Adverse Effects Of Corticosteroids Research Articles

Implantable intravitreal corticosteroids in chronic noninfectious uveitis

Uveitis leads to blindness in 10-15% of all cases in industrialized nations. The prevalence varies depending on the literature, ranging from 9to 730 cases per 100,000 inhabitants. Local and systemic steroid applications, along with treatment involving immunomodulators, are the primary treatment options. In cases of chronic and refractory uveitis, especially with the manifestation of uveitic macular edema, intravitreal corticosteroids can contribute to reduce or completely replace systemic immunomodulatory therapy with disease-modifying antirheumatic drugs (DMARDs), biologics or corticosteroids. This review article presents the currently available intravitreal corticosteroid implants used in the treatment of noninfectious uveitis. The indications, effectiveness, and side effect profiles are discussed within the context of the current literature. A total of 6randomized controlled studies about FAc and DEX implants with more than 100 patients were included in this review. One subgroup analysis from amulticentric randomized study with 315 patients has been included as well. The outcome is discussed in this article. The efficacy and safety profile of intravitreal corticosteroids in uveitic macular edema have been evaluated in several studies in recent years. In some studies, they have been compared to systemic treatment options. With long-acting corticosteroid implants the number of relapses can be reduced and the time interval between relapses can be prolonged. Short-acting corticosteroid implants represent atreatment option during acute uveitic activity. The adverse effects of corticosteroids can be well-controlled in most cases. In phakic and/or young patients, however, adverse effects (such as cataract development) should be discussed in depth before treatment initiation as most corticosteroids are applied as long-term treatment.

Autoimmune hepatitis with confluent necrosis indicates severe liver injury but responds well to standard immunosuppressive therapy.

We aimed to study the effects of different extensive confluent necrosis on complete biochemical remission, side effects of immunosuppressants, and outcomes in patients with autoimmune hepatitis (AIH). Patients with liver biopsy, receiving standard immunosuppressive therapy (IST), and regular follow-up were retrospectively recruited. Demographic and clinicopathological characteristics between Ishak confluent necrosis scores ≤4 (the non-severe AIH group) and ≥5 (the severe AIH group) were compared. The Kaplan-Meier Survival analysis, Cox regression analysis, and log-rank test were performed. Bilateral p<0.05 was considered statistical significance. One hundred and forty-two patients were enrolled, the median age was 56.0, and 83.8% were female. There were no significant differences in aminotransferases and immunological markers between the two groups. Patients in the severe AIH group had significantly worse liver synthetic function, a higher proportion of cirrhosis, and histologically a higher degree of portal inflammation, interface hepatitis, fibrosis stage, and a higher histological activity index score (all p<0.05). Patients in the severe AIH group had a lower response than the other group after four weeks (57.1% vs. 86.3%, p=0.002). However, differences in complete biochemical remission (CBR) were insignificant. Eight patients experienced end-point events. Kaplan-Meier survival analysis showed no significant difference between the two groups (p=0.343). For adverse effects of IST, patients in the severe group tended toward a higher incidence of corticosteroid adverse effects without statistical significance. Our study indicated that patients with histologically severe confluent necrosis (Ishak score≥5) had significantly worse liver synthetic function and a higher degree of liver fibrosis before IST. Compared with their counterparts, this subgroup of patients showed delayed biochemical response but eventually comparable CBRs, side effects, and long-term outcomes.

P109 Ocular manifestation of rheumatoid arthritis

Abstract Background/Aims Ocular manifestation associated with rheumatoid arthritis (RA) is common and should be systematically investigated by an ophthalmological examination. It may precede or complicate the disease. It manifests as a dry-eye syndrome in 38% to 45% of cases, scleritis in 0.2 to 6.3% of cases, episcleritis in 0.17 to 3.7% of cases, and peripheral ulcerative keratitis in 3% of cases. The aim of this study was to describe ocular involvement in RA and to identify factors predictive of its occurrence. Methods This is a retrospective study of patients with RA defined according to the ACR- EULAR 2010 criteria, followed up in the internal medicine department between 2015 and 2022. Patients were divided into two groups: G0 including patients without ocular involvement and G1 including patients with ocular involvement. Results Eighty patients were diagnosed, 65 women and 15 men, giving a sex ratio (F/H) of 4.33. The mean age was 60.79 years [extremes: 30-90 years]. The mean age of disease onset was 46.34 years [extremes: 22-82 years]. Among our 80 patients, 20 had RA-related ocular involvement (25%). These included 18 women and two men. Ocular involvement consisted of dry-eye syndrome (17 cases), superficial punctate keratitis (4 cases), corneal perforation (one case), and unilateral diffuse scleritis (one case). The ocular examination had also revealed corticosteroid adverse effects: corticosteroid-induced cataract (four cases) and corticosteroid-induced glaucoma (three cases). Sjogren’s syndrome associated with RA was present in 76.47% of cases. There was no difference between the two groups in terms of age (62.25 vs. 44.22 years, p = 0.943), age of disease onset (47, 23 years vs. 44.22 years, p = 0.569), rheumatoid factor level (335.29 IU/L vs. 329.15 IU/L, p = 0.393) and anti-CCP antibody level (225.08 IU/L vs. 119.23 IU/L, p = 0.070). CRP was significantly higher in patients with no ocular involvement (225.08 mg/l vs. 118.23 mg/l, p = 0.007). erosive character was observed more in G0 than in G1, but without any significant difference, respectively 85.29% vs. 68.42%; p = 0.146. Conclusion According to our study, a quarter of patients followed for RA had ocular manifestations dominated mainly by dry syndrome. However, no predictive risk factor was found for this condition, be it clinical, immunological, or radiological. Disclosure I. Fenniche: None. Z. Aydi: None. M. Somai: None. F. Daoud: None. B. Ben dhaou: None. S. Kochbati: None. I. Rachdi: None. F. Boussema: None.

Perception of burden of oral and inhaled corticosteroid adverse effects on asthma-specific quality of life

BackgroundA multistakeholder core outcome set created for asthma trials showed that asthma-specific quality of life (QoL) was a critically meaningful outcome. However, the definition and measurement methods were undetermined. The adverse effects (AEs) of corticosteroids may be a vital clinical trial outcome. Nevertheless, the AE burden from the patient perspective has not yet been elucidated in an asthma population. ObjectiveTo characterize patient burden of AEs in oral (OCS) and inhaled corticosteroids (ICS) and how this relates to QoL within an asthma population. MethodsWe used a convergent parallel mixed-methods design with quantitative surveys of known ICS and OCS AEs that were distributed through the Allergy & Asthma Network database, social channels, and the Asthma UK newsletter. Participants rated the AEs that were (1) most burdensome and (2) most desired to be eliminated. Qualitative interviews and focus groups were performed to better understand patient views on barriers reported in the quantitative data, and to identify patient-important barriers that were not a part of the quantitative survey. ResultsThe 3 most burdensome AEs for OCS were bone mineral density, infectious complications, and weight gain, whereas weight gain was the most desired to be eliminated. The 3 most burdensome AEs for ICS were pneumonia, hoarse voice, and oral thrush, with concordant results for the most desired to be eliminated. In the focus groups, OCS AEs were concordant with quantitative findings. Focus groups identified unmeasured psychosocial effects, such as embarrassment. ConclusionThe most burdensome AEs may not be those that would cause patients to stop therapy. Furthermore, qualitative focus groups suggest a psychosocial burden associated with ICS, which needs further investigation.

#5207 CENTRAL NERVOUS SYSTEM INVOLVEMENT IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS: A DIAGNOSTIC DILEMMA

Abstract Background Central nervous system involvement is extremely rare in eosinophilic granulomatosis with polyangiitis, and associated with very poor prognosis. A high index of suspicion is needed to diagnose this entity and initiate prompt treatment for this life-threatening condition. Case presentation A 71-year-old man was admitted to our hospital with lower limb weakness, loss of vision in the left eye and diplopia for four weeks. Four months prior to admission he reported unintentional weight loss and wheezing. Laboratory studies revealed anemia, eosinophilia and high antineutrophil cytoplasmic antibodies (ANCA) anti myeloperoxidase (MPO) levels. Brain computerized tomography (CT) was normal. Although corticosteroids were started, addition of other immunosupressants was delayed due to ongoing infection. During the next three days, the patient presented with worsening kidney function and was disoriented, agitated and combative. Lumbar puncture and brain CT scan showed no acute abnormalities. Therefore, plasmapheresis was started. During the third session of plasmapheresis, the patient became drowsy and non-responsive. Brain CT scan revealed subdural hematoma with uncal herniation. Trepanation and initiation of hemodialysis were required. Kidney biopsy revealed focal proliferative glomerulonephritis with fibrocellular crescents. Magnetic resonance imaging and ophthalmological evaluation showed abnormalities compatible with vasculitic disease. Cyclophosphamide was added to prednisolone, with renal and extra renal manifestations improvement. One year later, the patient is autonomous, with right hand paresis, stable kidney function (serum creatinine 2.5 mg/dL) and negative ANCA MPO serology. Conclusion Neurological involvement in GEPA is heterogeneous and requires differential diagnosis with central nervous system infections, adverse effects of corticosteroids and complication of plasmapheresis. The diagnosis is challenging and demands a high level of suspicion. Otherwise, it may lead to delayed, erroneous diagnosis and worse survival.

Anti-IL5 Monoclonal Antibodies Reduce Asthma Exacerbations and Corticosteroids Dose in Three Eosinophilic Granulomatosis with Polyangiitis Case Reports.

Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare multisystem necrotizing small and medium-sized vessel vasculitis with eosinophilic adult-onset asthma as part of its spectrum. Therapeutic choices include corticosteroids, immunosuppressive agents, and novel immunomodulators. Mepolizumab and benralizumab are monoclonal antibodies targeting Interleukin-5 (IL-5), which plays a leading role in every stage of production and maturation of eosinophils and are recently undergoing evaluation and administered in steroid-dependent, relapsing and/or refractory EGPA. Herein we describe the cases of three patients with a prior EGPA diagnosis, experiencing frequent asthmatic exacerbations despite oral and inhaled corticosteroid treatment (two patients) and adverse effects of corticosteroids (one patient). Two patients are under treatment with mepolizumab and one patient with benralizumab as an add-on supplemental regimen. In our case series anti-IL5 monoclonal antibodies proved efficient asthma-controlling and corticosteroid-sparing agents.

Toward a Predict and Prevent Approach in Obstructive Airway Diseases

Asthma and chronic obstructive pulmonary disease (COPD) are currently diagnosed and treated after demonstration of variable airflow limitation and symptoms. Under this framework, undiagnosed and unchecked airway inflammation is associated with recurrent acute attacks, airway remodeling, airflow limitation, adverse effects of corticosteroids, and impaired quality of life, ultimately leading to the collection of side-effects termed 'people remodeling'. This one-size-fits-all, damage control approach aims to control symptoms and treat exacerbations rather than modify the underlying disease process. The advent of highly effective therapies targeting proximal drivers of airways inflammation calls for a paradigm shift; upstream-acting therapies offer potential to alter the disease course and achieve clinical remission. We propose moving away from downstream firefighting and towards a predict and prevent model, measuring inflammation and providing anti-inflammatory therapy early, without waiting for further clinical deterioration. Much in the same way that high blood pressure and cholesterol are used to predict and prevent heart attacks, in asthma elevated blood eosinophils and/or exhaled nitric oxide (FeNO) can be used to predict and prevent asthma attacks. We advocate also moving research further upstream by identifying patients with subclinical airways inflammation or disease who may be at risk of progressing to airflow limitation and associated morbidities and intervening early to prevent them. In summary, we call for a 'predict and prevent' approach in obstructive airways disease.

Colchicine et inflammation oculaire non sévère hors maladie de Behcet : 16 cas et revue de la littérature

IntroductionColchicine is a narrow therapeutic margin drug that does not have the adverse effects of corticosteroids and immunosuppressants. Its use in non-severe ocular inflammatory disease excluding Behcet's disease has not been studied. MethodsWe included patients seen in the internal medicine department of Dijon University Hospital consecutively between September 2020 and September 2021 if they had received colchicine during their pathology. Patients with suspected Behçet's disease were excluded. Treatment efficacy was studied in patients with at least one year of disease progression who had received more than one year of colchicine. Successful treatment was defined as a 50 % reduction in the number of annual relapses on colchicine. ResultsSixteen patients were included (9 women and 7 men). They had recurrent anterior uveitis (n=10), recurrent scleritis (n=5) and intermediate uveitis. Opthalmological involvement was neither severe nor complicated. All patients combined, the annual relapse ratio (ARR) decreased from 1.8 (0.8–3.5) to 0.3 (0–1.6), (P=0.06). Colchicine was considered effective in three of 10 analyzable patients. In only one patient, treatment was stopped for adverse effects after six weeks. ConclusionIn view of the interesting benefit-risk ratio of colchicine, it seems appropriate to focus on this molecule in non-granulomatous anterior uveitis and non-severe recurrent scleritis.

Differential benefits of steroid therapies in adults following major burn injury

BackgroundMajor thermal injury induces a complex pathophysiological state characterized by burn shock and hypercatabolism. Steroids are used to modulate these post-injury responses. However, the effects of steroids on acute post-burn outcomes remain unclear. MethodsIn this study of 52 thermally injured adult patients (median total burn surface area 42%, 33 males and 19 females), the effects of corticosteroid and oxandrolone on mortality, multi-organ failure (MOF), and sepsis were assessed individually. Clinical data were collected at days 1, 3, 7, and 14 post-injury. ResultsTwenty-two (42%) and 34 (65%) burns patients received corticosteroids and oxandrolone within the same cohort, respectively. Following separate analysis for each steroid, corticosteroid use was associated with increased odds of in-hospital mortality (OR 3.25, 95% CI: 1.32–8•00), MOF (OR 2.36, 95% CI: 1.00–1.55), and sepsis (OR 5.95, 95% CI: 2.53–14.00). Days alive (HR 0.32, 95% CI: 0.18–0.60) and sepsis-free days (HR 0.54, 95% CI: 0.37–0.80) were lower among corticosteroid-treated patients. Oxandrolone use was associated with reduced odds of 28-day mortality (OR 0.11, 95% CI: 0.04–0.30), in-hospital mortality (OR 0.19, 95% CI: 0.08–0.43), and sepsis (OR 0.24, 95% CI: 0.08–0.69). Days alive, at 28 days (HR 6.42, 95% CI: 2.77–14.9) and in-hospital (HR 3.30, 95% CI: 1.93–5.63), were higher among the oxandrolone-treated group. However, oxandrolone was associated with increased MOF odds (OR 7.90, 95% CI: 2.89–21.60) and reduced MOF-free days (HR 0.23, 95% CI: 0.11–0.50). ConclusionSteroid therapies following major thermal injury may significantly affect patient prognosis. Oxandrolone was associated with better outcomes except for MOF. Adverse effects of corticosteroids and oxandrolone should be considered when managing burn patients.

Daily low-dose prednisolone to prevent relapse of steroid-sensitive nephrotic syndrome in children with an upper respiratory tract infection: PREDNOS2 RCT.

Most children with steroid-sensitive nephrotic syndrome have relapses that are triggered by upper respiratory tract infections. Four small trials, mostly in children already taking maintenance corticosteroid in countries of different upper respiratory tract infection epidemiology, showed that giving daily low-dose prednisone/prednisolone for 5-7 days during an upper respiratory tract infection reduces the risk of relapse. To determine if these findings were replicated in a large UK population of children with relapsing steroid-sensitive nephrotic syndrome on different background medication or none. A randomised double-blind placebo-controlled trial, including a cost-effectiveness analysis. A total of 122 UK paediatric departments, of which 91 recruited patients. A total of 365 children with relapsing steroid-sensitive nephrotic syndrome (mean age 7.6 ± 3.5 years) were randomised (1 : 1) according to a minimisation algorithm based on background treatment. Eighty children completed 12 months of follow-up without an upper respiratory tract infection. Thirty-two children were withdrawn from the trial (14 prior to an upper respiratory tract infection), leaving a modified intention-to-treat analysis population of 271 children (134 and 137 children in the prednisolone and placebo arms, respectively). At the start of an upper respiratory tract infection, children received 6 days of prednisolone (15 mg/m2) or an equivalent dose of placebo. The primary outcome was the incidence of first upper respiratory tract infection-related relapse following any upper respiratory tract infection over 12 months. The secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention-to-treat principle. The cost-effectiveness analysis used trial data and a decision-analytic model to estimate quality-adjusted life-years and costs at 1 year, which were then extrapolated over 16 years. There were 384 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the prednisolone arm, and 407 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms, respectively (adjusted risk difference -0.024, 95% confidence interval -0.14 to 0.09; p = 0.70). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. Giving daily prednisolone at the time of an upper respiratory tract infection was associated with increased quality-adjusted life-years (0.9427 vs. 0.9424) and decreased average costs (£252 vs. £254), when compared with standard care. The cost saving was driven by background therapy and hospitalisations after relapse. The finding was robust to sensitivity analysis. A larger number of children than expected did not have an upper respiratory tract infection and the sample size attrition rate was adjusted accordingly during the trial. The clinical analysis indicated that giving 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of steroid-sensitive nephrotic syndrome in UK children. However, there was an economic benefit from costs associated with background therapy and relapse, and the health-related quality-of-life impact of having a relapse. Further work is needed to investigate the clinical and health economic impact of relapses, interethnic differences in treatment response, the effect of different corticosteroid regimens in treating relapses, and the pathogenesis of individual viral infections and their effect on steroid-sensitive nephrotic syndrome. Current Controlled Trials ISRCTN10900733 and EudraCT 2012-003476-39. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 3. See the NIHR Journals Library website for further project information.

Evaluation of Daily Low-Dose Prednisolone During Upper Respiratory Tract Infection to Prevent Relapse in Children With Relapsing Steroid-Sensitive Nephrotic Syndrome

In children with corticosteroid-sensitive nephrotic syndrome, many relapses are triggered by upper respiratory tract infections. Four small studies found that administration of daily low-dose prednisolone for 5 to 7 days at the time of an upper respiratory tract infection reduced the risk of relapse, but the generalizability of their findings is limited by location of the studies and selection of study population. To investigate the use of daily low-dose prednisolone for the treatment of upper respiratory tract infection-related relapses. This double-blind, placebo-controlled randomized clinical trial (Prednisolone in Nephrotic Syndrome [PREDNOS] 2) evaluated 365 children with relapsing steroid-sensitive nephrotic syndrome with and without background immunosuppressive treatment at 122 pediatric departments in the UK from February 1, 2013, to January 31, 2020. Data from the modified intention-to-treat population were analyzed from July 1, 2020, to December 31, 2020. At the start of an upper respiratory tract infection, children received 6 days of prednisolone, 15 mg/m2 daily, or matching placebo preparation. Those already taking alternate-day prednisolone rounded their daily dose using trial medication to the equivalent of 15 mg/m2 daily or their alternate-day dose, whichever was greater. The primary outcome was the incidence of first upper respiratory tract infection-related relapse. Secondary outcomes included overall rate of relapse, changes in background immunosuppressive treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, and quality of life. The modified intention-to-treat analysis population comprised 271 children (mean [SD] age, 7.6 [3.5] years; 174 [64.2%] male), with 134 in the prednisolone arm and 137 in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 of 131 (42.7%) in the prednisolone arm and 58 of 131 (44.3%) in the placebo arm (adjusted risk difference, -0.02; 95% CI, -0.14 to 0.10; P = .70). No evidence was found that the treatment effect differed according to background immunosuppressive treatment. No significant differences were found in secondary outcomes between the treatment arms. A post hoc subgroup analysis assessing the primary outcome in 54 children of South Asian ethnicity (risk ratio, 0.66; 95% CI, 0.40-1.10) vs 208 children of other ethnicity (risk ratio, 1.11; 95% CI, 0.81-1.54) found no difference in efficacy of intervention in those of South Asian ethnicity (test for interaction P = .09). The results of PREDNOS 2 suggest that administering 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of nephrotic syndrome in children in the UK. Further work is needed to investigate interethnic differences in treatment response. isrctn.org Identifier: ISRCTN10900733; EudraCT 2012-003476-39.

Dermatologic management of ocular mucous membrane (cicatricial) pemphigoid with mycophenolate mofetil in 38 patients

To the Editor: Ocular cicatricial pemphigoid (OCP) is a functionally dangerous disorder that typically warrants long-term systemic therapy.1 Although the adverse effects of corticosteroids can preclude their prolonged use, mycophenolate mofetil (MMF) may be effective.2

Randomised clinical trial: adjunctive induction therapy with oral effervescent budesonide in newly diagnosed coeliac disease

The healing of the mucosal lesion in patients with coeliac disease is slow. To determine whether concurrent budesonide and gluten-free diet hasten small bowel healing and symptomatic improvement in patients with newly diagnosed coeliac disease. In a pilot, randomised, double-blind trial, effects on Marsh grading and quantitative duodenal morphometry of 10weeks' effervescent budesonide (initially 9mg/day) or placebo were assessed after 8 and 52weeks. Multiple clinical measures and adverse events were assessed. Nineteen patients were randomised to budesonide and 18 to placebo. No differences (all P>0.32) were observed for the week-8 mucosal response (Marsh 0 or 1) (budesonide: 37% vs placebo: 28%), week-8 remission (Marsh 0) (32% vs 17%), week-52 response (63% vs 44%) and week-52 remission (42% vs 33%). Likewise, the improvement from baseline in villous-height:crypt-depth ratio was not different for the treatment groups. There were no statistically significant differences in clinical measures or adverse events between the treatment groups. No corticosteroid adverse effects were observed. In a post hoc analysis of all patients, Marsh 3C was present at the diagnostic biopsy in 1/9 achieving mucosal remission at 8weeks versus 18/23 not (P<0.001) and mean villous-height:crypt-depth ratio was 1.06 (SD: 0.73) versus 0.46 (0.38) (P=0.005). In this pilot trial, induction therapy with budesonide had no significant effect on mucosal healing in patients with coeliac disease concurrently initiated on a gluten-free diet. Mucosal remission at 8weeks occurred in approximately one in four patients and was associated with less severe histological lesions at diagnosis.

CORTICOSTEROIDS USE: A SURVEY ON THE LEVEL OF KNOWLEDGE AND PRESCRIPTION PATTERN OF DOCTORS IN MAIDUGURI, NORTH-EASTERN NIGERIA

Background: Despite the high prescription rates of Corticosteroids (CS), physicians have poor knowledge of the long-term effects and monitoring of CS. Objectives: To evaluate the knowledge of doctors in Maiduguri, Nigeria, on the use, adverse effects, and monitoring of corticosteroids. Methodology: A cross sectional survey involving 248 consenting doctors practicing in Maiduguri between 1st of January and 30th of March, 2020. Results: Of the 248 doctors surveyed, 161 completed the survey (response rate of 64.9%). Mean age was 34±5.6 years with 95 (59%) males. Majority (74.5%) had only MBBS and 125 (77.6%) were practicing in a tertiary setting, 43 (26.7%) and 38 (23.6%) were from Medicine and General Outpatient Department respectively. Seventy-four (50.7%) had been practicing for one to five years. All had prescribed CS before. Duration of practice was not associated with frequency of CS prescription (χ2 = 24.08, p=0.091). Prednisolone was the most commonly prescribed CS (48.4%) while, the oral route was the preferred mode of prescription by 80 (49.7%) respondents. Seventy-three (45.3%) prescribed CS for allergy, respiratory diseases, and dermatological complaints. Most (67.7%) were not aware of the dosage classification of CS but 99 (61.5%) were aware of guidelines for stopping CS during treatment. Majority (92.5%) were aware of multiple adverse effects of CS with 24.2% reporting Cushingoid changes. Seventy-eight (48.4%) routinely assess patients for adverse effects. Only, 4 (2.5%) and 6 (3.7%) of respondents routinely screen for osteoporosis and tuberculosis respectively. Less than 44% and 22% routinely screen for drug-drug interaction and CS complications respectively. Conclusion: There is low level of knowledge regarding the use and monitoring of CS in Maiduguri.

CORTICOSTEROIDS USE: A SURVEY ON THE LEVEL OF KNOWLEDGE AND PRESCRIPTION PATTERN OF DOCTORS IN MAIDUGURI, NORTH-EASTERN NIGERIA.

Background: Despite the high prescription rates of Corticosteroids (CS), physicians have poor knowledge of the long-term effects and monitoring of CS. Objectives: To evaluate the knowledge of doctors in Maiduguri, Nigeria, on the use, adverse effects, and monitoring of corticosteroids. Methodology: A cross sectional survey involving 248 consenting doctors practicing in Maiduguri between 1st of January and 30th of March, 2020. Results: Of the 248 doctors surveyed, 161 completed the survey (response rate of 64.9%). Mean age was 34±5.6 years with 95 (59%) males. Majority (74.5%) had only MBBS and 125 (77.6%) were practicing in a tertiary setting, 43 (26.7%) and 38 (23.6%) were from Medicine and General Outpatient Department respectively. Seventy-four (50.7%) had been practicing for one to five years. All had prescribed CS before. Duration of practice was not associated with frequency of CS prescription (χ2 = 24.08, p=0.091). Prednisolone was the most commonly prescribed CS (48.4%) while, the oral route was the preferred mode of prescription by 80 (49.7%) respondents. Seventy-three (45.3%) prescribed CS for allergy, respiratory diseases, and dermatological complaints. Most (67.7%) were not aware of the dosage classification of CS but 99 (61.5%) were aware of guidelines for stopping CS during treatment. Majority (92.5%) were aware of multiple adverse effects of CS with 24.2% reporting Cushingoid changes. Seventy-eight (48.4%) routinely assess patients for adverse effects. Only, 4 (2.5%) and 6 (3.7%) of respondents routinely screen for osteoporosis and tuberculosis respectively. Less than 44% and 22% routinely screen for drug-drug interaction and CS complications respectively. Conclusion: There is low level of knowledge regarding the use and monitoring of CS in Maiduguri.

FC 132SHORT COURSE DAILY LOW-DOSE PREDNISOLONE AT THE TIME OF UPPER RESPIRATORY TRACT INFECTION (URTI) IN NON-SELECTED CHILDREN WITH RELAPSING STEROID SENSITIVE NEPHROTIC SYNDROME DOES NOT PREVENT URTI-RELATED RELAPSE: THE PREDNOS 2 TRIAL

Abstract Background and Aims At least 80% of children with steroid sensitive nephrotic syndrome (SSNS) have relapses and many are triggered by upper respiratory tract infections (URTIs). Previous small studies (4 studies, 232 patients in total), mostly in children already taking maintenance corticosteroid in countries where URTI epidemiology is different to Europe, showed that giving daily low-dose prednisolone for 5-7 days during an URTI reduces the risk of relapse. The objective of the PREDNOS 2 trial was to determine if these findings were replicated in a large UK population of children with relapsing SSNS on different background medication or none. Method A randomised, double-blind, placebo-controlled trial, including a model-based economic evaluation was carried out in 122 UK paediatric departments. Between February 2013 and January 2019, 365 children with relapsing SSNS (mean age: 7.6 ± 3.5 y) were recruited from 91 sites and randomised (1:1) according to a minimisation algorithm based on background treatment (no background treatment; low-dose prednisolone only; low-dose prednisolone and other immunosuppression; other immunosuppression only). At the start of an URTI, children received 6 days of prednisolone 15 mg/m2 or matching preparation of placebo. Those already taking alternate day prednisolone rounded their daily dose using trial medication to the equivalent of 15 mg/m2 or their alternate-day dose, whichever was the greater. The primary outcome was the incidence of first URTI-related relapse (URR) following any URTI over 12 months. Secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention to treat. The economic evaluation used trial data and a decision-analytic model to estimate Quality-Adjusted-Life-Years (QALYs) and costs at 1-year, which were then extrapolated over 16 years. Results 80 children completed 12 m follow-up without an URTI. Consent was withdrawn for 32 children, 14 prior to an URTI, leaving a modified intention to treat analysis population of 271 children (134 and 137 in prednisolone and placebo arms respectively). There were 384 URTIs and 82 URRs in the prednisolone arm, and 407 URTIs and 82 URRs in the placebo arm. The number of patients experiencing a URR was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms respectively (adjusted risk difference: -0.024, 95% CI: -0.14 to 0.095; P=0.7). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. A post-hoc subgroup analysis assessing primary outcome in 58 children of South Asian ethnicity (RR 0.66, 95% CI: 0.396 to 1.105) versus 213 of other ethnicity (RR 1.11, 95% CI: 0.806 to 1.535) showed possible efficacy of intervention in those of South Asian ethnicity (test for interaction P=0.09). Giving daily prednisolone at the time of an URTI was found to increase QALYs and decrease overall costs, when compared to standard care, a finding that was robust to sensitivity analysis. Conclusion In a large and methodologically-robust study, PREDNOS 2 has shown that giving 6 days of daily low-dose prednisolone at the time of an URTI does not reduce the risk of relapse of nephrotic syndrome in UK children, but could offer a cost-effective use of health care resources. Further work is needed to investigate inter-ethnic differences in treatment response, and the pathogenesis of individual viral infections and their effect on nephrotic syndrome.

Corticosteroids Replacement in a Patient With Panhypopituitarism and COVID-19 Infection

Background: Hypopituitarism refers to complete or partial insufficiency of pituitary hormone secretion and patients require lifelong hormone replacement. Those with ACTH deficiency rely on exogenous glucocorticoids and at times of intercurrent illness require stress doses to prevent an adrenal crisis. The benefits and adverse effects of corticosteroids for treatment of COVID-19 pneumonia are currently under investigation. We report our experience in a patient with COVID-19 pneumonia who received high dose corticosteroids for panhypopituitarism. Clinical Case: A 51-year-old man presented with one-week history of fever and generalized weakness. He had been diagnosed with a non-functional pituitary macro-adenoma causing panhypopituitarism 1 year ago when he developed generalized tonic-clonic seizures. He underwent trans-sphenoidal resection of the pituitary adenoma. However, he then discontinued his hormonal therapy and was lost to follow up. He had postural hypotension but was not tachypneic or hypoxemic. He tested positive for COVID-19 and chest x-ray showed prominent bilateral broncho-vascular markings; he was hospitalized as mild COVID-19 pneumonia. Laboratory investigations revealed secondary adrenal insufficiency, secondary hypothyroidism and hypogonadotropic hypogonadism. MRI of the pituitary now showed persistence of the pituitary macroadenoma, measuring 3.5 x 3.7 x 2.4 cm in dimensions, causing sellar obliteration and left cavernous sinus invasion. Treatment with stress dose steroids, Hydrocortisone 50 mg 4 times daily was initiated, followed by thyroid hormone replacement with Levothyroxine 125 mcg daily. He also received antivirals andsupportive care for COVID-19, guided by local hospital protocol. After significant clinical improvement, steroids were tapered down and he was discharged on a maintenance dose of 20 mg hydrocortisone per day in divided doses. The patient was stable at outpatient follow up after one month. He was started on testosterone replacement for erectile dysfunction due to hypogonadotropic hypogonadism. He was offered surgery for complete resection of the residual pituitary adenoma, but he declined and preferred to continue medical therapy. Conclusion: Hypopituitarism is associated with significant morbidity and premature mortality, a key risk factor being cortisol deficiency. Adrenal crisis is a life-threatening medical emergency and remains an important cause of death in patients with adrenal insufficiency. These patients are also vulnerable to develop severe complications from COVID-19 infection due to the absence of normal cortisol responses to stress. Despite receiving stress dose corticosteroids, this high-risk patient recovered from COVID-19 pneumonia without complications. These findings support the use of corticosteroids when necessary for treatment of coexisting conditions in patients with COVID-19.

Comparison of the effects of corticosteroid and hyaluronic acid-carboxymethylcellulose solution on selective nerve root block for lumbar radiculopathy: A prospective, double-blind, randomized controlled clinical trial.

Selective nerve root block (SNRB) was shown to effectively control radiating pain and reduce the need for surgical intervention. However, repetitive injections may trigger corticosteroid-induced side effects (hypercorticism, hyperglycemia, or fluid retention). This study aims to compare the potency of hyaluronic acid-carboxymethylcellulose (HA-CMC) solution versus that of corticosteroids regarding lower leg radiating pain (LLRP) improvement and functional outcome. Among 128 patients, 44 patients who complain about having LLRP due to lumbar spinal stenosis and do not have neurological symptoms requiring surgery were enrolled for this study. Group A with 22 patients injected with cocktail A (local anesthetics and corticosteroid) and group B with 22 patients injected with cocktail B (local anesthetics and HA-CMC). Outcome measures were the visual analog scale (VAS), Oswestry Disability Index (ODI), and short form-36 (SF-36). All patients were asked to fill in the questionnaires during the follow-up assessment period at 3days, 7days, 2weeks, 6weeks, and 12weeks. In all time periods, there were no statistical differences between the two groups for VAS scores and VAS improvement over time, ODI scores and ODI improvement over time, and SF-36 PCS scores and SF-36 mental component score scores. Additionally, the 95% confidence interval of the difference in VAS score improvement between the 2 groups in all time periods was within VAS 5.0, which is the minimum clinically relevant difference. Considering the adverse effects of corticosteroids, and the similar LLRP improvements, functional outcome, and quality of life, the HA-CMC solution may be an alternative option to corticosteroid in SNRB.

Perception of burden of oral and inhaled corticosteroid adverse effects by asthmatic patients

Patient perceptions of oral and inhaled corticosteroid (OCS and ICS) adverse effects (AEs) may influence their compliance to these therapies for asthma. However, AE burden has yet to be fully elucidated in an asthmatic population. We sought to characterize the level of burden from OCS and ICS AEs within this population.

Awareness of corticosteroids’ side effects among attendees in King Fahad Specialist Hospital, Buraydah city, Saudi Arabia

Background: Corticosteroids “steroids” are anti-inflammatory drugs prescribed to reduce inflammation and suppress the immune system in many conditions such as asthma, allergic rhinitis, systemic lupus erythematosus, urticaria, inflammatory bowel diseases, inflamed joints. Steroids are one of the most widely prescribed drugs. Despite its severe side effects, only a few studies have been reported the severity of the problem and the awareness of the patients in Saudi Arabia. This study primarily is focused on assessing understanding for corticosteroid users or non-user about corticosteroids’ adverse effects with different usage of dosage forms among attendees in King Fahad Specialist Hospital (KFSH) in Buraydah city. Methods: A cross-sectional survey was conducted. Convenient sampling was taken from attendees in KFSH in Buraydah city. The sample consisted of users and non-users for the corticosteroids drugs in any form, whether in outpatient or inpatients or visitors. Results: Overall, in our study, we found a low level of awareness among attendees “users and non-users” in KFSH about the adverse effects of corticosteroids, and the awareness of users was higher than non-users. Conclusion: Corticosteroid therapy is essential in clinical practice, yet it can have significant side effects if misused. Overall, we discovered that attendees at KFSH had a poor level of awareness of corticosteroids’ side effects; additionally, users were more aware of side effects than non-users, and the incidence of the disease will increase awareness about side effects. Younger age groups were more aware, and there was minimal variation of understanding in gender.