1
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Rahman A, Haider MF. A comprehensive review on glucocorticoids induced osteoporosis: A medication caused disease. Steroids 2024; 207:109440. [PMID: 38754651 DOI: 10.1016/j.steroids.2024.109440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
Glucocorticoids (GCs) are steroid hormones that are extensively used in the treatment of autoimmune diseases, inflammation, and cancer. The major ill effect of administering GCs is that it has a deleterious effect on bone, which leads to GC-induced osteoporosis. GC therapy induces bone loss and is associated with the risk of nonvertebral and vertebral fractures, as it works in combination by increasing bone reabsorption and suppressing bone formation during the initial phase of therapy. It is seen and established that GC in excess or in low dose for 3 months or more can be a risk factor for fracture, and the risk increases with an increase in dose and duration of usage. The most common cause of secondary osteoporosis is the administration of GC inside the body to treat various diseases. The degree of bone loss is directly proportional to the GC dose and the exposure duration. The first step is to evaluate the patients' risk factors for the development of glucocorticoids that induce osteoporosis, which include the dose, duration of use, patient age, sex, previous fractures, and other medical conditions.
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Affiliation(s)
- Asim Rahman
- Faculty of Pharmacy, Integral University, Lucknow 226026, India
| | - Md Faheem Haider
- Faculty of Pharmacy, Integral University, Lucknow 226026, India.
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2
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2024; 109:1657-1683. [PMID: 38724043 PMCID: PMC11180513 DOI: 10.1210/clinem/dgae250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Indexed: 06/18/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), 8091 Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, 81377 Munich, Germany
- The LOOP Zurich Medical Research Center, 8044 Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX 75390-8857, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol BS32 4QW, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR 97239-3098, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus, Denmark
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3
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Yu R, Jusko WJ. Physiologically Based Pharmacokinetic Modeling: The Reversible Metabolism and Tissue-Specific Partitioning of Methylprednisolone and Methylprednisone in Rats. Drug Metab Dispos 2024; 52:662-672. [PMID: 38653502 PMCID: PMC11185821 DOI: 10.1124/dmd.124.001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 04/25/2024] Open
Abstract
The pharmacokinetics (PK) of methylprednisolone (MPL) exhibited tissue-specific saturable binding and reversible conversion with its metabolite, methylprednisone (MPN). Blood and 11 tissues were collected in male rats after intravenous (i.v.) bolus doses of 50 mg/kg MPL and 20 mg/kg MPN and upon i.v. infusion of MPL and MPN at 0.3, 3, and 10 mg/h per kg. The concentrations of MPL and MPN were simultaneously measured. A comprehensive physiologically based pharmacokinetic (PBPK) model was applied to describe the plasma and tissue profiles and estimate PK parameters of the MPL/MPN interconversion system. Both dosed and formed MPL and MPN were in rapid equilibrium or achieved steady-state rapidly in plasma and tissues. MPL tissue partitioning was nonlinear, with highest capacity in liver (322.9 ng/ml) followed by kidney, heart, intestine, skin, spleen, bone, brain, muscle, and lowest in adipose (2.74 ng/ml) and displaying high penetration in lung. The tissue partition coefficient of MPN was linear but widely variable (0.15∼5.38) across most tissues, with nonlinear binding in liver and kidney. The conversion of MPL to MPN occurred in kidney, lung, and intestine with total clearance of 429 ml/h, and the back conversion occurred in liver and kidney at 1342 ml/h. The irreversible elimination clearance of MPL was 789 ml/h from liver and that of MPN was 2758 ml/h with liver accounting for 44%, lung 35%, and kidney 21%. The reversible metabolism elevated MPL exposure in rats by 13%. This highly complex PBPK model provided unique and comprehensive insights into the disposition of a major corticosteroid. SIGNIFICANCE STATEMENT: Our dual physiologically based pharmacokinetic (PBPK) study and model of methylprednisolone/methylprednisone (MPL/MPN) with multiple complexities reasonably characterized and parameterized their disposition, and provided greater insights into the interpretation of their pharmacodynamics in rats. Drug knowledge gained in this study may be translatable to higher-order species to appreciate the clinical utility of MPL. The complex model itself is instructive for advanced PBPK analysis of drugs with reversible metabolism and/or nonlinear tissue partitioning features.
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Affiliation(s)
- Ruihong Yu
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - William J Jusko
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
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4
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Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A. Diagnosis and management of secondary adrenal crisis. Rev Endocr Metab Disord 2024; 25:619-637. [PMID: 38411891 DOI: 10.1007/s11154-024-09877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 02/28/2024]
Abstract
Adrenal crisis (AC) is a life threatening acute adrenal insufficiency (AI) episode which can occur in patients with primary AI but also secondary AI (SAI), tertiary AI (TAI) and iatrogenic AI (IAI). In SAI, TAI and IAI, AC may develop when the HPA axis is unable to mount an adequate glucocorticoid response to severe stress due to pituitary or hypothalamic disruption. It manifests as an acute deterioration in multi-organ homeostasis that, if untreated, leads to shock and death. Despite the availability of effective preventive strategies, its prevalence is increasing in patients with SAI, TAI and IAI due to more frequent exogenous steroid administration, pituitary immune-related effects of immune checkpoint inhibitors and opioid use in pain management. The delayed diagnosis of acute AI which remains infrequently suspected increases the risk of AC. Its main precipitating factors are infections, emotional distress, surgery, cessation or reduction in GC doses, pituitary infarction or surgical cure of endogenous Cushing's syndrome. In patients not known previously to have SAI/TAI/IAI, recognition of its symptoms, signs, and biochemical abnormalities can be challenging and cause delay in proper diagnosis and therapy. Effective therapy of AC is rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h) and 0.9% saline. In diagnosed patients, preventive education in sick-day rules adjustment of glucocorticoid replacement and hydrocortisone parenteral self-administration must be performed repeatedly by trained health care providers. Strategies to improve the adequate preventive education in patients at risk for secondary AI should be promoted in collaboration with various medical specialist societies and patients support associations.
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Affiliation(s)
- Luciana Martel-Duguech
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada.
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5
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Lv Z, Liu Y. Clinical research progress on intrathecal glucocorticoids in the treatment of infections: A review. Medicine (Baltimore) 2024; 103:e38123. [PMID: 38758886 PMCID: PMC11098166 DOI: 10.1097/md.0000000000038123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/12/2024] [Indexed: 05/19/2024] Open
Abstract
In some infectious diseases, pathogenic microorganisms can directly or indirectly cause significant inflammatory reactions in the central nervous system, leading to severe neurological dysfunction, such as suppurative meningitis, tuberculous meningitis, and febrile infections. related epilepsy syndrome, etc. In these diseases, adjuvant administration of glucocorticoids is necessary to inhibit the release of proinflammatory cytokines, and intrathecal administration can deliver the drug more directly to the target. In this article, the authors studied intrathecal glucocorticoids for the treatment of infectious inflammatory reactions in terms of pharmacological effects and mechanisms, pharmacokinetics, clinical application, and safety. The authors concluded that the article could help provide new treatment strategies for infectious diseases.
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Affiliation(s)
- Zixv Lv
- Department of Pain, Zibo First Hospital, Zibo, Shandong, China
| | - Yingying Liu
- Department of Neurosurgery, Zibo First Hospital, Zibo, Shandong, China
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Trewin BP, Dale RC, Qiu J, Chu M, Jeyakumar N, Dela Cruz F, Andersen J, Siriratnam P, Ma KKM, Hardy TA, van der Walt A, Lechner-Scott J, Butzkueven H, Broadley SA, Barnett MH, Reddel SW, Brilot F, Kalincik T, Ramanathan S. Oral corticosteroid dosage and taper duration at onset in myelin oligodendrocyte glycoprotein antibody-associated disease influences time to first relapse. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333463. [PMID: 38744459 DOI: 10.1136/jnnp-2024-333463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/03/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND We sought to identify an optimal oral corticosteroid regimen at the onset of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), which would delay time to first relapse while minimising cumulative corticosteroid exposure. METHODS In a retrospective multicentre cohort study, Cox proportional hazards models examined the relationship between corticosteroid course as a time-varying covariate and time to first relapse. Simon-Makuch and Kaplan-Meier plots identified an optimal dosing strategy. RESULTS We evaluated 109 patients (62 female, 57%; 41 paediatric, 38%; median age at onset 26 years, (IQR 8-38); median follow-up 6.2 years (IQR 2.6-9.6)). 76/109 (70%) experienced a relapse (median time to first relapse 13.7 months; 95% CI 8.2 to 37.9). In a multivariable model, higher doses of oral prednisone delayed time to first relapse with an effect estimate of 3.7% (95% CI 0.8% to 6.6%; p=0.014) reduced hazard of relapse for every 1 mg/day dose increment. There was evidence of reduced hazard of relapse for patients dosed ≥12.5 mg/day (HR 0.21, 95% CI 0.07 to 0.6; p=0.0036), corresponding to a 79% reduction in relapse risk. There was evidence of reduced hazard of relapse for those dosed ≥12.5 mg/day for at least 3 months (HR 0.12, 95% CI 0.03 to 0.44; p=0.0012), corresponding to an 88% reduction in relapse risk compared with those never treated in this range. No patient with this recommended dosing at onset experienced a Common Terminology Criteria for Adverse Events grade >3 adverse effect. CONCLUSIONS The optimal dose of 12.5 mg of prednisone daily in adults (0.16 mg/kg/day for children) for a minimum of 3 months at the onset of MOGAD delays time to first relapse.
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Affiliation(s)
- Benjamin P Trewin
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Russell C Dale
- Clinical Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Kids Research Institute at the Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jessica Qiu
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Melissa Chu
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Niroshan Jeyakumar
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fionna Dela Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jane Andersen
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Brain Autoimmunity, Kids Neuroscience Centre, Kids Research at the Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Pakeeran Siriratnam
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Kit Kwan M Ma
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Todd A Hardy
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Helmut Butzkueven
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon A Broadley
- School of Medicine, Griffith University, Nathan, Queensland, Australia
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michael H Barnett
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University Of Sydney, Camperdown, New South Wales, Australia
| | - Stephen W Reddel
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
| | - Fabienne Brilot
- Brain Autoimmunity, Kids Neuroscience Centre, Kids Research at the Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tomas Kalincik
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre and Brain and Mind Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
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7
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024; 190:G25-G51. [PMID: 38714321 DOI: 10.1093/ejendo/lvae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 05/09/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, Munich, Germany
- The LOOP Zurich Medical Research Center, Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic Rocheste r, MN 55905, US
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, MN 55905, US
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Dhaliwal S, Gill FS, Hamid P. The Unprecedented Success of Chimeric Antigen Receptor T-Cell Therapy in the Treatment of Hematological Malignancies. Cureus 2024; 16:e59951. [PMID: 38854249 PMCID: PMC11162278 DOI: 10.7759/cureus.59951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 05/05/2024] [Indexed: 06/11/2024] Open
Abstract
Chimeric antigen receptor (CAR) therapy is one of the most unprecedented advancements in the treatment of hematological malignancies, especially B-cell malignancies. The fundamental notion behind the success of this therapy is to generate a synthetic protein (CAR) capable of redirecting T lymphocytes to act against cancer cells. New insights into the genetic and molecular base of hematological malignancies have more recently given rise to the development of targeted treatments. CAR T-cell therapy is one of these immunological treatment techniques that has recently received a lot of attention and paved a light of hope for the effective cure of relapsed and refractory hematological malignancies and some solid malignancies. Researchers of today might not know what the future holds for CAR T-cell therapy, but from whatever research has been done so far, this therapy has proven to be a success despite its limitations, and it can be assumed that the spectrum of its application is expanding with each passing day.
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Affiliation(s)
- Sargam Dhaliwal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Fatehpal S Gill
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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9
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Chastain DB, Spradlin M, Ahmad H, Henao-Martínez AF. Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults. Clin Infect Dis 2024; 78:e37-e56. [PMID: 37669916 DOI: 10.1093/cid/ciad474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 09/07/2023] Open
Abstract
Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Megan Spradlin
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hiba Ahmad
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
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10
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Zychar BC, Gonçalves LRC. Understanding Local Reactions Induced by Bothrops jararaca Venom: The Role of Inflammatory Mediators in Leukocyte-Endothelium Interactions. Biomedicines 2024; 12:734. [PMID: 38672090 PMCID: PMC11048348 DOI: 10.3390/biomedicines12040734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/04/2024] [Accepted: 03/13/2024] [Indexed: 04/28/2024] Open
Abstract
In recent years, extensive research has delved into the pathophysiology of local reactions triggered by Bothrops snake venoms. Even though antivenom works well at reducing death and systemic effects, it is still not very effective in treating local reactions because it cannot counteract damage that has already been triggered. This limitation might be attributed to certain molecules that amplify the venom-induced innate response. While evidence suggests endogenous mediators at the venom site play a role in this envenomation, in Brazil, the concurrent use of anti-inflammatory agents or other drugs alongside antivenom remains uncommon. This study evaluated the pharmacological mediation of alterations in leukocyte-endothelium interactions following the experimental envenomation of mice with Bothrops jararaca venom, the main culprit of snake-related accidents in Southeast Brazil. We treated envenomed mice with inhibitors of different pharmacological pathways and observed the cremaster muscle microcirculation with intravital microscopy. We found that eicosanoids related to cyclooxygenase pathways and nitric oxide significantly contributed to B. jararaca venom-induced alterations in leukocyte-endothelium interactions. Conversely, lipoxygenase-mediated eicosanoids, histamine, and serotonin had minimal participation. Notably, dexamethasone and antivenom treatment diminished B. jararaca venom-induced alterations in leukocyte-endothelium interactions. The limited efficacy of the antivenom in managing Bothrops venom-induced local reactions emphasizes the critical need for supplementary treatments to enhance therapeutic outcomes.
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Affiliation(s)
- Bianca Cestari Zychar
- Laboratório de Fisiopatologia, Instituto Butantan, Av. Vital Brazil 1500, São Paulo 05503-900, Brazil
| | - Luís Roberto C. Gonçalves
- Laboratório de Fisiopatologia, Instituto Butantan, Av. Vital Brazil 1500, São Paulo 05503-900, Brazil
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11
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Sze Y, Brunton PJ. How is prenatal stress transmitted from the mother to the fetus? J Exp Biol 2024; 227:jeb246073. [PMID: 38449331 DOI: 10.1242/jeb.246073] [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] [Indexed: 03/08/2024]
Abstract
Prenatal stress programmes long-lasting neuroendocrine and behavioural changes in the offspring. Often this programming is maladaptive and sex specific. For example, using a rat model of maternal social stress in late pregnancy, we have demonstrated that adult prenatally stressed male, but not prenatally stressed female offspring display heightened anxiety-like behaviour, whereas both sexes show hyperactive hypothalamo-pituitary-adrenal (HPA) axis responses to stress. Here, we review the current knowledge of the mechanisms underpinning dysregulated HPA axis responses, including evidence supporting a role for reduced neurosteroid-mediated GABAergic inhibitory signalling in the brains of prenatally stressed offspring. How maternal psychosocial stress is signalled from the mother to the fetuses is unclear. Direct transfer of maternal glucocorticoids to the fetuses is often considered to mediate the programming effects of maternal stress on the offspring. However, protective mechanisms including attenuated maternal stress responses and placental 11β-hydroxysteroid dehydrogenase-2 (which inactivates glucocorticoids) should limit materno-fetal glucocorticoid transfer during pregnancy. Moreover, a lack of correlation between maternal stress, circulating maternal glucocorticoid levels and circulating fetal glucocorticoid levels is reported in several studies and across different species. Therefore, here we interrogate the evidence for a role for maternal glucocorticoids in mediating the effects of maternal stress on the offspring and consider the evidence for alternative mechanisms, including an indirect role for glucocorticoids and the contribution of changes in the placenta in signalling the stress status of the mother to the fetus.
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Affiliation(s)
- Ying Sze
- Centre for Discovery Brain Sciences, Hugh Robson Building, University of Edinburgh, George Square, Edinburgh EH8 9XD, UK
| | - Paula J Brunton
- Centre for Discovery Brain Sciences, Hugh Robson Building, University of Edinburgh, George Square, Edinburgh EH8 9XD, UK
- Zhejiang University-University of Edinburgh Joint Institute, Haining, Zhejiang 314400, P.R. China
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12
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Lachaux J, Giéré PA, Vuillemin Q, Colléony T, Crambert A, Siegrist S, Parietti-Winkler C, Schwartzbrod PÉ, Andéol G. Long-Term Hearing Loss after Acute Acoustic Trauma in the French Military: A Retrospective Study. Mil Med 2024; 189:e698-e704. [PMID: 37651596 DOI: 10.1093/milmed/usad337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/25/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Acute acoustic trauma (AAT) is characterized by cochlea-vestibular signs following intense noise exposure, often caused by impulse noise. French military faces a high risk of AAT because of the use of weapons with peak sound levels exceeding 150 dB. Hearing loss (HL) resulting from AAT can have a significant impact on quality of life and operational capacity. The aim of this study was to assess the prevalence of long-term hearing impairment after AAT. MATERIALS AND METHODS The study involved a retrospective review of computer-based patient records from four military medical centers in Northeast France between January 2016 and December 2021. The inclusion criteria required the presence of cochlea-vestibular signs following impulse acoustic exposure and the absence of other causes. Sociodemographic and clinical data were collected, including audiometric data before and after exposure. The primary end point was the presence of a threshold elevation greater than 10 dB between reference and late audiograms. RESULTS A total of 419 patients were included in the analysis, with a majority of males (n = 419; 84.7%) and a mean age of 23.6 yrs. The most common causative agent was the 5.56-mm assault rifle (n = 327; 78.0%). Tinnitus was the most frequent symptom (n = 366; 87.4%), followed by hypoacusis (n = 147; 35.1%) and earache (n = 89; 21.2%). The initial audiograms showed no HL in 31.0% of cases, while the mean deficit across all frequencies was 15.4 dB. All patients received corticosteroid therapy, with a mean duration of 6.0 d. Late audiograms conducted at an average interval of 448.0 d after AAT revealed a prevalence of long-term HL exceeding 20%. Higher doses of corticosteroid therapy (>1 mg/kg) were associated with a reduced frequency of long-term HL. CONCLUSIONS This study highlights the prevalence of long-term hearing impairment after AAT in the French military. The findings emphasize the importance of preventive measures, including proper use of hearing protection devices, and the need for timely diagnosis and treatment. Further research is warranted to explore gender susceptibility to AAT and evaluate the impact of different weapons on AAT characteristics. The study also underscores the potential benefits of higher doses of corticosteroid therapy in reducing the risk of long-term hearing impairment. Overall, the findings contribute to a better understanding of AAT and can inform strategies for its prevention and management in military settings.
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Affiliation(s)
| | | | | | | | - Anna Crambert
- ORL Department, Percy Army Training Hospital, Clamart 92140, France
| | - Sophie Siegrist
- Medical school, University of Lorraine, Vandoeuvre-lès-Nancy 54505, France
| | | | | | - Guillaume Andéol
- French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge 91220, France
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13
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Bonaventura I, Tomaselli A, Angelini F, Ferrari D, De Alcubierre D, Hasenmajer V, Sbardella E, Cozzolino A, Paganini AM, Isidori AM, Minnetti M, Pofi R. Predicting postoperative hypocortisolism in patients with non-aldosterone-producing adrenocortical adenoma: a retrospective single-centre study. J Endocrinol Invest 2024:10.1007/s40618-023-02283-1. [PMID: 38386266 DOI: 10.1007/s40618-023-02283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/14/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy. METHODS A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery. RESULTS Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery. CONCLUSIONS The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy.
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Affiliation(s)
- I Bonaventura
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Tomaselli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Angelini
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Cancer Research Center of Lyon, Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Lyon, France
| | - V Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Policlinico Umberto I, Centre for Rare Diseases (Endo-ERN Accredited), Rome, Italy
| | - M Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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Peel A, Rushworth RL, Torpy DJ. Novel agents to treat adrenal insufficiency: findings of preclinical and early clinical trials. Expert Opin Investig Drugs 2024; 33:115-126. [PMID: 38284211 DOI: 10.1080/13543784.2024.2311207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/24/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Adrenal insufficiency currently affects over 300/million population, with higher morbidity and mortality compared to the general population. Current glucocorticoid replacement therapy is limited by a lack of reliable biomarkers to guide dosing, inter-patient variation in metabolism and narrow therapeutic window. Increased morbidity and mortality may relate to unappreciated under- or over-exposure to glucocorticoids and impaired cortisol circadian rhythm. New agents are required to emulate physiological cortisol secretion and individualize glucocorticoid dosing. AREAS COVERED History of glucocorticoid therapy, current limitations, and novel chronotherapeutic glucocorticoid delivery mechanisms. Literature search incorporated searches of PubMed and Embase utilizing terms such as adrenal insufficiency, Chronocort, Plenadren, continuous subcutaneous hydrocortisone infusion (CHSI), and glucocorticoid receptor modulator. EXPERT OPINION Glucocorticoid chronotherapy is necessary to optimize glucocorticoid exposure and minimize complications. Current oral chronotherapeutics provide improved dosing functionality, but are modifiable only in specific increments and cannot accommodate ultradian cortisol variation. Current data show improvement in quality of life but not morbidity or mortality outcomes. CHSI has significant potential for individualized glucocorticoid dosing, but would require a suitable biomarker of glucocorticoid adequacy to be implementable. Avenues for future research include determining a glucocorticoid sufficiency biomarker, development of interstitial or systemic cortisol monitoring, or development of glucocorticoid receptor modulators.
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Affiliation(s)
- Andrew Peel
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Australia, Sydney, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
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15
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Arshad MF, Elder C, Newell-Price J, Ross R, Debono M. A retrospective study on weaning glucocorticoids and recovery of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab 2024:dgae059. [PMID: 38298131 DOI: 10.1210/clinem/dgae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/02/2024]
Abstract
CONTEXT Glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis resulting in tertiary adrenal insufficiency (AI). When weaning patients off glucocorticoids there is no consensus on whether to maintain patients on prednisolone or convert to hydrocortisone. OBJECTIVE Investigate HPA axis recovery in patients on long-term prednisolone and assess outcome after hydrocortisone conversion. DESIGN Retrospective cohort study. SETTING Outpatient endocrine steroid clinic. PATIENTS Patients on long-term prednisolone referred for HPA axis testing between 2015-2022. MAIN OUTCOMES MEASURED 1) HPA axis recovery rate in patients on prednisolone demonstrated by normal ACTH stimulation test (AST).2) HPA axis recovery rate sub-analysis of dose-matched patients with confirmed tertiary AI on prednisolone or hydrocortisone. RESULTS 206 patients on prednisolone were tested for tertiary AI. Of these 176 remained on prednisolone while 30 were converted to hydrocortisone. The overall HPA axis recovery rate for patients on prednisolone after interval testing was 137/206 (66.5%). HPA axis recovery rate in dose-matched prednisolone and hydrocortisone conversion groups was 7/10 (70%) and 2/13 (15%) (p=0.008), respectively. There was no difference in mean (SD) age (67.1(12.2) v 63.4(11.1) years; p=0.464) and baseline cortisol (5.3(4.2) v 4.6(3.1)µg/dL; p=0.648) and median [IQR] glucocorticoids duration (1213[1114] v 2316[4808] days; p=0.693) and baseline ACTH (20.5[29.0] v 16.3[14.8]ng/L; p=0.905) between dose-matched prednisolone and hydrocortisone groups. Follow-up duration in prednisolone group was significantly lower (median [IQR] 348[975] v 667[884] days; p=0.012). CONCLUSIONS Patients with glucocorticoid induced AI maintained on once-daily prednisolone can recover HPA axis function when weaning. There is no apparent advantage to recover HPA axis function in converting to multiple dosing hydrocortisone.
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Affiliation(s)
- Muhammad Fahad Arshad
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlotte Elder
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - John Newell-Price
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Ross
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
| | - Miguel Debono
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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16
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Kintzel PE. Elotuzumab: Empiric analysis of dexamethasone administration schedule. J Oncol Pharm Pract 2024; 30:235-238. [PMID: 37876226 DOI: 10.1177/10781552231207855] [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: 10/26/2023]
Abstract
Elotuzumab in combination with dexamethasone and immunomodulating agents (IMiDs) lenalidomide or pomalidomide is 2nd to 4th line therapy for multiple myeloma. The labelled dosage of dexamethasone for use in conjunction with elotuzumab and IMiDs splits the dexamethasone dose into two administrations, one oral and one intravenous, on the days of each elotuzumab infusion. Administration of split dose dexamethasone on days of elotuzumab administration is based on the registration trials submitted for drug approval and was intended to ensure standard well-timed immunotherapy premedication using pharmacologically equivalent dexamethasone doses for both study arms. Administration of dexamethasone in the manner delineated by the elotuzumab product label adds complexity to the delivery of care. This commentary provides an empirical assessment of established medication safety and effectiveness which supports administration of dexamethasone standard intermittent dose instead of the split dose approach delineated on elotuzumab package insert. Simplification of regimen administration improves medication adherence, reduces the risk of inadvertent omission or duplication of medication therapy, and improves the workflow required for delivery of care.
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17
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Pietris J, Lam A, Bacchi S, Gupta AK, Kovoor JG, Simon S, Slee M, Chan W. The Efficacy, Adverse Effects and Economic Implications of Oral Versus Intravenous Methylprednisolone for the Treatment of Optic Neuritis: A Systematic Review. Semin Ophthalmol 2024; 39:6-16. [PMID: 38013424 DOI: 10.1080/08820538.2023.2287100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/27/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Optic neuritis may occur in a variety of conditions, including as a manifestation of multiple sclerosis. Despite significant research into the efficacy of corticosteroids as a first-line treatment, the optimal route of administration has not been well defined. This review aims to explore the efficacy, adverse effects and economic implications of using oral versus intravenous methylprednisolone to treat acute optic neuritis. METHODS A systematic search of the databases PubMed/MEDLINE, Embase and CENTRAL was performed to July 2022, prior to data collection and risk of bias analysis in accordance with the PRISMA guidelines. RESULTS Six articles fulfilled the inclusion criteria. The results showed that in the treatment of acute optic neuritis, oral methylprednisolone has a non-inferior efficacy and adverse effect profile in comparison to intravenous methylprednisolone. In a cost analysis, oral methylprednisolone to be more cost-effective than intravenous methylprednisolone. CONCLUSIONS Oral methylprednisolone has comparable efficacy and adverse effect profiles to intravenous methylprednisolone for the treatment of optic neuritis. The analysis suggests oral administration is more cost-effective than intravenous administration; however, further analyses of the formal cost-benefit ratio are required.
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Affiliation(s)
- James Pietris
- Faculty of Medicine, University of Queensland, Herston, Australia
- Princess Alexandra Hospital, Woolloongabba, Australia
| | - Antoinette Lam
- University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
- College of Medicine and Public Health Flinders University, Bedford Park, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, Australia
- Gold Coast University Hospital, Southport, Australia
| | - Joshua G Kovoor
- University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
| | - Sumu Simon
- Royal Adelaide Hospital, Adelaide, Australia
| | - Mark Slee
- College of Medicine and Public Health Flinders University, Bedford Park, Australia
| | - WengOnn Chan
- University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
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Rassouli A, Shihmani B, Mehrzad J, Shokrpoor S. The immunomodulatory effect of minocycline on gene expression of inflammation related cytokines in lipopolysaccharide-treated human peripheral blood mononuclear cells. Anim Biotechnol 2023; 34:2159-2165. [PMID: 35622407 DOI: 10.1080/10495398.2022.2077743] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
To evaluate the immunomodulatory effect of minocycline, the present study was carried out on the gene expression of toll-like receptor type-4 (TLR4) and some pro-inflammatory (IL-1β, IL-6) and anti-inflammatory cytokines (IL-10) associated with lipopolysaccharide (LPS) -induced inflammation in human peripheral blood mononuclear cells (PBMCs). The PBMCs were collected and then 5.4 × 106 PBMCs/mL were used in eight groups as follows: control group (only media), LPS group (only LPS), methylprednisolone (Pred) group (LPS plus Pred), meloxicam (Melo) group (LPS plus Melo), three minocycline groups [M1, M5 and M25] (LPS plus 1, 5, and 25 µg/mL minocycline, respectively) and minocycline control (MC) group (5 µg/mL minocycline). After incubation for 24 h, the PBMCs were subjected to quantitative PCR assays. Gene expression levels of TLR4 were not changed in any groups. The IL-1β levels were increased in the LPS group but the increases were much more intense in the other groups except Pred group. Compared with control group, IL-6 levels increased significantly in Melo, M1 and M25 groups. Significant increases of IL-10 levels were also observed in Melo, M25 and MC groups. It can be concluded that minocycline had dual pro- and anti-inflammatory activities with potential clinical immunomodulatory effects.
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Affiliation(s)
- Ali Rassouli
- Pharmacology Division, Department of Comparative Biosciences, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Basim Shihmani
- Department of Comparative Biosciences, University of Tehran, Tehran, Iran
| | - Jalil Mehrzad
- Department of Microbiology and Immunology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Sara Shokrpoor
- Department of Pathology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
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19
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Delli Colli L, Al Ali A, Gabrielli S, Delli Colli M, Mule P, Lawson B, Clarke AE, Morris J, Gravel J, Lim R, Chan ES, Goldman RD, O'Keefe A, Gerdts J, Chu DK, Upton J, Hochstadter E, Bretholz A, McCusker C, Zhang X, Benor S, Simons E, Abrams EM, Protudjer JLP, Ben-Shoshan M. Managing anaphylaxis: Epinephrine, antihistamines, and corticosteroids: More than 10 years of Cross-Canada Anaphylaxis REgistry data. Ann Allergy Asthma Immunol 2023; 131:752-758.e1. [PMID: 37689113 DOI: 10.1016/j.anai.2023.08.606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/04/2023] [Accepted: 08/22/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse. OBJECTIVE To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management. METHODS Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form. Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes. RESULTS Among 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286]). CONCLUSION Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited.
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Affiliation(s)
- Luca Delli Colli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Adnan Al Ali
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sofianne Gabrielli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina Delli Colli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pasquale Mule
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Lawson
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ann E Clarke
- Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Judy Morris
- Department of Emergency Medicine, Sacré-Coeur Hospital, Montreal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Université de Montréal, Quebec, Canada
| | - Rod Lim
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at London Health Science Centre, London, Ontario, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ran D Goldman
- Division of Clinical Pharmacology and Emergency Medicine, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew O'Keefe
- Faculty of Medicine, Department of Pediatrics, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Jennifer Gerdts
- Executive Director, Food Allergy Canada, Toronto, Ontario, Canada
| | - Derek K Chu
- Division of Clinical Immunology & Allergy, Department of Medicine, and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elana Hochstadter
- Department of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Bretholz
- Department of Pediatric Emergency Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Christine McCusker
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xun Zhang
- Center for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Shira Benor
- Allergy and Clinical Immunology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Elinor Simons
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer L P Protudjer
- Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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20
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Farinelli DG, Oliveira KC, Hayashi LF, Kater CE. Overnight 1-mg Dexamethasone Suppression Test for Screening Cushing Syndrome and Mild Autonomous Cortisol Secretion (MACS): What Happens when Serum Dexamethasone Is Below Cutoff? How Frequent Is it? Endocr Pract 2023; 29:986-993. [PMID: 37734596 DOI: 10.1016/j.eprac.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To determine the frequency of "invalid" 1-mg overnight dexamethasone (Dex) suppression tests (DSTs) (1-mg DST) on a large series of patients investigated for hypercortisolism and examine the interference of substances and clinical conditions that may explain low serum Dex levels. METHODS A retrospective analysis of 1300 Dex-controlled 1-mg DST applied to patients screened for Cushing syndrome or mild autonomous cortisol secretion in a single center for which there were identified invalid tests and distinctive characteristics that may have interfered with the outcome. RESULTS Among all tests, 146 (11.2%) were considered invalid (serum Dex levels <140 ng/dL, 36 [24.7%] of which were undetectable [<19.5 ng/dL]). In the Dex-undetectable group, 17% failed to take Dex correctly, 25% were on glucocorticoids (GCs), and 20% were on anticonvulsants and moderate CYP3A4 inducers. In the remaining 110 tests (serum Dex 20-140 ng/dL), 6.5% did not take Dex or were using GC, 22% were on anticonvulsants or CYP3A4 inducers, and another 13% had previous gastrointestinal tract abnormalities impairing drug absorption. CONCLUSION Inappropriately low serum Dex levels during the 1-mg DST may lead to false-positive results. This is associated with recurrent use of CYP3A4-inducing drugs and/or gastrointestinal abnormalities. When serum Dex is undetectable, the key reason is failure to take the medication or the use of GC (when cortisol is suppressed). Simultaneous measurement of serum cortisol and Dex allows for DST validation, improving its accuracy and avoiding unnecessary repetitions. Adherence to verbal/written recommendations and actual use of medication are critical for interpreting the test.
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Affiliation(s)
- Denise G Farinelli
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Kelly C Oliveira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Lilian F Hayashi
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil
| | - Claudio E Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine at the Federal University of São Paulo School of Medicine (EPM/UNIFESP), São Paulo, SP, Brazil.
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21
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Falter J, Lohmeier A, Eberl P, Stoerr EM, Koskimäki J, Falter L, Rossmann J, Mederer T, Schmidt NO, Proescholdt M. CXCR2-Blocking Has Context-Sensitive Effects on Rat Glioblastoma Cell Line Outgrowth (S635) in an Organotypic Rat Brain Slice Culture Depending on Microglia-Depletion (PLX5622) and Dexamethasone Treatment. Int J Mol Sci 2023; 24:16803. [PMID: 38069130 PMCID: PMC10706712 DOI: 10.3390/ijms242316803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
In glioblastoma (GBM), the interplay of different immune cell subtypes, cytokines, and/or drugs shows high context-dependencies. Interrelations between the routinely applied dexamethasone (Dex) and microglia remain elusive. Here, we exploited rat organotypic brain slice co-cultures (OBSC) to examine the effects on a rat GBM cell line (S635) outgrowth resulting from the presence of Dex and pretreatment with the colony-stimulating factor receptor 1 (CSF1-R) inhibitor PLX5622: in native OBSC (without PLX5622-pretreatment), a diminished S635 spheroid outgrowth was observable, whereas Dex-treatment enhanced outgrowth in this condition compared to PLX5622-pretreated OBSC. Screening the supernatants of our model with a proteome profiler, we found that CXCL2 was differentially secreted in a Dex- and PLX5622-dependent fashion. To analyze causal interrelations, we interrupted the CXCL2/CXCR2-axis: in the native OBSC condition, CXCR2-blocking resulted in increased outgrowth, in combination with Dex, we found potentiated outgrowth. No effect was found in the PLX5622-pretreated. Our method allowed us to study the influence of three different factors-dexamethasone, PLX5622, and CXCL2-in a well-controlled, simplified, and straight-forward mechanistic manner, and at the same time in a more realistic ex vivo scenario compared to in vitro studies. In our model, we showed a GBM outgrowth enhancing synergism between CXCR2-blocking and Dex-treatment in the native condition, which was levelled by PLX5622-pretreatment.
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Affiliation(s)
- Johannes Falter
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Annette Lohmeier
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Petra Eberl
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Eva-Maria Stoerr
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Janne Koskimäki
- Department of Neurosurgery, Oulu University Hospital, P.O. Box 25, 90029 Oulu, Finland
| | - Lena Falter
- Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, 93053 Regensburg, Germany
| | - Jakob Rossmann
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Tobias Mederer
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Martin Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93042 Regensburg, Germany
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22
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Bourdin V, Bigot W, Vanjak A, Burlacu R, Lopes A, Champion K, Depond A, Amador-Borrero B, Sene D, Comarmond C, Mouly S. Drug-Drug Interactions Involving Dexamethasone in Clinical Practice: Myth or Reality? J Clin Med 2023; 12:7120. [PMID: 38002732 PMCID: PMC10672071 DOI: 10.3390/jcm12227120] [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: 09/19/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Concomitant administration of multiple drugs frequently causes severe pharmacokinetic or pharmacodynamic drug-drug interactions (DDIs) resulting in the possibility of enhanced toxicity and/or treatment failure. The activity of cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), a drug efflux pump sharing localization and substrate affinities with CYP3A4, is a critical determinant of drug clearance, interindividual variability in drug disposition and clinical efficacy, and appears to be involved in the mechanism of numerous clinically relevant DDIs, including those involving dexamethasone. The recent increase in the use of high doses of dexamethasone during the COVID-19 pandemic have emphasized the need for better knowledge of the clinical significance of drug-drug interactions involving dexamethasone in the clinical setting. We therefore aimed to review the already published evidence for various DDIs involving dexamethasone in vitro in cell culture systems and in vivo in animal models and humans.
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Affiliation(s)
- Venceslas Bourdin
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - William Bigot
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Anthony Vanjak
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Ruxandra Burlacu
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Amanda Lopes
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Karine Champion
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Audrey Depond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Blanca Amador-Borrero
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Damien Sene
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Chloe Comarmond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Stéphane Mouly
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM UMR-S1144, Hôpital Fernand Widal, 75010 Paris, France
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23
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Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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24
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Dequin PF, Ramirez JA, Waterer G. What's new with glucocorticoids in severe community-acquired pneumonia? Intensive Care Med 2023; 49:1397-1399. [PMID: 37606740 DOI: 10.1007/s00134-023-07179-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Pierre-François Dequin
- INSERM UMR 1100, Research Center for Respiratory Diseases, Tours University, Tours, France.
- Médecine Intensive Réanimation and INSERM Centre d'Investigation Clinique 1415, Bretonneau University Hospital, Tours, France.
- CRICS-TriGGERSep Network, Tours, France.
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
- Emeritus Professor of Medicine, Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Grant Waterer
- East Metropolitan Health Service, Perth, WA, Australia
- Royal Perth Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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25
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Tekin A, Domecq JP, Valencia Morales DJ, Surapeneni KM, Zabolotskikh IB, Cartin-Ceba R, Clevenbergh P, Mesland JB, Claure-Del Granado R, Gavidia OY, Kumar VK, Kashyap R, Walkey AJ, Gajic O, Odeyemi Y. Biomarker-Concordant Steroid Administration in Severe Coronavirus Disease-2019. J Intensive Care Med 2023; 38:1003-1014. [PMID: 37226483 DOI: 10.1177/08850666231177200] [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: 05/26/2023]
Abstract
BACKGROUND Although corticosteroids have become the standard of care for patients with coronavirus disease-2019 (COVID-19) on supplemental oxygen, there is growing evidence of differential treatment response. This study aimed to evaluate if there was an association between biomarker-concordant corticosteroid treatment and COVID-19 outcomes. METHODS This registry-based cohort study included adult COVID-19 hospitalized patients between January 2020 and December 2021 from 109 institutions. Patients with available C-reactive protein (CRP) levels within 48 h of admission were evaluated. Those on steroids before admission, stayed in the hospital for <48 h, or were not on oxygen support were excluded. Corticosteroid treatment was biomarker-concordant if given with high baseline CRP ≥150 mg/L or withheld with low CRP (<150 mg/L) and vice-versa was considered discordant (low CRP with steroids, high CRP without steroids). Hospital mortality was the primary outcome. Sensitivity analyses were conducted using varying CRP level thresholds. The model interaction was tested to determine steroid effectiveness with increasing CRP levels. RESULTS Corticosteroid treatment was biomarker-concordant in 1778 (49%) patients and discordant in 1835 (51%). The concordant group consisted of higher-risk patients than the discordant group. After adjusting for covariates, the odds of in-hospital mortality were significantly lower in the concordant group than the discordant (odds ratio [95% confidence interval (C.I.)] = 0.71 [0.51, 0.98]). Similarly, adjusted mortality difference was significant at the CRP thresholds of 100 and 200 mg/L (odds ratio [95% C.I.] = 0.70 [0.52, 0.95] and 0.57 [0.38, 0.85], respectively), and concordant steroid use was associated with lower need for invasive ventilation for 200 mg/L threshold (odds ratio [95% C.I.] = 0.52 [0.30, 0.91]). In contrast, no outcome benefit was observed at CRP threshold of 50. When the model interaction was tested, steroids were more effective at reducing mortality as CRP levels increased. CONCLUSION Biomarker-concordant corticosteroid treatment was associated with lower odds of in-hospital mortality in severe COVID-19.
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Affiliation(s)
- Aysun Tekin
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Domecq
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Krishna Mohan Surapeneni
- Departments of Biochemistry, Molecular Virology, Research and Clinical Skills & Simulation, Panimalar Medical College Hospital & Research Institute, Chennai, Tamil Nadu, India
| | - Igor B Zabolotskikh
- Department of Anesthesiology, Intensive Care Medicine and Transfusiology, Kuban State Medical University with affiliation Territorial Hospital #2, Krasnodar, Russia
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | | | | | | | | | | | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allan J Walkey
- Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Evans Center of Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yewande Odeyemi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
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26
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Jensen EA, Watterberg KL. Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia. Neoreviews 2023; 24:e691-e703. [PMID: 37907402 DOI: 10.1542/neo.24-11-e691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common, severe chronic respiratory disease that affects very preterm infants. In utero and postnatal exposure to proinflammatory stimuli contribute to the pathophysiology of BPD. Corticosteroids, because of their potent anti-inflammatory properties, may decrease respiratory morbidity and reduce the risk of BPD in very preterm infants. However, these medications can have adverse effects on the developing brain and other organ systems. This review examines current evidence on the risks and benefits of postnatal corticosteroids used to prevent BPD in preterm infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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27
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Li B, Li H, Huang Q, Zheng Y. Optimizing glucocorticoid therapy for Behçet's uveitis: efficacy, adverse effects, and advances in combination approaches. Int Ophthalmol 2023; 43:4373-4381. [PMID: 37420127 PMCID: PMC10520171 DOI: 10.1007/s10792-023-02808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Behçet's uveitis (BU) is a debilitating manifestation of Behçet's disease, often requiring prompt and aggressive treatment to prevent vision loss. Glucocorticoids (GCS) serve as a first-line therapy for BU; however, their long-term, high-dose use can result in significant adverse effects. This review summarizes the efficacy, adverse effects, and advances in combination therapy involving GCS for the management of BU. We discuss the benefits and drawbacks of various GCS administration routes, including periocular and intravitreal injections, intravitreal sustained-release devices, and systemic therapy, highlighting the role of fluocinolone acetonide and dexamethasone as primary sustained-release formulations. Moreover, we underscore the importance of combining GCS with immunosuppressive drugs and biological agents to minimize adverse reactions and optimize therapeutic outcomes. The review concludes that, while GCS remain a crucial component of BU treatment, careful consideration of their administration and combination with other therapies is essential to achieve long-term remission and improved visual outcomes for patients with BU.
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Affiliation(s)
- Biao Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Haoran Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qun Huang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yanlin Zheng
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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28
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Chen S, Dai M. The miR-224-5p/SIRT3/AMPK/mTOR axis is involved in the melatonin-mediated inhibition of glucocorticoid-induced osteoporosis by activating autophagy. Hum Cell 2023; 36:1965-1977. [PMID: 37486565 DOI: 10.1007/s13577-023-00929-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/02/2023] [Indexed: 07/25/2023]
Abstract
Melatonin has been shown to exert an inhibitory effect on osteoporosis. This study investigates the function of the miR-224-5p/SIRT3/AMPK/mTOR axis in melatonin-mediated effects against osteoporosis. Human bone marrow mesenchymal stem cells (hBMSCs) were treated with glucocorticoid dexamethasone to induce an in vitro osteoporosis model. After melatonin treatment, miR-224-5p and SIRT3 levels were measured by RT‒PCR. Transmission electron microscopy and immunofluorescence were conducted for evaluating autophagy. Western blotting was carried out to determine the expression of osteogenesis-related proteins (Runx2, OSX, OPN, and OCN), SIRT3-AMPK-mTOR axis, and autophagy-related markers (LC3 and p62). Alizarin red staining was used to measure matrix mineralization. The data showed that melatonin inhibited dexamethasone-induced osteoporosis in vitro, and enhanced autophagic levels (as indicated by increased LC3 puncta, LC3II/I ratio, and autophagic vacuoles). In terms of the mechanisms, melatonin decreased miR-224-5p expression and increased SIRT3. SRIT3 was shown to be a direct target of miR-224-5p. miR-224-5p upregulation or SIRT3 downregulation reversed the effects of melatonin on osteoporosis and suppressed autophagy. Additionally, miR-224-5p inhibited SIRT3 expression and AMPK pathway activation. In summary, we discovered that melatonin suppressed glucocorticoid-induced osteoporosis and autophagy inhibition via the miR-224-5p/SIRT3/AMPK/mTOR axis.
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Affiliation(s)
- Sheng Chen
- Department of Orthopedic, Shaoxing Second Hospital, No.123 Yan'an Road, Shaoxing, 312000, Zhejiang, China
| | - Min Dai
- Department of Orthopedic, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China.
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29
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Amodeo G, Cerbelli E, Pisano A, Minieri L, Scopelliti D. The Influence of Bolus of Methylprednisolone on Postorthognathic Surgery Symptoms: A Controlled Clinical Trial. J Craniofac Surg 2023; 34:2112-2115. [PMID: 37317004 DOI: 10.1097/scs.0000000000009492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE Despite improvements in maxillary and mandibular osteotomy, complications still result in around 20%. Post and intraoperative standard therapies, based on the use of betamethasone and tranexamic acid, could help to minimize the onset of side effects. The aim of the study was to compare the role of a supplementary bolus of methylprednisolone rather than the standard therapy in the onset of postoperative symptoms. METHODS The authors enrolled 10 patients, affected by class 2 and 3 Dentoskeletal, submitted to the institution for maxillomandibular repositioning osteotomy between October 2020 and April 2021. Patients were divided into 2 groups as follows: 5 patients (group A ) received standard therapy consisting of the administration of 4 mg of betamethasone, intraoperatively, and 1 g of tranexamic acid in 2 administrations. The remaining 5 patients (group B ) received a supplementary bolus of 20 mg methylprednisolone before the end of the surgery.All patients received, in the postoperative period, 4 mg of betamethasone every 12 hours, for 3 days. Postoperative outcomes were evaluated with a questionnaire evaluating speaking discomfort, pain when swallowing, feeding discomfort, drinking discomfort, swelling, and ache. Each parameter was associated with a numeric rating scale ranging from 0 to 5. RESULTS The authors observed that patients treated with a supplementary bolus of methylprednisolone (group B ) had a statistically significant reduction of all postoperative symptoms as compared with patients of group A (* P < 0.05, ** P <0.01 Fig. 1 ). CONCLUSION The study highlighted that the additional bolus of methylprednisolone improved all of the 6 parameters investigated by the questionnaire submitted to patients, resulting in a faster recovery and improvement of the patient's compliance with surgery. Further studies with a larger population are needed to confirm preliminary results.
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Affiliation(s)
- Giulia Amodeo
- Department of UOC Maxillofacial Surgery, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
- Smile House Fondazione ETS, Rome, Italy
| | | | - Annalinda Pisano
- Department of UOC Anesthesiology and Reanimation, San Filippo Neri Hospital, ASL Roma1, Rome, Italy
| | - Luciana Minieri
- Department of UOC Maxillofacial Surgery, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
- Smile House Fondazione ETS, Rome, Italy
- Department of UOC Maxillofacial Surgery, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
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Corrêa LQ, do Couto BP, de Carvalho EFG, de Sousa JEN, da Silva Ribeiro V, Gonzaga HT, Costa-Cruz JM. Route of dexamethasone administration influences parasite burden in Strongyloides hyperinfection model. J Parasit Dis 2023; 47:520-526. [PMID: 37520210 PMCID: PMC10382442 DOI: 10.1007/s12639-023-01595-6] [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: 02/15/2023] [Accepted: 05/06/2023] [Indexed: 08/01/2023] Open
Abstract
Rodents infected with Strongyloides venezuelensis are experimental models applied to strongyloidiasis research. This study evaluated oral and subcutaneous dexamethasone (DEX) treatments to establish immunosuppression in an experimental model of Strongyloides hyperinfection. Rattus norvegicus Wistar were divided: G I (-): untreated and uninfected animals, G II (+): untreated and infected, G III (o -) orally treated and uninfected, G IV (o +) orally treated and infected, G V (sc -) subcutaneously treated and uninfected, G VI (sc +) subcutaneously treated and infected. For oral administration, DEX was diluted in sterile water (5 µg/ml) and made available to the animals on intervals in experimental days - 5-0, 8-13 and 21-26. For subcutaneous administration, animals received daily injections of DEX disodium phosphate (2 mg/kg). Infection was established by the subcutaneous inoculation of 3000 S. venezuelensis filarioid larvae. Groups were evaluated by egg per gram of feces and parasite females counts and IgG, IgG1 and IgG2a detection. GIV (o +) had egg peaks count on days 13 and 26 and maintained egg elimination until the last experimental day. Parasitic females recovery at day 30 was significantly higher in G IV (o +) when compared to G VI (sc +). Levels of IgG, IgG1 and IgG2a of all groups, except the positive control GII (+), were below the detection threshold. Pharmacological immunosuppression induced by oral administration of DEX produced high parasitic burden, and is a noninvasive method, useful to establish immunosuppression in strongyloidiasis hyperinfection model in rats.
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Affiliation(s)
- Luisa Queiroz Corrêa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Bruna Patrícia do Couto
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Edson Fernando Goulart de Carvalho
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - José Eduardo Neto de Sousa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Vanessa da Silva Ribeiro
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Henrique Tomaz Gonzaga
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Julia Maria Costa-Cruz
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
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Machet T, Quémeneur T, Ledoult E, Mesbah R, Lebas C, Hachulla E, Pokeerbux MR. Rituximab resistance at 3months of induction therapy in newly diagnosed or relapsing ANCA-associated vasculitis: A French multicentre retrospective study in 116 patients. Joint Bone Spine 2023; 90:105591. [PMID: 37230162 DOI: 10.1016/j.jbspin.2023.105591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/02/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To evaluate rituximab (RTX) resistance at 3months (M3) of induction therapy in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). METHODS Multicentre French retrospective study conducted between 2010 and 2020 including patients with newly diagnosed or relapsing AAV (granulomatosis with polyangiitis or microscopic polyangiitis) having received induction therapy with RTX. Primary endpoint was the presence of RTX resistance at 3months (M3) defined as uncontrolled disease (worsening feature on the BVAS/WG 1month after RTX induction) or disease flare (increase in BVAS/WG of≥1 point before M3). RESULTS Out of 121 patients included, we analysed 116 patients. Fourteen patients (12%) had RTX resistance at M3 with no difference in baseline demographics, vasculitis type, ANCA type, disease status or organ involvement. Patients with RTX resistance at M3 had a greater proportion of localized disease (43% vs. 18%, P<0.05) and were less often treated by initial methylprednisolone (MP) pulse (21% vs. 58%, P<0.01). Out of the 14 patients with RTX resistance, seven received additional immunosuppressive therapy. All patients were in remission at 6months. Compared to responders, patients with RTX resistance at M3 were less often treated with prophylactic trimethoprim-sulfamethoxazole (57% vs. 85%, P<0.05). Twenty-four patients died during follow-up, one-third of them from infections and half of them from SARS-CoV-2. CONCLUSION Twelve percent of patients had RTX resistance at M3. These patients more often had localized form of the disease and were less treated by initial MP pulse and by prophylactic trimethoprim-sulfamethoxazole.
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Affiliation(s)
- Thomas Machet
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Service de Médecine Interne et d'Immunologie Clinique, 59000 Lille, France.
| | - Thomas Quémeneur
- CH de Valenciennes, Service de Néphrologie et Médecine Interne, 59300 Valenciennes, France
| | - Emmanuel Ledoult
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Service de Médecine Interne et d'Immunologie Clinique, 59000 Lille, France
| | - Rafik Mesbah
- CH de Boulogne-sur-Mer, Service de Néphrologie, 62321 Boulogne-sur-Mer, France
| | - Celine Lebas
- CHU de Lille, Service de Néphrologie, 59000 Lille, France
| | - Eric Hachulla
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Service de Médecine Interne et d'Immunologie Clinique, 59000 Lille, France
| | - Mohammad Ryadh Pokeerbux
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Service de Médecine Interne et d'Immunologie Clinique, 59000 Lille, France
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32
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Pan L, Liu J, Liu C, Guo L, Punaro M, Yang S. Childhood-onset systemic lupus erythematosus: characteristics and the prospect of glucocorticoid pulse therapy. Front Immunol 2023; 14:1128754. [PMID: 37638017 PMCID: PMC10448525 DOI: 10.3389/fimmu.2023.1128754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/21/2023] [Indexed: 08/29/2023] Open
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease that results in significant damage and often needs more aggressive treatment. Compared to adult-onset SLE, cSLE has a stronger genetic background and more prevalent elevated type I Interferon expression. The management of cSLE is more challenging because the disease itself and treatment can affect physical, psychological and emotional growth and development. High dose oral glucocorticoid (GC) has become the rule for treating moderate to severe cSLE activity. However, GC-related side effects and potential toxicities are problems that cannot be ignored. Recent studies have suggested that GC pulse therapy can achieve disease remission rapidly and reduce GC-related side effects with a reduction in oral prednisone doses. This article reviews characteristics, including pathogenesis and manifestations of cSLE, and summarized the existing evidence on GC therapy, especially on GC pulse therapy in cSLE, followed by our proposal for GC therapy according to the clinical effects and pathogenesis.
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Affiliation(s)
- Lu Pan
- Department of Pediatric Rheumatology, Immunology and Allergy, The First Hospital, Jilin University, Changchun, China
| | - Jinxiang Liu
- Department of Pediatric Rheumatology, Immunology and Allergy, The First Hospital, Jilin University, Changchun, China
| | - Congcong Liu
- Department of Pediatric Rheumatology, Immunology and Allergy, The First Hospital, Jilin University, Changchun, China
| | - Lishuang Guo
- Department of Pediatric Rheumatology, Immunology and Allergy, The First Hospital, Jilin University, Changchun, China
| | - Marilynn Punaro
- Pediatric Rheumatology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Rheumatology, Texas Scottish Rite Hospital for Children, Houston, TX, United States
- Pediatric Rheumatology, Children’s Medical Center of Dallas, Dallas, TX, United States
| | - Sirui Yang
- Department of Pediatric Rheumatology, Immunology and Allergy, The First Hospital, Jilin University, Changchun, China
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Pitre T, Abdali D, Chaudhuri D, Pastores SM, Nei AM, Annane D, Rochwerg B, Zeraatkar D. Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis. J Gen Intern Med 2023; 38:2593-2606. [PMID: 37076606 PMCID: PMC10115386 DOI: 10.1007/s11606-023-08203-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP). METHODS We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool. RESULTS We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty). CONCLUSION Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission.
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Affiliation(s)
- Tyler Pitre
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Daniyal Abdali
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, Rochester, MN200 First St SW, Rochester, MN, 55905, USA
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré hospital (APHP); Lab infection & inflammation U1173 School of medicine Simone Veil, University Paris Saclay, Paris, France
| | - Bram Rochwerg
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesiology, McMaster University, Hamilton, ON, Canada
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34
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Deutsch AJ, Schroeder PH, Mandla R, Kang S, Erenler F, Mercader JM, Udler MS, Florez JC, Brenner LN. Type 2 Diabetes Polygenic Score Predicts the Risk of Glucocorticoid-Induced Hyperglycemia in Patients Without Diabetes. Diabetes Care 2023; 46:1541-1545. [PMID: 37353344 PMCID: PMC10369128 DOI: 10.2337/dc23-0353] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/26/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To assess whether increased genetic risk of type 2 diabetes (T2D) is associated with the development of hyperglycemia after glucocorticoid treatment. RESEARCH DESIGN AND METHODS We performed a retrospective analysis of individuals with no diagnosis of diabetes who received a glucocorticoid dose of ≥10 mg prednisone. We analyzed the association between hyperglycemia and a T2D global extended polygenic score, which was constructed through a meta-analysis of two published genome-wide association studies. RESULTS Of 546 individuals who received glucocorticoids, 210 developed hyperglycemia and 336 did not. T2D polygenic score was significantly associated with glucocorticoid-induced hyperglycemia (odds ratio 1.4 per SD of polygenic score; P = 0.038). CONCLUSIONS Individuals with increased genetic risk of T2D have a higher risk of glucocorticoid-induced hyperglycemia. This finding offers a mechanism for risk stratification as part of a precision approach to medical treatment.
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Affiliation(s)
- Aaron J. Deutsch
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Philip H. Schroeder
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ravi Mandla
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sarah Kang
- Tufts University School of Medicine, Boston, MA
| | - Feyza Erenler
- Division of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, Boston, MA
| | - Josep M. Mercader
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Miriam S. Udler
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jose C. Florez
- Diabetes Unit, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Laura N. Brenner
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Pulmonary and Critical Care Division, Massachusetts General Hospital, Boston, MA
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35
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Zhang J, Ge P, Liu J, Luo Y, Guo H, Zhang G, Xu C, Chen H. Glucocorticoid Treatment in Acute Respiratory Distress Syndrome: An Overview on Mechanistic Insights and Clinical Benefit. Int J Mol Sci 2023; 24:12138. [PMID: 37569514 PMCID: PMC10418884 DOI: 10.3390/ijms241512138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Acute lung injury/acute respiratory distress syndrome (ALI/ARDS), triggered by various pathogenic factors inside and outside the lungs, leads to diffuse lung injury and can result in respiratory failure and death, which are typical clinical critical emergencies. Severe acute pancreatitis (SAP), which has a poor clinical prognosis, is one of the most common diseases that induces ARDS. When SAP causes the body to produce a storm of inflammatory factors and even causes sepsis, clinicians will face a two-way choice between anti-inflammatory and anti-infection objectives while considering the damaged intestinal barrier and respiratory failure, which undoubtedly increases the difficulty of the diagnosis and treatment of SAP-ALI/ARDS. For a long time, many studies have been devoted to applying glucocorticoids (GCs) to control the inflammatory response and prevent and treat sepsis and ALI/ARDS. However, the specific mechanism is not precise, the clinical efficacy is uneven, and the corresponding side effects are endless. This review discusses the mechanism of action, current clinical application status, effectiveness assessment, and side effects of GCs in the treatment of ALI/ARDS (especially the subtype caused by SAP).
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Affiliation(s)
- Jinquan Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Peng Ge
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Jie Liu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Yalan Luo
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Haoya Guo
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Guixin Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
| | - Caiming Xu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Comprehensive Cancer Center, Monrovia, CA 91016, USA
| | - Hailong Chen
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian 116044, China
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
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Turolo S, Edefonti A, Syren ML, Montini G. Pharmacogenomics of Old and New Immunosuppressive Drugs for Precision Medicine in Kidney Transplantation. J Clin Med 2023; 12:4454. [PMID: 37445489 DOI: 10.3390/jcm12134454] [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: 05/18/2023] [Revised: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Kidney transplantation is the preferred therapeutic option for end-stage kidney disease, but, despite major therapeutic advancements, allograft rejection continues to endanger graft survival. Every patient is unique due to his or her clinical history, drug metabolism, genetic background, and epigenetics. For this reason, examples of "personalized medicine" and "precision medicine" have steadily increased in recent decades. The final target of precision medicine is to maximize drug efficacy and minimize toxicity for each individual patient. Immunosuppressive drugs, in the setting of kidney transplantation, require a precise dosage to avoid either adverse events (overdosage) or a lack of efficacy (underdosage). In this review, we will explore the knowledge regarding the pharmacogenomics of the main immunosuppressive medications currently utilized in kidney transplantation. We will focus on clinically relevant pharmacogenomic data, that is, the polymorphisms of the genes that metabolize immunosuppressive drugs.
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Affiliation(s)
- Stefano Turolo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Nephrology, Dialysis and Transplant Unit, 20122 Milan, Italy
| | - Alberto Edefonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Nephrology, Dialysis and Transplant Unit, 20122 Milan, Italy
| | - Marie Luise Syren
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giovanni Montini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Nephrology, Dialysis and Transplant Unit, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Levitte S, Ganguly A, Frolik S, Guevara-Tique AA, Patel S, Tadas A, Klein O, Shyr D, Agarwal-Hashmi R, Beach L, Callard E, Weinacht K, Bertaina A, Thakor AS. Precision Delivery of Steroids as a Rescue Therapy for Gastrointestinal Graft-versus-Host Disease in Pediatric Stem Cell Transplant Recipients. J Clin Med 2023; 12:4229. [PMID: 37445274 DOI: 10.3390/jcm12134229] [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: 05/13/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Graft versus host disease (GVHD) is one of the most serious complications following stem cell transplant in children and is a major cause of morbidity and mortality. Corticosteroids remain the mainstay of treatment, and although a majority of children respond to systemic steroids, those refractory to or dependent upon corticosteroids suffer from complications secondary to long-term steroid administration. This problem has prompted consideration of steroid-sparing treatment strategies, although the time to clinical remission can be variable. Intraarterial corticosteroid delivery has been used in adults as a rescue therapy in steroid-resistant patients, but its use in children has been limited. We investigated the feasibility of intraarterial steroid administration into the bowel and/or liver in a cohort of six pediatric patients with acute GVHD. All patients successfully underwent treatment with no serious adverse effects. Five of five (100%) patients with gastrointestinal bleeding due to GVHD had rapid symptom improvement by 48 h, which was durable up to three weeks. Three of four (75%) patients with hepatic GVHD had improved cholestasis following intraarterial steroid administration. Our experience with this small cohort preliminarily demonstrated the feasibility and safety of intraarterial steroid administration in children with acute GVHD. This approach warrants consideration as a rescue therapy in steroid-refractory cases and as a "bridge" therapy for children with severe acute GVHD who are transitioning to steroid-sparing regimens.
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Affiliation(s)
- Steven Levitte
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Abantika Ganguly
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Sophie Frolik
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Alix A Guevara-Tique
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Shaini Patel
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Ann Tadas
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Orly Klein
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - David Shyr
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Rajni Agarwal-Hashmi
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Lynn Beach
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Elizabeth Callard
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Katja Weinacht
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Alice Bertaina
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation, and Regenerative Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Avnesh S Thakor
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
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38
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McManus D, Davis MW, Ortiz A, Britto-Leon C, Dela Cruz CS, Topal JE. Immunomodulatory Agents for Coronavirus Disease-2019 Pneumonia. Clin Chest Med 2023; 44:299-319. [PMID: 37085221 PMCID: PMC9678826 DOI: 10.1016/j.ccm.2022.11.009] [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] [Indexed: 11/23/2022]
Abstract
Morbidity and mortality from COVID-19 is due to severe inflammation and end-organ damage caused by a hyperinflammatory response. Multiple immunomodulatory agents to attenuate this response have been studied. Corticosteroids, specifically dexamethasone, have been shown to reduce mortality in hospitalized patients who require supplemental oxygen. Interleukin-6 antagonist, tocilizimab, and Janus kinase inhibitors have also been shown to reduce mortality. However, patients who have severe pulmonary end-organ damage requiring mechanical ventilation or extracorporeal membrane oxygenation appear not to benefit from immunomodulatory therapies. This highlights the importance of appropriate timing to initiate immunomodulatory therapies in the management of severe COVID-19 disease.
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Affiliation(s)
- Dayna McManus
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
| | - Matthew W Davis
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA
| | - Alex Ortiz
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Clemente Britto-Leon
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Jeffrey E Topal
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
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Kuperminc E, Heming N, Carlos M, Annane D. Corticosteroids in ARDS. J Clin Med 2023; 12:jcm12093340. [PMID: 37176780 PMCID: PMC10179626 DOI: 10.3390/jcm12093340] [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: 03/23/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is frequently associated with sepsis. ARDS and sepsis exhibit a common pathobiology, namely excessive inflammation. Corticosteroids are powerful anti-inflammatory agents that are routinely used in septic shock and in oxygen-dependent SARS-CoV-2 related acute respiratory failure. Recently, corticosteroids were found to reduce mortality in severe community-acquired pneumonia. Corticosteroids may therefore also have a role to play in the treatment of ARDS. This narrative review was undertaken following a PubMed search for English language reports published before January 2023 using the terms acute respiratory distress syndrome, sepsis and steroids. Additional reports were identified by examining the reference lists of selected articles and based on personnel knowledge of the authors of the field. High-quality research is needed to fully understand the role of corticosteroids in the treatment of ARDS and to determine the optimal timing, dosing and duration of treatment.
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Affiliation(s)
- Emmanuelle Kuperminc
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin-University Paris Saclay, 92380 Garches, France
| | - Nicholas Heming
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin-University Paris Saclay, 92380 Garches, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, 92380 Garches, France
- FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), 92380 Garches, France
| | - Miguel Carlos
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin-University Paris Saclay, 92380 Garches, France
| | - Djillali Annane
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin-University Paris Saclay, 92380 Garches, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, 92380 Garches, France
- FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), 92380 Garches, France
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40
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Kirby D, Donnelly M, Catalano W, Buchalter D, Glickel S, Hacquebord J. The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release. Hand (N Y) 2023; 18:430-435. [PMID: 34308719 PMCID: PMC10152525 DOI: 10.1177/15589447211032331] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. METHODS A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. RESULTS Of 3234 patients who underwent trigger finger release, 58 (1.8%) were identified with postoperative infections, 6 (0.2%) of which were deep infections. History of corticosteroid injection was significantly more common in patients with postoperative infection. Compared with an age-matched, gender-matched, and body mass index-matched cohort, patients with postoperative infection had significantly increased rate of diabetes mellitus at 34.5% to 19% (P = .04). CONCLUSIONS While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.
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Affiliation(s)
- David Kirby
- NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Megan Donnelly
- University of California, Irvine School of Medicine, USA
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Pitre T, Su J, Mah J, Helmeczi W, Danho S, Plaxton W, Giilck S, Rochwerg B, Zeraatkar D. Higher- versus Lower-Dose Corticosteroids for Severe to Critical COVID-19: A Systematic Review and Dose-Response Meta-analysis. Ann Am Thorac Soc 2023; 20:596-604. [PMID: 36449393 PMCID: PMC10112407 DOI: 10.1513/annalsats.202208-720oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
Rationale: Corticosteroids are standard of care for patients with severe coronavirus disease (COVID-19). However, the optimal dose is uncertain. Objectives: To compare higher doses of corticosteroids with lower doses in patients with COVID-19. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, MedRxiv, and Web of Science from inception to August 1, 2022, for trials that randomized patients with severe-to-critical COVID-19 to corticosteroids, standard care, or placebo. Reviewers, working in duplicate, screened references, extracted data, and assessed risk of bias using a modified version of the Cochrane risk of bias 2.0 tool. We performed a dose-response meta-analysis and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess the certainty of evidence. We present our results both in relative risk and absolute risk difference per 1,000, with 95% confidence intervals (CIs). Results: We included 20 trials, with 10,155 patients. We show that, compared with lower-dose corticosteroids, higher-dose corticosteroids probably reduce mortality (absolute risk difference, 14 fewer deaths per 1,000 [95% CI, 26 fewer to 2 fewer]; moderate certainty) and may reduce the need for mechanical ventilation (absolute risk difference, 11.6 fewer per 1,000 [95% CI, 23.2 fewer to 6.9 more]; low certainty). The effect of corticosteroids on nosocomial infections is uncertain (16.7 fewer infections per 1,000 [95% CI, 5.4 fewer to 25.0 fewer]; very low certainty). Conclusions: Relatively higher doses of corticosteroids may be beneficial in patients with severe-to-critical COVID-19 and may not increase the risk of nosocomial infections.
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Affiliation(s)
| | | | - Jasmine Mah
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Wryan Helmeczi
- Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada; and
| | | | | | - Stephen Giilck
- Department of Medicine, Grand River Hospital, Kitchener, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods Evidence and Impact, and
| | - Dena Zeraatkar
- Department of Health Research Methods Evidence and Impact, and
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada
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Levitte S, Yarani R, Ganguly A, Martin L, Gubatan J, Nadel HR, Franc B, Gugig R, Syed A, Goyal A, Park KT, Thakor AS. Case Series of Precision Delivery of Methylprednisolone in Pediatric Inflammatory Bowel Disease: Feasibility, Clinical Outcomes, and Identification of a Vasculitic Transcriptional Program. J Clin Med 2023; 12:jcm12062386. [PMID: 36983386 PMCID: PMC10053508 DOI: 10.3390/jcm12062386] [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: 01/24/2023] [Revised: 03/05/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Systemic steroid exposure, while useful for the treatment of acute flares in inflammatory bowel disease (IBD), is associated with an array of side effects that are particularly significant in children. Technical advancements have enabled locoregional intraarterial steroid delivery directly into specific segments of the gastrointestinal tract, thereby maximizing tissue concentration while limiting systemic exposure. We investigated the feasibility of intraarterial steroid administration into the bowel in a cohort of nine pediatric patients who had IBD. This treatment approach provided symptom relief in all patients, with sustained relief (>2 weeks) in seven out of nine; no serious adverse effects occurred in any patient. In addition, we identified patterns of vascular morphologic changes indicative of a vasculopathy within the mesenteric circulation of inflamed segments of the bowel in pediatric patients with Crohn's disease, which correlated with disease activity. An analysis of publicly available transcriptomic studies identified vasculitis-associated molecular pathways activated in the endothelial cells of patients with active Crohn's disease, suggesting a possible shared transcriptional program between vasculitis and IBD. Intraarterial corticosteroid treatment is safe and has the potential to be widely accepted as a locoregional approach for therapy delivery directly into the bowel; however, this approach still warrants further consideration as a short-term "bridge" between therapy transitions for symptomatic IBD patients with refractory disease, as part of a broader steroid-minimizing treatment strategy.
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Affiliation(s)
- Steven Levitte
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Reza Yarani
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Abantika Ganguly
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Lynne Martin
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - John Gubatan
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94304, USA
| | - Helen R Nadel
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Benjamin Franc
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Ali Syed
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
| | - Alka Goyal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - K T Park
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA
| | - Avnesh S Thakor
- Interventional Radiology Innovation at Stanford (IRIS), 3155 Porter Drive, Palo Alto, CA 94304, USA
- Department of Pediatric Radiology, Interventional Radiology, Stanford University, Palo Alto, CA 94304, USA
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Roddy MR, Sellers AR, Darville KK, Teppa-Sanchez B, McKinley SD, Martin M, Goldenberg NA, Nakagawa TA, Sochet AA. Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial. Pediatr Pulmonol 2023; 58:1719-1727. [PMID: 36929864 DOI: 10.1002/ppul.26386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma. METHODS A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events). RESULTS Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001). CONCLUSIONS Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.
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Affiliation(s)
- Meghan R Roddy
- Departments of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin R Sellers
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Kristina K Darville
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Beatriz Teppa-Sanchez
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Scott D McKinley
- Departments of Pulmonlogy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Meghan Martin
- Departments of Emergency Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Nakagawa
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Florida-Jacksonville, Jacksonville, Florida, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Gibble TH, Naegeli AN, Grabner M, Isenberg K, Shan M, Teng CC, Curtis JR. Identification of inadequate responders to advanced therapy among commercially-insured adult patients with Crohn's disease and ulcerative colitis in the United States. BMC Gastroenterol 2023; 23:63. [PMID: 36894911 PMCID: PMC9996947 DOI: 10.1186/s12876-023-02675-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND The purpose of this analysis was to assess the frequency of inadequate response over 1 year from advanced therapy initiation among patients with Crohn's disease (CD) or ulcerative colitis (UC) in the United States using a claims-based algorithm. Factors associated with inadequate response were also analyzed. METHODS This study utilized claims data of adult patients from the HealthCore Integrated Research Database (HIRD®) from January 01, 2016 to August 31, 2019. Advanced therapies used in this study were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics. Inadequate response to an advanced therapy was identified using a claims-based algorithm. The inadequate response criteria included adherence, switching to/added a new treatment, addition of a new conventional synthetic immunomodulator or conventional disease-modifying drugs, increase in dose/frequency of advanced therapy initiation, and use of a new pain medication, or surgery. Factors influencing inadequate responders were assessed using multivariable logistic regression. RESULTS A total of 2437 patients with CD and 1692 patients with UC were included in this analysis. In patients with CD (mean age: 41 years; female: 53%), 81% had initiated TNFi, and 62% had inadequate response. In patients with UC (mean age: 42 years; female: 48%), 78% had initiated a TNFi, and 63% had an inadequate response. In both patients with CD and UC, inadequate response was associated with low adherence (CD: 41%; UC: 42%). Inadequate responders were more likely to be prescribed a TNFi (for CD: odds ratio [OR] = 1.94; p < 0.001; for UC: OR = 2.76; p < 0.0001). CONCLUSION More than 60% of patients with CD or UC had an inadequate response to their index advanced therapy within 1 year after initiation, mostly driven by low adherence. This modified claims-based algorithm for CD and UC appears useful to classify inadequate responders in health plan claims data.
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Liu W, Shao F, You X, Cao Y, Xi J, Wu J, Wan J, Zhang X, Fei J, Luan Y. Non-carcinogenic/non-nephrotoxic aristolochic acid IVa exhibited anti-inflammatory activities in mice. J Nat Med 2023; 77:251-261. [PMID: 36525161 DOI: 10.1007/s11418-022-01665-8] [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: 08/18/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
Aristolochic acid (AA)-containing herbs have been prescribed for thousands of years as anti-inflammatory drugs, despite the active pharmaceutical ingredients remaining unclear. However, exposure to AAI and AAII has been proven to be a significant risk factor for severe nephropathy and carcinogenicity. AAIVa, an analogue abundant in AA-containing herbs, showed neither carcinogenicity nor nephrotoxicity in our study and other reports, implying that the pharmacological effects of AAIVa on inflammation are worth studying. Herein, we employed RAW 264.7 cells, the ear edema mouse model, and the lipopolysaccharide (LPS)-induced systematic inflammation model in TNF-IRES-Luc mice (tracking TNFα luciferase activities in real-time) to evaluate the anti-inframammary effect of AAIVa. Our results showed that AAIVa could decrease pro-inflammatory cytokines (TNFα and IL-6) production in LPS-stimulated RAW 264.7 cells, indicating its anti-inflammatory effects in vitro. Furthermore, the application of AAIVa (400 and 600 μg/ear) could significantly inhibit phorbol 12-myristate 13-acetate-induced ear edema, suggesting its topical anti-inflammatory activity in vivo. Moreover, LPS-stimulated TNF-IRES-Luc mice were used to investigate the onset and duration of AAIVa on systematic inflammation. A single dosage of AAIVa (100 mg/kg, i.g.) could suppress LPS-triggered inflammation, by decreasing luciferase activities of TNFα at 3 h in TNF-IRES-Luc mice. In addition, the online pharmacological databases predicted that AAIVa might target the regulation of T cell activation-related protein (ADA, ADORA2A, ERBB2) to exhibit anti-inflammatory effect. In conclusion, we demonstrated that AAIVa had anti-inflammatory effect for the first time; our findings are constructive for further studies on pharmacological mechanism of AAIVa.
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Affiliation(s)
- Weiying Liu
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Fangyang Shao
- School of Life Science and Technology, Tongji University, Shanghai, China
- Shanghai Engineering Research Center for Model Organisms, SRCMO/SMOC, Shanghai, 201203, China
| | - Xinyue You
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Yiyi Cao
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Jing Xi
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Jiaying Wu
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Jingjing Wan
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Xinyu Zhang
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China
| | - Jian Fei
- School of Life Science and Technology, Tongji University, Shanghai, China
- Shanghai Engineering Research Center for Model Organisms, SRCMO/SMOC, Shanghai, 201203, China
| | - Yang Luan
- School of Public Health, Hongqiao International Institute of Medicine, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Road, Shanghai, 200025, China.
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Remmington C, Barrett NA, Agarwal S, Lams B, Collins P, Camarda V, Meadows C, Hanks F, Sanderson B, Retter A, Camporota L. Steroid exposure and outcome in COVID-19 pneumonia. BJA OPEN 2023; 5:100128. [PMID: 36744291 PMCID: PMC9886648 DOI: 10.1016/j.bjao.2023.100128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023]
Abstract
Background Corticosteroids are used to treat COVID-19 pneumonia. However, the optimal dose is unclear. This study describes the association between corticosteroid exposure with disease severity and outcome in COVID-19 pneumonia. Methods This is a single-centre retrospective, observational study including adult ICU patients who received systemic corticosteroids for COVID-19 pneumonia between March 2020 and March 2021. We recorded patient characteristics, disease severity, total steroid exposure, respiratory support and gas exchange data, and 90-day mortality. Results We included 362 patients. We allocated patients to groups with increasing disease severity according to the highest level of respiratory support that they received: high-flow nasal oxygen or continuous positive airway pressure (HFNO/CPAP) in 12.7%, invasive mechanical ventilation (IMV) in 61.6%, and extracorporeal membrane oxygenation (ECMO) in 25.7%. For these three groups, the median (inter-quartile range [IQR]) age was 61 (54-71) vs 58 (50-66) vs 46 (38-53) yr, respectively (P<0.001); median (IQR) APACHE (Acute Physiology and Chronic Health Evaluation) II scores were 12 (9-15) vs 14 (12-18) vs 15 (12-17), respectively (P=0.006); the median (IQR) lowest P a O 2 /FiO2 ratio was 15.1 (11.8-21.7) vs 15.1 (10.7-22.2) vs 9.5 (7.9-10.9) kPa, respectively (P<0.001). Ninety-day mortality was 9% vs 27% vs 37% (P=0.002). Median (IQR) dexamethasone-equivalent exposure was 37 (24-62) vs 174 (86-504) vs 535 (257-1213) mg (P<0.001). 'Pulsed' steroids were administered to 26% of the IMV group and 48% of the ECMO group. Patients with higher disease severity who received pulse steroids had a higher 90-day mortality. Conclusions Corticosteroid exposure increased with the severity of COVID-19 pneumonia. Pulsed dose steroids were used more frequently in patients receiving greater respiratory support. Future studies should address patient selection and outcomes associated with pulsed dose steroids in patients with severe and deteriorating COVID-19 pneumonia.
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Affiliation(s)
- Christopher Remmington
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK,Institute of Pharmaceutical Science, King's College London, London, UK,Corresponding author. Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas A Barrett
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Sangita Agarwal
- Department of Rheumatology and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Boris Lams
- Department of Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Patrick Collins
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Valentina Camarda
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chris Meadows
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fraser Hanks
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Barnaby Sanderson
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Retter
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Weerasooriya WALK, Abeyagunawardena AS, Thalgahagoda RS. Single vs split dose of prednisolone in the treatment of relapses of childhood nephrotic syndrome. Eur J Pediatr 2023; 182:1741-1747. [PMID: 36757496 DOI: 10.1007/s00431-023-04804-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 02/10/2023]
Abstract
Nephrotic syndrome is the commonest glomerular disease in childhood. It usually follows a relapsing and remitting course. Corticosteroids are the mainstay of treatment for both the first episode and subsequent relapses. This study was conducted at a single centre to compare the clinical response to a single dose vs. split dose of prednisolone in the treatment of relapses of childhood nephrotic syndrome. Children between the ages of 1 and 14 years admitted with a relapse of idiopathic steroid sensitive nephrotic syndrome from August 2019 to February 2020 were considered for recruitment. A block randomization method based on age was used for allocation. Patients randomised to group A received oral prednisolone at 60 mg/m2 as a single morning dose, while those randomised to group B received the same total dose as two divided doses, of which 2/3 was given in the morning and the rest in the evening. Treatment was continued until remission was achieved following which all patients were switched to alternate day prednisolone. An independent sample t test was used to compare the two groups. One hundred and four episodes of relapse occurring in 96 children were included of which 49 were treated with prednisolone as a split dose and 55 were treated with a single dose of prednisolone. The mean duration to achieve remission for the split-dose group was 8.02 days (SD 1.58) while it was 9.74 days (SD 3.72) for the single-dose group. This difference was statistically highly significant (t(102) = 3.004; p = 0.001; CI 0.58 to 2.86). There was no difference in the adverse events profile of the two groups. Conclusion: The use of prednisolone as a split dose results in a shorter duration to achieve remission when compared to a single morning dose, resulting in a lower cumulative dose of prednisolone to achieve remission. What is Known: • Corticosteroids are the mainstay of treatment for childhood nephrotic syndrome. • Corticosteroids are given as a single dose in the morning to minimise adrenocortical suppression. What is New: • A more rapid attainment of remission can be achieved with a split dose of corticosteroids.
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Affiliation(s)
- W A L K Weerasooriya
- Professorial Paediatric Unit, Teaching Hospital Peradeniya, Peradeniya, Sri Lanka
| | - A S Abeyagunawardena
- Department of Paediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - R S Thalgahagoda
- Department of Paediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
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Hegde V, Shanmugasundaram S, Shaikh S, Kulkarni V, Suresh N, Setzer FC, Nagendrababu V. Effect of Preoperative Oral Steroids in Comparison to Anti-inflammatory on Anesthetic Success of Inferior Alveolar Nerve Block in Mandibular Molars with Symptomatic Irreversible Pulpitis-A Double-blinded Randomized Clinical Trial. J Endod 2023; 49:354-361. [PMID: 36736586 DOI: 10.1016/j.joen.2023.01.007] [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: 12/14/2022] [Revised: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION This randomized double-blinded trial aimed to compare the anesthetic success of inferior alveolar nerve blocks (IANBs) with 2% lidocaine in mandibular molars with symptomatic irreversible pulpitis (SIP) after oral premedication of prednisolone, dexamethasone, and ketorolac with placebo. METHODS One hundred eighty-four patients diagnosed with SIP in mandibular molars randomly received prednisolone, dexamethasone, ketorolac, or placebo (n = 46 each) 60 minutes before the administration of an IANB. The access cavity preparation was initiated after successfully confirming lip numbness and two consecutive negative responses to electric pulp testing. The success of the anesthesia was clinically confirmed when pain was absent during the endodontic access or instrumentation. A one-way analysis of variance test was used to compare quantitative variables among the groups, and chi-square tests were used for comparing categorical variables. Binary logistic regression was performed to analyze the relationship of age, preoperative pain, and preoperative medications. RESULTS When premedicated with oral dexamethasone, ketorolac, prednisolone, and placebo, the success rate of IANB was determined to be 60.86 %, 65.21 %, 56.52 %, and 21.73 %, respectively. Compared to the placebo, the success rate of IANB was significantly increased when patients were premedicated with prednisolone, dexamethasone, or ketorolac. However, there were no statistically significant differences among prednisolone, dexamethasone, and ketorolac. One individual in the ketorolac group reported gastritis, whereas no adverse effects were reported in the dexamethasone or prednisolone groups. CONCLUSIONS Preoperative use of oral ketorolac, dexamethasone, or prednisolone may increase the anesthetic efficacy of IANB in mandibular molars with SIP.
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Affiliation(s)
- Vivek Hegde
- Department of Conservative Dentistry and Endodontics, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
| | - Srilatha Shanmugasundaram
- Department of Conservative Dentistry and Endodontics, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
| | - Samia Shaikh
- Department of Conservative Dentistry and Endodontics, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
| | - Vaidehi Kulkarni
- Department of Conservative Dentistry and Endodontics, M.A. Rangoonwala College of Dental Sciences and Research Center, Pune, India
| | - Nandini Suresh
- Faculty of dentistry, Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Meenakshi Academy of Higher Education and Research (MAHER), Tamilnadu, India
| | - Frank C Setzer
- Department of Endodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Venkateshbabu Nagendrababu
- Department of Preventive and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, UAE.
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Abstract
Coronavirus disease 2019 (COVID-19) pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in significant mortality in pandemic proportions. Inflammation in response to the infection contributes to the pathogenesis of pneumonia. This review will discuss prior studies on the use of glucocorticoids to treat respiratory infections, the rationale for the use glucocorticoids in COVID-19, and review of existing data. We will also highlight outstanding research questions for future studies.
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Affiliation(s)
- Francesco Amati
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - John Huston
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
| | - Charles S. Dela Cruz
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
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50
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Perioperative Intravenous Glucocorticoids in Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2023; 31:e94-e106. [PMID: 36580055 DOI: 10.5435/jaaos-d-22-00232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Total joint arthroplasties (TJAs) of the hip and knee are common orthopaedic procedures. Postoperative pain in TJA is managed with opioids, which carry notable adverse effects and are associated with high dependency rates. With newer multimodal pain control regimens, perioperative glucocorticoid administration has shown promise as a means of mitigating postoperative pain. The objective of this review was to identify the effects of perioperative intravenous glucocorticoid administration on postoperative outcomes in TJA. MATERIALS AND METHODS A systematic review was done. The EMBASE database was searched from inception through September 1, 2020, to identify studies of perioperative glucocorticoids in TJA. Primary outcomes were postoperative pain, nausea, and vomiting. Secondary outcomes included hospital length of stay, postoperative opioid utilization, antiemetic rescue medication use, and postoperative surgical complications. RESULTS Our search yielded 429 publications; 14 studies were ultimately included, incorporating 1704 patients. In 13 of 14 studies, pain scores improved with perioperative steroid administration. Regarding postoperative nausea and vomiting, most of the studies found a notable association between steroids and improved VAS-N (visual analogue scale for nausea) and decreased postoperative nausea and vomiting incidence. There were inconclusive data on the effects of perioperative steroids regarding postoperative length of stay, fatigue, and range of motion of the affected joint. In all 14 studies, no notable difference was found between study groups regarding postoperative surgical complications. CONCLUSION This systematic review supports the use of perioperative steroids in TJA for mitigating postoperative pain, nausea, and systemic inflammation. Additional randomized trials are needed to form a consensus on optimal dosing, delivery method, and timing of perioperative glucocorticoids in TJA.
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