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Muirhead CA, Lanocha N, Markwardt S, MacDonald KD. Evaluation of rescue oral glucocorticoid therapy during inpatient cystic fibrosis exacerbations. Pediatr Pulmonol 2021; 56:891-900. [PMID: 33289316 DOI: 10.1002/ppul.25204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Abstract
An acute pulmonary exacerbation (APE) in cystic fibrosis (CF) is characterized by increased pulmonary symptoms attributed to bacterial colonization, neutrophil recruitment, and inflammation. Antimicrobials, airway clearance, and nutrition are the mainstay of therapy. However, when patients fail to improve, corticosteroids have been added to therapy. We retrospectively examined the use of rescue steroids in a children's hospital from 2013 to 2017 during CF APE treatment following at least 1 week of inpatient therapy without expected clinical improvement. In total, 106 encounters of 53 unique patients, aged 6-20 years, who had FEV1 percent predicted (FEV1pp) data at baseline, admission, midpoint, and discharge, and had admission duration of at least 12 days were studied. Encounters treated with steroids had less improvement at midpoint percent change from admission in FEV1pp (4.9 ± 11.3) than nonsteroid group change in FEV1pp (20.1 ± 24.6; p < .001). Failure to improve as expected was the rationale for steroid use. At discharge, there was no difference in mean FEV1pp (p = .76). Delays in steroid therapy by waiting until the end of the second week increased the total length of stay (LOS). Propensity matching, comparing outcomes in patients without midpoint improvement in FEV1pp, was also evaluated. There was no difference in admission or discharge FEV1pp between groups. Equally, no difference in FEV1pp at follow-up visit or in time until the next APE was detected. Secondary analysis for associations including gender, genotype, fungal colonization, or inhaled antimicrobials was nonsignificant. These data suggest rescue use of corticosteroids during APE does not predictably impact important outcome measures during CF APE treatment.
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Affiliation(s)
- Corinne A Muirhead
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Natalie Lanocha
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sheila Markwardt
- Department of Biostatistics, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelvin D MacDonald
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
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Bui S, Dournes G, Fayon M, Bouchet S, Burgel PR, Macey J, Murris M, Delhaes L. [Allergic Broncho-Pulmonary Aspergillosis (ABPA) in cystic fibrosis: Mechanisms, diagnosis and therapeutic options]. Rev Mal Respir 2021; 38:466-476. [PMID: 33926779 DOI: 10.1016/j.rmr.2021.04.004] [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: 05/28/2019] [Accepted: 01/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Fungal aspergillosis colonization and allergic bronchopulmonary aspergillosis (ABPA) can have a strong impact on the prognosis in cystic fibrosis (CF). We conducted round table discussions involving French experts from pediatric and adult centers caring for patients with CF, microbiologists, radiologists and pharmacists. The aim was to explore the current state of knowledge on: the pathophysiological mechanisms of Aspergillus and other micromycetes infections in CF (such as Scedosporium sp.), and on the clinico-biological diagnosis of ABPA. In perspective, the experts explored the role of imaging in the diagnosis of APBA, specifically CT and MRI; as well as the role of bronchoscopy in the management. We also reviewed the therapeutic management, including different corticosteroid regimens, antifungals and anti-IgE antibodies. CONCLUSION The diagnosis of ABPA in CF should be based on more standardized biological assays and imaging to optimize treatment and follow-up.
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Affiliation(s)
- S Bui
- CRCM pédiatrique, Centre d'investigation clinique (CIC 1401), hôpital Pellegrin-Enfants, CHU de Bordeaux, Bordeaux, France.
| | - G Dournes
- Service de radiologie, hôpital Haut L'Evêque, CHU de Bordeaux, Bordeaux, France
| | - M Fayon
- CRCM pédiatrique, Centre d'investigation clinique (CIC 1401), hôpital Pellegrin-Enfants, CHU de Bordeaux, Bordeaux, France
| | - S Bouchet
- Service de pharmacologie, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - P R Burgel
- CRCM Adultes, AP-HP, hôpital Cochin, Paris, France
| | - J Macey
- CRCM adultes, hôpital Haut L'Evêque, CHU de Bordeaux, Bordeaux, France
| | - M Murris
- CRCM adultes, hôpital Larrey, CHU de Toulouse, Toulouse, France
| | - L Delhaes
- Service de parasitologie, CHU de Bordeaux, hôpital Pellegrin, Bordeaux, France
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Asthma in Cystic Fibrosis: Definitions and Implications of This Overlap Syndrome. Curr Allergy Asthma Rep 2021; 21:9. [PMID: 33560464 DOI: 10.1007/s11882-020-00985-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is a multisystem, autosomal recessive disease that leads to progressive loss of lung function. Respiratory symptoms for both CF and asthma include cough, wheezing, and dyspnea. There is debate within the CF community on how to best define and distinguish CF-asthma overlap syndrome (CFAOS) from asthma-like features, though CFAOS is well-recognized. We aim to review the epidemiology, diagnosis, and treatment of asthma in CF and explore areas where further research is needed. RECENT FINDINGS There has been considerable improvement in the understanding and treatment of asthma over the past two decades leading to novel therapies such as biologic agents that target the airway inflammation in asthmatics based on their asthma phenotype. These therapies are being studied in CFAOS and are promising treatments. This review provides a comprehensive overview of the definition, epidemiology, diagnosis, and current treatment of CFAOS.
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Epps QJ, Epps KL, Zobell JT, Young DC. Optimization of antimicrobials in the treatment of cystic fibrosis pulmonary exacerbations: II. Therapies for allergic bronchopulmonary aspergillosis. Pediatr Pulmonol 2020; 55:3541-3572. [PMID: 32946194 DOI: 10.1002/ppul.25080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022]
Abstract
This review is the second article in the State-of-the-Art series and aims to evaluate medications used in the treatment of allergic bronchopulmonary aspergillosis (ABPA) in pediatric and adult patients with cystic fibrosis (CF). ABPA is one of several organisms that are found in the airways of CF patients. This review provides an evidence-based summary of pharmacokinetic (PK)/pharmacodynamic (PD), tolerability, and efficacy studies of medications including corticosteroids, amphotericin B, azole antifungals (isavuconazole, itraconazole, posaconazole, and voriconazole), and a monoclonal antibody omalizumab in the treatment of ABPA and identifies areas where further study is warranted.
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Affiliation(s)
- Quovadis J Epps
- Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences, Florida Agricultural and Mechanical University, Jacksonville, Florida, USA
| | - Kevin L Epps
- Department of Pharmacy, The Mayo Clinic, Jacksonville, Florida, USA
| | - Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA.,Intermountain Healthcare, Primary Children's Cystic Fibrosis Pediatric Center, Salt Lake City, Utah, USA
| | - David C Young
- Department of Pharmacy Practice, L.S. Skaggs Pharmacy Institute, University of Utah College of Pharmacy, Salt Lake City, Utah, USA.,University of Utah, University of Utah Adult Cystic Fibrosis Center, Salt Lake City, Utah, USA
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5
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Muthu V, Agarwal R. Allergic Bronchopulmonary Aspergillosis. CLINICAL PRACTICE OF MEDICAL MYCOLOGY IN ASIA 2020:137-164. [DOI: 10.1007/978-981-13-9459-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Schultz A, Marsh JA, Saville BR, Norman R, Middleton PG, Greville HW, Bellgard MI, Berry SM, Snelling T. Trial Refresh: A Case for an Adaptive Platform Trial for Pulmonary Exacerbations of Cystic Fibrosis. Front Pharmacol 2019; 10:301. [PMID: 30983998 PMCID: PMC6447696 DOI: 10.3389/fphar.2019.00301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Cystic fibrosis is a genetic disease typically characterized by progressive lung damage and premature mortality. Pulmonary exacerbations, or flare-ups of the lung disease, often require hospitalization for intensive treatment. Approximately 25% of patients with cystic fibrosis do not recover their baseline lung function after pulmonary exacerbations. There is a relative paucity of evidence to inform treatment strategies for exacerbations. Compounding this lack of evidence, there are a large number of treatment options already as well as becoming available. This results in significant variability between medication regimens prescribed by different physicians, treatment centers and regions with potentially adverse impact to patients. The conventional strategy is to undertake essential randomized clinical trials to inform treatment decisions and improve outcomes for patients with exacerbations. However, over the past several decades, clinical trials have generally failed to provide information critical to improved treatment and management of exacerbations. Bayesian adaptive platform trials hold the promise of addressing clinical uncertainties and informing treatment. Using modeling and response adaptive randomization, they allow for the evaluation of multiple treatments across different management domains, and progressive improvement in patient outcomes throughout the course of the trial. Bayesian adaptive platform trials require substantial amounts of preparation. Basic preparation includes extensive stakeholder involvement including elicitation of consumer preferences and clinician understanding of the research topic, defining the research questions, determining the best outcome measures, delineating study sub-groups, in depth statistical modeling, designing end-to-end digital solutions seamlessly supporting clinicians, researchers and patients, constructing randomisation algorithms and importantly, defining pre-determined intra-study end-points. This review will discuss the motivation and necessary steps required to embark on a Bayesian adaptive platform trial to optimize medication regimens for the treatment of pulmonary exacerbations of cystic fibrosis.
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Affiliation(s)
- Andre Schultz
- Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, WA, Australia.,Department of Respiratory Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia
| | - Benjamin R Saville
- Berry Consultants, Austin, TX, United States.,Department of Biostatistics, Vanderbilt University, Nashville, TN, United States
| | - Richard Norman
- School of Public Health, Curtin University, Bentley, WA, Australia
| | - Peter G Middleton
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Hugh W Greville
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew I Bellgard
- eResearch Office, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Tom Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
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Agarwal R, Chakrabarti A, Shah A, Gupta D, Meis JF, Guleria R, Moss R, Denning DW. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy 2013; 43:850-873. [DOI: 10.1111/cea.12141] [Citation(s) in RCA: 537] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- R. Agarwal
- Department of Pulmonary Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - A. Chakrabarti
- Division of Medical Mycology; Department of Medical Microbiology; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - A. Shah
- Department of Pulmonary Medicine; Vallabhbhai Patel Chest Institute; University of Delhi; New Delhi India
| | - D. Gupta
- Department of Pulmonary Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - J. F. Meis
- Department of Medical Microbiology and Infectious Diseases; Canisius-Wilhelmina Hospital; Nijmegen The Netherlands
- Department of Medical Microbiology; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - R. Guleria
- Department of Internal Medicine; All India Institute of Medical Sciences; New Delhi India
| | - R. Moss
- Department of Pediatrics; Stanford University; Palo Alto CA USA
| | - D. W. Denning
- Manchester Academic Health Science Centre; The National Aspergillosis Centre; University of Manchester; University Hospital of South Manchester; Manchester UK
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de Benedictis FM, Bush A. Corticosteroids in respiratory diseases in children. Am J Respir Crit Care Med 2012; 185:12-23. [PMID: 21920920 DOI: 10.1164/rccm.201107-1174ci] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We review recent advances in the use of corticosteroids (CS) in pediatric lung disease. CS are frequently used, systemically or by inhalation. Their mechanisms of action in pulmonary diseases are ill defined. CS exert direct inhibitory effects on many inflammatory cells through genomic mechanisms. There is a time lag before clinical response, and the washout of effects is also prolonged. Prompt relief in some conditions, such as croup, may be related to airway mucosal vasoconstriction through a nongenomic mechanism. CS have proven beneficial roles in the treatment of asthma, croup, allergic bronchopulmonary aspergillosis, and subglottic hemangioma. In some conditions, such as bronchiolitis, cystic fibrosis, and bronchopulmonary dysplasia, their use is controversial and is not recommended routinely. In other conditions, such as tuberculosis, interstitial lung disease, acute lung aspiration, and acute respiratory distress syndrome, CS are often used empirically despite the lack of clear evidence of their benefit. New drug regimens, including the more flexible use of inhaled corticosteroids and long-acting β-agonists in asthma, the lack of efficacy of oral corticosteroids in preschool children with acute wheeze, the severe complications of systemic dexamethasone used to prevent bronchopulmonary dysplasia and thus more restricted use, and the beneficial effect of pulse high-dose intravenous methylprednisolone in patients with allergic bronchopulmonary aspergillosis or cystic fibrosis are among the major recent developments. There is concern about adverse effects, especially growth and adrenal suppression, induced by systemic CS in children. These have been reduced, but not eliminated, with the use of the inhaled route. The benefits must be weighed against the potential detrimental effects.
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