Oral Corticosteroid Prescriptions Research Articles

Risk of opportunistic infections in patients with antineutrophil cytoplasmic antibody-associated vasculitis, using a Japanese health insurance database.

Opportunistic infections (OIs) adversely affect outcomes in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). This study aimed to identify the incidence proportion of risk factors for OIs in patients with AAV who were on remission-induction therapy, using a Japanese health insurance database. This retrospective longitudinal population-based study was conducted using claims data provided by Medical Data Vision Co., Ltd. We defined individuals as AAV cases receiving remission-induction therapy if they met all of the following criteria: (a) having OIs with at least 1 specified International Statistical Classification of Diseases and Related Health Problems, 10th Revision code (M300, M301, M313, or M318); (b) receiving at least 1 prescription of oral corticosteroids (CS) with prednisolone (PSL)-equivalent dosage ≥30mg/d, CS pulse therapy, immunosuppressive agents or rituximab during hospitalization between April 2008 and April 2017; and (c) at least 7days of hospitalization while on the above-mentioned therapies. We calculated incidence and proportion of OIs during the year following remission-induction therapy and the adjusted odds ratio (OR) using a logistic regression model. We included 2299 patients with AAV in this study. OIs occurred in 460 patients (20.0%), with the most frequently occurring OI being cytomegalovirus infection (n=122, 6.5%). After adjusting for covariates, age by decade (OR 1.24, 95% CI: 1.12-1.36), daily PSL dose per 10mg (OR 1.16, 95% CI: 1.08-1.25), and CS pulse therapy (OR 1.29, 95% CI: 1.04-1.60) were found to be significantly associated with occurrence of OIs. Older age and corticosteroid use were found to be significant risk factors for OIs in patients with AAV on remission-induction therapy, using a health insurance database.

Comparative effectiveness of triple therapy versus dual bronchodilation in COPD.

This real-world study compared the effectiveness of triple therapy (TT; long-acting muscarinic antagonists (LAMAs)/long-acting inhaled β-agonists (LABAs)/inhaled corticosteroids (ICSs)) versus dual bronchodilation (DB; LAMAs/LABAs) among patients with frequently exacerbating COPD. A matched historical cohort study was conducted using United Kingdom primary care data. Patients with COPD aged ≥40 years with a history of smoking were included if they initiated TT or DB from no maintenance/LAMA therapy and had two or more exacerbations in the preceding year. The primary outcome was time to first COPD exacerbation. Secondary outcomes included time to treatment failure, first acute respiratory event, and first acute oral corticosteroid (OCS) course. Potential treatment effect modifiers were investigated. In 1647 matched patients, initiation of TT reduced exacerbation risk (adjusted hazard ratio (HR) 0.87, 95% CI 0.76–0.99), risk of acute respiratory event (HR 0.74, 95% CI 0.66–0.84) and treatment failure (HR 0.83, 95% CI 0.73–0.95) compared with DB. Risk reduction for acute respiratory events was greater for patients with higher rates of previous exacerbations. At baseline blood eosinophil counts (BECs) ≥ 0.35×109 cells·L−1, TT was associated with lower risk of OCS prescriptions than DB. This study provides real-life evidence of TT being more effective in reducing exacerbation risk than DB, which became more accentuated with increasing BEC and previous exacerbation rate.

PRS51 THREE METHODS FOR DEFINING ASTHMA EXACERBATIONS IN REAL-WORLD DATA

Asthma exacerbations are a primary research endpoint due to the associated cost burden. The generally accepted claims-based algorithm for identifying exacerbations (non-hospitalized) consists of an office visit with an asthma diagnosis and an oral corticosteroid prescription ±7 days of the visit. However, physician-administered biologic therapies for asthma pose specific challenges to this algorithm, due to requiring scheduled visits for administration. We evaluated 2 adjustments to the standard definition to exclude scheduled visits for biologic administration. A retrospective cohort study of commercially insured patients using omalizumab, the biologic with most market exposure, was conducted using medical/pharmacy claims 11/1/14 - 9/30/17. Inclusion criteria were 12-months of continuous enrolment in the year prior to (baseline) and post (follow-up) the 1st administration, age ≥12, asthma diagnosis during baseline, and ≥2 doses of omalizumab. Patients administered another asthma biologic were excluded. A post-hoc analysis was conducted using 2 adjustments with increasing refinement to the standard exacerbation definition (#1) which does not exclude scheduled visits; (#2) excluding visits using the omalizumab J-code; and (#3) excluding visits within 28 days of omalizumab administration due to the usual 4-week dosing schedule. 799 patients were identified. Using approach #1, 71.0% of patients in the baseline vs. 63.5% in follow-up had ≥1 asthma exacerbation with a mean(±SD) of 1.7 (1.8) vs. 1.7 (2.1), resulting in no reduction in the exacerbation rate (p=0.837). Using approach #2, 59.6% of patients had ≥1 asthma exacerbation with a mean of 1.5(1.9), resulting in an 11.8% reduction in exacerbation rate (p=0.030). For approach #3, 55.2% of patients had ≥1 asthma exacerbation with a mean of 1.2(1.7), resulting in a 29.4% reduction in exacerbation rate (p<0.001). These findings demonstrate that the standard approach for identifying asthma exacerbations for biologic therapies may result in an overestimate of exacerbations due to including scheduled visits for biologic administration.

Explainable AI in Healthcare

The traditional cardiology prediction model includes factors like age, total cholesterol, HDL cholesterol, smoking, blood pressure, and diabetes. But the machine algorithms turned up a wider array of factors in their models, including: COPD, severe mental illness, prescription of oral corticosteroids, triglyceride levels, atrial fibrillations, chronic kidney disease, and rheumatoid arthritis. Allowing machines to learn risk factors in a huge number of patients makes for better predictions of heart attacks. Machine-learning significantly improves accuracy of cardiovascular risk prediction, increasing the number of patients identified who could benefit from preventive treatment, while avoiding unnecessary treatment of others. However, the use of machine learning algorithms has been limited due to the lack of interpretability of more complex models, reducing the trust of users in the model. The solution to the limitation of the ‘black-box’ nature of machine-learning algorithms, in particular neural networks, which are difficult to interpret, the inherent complexity in how the risk factor variables are interacting and their independent effects on the outcome is achieved through explainable AI.

Implementing a quality improvement initiative for the management of chronic obstructive pulmonary disease in rural Nepal

BackgroundChronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal...

Preoperative and postoperative medical therapies for chronic rhinosinusitis: National surveys among Chinese otolaryngologists.

ObjectiveThe aim of this study was to evaluate clinical practice patterns of preoperative and postoperative medical therapies immediately surrounding sinus surgery for chronic rhinosinusitis (CRS) by Chinese otolaryngologists.MethodsTwo anonymous web-based surveys of preoperative and postoperative medical therapies were performed. These surveys assessed the frequency of prescription of oral corticosteroids, intranasal corticosteroid sprays, oral antibiotics, nasal saline irrigation, oral antihistamines, nasal antihistamines, anti-leukotriene agents, topical decongestants and oral mucolytics.ResultsA total of 304 (17.5%) preoperative and 143 (23.5%) postoperative questionnaires were completed and returned. Seventy-eight percent, 63% and 56% of respondents used preoperative intranasal corticosteroid sprays, oral antibiotics and oral mucolytics “always or often”, respectively. Ninety-four percent, 93%, 72% and 69% of respondents used postoperative intranasal corticosteroid sprays, nasal saline irrigation, oral antibiotics and oral mucolytics “always or often”, respectively. Oral antihistamines, nasal antihistamines, anti-leukotrienes and topical decongestants were not commonly used preoperatively or postoperatively.ConclusionsOur study demonstrated that current practice patterns of preoperative medical therapies among otolaryngologists are not uniformly based on evidence-based outcomes research. Postoperative oral antibiotics, intranasal corticosteroid sprays, nasal saline irrigation and oral mucolytics are commonly used by a majority of Chinese otolaryngologist for CRS. Practice patterns of postoperative medical therapy reflect recent guidelines.

Matched cohort study of therapeutic strategies to prevent preschool wheezing/asthma attacks.

BackgroundAn inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent wheezing/asthma attacks in preschoolers with recurrent wheeze when added to short-acting β-agonist (SABA).ObjectiveThe aim of this historical matched cohort study was to assess the effectiveness of these treatments for preventing wheezing/asthma attacks.MethodsElectronic medical records from the Optimum Patient Care Research Database were used to characterize a UK preschool population (1–5 years old) with two or more episodes of wheezing during 1 baseline year before first prescription (index date) of ICS or LTRA, or repeat prescription of SABA. Children initiating ICS or LTRA on the index date were matched 1:4 to those prescribed only SABA for age, sex, year of index prescription, mean baseline SABA dose, baseline attacks, baseline antibiotic prescriptions, and eczema diagnosis. Wheezing/asthma attacks (defined as asthma-related emergency attendance, hospital admission, or acute oral corticosteroid prescription) during 1 outcome year were compared using conditional logistic regression.ResultsMatched ICS and SABA cohorts included 990 and 3,960 children, respectively (61% male; mean [SD] age 3.2 [1.3] years), and matched LTRA and SABA cohorts included 259 and 1,036 children, respectively (65% male; mean [SD] age 2.6 [1.2] years). We observed no significant difference between matched cohorts in the odds of a wheezing/asthma attack: ICS vs SABA, OR (95% CI) 1.01 (0.85–1.19) and LTRA vs SABA, OR (95% CI) 1.28 (0.96–1.72).ConclusionWe found no evidence that initiation of ICS or LTRA therapy is associated with fewer attacks during 1 outcome year than SABA alone for a heterogeneous group of preschool children with recurrent wheeze in the real-life clinical setting.

Case-control study examining the association between herpes zoster and oral corticosteroids use in older adults.

Little research focuses on the association between herpes zoster and oral corticosteroids use in older adults. The aim of the study was to explore this issue. We performed a case-control study using the database of the Taiwan National Health Insurance Program. There were 10,912 participants aged 65years and older with newly diagnosed herpes zoster in 2000-2013 as the cases. We randomly selected 42,676 sex-matched and age-matched participants without herpes zoster as the controls. Ever use of oral corticosteroids was defined as participants who at least had a prescription for oral corticosteroids before the index date. Never use was defined as participants who did not have a prescription for oral corticosteroids before the index date. The odds ratio (OR) and 95% confidence interval (CI) for herpes zoster associated with oral corticosteroids use were estimated using the logistic regression model. The adjusted OR of herpes zoster was 3.13 for participants with ever use of oral corticosteroids (95% CI 2.84-3.46), compared with never use. In a further analysis, the adjusted ORs of herpes zoster were 3.10 for cumulative duration of oral corticosteroids use < 12months (95% CI 2.81-3.42) and 3.65 for cumulative duration ≥ 12months (95% CI 3.20-4.18). Older adults with oral corticosteroids use are associated with a threefold increase in odds of herpes zoster in Taiwan. There is a duration-related effect of oral corticosteroids use on the risk of herpes zoster.

Incorporation of antibiotics and systemic steroids by sinus surgeons: is there widespread consensus?

The objective of this work was to evaluate factors associated with antibiotic and oral corticosteroid (OCS) prescription among otolaryngologists regularly performing sinus surgery. Fellowship-trained rhinologists, including fellowship directors, were identified via the American Rhinologic Society (ARS) website. Non-fellowship-trained otolaryngologists performing ≥25 balloons (frontal/maxillary) or ≥25 functional endoscopic sinus surgeries (FESSs) (frontal/maxillary/ethmoids) were also included in "balloon surgeons" and "sinus surgeon" cohorts, respectively. Prescribing data for Medicare Part D beneficiaries was obtained for 2015. Otolaryngologists included in this analysis wrote a median of 54 scripts for antibiotics, with a 15.1% antibiotic prescription rate. The overall script length per antibiotic was 11.1 days. Of fellowship-trained rhinologists, 90.2% wrote fewer than 100 scripts, compared to 25.6% and 32.5% of sinus surgeons and balloon surgeons, respectively. Fellowship-trained rhinologists wrote lengthier antibiotic scripts (14.1 vs 10.3 days, p < 0.05). Clinicians who have been in practice longer prescribed antibiotics significantly more frequently. Fellowship-trained rhinologists had a greater OCS rate (8.9%) than balloon and sinus surgeons (7.1%), also writing lengthier courses (15.0 vs 8.1 days). Early-career otolaryngologists wrote lengthier steroid prescriptions than those with 11 to 20 years and >20 years in practice. Antibiotic and OCS utilization varies by type of training, as non-fellowship-trained sinus surgeons and balloon surgeons tend to utilize antibiotics more aggressively, and fellowship-trained rhinologists utilize OCS more frequently. Otolaryngologists with more years in practice are more likely to incorporate antibiotics in the management of sinus disorders, although these conclusions must be considered in the context of this resource's limitations. Further clarification of guidelines may be helpful for minimizing divergent practices and maintaining a consensus.

Severe, eosinophilic asthma in primary care in Canada: a longitudinal study of the clinical burden and economic impact based on linked electronic medical record data

BackgroundStratification of patients with severe asthma by blood eosinophil counts predicts responders to anti-interleukin (IL)-5 (mepolizumab and reslizumab) and anti-IL-5 receptor α (benralizumab) therapies. This study characterized patients with severe asthma who could qualify for these biologics in a primary care setting.MethodsWe retrospectively selected patients from July 1, 2010, to June 30, 2014, using a linked electronic medical records (EMR) database (IMS Evidence 360 EMR Canada) for > 950,000 patients in primary care in Ontario, Canada. Patients aged ≥ 12 years with ≥ 2 documented asthma diagnoses were identified as having severe asthma based on prescriptions for high-dosage inhaled corticosteroids (ICS) plus either a leukotriene receptor antagonist, long-acting β2-agonist (LABA), or theophylline filled on the same day. Patients’ asthma was considered severe also if they received a prescription for ICS with oral corticosteroids (OCS) or an additional prescription for omalizumab. Patient characteristics, asthma-related medications, and blood eosinophil counts were captured using observed care patterns for the year prior to ICS/LABA and/or OCS prescription. Health care resource use (HCRU) and costs were captured throughout the 1-year follow-up period.ResultsWe identified 212 patients who met the criteria for severe asthma. These patients required an average of 6.5 physician visits during the 1-year follow-up period (95% confidence interval 5.7–7.3), and 20 (9%) were referred to respiratory specialists. Overall, 56 patients (26%) with severe asthma had complete blood counts, of whom 23 (41%) had blood eosinophil counts ≥ 300 cells/μL and might be considered for anti-eosinophil therapies. Patients with severe asthma and blood eosinophil counts ≥ 300 cells/μL had more respiratory specialist referrals (17% vs. 12%) than patients with blood eosinophils < 300 cells/μL.ConclusionsOur data suggest that during 2010–2014, Ontario primary care patients with severe asthma and high blood eosinophil counts had greater HRCU than those with lower counts. Approximately 41% of patients with severe asthma could qualify for anti-eosinophil drugs based on blood eosinophil counts. However, the eosinophilic status of most patients was unknown. It is appropriate to increase awareness of the use of blood eosinophil counts to identify patients who could be considered for anti-eosinophil therapies.

Asthma control, lung function, symptoms, and corticosteroid sparing after omalizumab initiation in patients with allergic asthma.

Omalizumab is approved in patients with moderate-to-severe allergic asthma with symptoms uncontrolled, despite the mainstay therapy. Electronic medical records (EMR) were used to increase the knowledge of omalizumab effectiveness in a real-world setting. Patients with uncontrolled moderate-to-severe allergic asthma, ages ≥12 years old, initiated on omalizumab (index date), with ≥12 months of pre- and postindex data, were identified in an EMR data base. An Asthma Control Test score (≥20 is considered well controlled), forced expiratory volume in 1 second as a percentage of the predicted value (<80% considered below normal), symptoms, and oral corticosteroid (OCS) and inhaled corticosteroid (ICS) use were compared in the 12-month post- versus the preindex period with univariate generalized estimating equations adjusted for repeated measurements. A total of 208 patients (mean ± standard deviation[SD] age, 41 ± 19 years; 64.9% women; 71.2% white; and with a mean ± SD serum total immunoglobulin E level of 455.4 ± 644.7 IU/mL) were identified. In the post- versus preindex period, the patients were significantly more likely to have well-controlled asthma (odds ratio [OR] 1.72 [95% confidence interval {CI}, 1.11-2.64]) and less likely to have a lung function value below normal (nonsignificant) after omalizumab initiation. The patients experienced significantly less coughing (OR 0.66 [95% CI, 0.49-0.91]), shortness of breath (OR 0.60 [95% CI, 0.44-0.83]), and wheezing (OR 0.59 [95% CI, 0.43-0.81]), with no improvement in chest tightness. A significantly lower likelihood of new OCS prescriptions (OR 0.58 [95% CI, 0.41-0.82]) was observed. A lower likelihood of new high- and medium-dose ICS prescriptions was nonsignificant. Omalizumab was associated with beneficial effects on asthma control and symptoms, and the likelihood of requiring new OCS prescriptions. An observed trend of improved lung function and lower likelihood of requiring high- and medium-dose ICS did not reach statistical significance.

The effect of DPP-4 inhibitors on asthma control: an administrative database study to evaluate a potential pathophysiological relationship.

RationaleDPP-4 may regulate immunological pathways implicated in asthma. Assessing whether DPP-4 inhibitor (DPP-4i) use might affect asthma control is clinically important because DPP-4i use in type 2 diabetes mellitus management (T2DM) is increasing. This study evaluated associations between DPP-4i use and asthma control.MethodsThis was a retrospective, observational, matched cohort study using administrative claims in the MarketScan® Commercial Claims and Encounters (Commercial) and Medicare Supplemental and Coordination of Benefits (Medicare Supplemental) databases. Adult asthma patients initiating an oral DPP-4i or a non-DPP-4i between November 1, 2006 and March 31, 2014 were included. Patients were followed for asthma-related outcomes for 12 months after initiation of the antidiabetes medication. Outcomes included risk-domain asthma control (RDAC), defined as no asthma hospitalizations, no lower respiratory tract infections, and no oral corticosteroid (OCS) prescriptions; overall asthma control (RDAC criteria plus limited short-acting beta agonist use); treatment stability (RDAC criteria plus no increase of ≥50% in inhaled corticosteroid dose or addition of other asthma therapy); and severe asthma exacerbation rates (asthma-related hospitalizations, emergency room visits, or acute treatments with OCS). Comparisons were made between two matched cohorts (DPP-4i vs. non-DPP-4i initiators) using multivariable logistic regression and generalized linear modeling. Covariates included baseline demographic and clinical characteristics related to asthma and T2DM.ResultsThe adjusted odds of achieving RDAC (odds ratio [OR]: 1.05; 95% CI: 0.964 to 1.147), overall asthma control (OR: 1.04; 95% CI: 0.956 to 1.135), and treatment stability (OR: 1.04; 95% CI: 0.949 to 1.115) did not differ between the DPP-4i and non-DPP-4i cohorts. A difference was not found between cohorts in severe asthma exacerbation rates during the 12 months following initiation of antidiabetes treatment (mean = 0.32 vs. 0.34 exacerbations per subject-year, respectively; p=0.064).ConclusionAsthma control was similar between patients initiating DPP-4i and non-DPP-4i antidiabetes medications, suggesting no association between DPP-4i use and asthma control.

Use of Oral Corticosteroids and Risk of Hip Fracture in the Elderly in a Case-Control Study.

Aim: Little is known regarding the relationship between use of oral corticosteroids and hip fracture in the elderly in Taiwan. The aim of the study was to examine this issue.Methods: A retrospective population-based case-control study using the database of the Taiwan National Health Insurance Program (2000–2013) was conducted. We identified 4538 individuals aged ≥ 65 years with newly diagnosed hip fracture as the cases. We randomly selected 4538 individuals without hip fracture as the control subjects. The cases and the control subjects were matched with sex, age, comorbidities, and the year of index date. Individuals who never had a prescription for oral corticosteroids were defined as never use. Individuals who ever had at least one prescription for oral corticosteroids were defined as ever use. The odds ratio (OR) and 95% confidence interval (CI) of hip fracture associated with oral corticosteroids use was estimated by a multivariable unconditional logistic regression analysis.Results: After adjustments for potential confounding factors, the multivariable logistic regression model showed that the adjusted OR of hip fracture was 1.17 for individuals with ever use of oral corticosteroids (95%CI 1.08, 1.28), compared to those with never use of oral corticosteroids. An sub-analysis showed that for every 1-mg increase in cumulative dose of oral corticosteroids, the adjusted OR of hip fracture was 1.01 (95% CI 1.01, 1.02). The adjusted ORs were 1.31 (95% CI 1.17, 1.47) for cumulative exposure to oral corticosteroids ≥ 3 months and 1.09 (95% CI 0.98, 1.20) for cumulative exposure < 3 months.Conclusion: We conclude that oral corticosteroids use is associated with a trivial but statistically significant increase in risk of hip fracture in Taiwan. Additionally, the results suggest that there are dose-response and duration-response effects of oral corticosteroids on the risk of hip fracture. The results confirm our understanding of oral corticosteroid-associated hip fracture in the elderly.

Comorbidities in Difficult-to-Control Asthma

Difficult-to-control asthma is associated with significant medical and financial burden. Comorbidities are known to contribute to uncontrolled asthma. Better insight into the prevalence, nature, and risk factors of comorbidities may optimize treatment strategies in patients with difficult-to-control asthma and decrease disease burden. The objectives of this study were to assess the prevalence, number, and type of comorbidities in difficult-to-control asthma compared with not-difficult-to-control asthma, and to investigate whether specific patient characteristics are associated with particular comorbidities. A total of 5,002 adult patients with a prescription for high-dose (>1,000 μg) fluticasone or oral corticosteroids, extracted from 65 Dutch pharmacy databases, were sent questionnaires about patient characteristics. Of the 2,312 patients who returned the questionnaires, 914 were diagnosed with difficult-to-control asthma. Diagnoses of comorbidities (gastroesophageal reflux, nasal polyps, cardiovascular disease, anxiety/depression, obesity, and diabetes) were based on treatment prescriptions or questionnaires. Associations were assessed using multivariable logistic regression analyses. A total of 92% of patients with difficult-to-control asthma had ≥1 comorbidity. Patients with difficult-to-control asthma had more comorbidities (mean ± SD comorbidities 2.22 ± 1.27 vs 1.69 ± 1.32; P < .01), and a significantly higher prevalence of each comorbidity, compared with patients with not-difficult-to-control asthma, except for diabetes and nasal polyposis. Comorbidities were associated with specific patient characteristics, including older age, female gender, smoking history, and chronic prednisone use. Almost all patients with difficult-to-control asthma have comorbidities, in particular asthmatic women of older age, former smokers, and asthmatics who are prednisone dependent. Recognition of these typical characteristics can help physicians in the diagnostic workup, so that adequate preventive measures can be taken.

Prescription of oral short-acting beta 2-agonist for asthma in non-resource poor settings: A national study in Malaysia.

ObjectiveUse of oral short-acting beta 2-agonist (SABA) persists in non-resource poor countries despite concerns for its lower efficacy and safety. Utilisation and reasons for such use is needed to support the effort to discourage the use of oral SABA in asthma. This study examined the frequency of oral short-acting Beta 2-agonist (SABA) usage in the management of asthma in primary care and determined correlates of its usage.MethodsData used were from the 2014 National Medical Care Survey in Malaysia, a nationally representative survey of primary care encounters (weighted n = 325818). Using methods of analysis of data for complex surveys, we determined the frequency of asthma diagnosis in primary care and the rate of asthma medication prescription, which includes oral SABA. Multivariate logistic regression models were built to assess associations with the prescription of oral SABA.ResultsA weighted estimate of 9241 encounters presented to primary care with asthma in 2014. The mean age of the patients was 39.1 years. The rate of oral SABA, oral steroids, inhaled SABA and inhaled corticosteroids prescriptions were 33, 33, 50 and 23 per 100 asthma encounters, respectively. It was most commonly used in patients with the age ranged between 20 to less than 40 years. Logistic regression models showed that there was a higher odds of oral SABA usage in the presence of respiratory infection, prescription of oral corticosteroids and in the private sector.ConclusionOral SABA use in asthma is found to be common in a non- resource poor setting and its use could be attributed to a preference for oral medicines along undesirable clinical practices within a fragmented health system.

Nation-based case-control study investigating the relationship between oral corticosteroids use and pulmonary tuberculosis

Background and objectiveNo published formal study focuses on the relationship between oral corticosteroids use and pulmonary tuberculosis in Taiwan. The aim of the study was to investigate whether oral corticosteroids use was associated with increased odds of pulmonary tuberculosis. MethodsThe retrospective, nation-based, case-control study was conducted to analyze the database of the Taiwan National Health Insurance Program between 2000 and 2013. Subjects aged 20 to 84years with newly diagnosed pulmonary tuberculosis were defined as the cases (n=6021). Randomly selected subjects without pulmonary tuberculosis aged 20 to 84years were defined as the controls (n=6021). Subjects who never had a prescription for oral corticosteroids were defined as never use. Subjects who ever had a prescription for oral corticosteroids were defined as ever use. ResultsAfter adjustment for confounders, the adjusted odds ratio of pulmonary tuberculosis was 1.91 for subjects with even use of oral corticosteroids (95% confidence interval 1.73, 2.11), comparing with never use. The adjusted odds ratio of pulmonary tuberculosis was 1.03 for subjects with increasing cumulative dose of oral corticosteroids for per milligram (95% confidence interval 1.02, 1.03), comparing with never use. In addition, the adjusted odds ratios of pulmonary tuberculosis were 1.83 (95% CI 1.65, 2.02) for subjects with cumulative duration of oral corticosteroids<3months, and 2.12 (95% CI 1.87, 2.40) for subjects with cumulative duration≥3months, comparing with never use. ConclusionThough the finding is not unexpected, use of oral corticosteroids is significantly associated with 1.9-fold increased odds of pulmonary tuberculosis, independent of other risk comorbidities. There are dose-dependent and duration-dependent effects of oral corticosteroids use on the risk of pulmonary tuberculosis.

Oral corticosteroid exposure and adverse effects in asthmatic patients

Significant adverse effects (AEs) have been associated with continuous exposure to oral corticosteroids (OCSs). The potential association with intermittent exposure is unknown. We sought to assess the association between OCSs and AEs based on the number of OCS prescriptions. This was a retrospective cohort study of asthmatic patients 18years and older in the 2000-2014 MarketScan data set. Propensity score matching was used at baseline (12months before the index date: first OCS use). Logistic regression was used to examine the association between OCSs and new incident AEs (either combined or individual) controlling for covariates. Follow-up continued for 24months minimum and 10years maximum after the index date. There were 72,063 and 156,373 subjects in the OCS and no OCS cohorts, respectively. Subjects taking 4 or more OCS (1-3) prescriptions within the year had 1.29 (1.04) times the odds of experiencing a new AE within the year. Each year of exposure to 4 or more OCS prescriptions (current and past) resulted in 1.20 times the odds of having an AE in the current year. Exposure to 4 or more prescriptions was associated with significantly greater odds of AEs for osteoporosis, hypertension, obesity, type 2 diabetes, gastrointestinal ulcers/bleeds, fractures, and cataracts (odds, 1.21-1.44 depending on the AE). Although previous research has documented the deleterious effect of continuous OCS exposure in patients with severe asthma, our results suggest that each OCS prescription might result in a cumulative burden on current and future health regardless of dose and duration. OCS-sparing strategiesare extremely important to improve patient outcomes.

Association between Postdischarge Oral Corticosteroid Prescription Fills and Readmission in Children with Asthma

To assess the relationships between postdischarge emergency department visits, oral corticosteroid (OCS) use, and 15- to 90-day asthma readmission in children. Retrospective study of 9288 children from 12 states in the Truven MarketScan Database, ages 2-18 years, hospitalized between January 1, 2009, and June 30, 2011, with asthma, and continuously enrolled in Medicaid for 6 months prior and 3 months after hospitalization. The primary outcome was 15- to 90-day readmission for asthma. Secondary outcomes were postdischarge emergency department visits (within 28 days) and outpatient OCS prescription fills (6-28 days postdischarge or earlier if coinciding with an outpatient asthma visit). Logistic regression was used to assess the relationship of hospital readmission with patient characteristics and asthma health services surrounding the index admission. Median age at index admission was 6 years (IQR, 3-9); 62% were male and 49% were black; 2.8% had a 15- to 90-day readmission (median, 50 days; IQR, 32-70). After index discharge, 4% had an emergency department visit (median, 17 days; IQR, 12-24) and 11% had an outpatient OCS fill (median, 14 days; IQR, 6-21). In multivariable analysis, children with a postdischarge outpatient OCS fill (OR, 3.2; 95% CI, 2.4-4.6) or hospitalization within 6 months preceding the index admission (OR, 2.9; 95% CI, 2.0-4.0) had the greatest likelihood for hospital readmission. OCS fill within 28 days of hospital discharge was most strongly associated with 15- to 90-day hospital readmission. This finding may inform evolving strategies to reduce asthma readmissions in children.

Corticosteroid Usage Is Associated With Increased Artificial Urinary Sphincter Reoperation

To determine if oral corticosteroid use is associated with an increased risk of artificial urinary sphincter (AUS)-related reoperation. Administrative data from Ontario were used to conduct a retrospective cohort study. Men >65 years of age who underwent implantation of an AUS between 2002 and 2013 were included. Prescriptions for oral corticosteroids were identified, and men were considered exposed from the date the prescription was dispensed to 180 days after the expected end of the prescription. The primary outcome was AUS reoperation. Data were analyzed using a Cox proportional hazards model with corticosteroid usage modeled as a time-varying covariate. We identified 747 men who met our inclusion criteria (median age of 71 years; interquartile range [IQR]: 68-75), of which 592 (79.3%) had a prior radical prostatectomy. The median duration of follow-up was 3.2 years (IQR: 1.3-5.9). One hundred seventy-five (23.4%) patients were exposed to corticosteroids during the study period (median duration of use was 21 days; IQR: 5-100). We identified an AUS reoperation in 176 men (23.6%). After adjusting for age, radiation exposure, and year of implantation, exposure to corticosteroids was significantly associated with the risk of AUS reoperation (hazard ratio: 1.68, 95% confidence interval: 1.03-2.75, P = .04). Radiation after AUS implantation was also significantly associated with AUS reoperation (hazard ratio: 2.07, 95% confidence interval: 1.06-4.07, P = .03). There is a significantly increased risk of AUS reoperation among men using oral corticosteroids.

Exploring asthma control cutoffs and economic outcomes using the Asthma Control Questionnaire

BackgroundUnderstanding the effect of worsening asthma control on expenditures and health resource utilization (HRU) is important. ObjectiveTo explore the association of economic outcomes with asthma control cutoffs and longitudinal changes on the Asthma Control Questionnaire 5 (ACQ-5). MethodsThe Observational Study of Asthma Control and Outcomes was a survey of patients with persistent asthma who were patients of Kaiser Colorado, including claims-based HRU. Patients completed the ACQ-5 three times during 1 year between April 2011 and June 2012. The ACQ-5 cutoffs that indicated control were assessed in cross-sectional analyses. Longitudinal changes in control were explored: controlled (ACQ-5 score <0.75), indeterminate (ACQ-5 score 0.75 to <1.5), not well controlled (ACQ-5 score 1.5 to <3.0), and very poorly controlled (ACQ-5 score ≥3.0). Analyses used generalized linear models with log link (expenditures) and negative binomial regression (HRU). ResultsThere were 6,666 completed surveys (1,799 individuals completed all 3 survey waves). In the cross-sectional analyses, compared with an ACQ-5 score less than 0.5, individuals with ACQ-5 scores of 4 to 4.5 incurred 7.2 times the number of oral corticosteroid prescriptions, 4.3 times the number of emergency department visits, 6 times the number of inpatient visits, 10.4 times the number of asthma-specific emergency department visits, 4.58 times the number of asthma-specific inpatient visits, and $2,892 more in all-cause and $1,877 in asthma-specific expenditures during 4 months. In the longitudinal change analyses, individuals who improved from an ACQ-5 of 3.0 or greater to less than 0.75 incurred $6,023 less in asthma-specific expenditures during 4 months than those remaining at an ACQ-5 score of 3.0 or higher. ConclusionResults provide preliminary economic data on possible control cutoffs for the ACQ-5. Improving asthma control over time may result in significant savings that may justify financial investments designed to improve control.