Use of Fractional Exhaled Nitric Oxide to Guide the Treatment of Asthma: An Official American Thoracic Society Clinical Practice Guideline

Background: The fractional exhaled nitric oxide (FE_NO) test is a point-of-care test that is used in the assessment of asthma.

Objective: To provide evidence-based clinical guidance on whether FE_NO testing is indicated to optimize asthma treatment in patients with asthma in whom treatment is being considered.

Methods: An international, multidisciplinary panel of experts was convened to form a consensus document regarding a single question relevant to the use of FE_NO. The question was selected from three potential questions based on the greatest perceived impact on clinical practice and the unmet need for evidence-based answers related to this question. The panel performed systematic reviews of published randomized controlled trials between 2004 and 2019 and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence-to-decision framework to develop recommendations. All panel members evaluated and approved the recommendations.

Main Results: After considering the overall low quality of the evidence, the panel made a conditional recommendation for FE_NO-based care. In patients with asthma in whom treatment is being considered, we suggest that FE_NO is beneficial and should be used in addition to usual care. This judgment is based on a balance of effects that probably favors the intervention; the moderate costs and availability of resources, which probably favors the intervention; and the perceived acceptability and feasibility of the intervention in daily practice.

Conclusions: Clinicians should consider this recommendation to measure FE_NO in patients with asthma in whom treatment is being considered based on current best available evidence.

Corticosteroids vs autologous blood injection for lateral epicondylitis: Study protocol for a cohort trial

BACKGROUND

There is limited evidence to assess the evaluation of the safety and effectiveness of autologous blood injections in the treatment of lateral epicondylitis patients. For this study, the aim was to compare the efficiency of corticosteroid and autologous blood injections for the treatment of lateral epicondylitis in a retrospective cohort trial in our single center.

METHODS

After being approved by the institutional review committee of Chongqing General Hospital (IRB# 2018.417.C, November 9, 2018), we performed a single-center, retrospective study between November 2018 and January 2020. All participants provided written informed consent. The criteria for inclusion in our experiment are as follows: over 18 years old; with the history of at least 6 months of lateral epicondylitis; and the palpation of lateral epicondyle tenderness; visual analog scale (≥4). In the group A, the patient were injected the autologous blood. In group B, the patients were immersed with 0.5% of bupivacaine (1 ml) and local corticosteroids (2 ml) at lateral epicondyle. The outcomes were composed of a visual analog scores of subjective pain severity over the past 24 hours as the primary result; and limb function in various tasks of daily activity measured with disabilities of the arm, shoulder, and hand quick questionnaire scores, the maximum grip strength and the modified scores of Nirschl, as secondary results. All the results were assessed before the injection and at 4 weeks and 8 weeks after the injection. For all examination, when the P value was less than .05, it would be defined to be a statistically significant difference.

RESULTS

The results of this study would provide new information about the influence of autologous blood injections in treating the lateral epicondylitis.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6263).

Assessing the quality of antenatal corticosteroids in low- and middle-income countries: A systematic review

Background

The World Health Organization (WHO) recommends the administration of intramuscular antenatal corticosteroids to women at risk of preterm birth to prevent preterm-associated neonatal mortality and morbidity. Poor quality medicines are a major problem for health services in low- and middle-income countries (LMICs), however the quality of antenatal corticosteroids is not well understood. We aimed to conduct a systematic review of available studies describing the quality of recommended injectable antenatal corticosteroids (dexamethasone or betamethasone) in LMICs.

Methods

Structured search strategy was applied to six databases (MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, Global Index Medicus, WHO Medicines Quality Database), without year or language restrictions. Any primary study reporting any medicine quality parameter (Active Pharmacological Ingredient, pH and sterility) for injectable dexamethasone or betamethasone was eligible. Two authors independently screened studies for eligibility, extracted data on included studies and applied Medicine Quality Assessment Reporting Guidelines tool to assess study quality. Results were reported narratively, stratified by country of manufacture, organisation type and level of care.

Results

In total, 15,547 citations were screened with two eligible studies identified that focussed on dexamethasone quality (no studies of betamethasone were identified). One study included 19 samples from 9 LMICs, and the other included “less than 100 samples” from India. The prevalence of failed dexamethasone samples ranged from 3.14% to 32.2% due to inadequate Active Pharmacological Ingredient. A higher prevalence of failed dexamethasone samples were seen at the point of care and the public sector.

Conclusions

Poor quality maternal and newborn health medicines can endanger women and newborns. Though available evidence on antenatal corticosteroids quality in LMICs is limited, results suggested poor quality dexamethasone may be prevalent in some countries. More primary studies are required to confirm these findings and guide policymakers on procurement of good-quality maternal and newborn health medicines.

Recommendations for the Management of Neuro-Behçet's Disease by the Japanese National Research Committee for Behçet's Disease

Objective Brain parenchymal involvement in Behçet's disease (BD) (neuro-Behçet's disease, NB) can be classified into acute type (ANB) and chronic progressive type (CPNB) based on differences in the clinical course and responses to corticosteroid treatment. The present study developed evidence-based recommendations for the management of NB.Methods The task force of the research subcommittee consisted of seven board-certified rheumatologists (one was also a board-certified neurologist) and three board-certified neurologists. First, several clinical questions (CQs) were established. A systematic literature search was performed by The Japan Medical Library Association in order to develop recommendations. The final recommendations for each CQ developed from three blind Delphi rounds, for which the rate of agreement scores [range 1 (strongly disagree)-5(strongly agree)] was determined through voting by the task force.Results A flow chart of the algorithm was established for the management of ANB and CPNB. Thirteen recommendations were developed for NB (general 1, ANB 7, CPNB 5). The strength of each recommendation was established based on the evidence level as well as the rate of agreement.Conclusion The recommendations generated in this study are based on the results of uncontrolled evidence from open trials, retrospective cohort studies and expert opinions, due to the lack of randomized clinical trials. Nevertheless, these recommendations can be used for international studies, although verification by further properly designed controlled clinical trials is required.

Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society.

Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β₂-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy.

Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.

Budesonide versus systemic corticosteroids in IgA Nephropathy: A retrospective, propensity-matched comparison

IgA Nephropathy (IgAN) is characterized by mesangial deposition of dominant, polymeric, galactose-deficient IgA1 molecules of gut-associated lymphoid tissue origin. We sought to evaluate the efficacy of targeting the mucosal immune system dysregulation underlying IgAN pathogenesis with a pH-modified formulation of budesonide with a maximum release of active compound in the distal ileum and proximal colon.We did a retrospective study evaluating the efficacy of budesonide (Budenofalk) in the treatment of IgAN. From a retrospective cohort of 143 patients with IgAN followed in our department we identified 21 patients that received treatment with budesonide. These patients received budesonide at a dose of 9 mg/d in the first 12 months, followed by a dose reduction to 3 mg/d for the subsequent period. Only patients that received a 24-month treatment with budesonide were included in the analysis (n = 18). We matched the budesonide-treated cohort to 18 patients with IgAN treated with systemic steroids from the same retrospective cohort. Efficacy was measured as change in proteinuria, hematuria and estimated glomerular filtration rate over a 24-month period.Treatment with budesonide was associated with a 24-month renal function decline of -0.22 (95%CI, -8.2 to 7.8) ml/min/1.73m, compared to -5.89 (95%CI, -12.2 to 0.4) ml/min/1.73m in the corticosteroid treatment group (p = 0.44, for between group difference). The median reduction in proteinuria at 24-month was 45% (interquartile range [IQR]: -79%; -22%) in the budesonide group and 11% (IQR: -39%; 43%) in the corticosteroid group, respectively (P = .009, for between group difference). The median reduction in hematuria at 24-month was 72% (IQR: -90%; -45%) in the budesonide group and 73% (IQR: -85%; 18%) in the corticosteroid group, respectively (P = .22, for between group difference). Treatment with budesonide was well tolerated with minimal side effects.Budesonide (Budenofalk) was effective in the treatment of patients with IgAN at high-risk of progression in terms of reducing proteinuria, hematuria and preserving renal function over 24 months of therapy.

Getting tendinopathy treatment (and terminology) right

Tendinopathy, tendinitis, tendinosis, paratenonitis-they are not synonymous. Here you'll find a review of their pathophysiology and best approaches to treatment.

Drug safety in the treatment of Crohn's disease

The management of Crohn's disease usually consists of a succession of short-term acute phase treatments followed by long-term maintenance therapy. The disease affects young patients and for this reason the long-term safety of the drugs needs to be especially taken into consideration. The safety, dose, duration for optimal efficacy and the most frequent adverse events will be described in this article.

Defining the effects of an inhaled corticosteroid and long-acting beta-agonist on therapeutic targets

The effects of inhaled corticosteroids (ICSs) and long-acting beta 2-agonists (LABAs) on therapeutic targets have significant clinical relevance regarding optimal management of asthma. Asthma pathophysiology involves two main components: smooth muscle dysfunction and airway inflammation. LABAs and ICSs provide complementary modes of action in that these agents modulate smooth muscle dysfunction/bronchoconstriction and airway inflammation, respectively. Despite the documented benefits of ICSs, they remain underutilized because of a variety of physician- and patient-associated reasons including safety concerns. Underlying these concerns are published reports that suggest systemic effects of high doses of ICSs: skin bruising, reduction of bone mineral density, cataracts, glaucoma, and impaired short-term growth in children. Simple strategies to reduce the potential adverse effects of inhaled steroids include using the lowest effective maintenance dose and optimizing steroid-sparing strategies, specifically combination therapy with a LABA, leukotriene modifier, or theophylline. LABA therapy, when added to ICS therapy, provides clinically significant steroid-sparing effects while at the same time reducing the rate at which asthma exacerbations occur. Available clinical evidence suggests that the combination of ICS plus LABA is the best available option for the management of moderate persistent asthma. Consequently, this combination is the preferred choice for treating moderate persistent asthma based on current National Asthma Education and Prevention Program guidelines for the diagnosis and treatment of asthma.

Implementation of asthma guideline in Taiwan--the management in medical centers

The asthma guideline was published in Taiwan in 1995. In order to understand the implementation of the guidelines and patients' attitudes to inhaled corticosteroid (ICS), in 1999, we conducted two studies: one by reviewing medical records of 230 stable asthmatic patients cared for by 23 pulmonologists in four medical centers and another through aface-to-face questionnaire survey for 246 asthmatic patients at the outpatient clinics. The results revealed that oral bronchodilators were prescribed to 85.7% (197/230) of the patients, while inhaled beta2 agonists were prescribed to 66.1% (152/230) of the patients. Inhaled corticosteroids and oral corticosteroids were prescribed to 120 (52.2%) and 64 (27.8%) patients, respectively. Twenty-three (10%) patients were treated with oral corticosteroids without prescription of ICS. Only 25 (10.9%) patients had records of peak expiratory flow (PEF) every month. Thirty-eight (16.5%) patients sometimes measured PEF. The remaining 167 (72.6%) patients never measured PEF. The face-to-face questionnaire survey revealed that 56.5% (139/246) of the patients worried about adverse reactions of corticosteroids. Among them 40 (16.3%) patients were very worried about it. Only 101 of 189 (53.4%) patients currently using ICS took the daily doses according to doctor's orders. Seventy-four (39.2%) patients decreased the dose and 14 (7.4%) patients actually did not take ICS. In the 57 patients not treated with ICS, 13 (22.8%) patients answered that they would refuse to take ICS. In conclusion, the adherence to asthma guidelines is suboptimal for pulmonologists in the medical center. Poor adherence to asthma guidelines may be due to doctors' behavior and patients' attitudes.

Sample sizes for comparative inhaled corticosteroid trials with emphasis on showing therapeutic equivalence

In the near future it is to be expected that many new inhaled corticosteroids or formulations of these drugs will be compared with older ones, to discover whether they are therapeutically equivalent or not. The statistical evaluation of these trials differs from the classic methods. When two averages are similar or differ only slightly, power is very low. The regulatory bodies demand a power of at least 80%. This problem was initially solved by using the so-called power approach. Researchers included enough volunteers to enable them to detect a predefined difference, considered to be without any clinical significance, with a power of 80%. This approach, however, has been shown to be incorrect and has been replaced by the two one-sided tests procedure, where a new sample size equation is derived. Important elements of this new equation are the coefficient of variation of the parameter measured, the difference between the averages of the two groups and the equivalence limit (the difference between the means still tolerable). This equation was used in the present study to estimate the number of volunteers needed in a parallel inhaled corticosteroids equivalence trial. The end points chosen were the changes in FEV1 and PC20 due to the corticosteroid effect. Calculations were performed by extracting data from published placebo-controlled trials, and defining a range of equivalence limits and differences between the group averages. It was shown that a huge number of volunteers (500-1000) will be needed, as a result of the small corticosteroid effect and the high variance.(ABSTRACT TRUNCATED AT 250 WORDS)

A French controlled multicenter study of intraarticular orgotein versus intraarticular corticosteroids in the treatment of knee osteoarthritis: a one-year followup

The efficacy of injection of orgotein was compared with that of betamethasone over a one-year period in 419 patients with osteoarthritis of the knee. The criteria for efficacy were the number of recurrences, the rate of persistence in the trial and, secondarily, Lequesne index and the visual analogue scale. Though betamethasone was quicker-acting, the efficacy of orgotein at low doses (4 or 8 mg) was comparable with that of the corticosteroid from Week 4 and up to a year after the beginning of the study, at the cost of a greater number of injections and more numerous local side effects.