimen and telephone follow-up. The dexamethasone group by a small margin surpassed the preset 8% difference between groups for noninferiority in relapse rates within 14 days (12.1% versus 9.8%; difference 2.3%; 95% confidence interval -4.1% to 8.6%). Subjects in the 2 groups had similar rates of hospitalization for their relapse visit (dexamethasone 3.4% versus prednisone 2.9%; difference 0.5%; 95% confidence interval -4.1% to 3.1%). Adverse effect rates were generally the same in the 2 groups. CONCLUSION A single dose of oral dexamethasone did not demonstrate noninferiority to prednisone for 5 days by a very small margin for treatment of adults with mild to moderate asthma exacerbations. Enhanced compliance and convenience may support the use of dexamethasone regardless.
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Affiliation(s)
- Matthew W Rehrer
- Department of Emergency Medicine, Kaiser Permanente, Oakland, CA.
| | - Bella Liu
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Marcela Rodriguez
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Joseph Lam
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Harrison J Alter
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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13
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Albertson TE, Sutter ME, Chan AL. The acute management of asthma. Clin Rev Allergy Immunol 2015; 48:114-25. [PMID: 25213370 DOI: 10.1007/s12016-014-8448-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.
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Affiliation(s)
- Timothy E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, PSSB 3400, 4150 V Street, Sacramento, CA, 95817, USA,
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14
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Adams JY, Sutter ME, Albertson TE. The patient with asthma in the emergency department. Clin Rev Allergy Immunol 2013; 43:14-29. [PMID: 21597902 DOI: 10.1007/s12016-011-8273-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a highly prevalent disease that presents commonly to the emergency department (ED) in acute exacerbation. Recent asthma treatment guidelines have added content dedicated to the management of acute exacerbations. Effective management of an exacerbation requires rapid assessment of severity through physical examination, measurement of peak expiratory flow rate, and response to initial treatment. Most therapies are directed at alleviating bronchospasm and decreasing airway inflammation. While inhaled short-acting beta-agonists, systemic corticosteroids, and supplemental oxygen are the initial and often only therapies required for patients with mild moderate exacerbations, high-dose beta agonists and inhaled anti-cholinergics should also be given to patients with severe exacerbations. Adjunctive therapy with intravenous magnesium and Heliox-driven nebulization of bronchodilators should be considered for patients presenting with severe and very severe exacerbations. Early recognition and appropriate management of respiratory failure are required to mitigate the risk of complications including death. Disposition should be determined based on serial assessments of the response to therapy over the first 4 h in the ED. Patients stable for discharge should receive medications, asthma education including a written asthma action plan, and should have follow-up scheduled for them by ED staff. Rapid implementation of evidence-based, multi-disciplinary care is required to ensure the best possible outcomes for this potentially treatable disease.
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Affiliation(s)
- Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis Medical Center, 4150 V Street, Sacramento, CA 95817, USA.
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Abstract
Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.
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16
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Camargo CA, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Emerg Med 2009; 37:S6-S17. [PMID: 19683665 DOI: 10.1016/j.jemermed.2009.06.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Carlos A Camargo
- Department of Emergency Medicine and Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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17
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Krishnan JA, Nowak R, Davis SQ, Schatz M. Anti-inflammatory treatment after discharge home from the emergency department in adults with acute asthma. J Emerg Med 2009; 37:S35-41. [PMID: 19683663 DOI: 10.1016/j.jemermed.2009.06.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jerry A Krishnan
- Asthma and COPD Center, Department of Medicine, and Department of Health Studies, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
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Krishnan JA, Davis SQ, Naureckas ET, Gibson P, Rowe BH. An umbrella review: corticosteroid therapy for adults with acute asthma. Am J Med 2009; 122:977-91. [PMID: 19854321 PMCID: PMC2768615 DOI: 10.1016/j.amjmed.2009.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 02/07/2009] [Accepted: 02/09/2009] [Indexed: 11/16/2022]
Abstract
The objective of this "umbrella" review is to synthesize the evidence and provide clinicians a single report that summarizes the state of knowledge regarding the use of corticosteroids in adults with acute asthma. Systematic reviews in the Cochrane Library and additional clinical trials published in English from 1966 to 2007 in MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL, and references from bibliographies of pertinent articles were reviewed. Results indicate that the evidence base is frequently limited to small, single-center studies. Findings suggest that therapy with systemic corticosteroids accelerates the resolution of acute asthma and reduces the risk of relapse. There is no evidence that corticosteroid doses greater than standard doses (prednisone 50-100 mg equivalent) are beneficial. Oral and intravenous corticosteroids, as well as intramuscular and oral corticosteroid regimens, seem to be similarly effective. A nontapered 5- to 10-day course of corticosteroid therapy seems to be sufficient for most discharged patients. Combinations of oral and inhaled corticosteroids on emergency department/hospital discharge might minimize the risk of relapse.
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Affiliation(s)
- Jerry A. Krishnan
- Department of Medicine, University of Chicago
- Health Studies, University of Chicago
| | | | | | - Peter Gibson
- Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, John Hunter Hospital
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta
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Ornato JP. Treatment strategies for reducing asthma-related emergency department visits. J Emerg Med 2007; 32:27-39. [PMID: 17239730 DOI: 10.1016/j.jemermed.2006.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2005] [Revised: 08/04/2005] [Accepted: 04/07/2006] [Indexed: 11/28/2022]
Abstract
Acute asthma exacerbations reflect inadequate long-term disease control. Treatment to control acute asthma exacerbations includes: 1) rapid reversal of airflow obstruction with bronchodilators and systemic corticosteroids and reversing hypoxemia with oxygen in the emergency department (ED); 2) preventing early relapse by prescribing beta(2) agonists and oral corticosteroids at discharge and ensuring patients have an adequate supply of their other asthma medications; and 3) preventing future asthma exacerbations and ED visits through effective treatment in primary care. This article discusses each treatment and reviews the role of emergency physicians in treating patients to reverse airflow obstruction and prevent early relapse, future exacerbations, and ED visits by communicating the need for additional asthma control to patients' primary care physicians.
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Affiliation(s)
- Joseph P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond 23298-0401, USA
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Abstract
Acute exacerbations of asthma may represent reactions to airway irritants or failures of chronic treatment. The costs to both the patient and society are high. Exacerbations often are frightening episodes that can cause significant morbidity and sometimes death. The emergency department (ED) visits and hospitalizations often required lead to significant health care expenses. Thus, preventing and optimizing management of acute exacerbations is critical. Corticosteroids are a cornerstone of asthma therapy. They have been shown to lower admission rates and reduce risk of relapse. This article provides an overview of the role of corticosteroids (including betamethasone, dexamethasone, methylprednisolone, and prednisolone) in the management of acute asthma exacerbations, with an aim toward effective decision making about the choice of therapy.
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Affiliation(s)
- Stanley B Fiel
- Department of Medicine, Morristown Memorial Hospital, Morristown, New Jersey, USA.
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22
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Shee C. Corticosteroids and acute asthma. Lancet 2005; 365:294. [PMID: 15664221 DOI: 10.1016/s0140-6736(05)17779-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- Francine M Ducharme
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, H3 h 1P3, Canada.
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