Use Of Oral Prednisone Research Articles

Oral Prednisone Use Following Primary Total Knee Arthroplasty Does Not Increase Infections, but can be Associated With Higher Risk for Medical and Surgical Complications

BackgroundPostoperative use of oral prednisone to augment the effect of multimodal pain regimens after total knee arthroplasty (TKA) has increased in popularity. However, data on the risks of its utilization, especially as it relates to infection, have been lacking. We tested the null hypothesis that perioperative prednisone use is not associated with the incidence of surgical and medical complications after TKA. MethodsUsing a national administrative claims database, we identified 949,555 patients undergoing primary TKA. We excluded patients who filled oral prednisone prescriptions within 90 days prior to surgery or between 90 and 364 days after surgery. Patients who had acute prednisone use were defined as those who filled prednisone prescriptions only within 30 days after surgery. Outcomes consisted of surgical and medical complications after TKA. Multivariable logistic regression models were used to evaluate the association between acute prednisone use and complications, adjusting for age, sex, region, insurance plan, and Elixhauser comorbidities. ResultsPatients in the acute prednisone cohort had greater adjusted odds of subsequent manipulation under anesthesia (adjusted odds ratio [OR] = 1.23 [95% confidence interval {CI}: 1.09 to 1.38]; P < .001) and lysis of adhesions (adjusted OR = 1.58 [95% CI: 1.02 to 2.33]; P = .03) compared to patients who did not have acute prednisone use. Patients who had acute prednisone use also had greater adjusted odds of acute kidney injury (adjusted OR = 1.47 [95% CI: 1.25 to 1.71]; P < .001) and pneumonia (adjusted OR = 4.04 [95% CI: 3.53 to 4.59]; P < .001). There was no increased incidence of infection. ConclusionsPrednisone use shortly following TKA may be associated with a higher incidence of certain surgical and medical complications, but without increased risk for infection. However, given these risks, the optimal patient profile for postoperative prednisone use remains to be defined.

Effect of Oral Prednisone on the Prevention and Management of Proliferative Vitreoretinopathy After Open-Globe Injury.

Purpose: To determine the impact of oral prednisone on the final visual acuity (VA) and prevention of proliferative vitreoretinopathy (PVR) in patients having pars plana vitrectomy (PPV) for globe injuries. Methods: A retrospective chart review was performed of all globe injuries with an initial repair and subsequent PPV between 2009 and 2018. Data included the initial VA, zones of injury, initial closure date, time to secondary intervention (PPV), oral prednisone (1 mg/kg/day) use, the final VA, and enucleation rate. Multivariable regression models were used to assess the impact of oral prednisone use on anatomic and functional outcomes. Results: The mean (±SD) patient age was 46.25 ±18.56 years (range, 13-92); 131 (83.9%) were men. Oral prednisone intake was recorded in 81 patients (52.3%). The prednisone group had significantly more zone 3 involvement (P = .001), worse initial VA (2.28 vs 1.92 logMAR; P = .003), and a greater mean number of surgeries (P = .020) than the no-steroids (control) group but an equivalent final logMAR VA (1.57 vs 1.52; P = .881). The prednisone group had significant VA improvement (P = .025); however, oral prednisone use did not predict the development of PVR (29.23% vs 12.90%; odds ratio [OR], 2.81; 95% CI, 0.89-8.85) or retinal detachment (27.27% vs 29.58%; OR, 0.59; 95% CI, 0.23-1.56). Conclusions: Despite a worse initial clinical presentation, patients who received oral prednisone had significant visual improvement compared with the control group. However, oral prednisone (1 mg/kg/day) use at the time of injury did not decrease the PVR rate.

Comparison of prescribing patterns of non-physician clinicians and dermatologists in the Medicare population.

Non-physician clinicians (NPCs) are playing an increasing role in dermatologic patient care. This study expands upon existing workforce assessments of dermatology NPCs through the use of publicly-available Medicare datasets to better clarify prescribing patterns among independently-billing dermatology NPCs. The findings demonstrate prescribing similarities between NPCs and dermatologists for most medications, including biologic and immunosuppressive medications, although with higher use of oral prednisone, gabapentin, and hydroxyzine among NPCs. Dermatologists more frequently utilized high-potency topical steroids. These data provide initial insights into NPC prescribing patterns and should motivate further study of the identified differences and potential implications for patient care.

Effect of Omalizumab for Autoimmune Progesterone Dermatitis Refractory to Bilateral Oophorectomy: A Case Report

Background: Autoimmune progesterone dermatitis (APD) is a rare skin condition caused by sensitivity to high levels of progesterone secreted during the luteal phase of the menstrual cycle. This may be due to various pathophysiological mechanisms including a Type I and Type IV hypersensitivity reaction, and potential cross-reactivity with other endogenous steroid hormones such as 17-α-hydroxyprogesterone. We present the case of a patient with APD who had her flare-up episodes controlled using omalizumab, after a bilateral oophorectomy failed to resolve her symptoms. Clinical Case: A 34-year-old female presented to our Endocrine Clinic with marked Cushingoid features secondary to high-dose oral prednisone prescribed for APD diagnosed six years earlier. She first developed a pruritic maculopapular rash on her arms and legs just after the birth of her second child in 2009. The rash was also associated with headaches and diffuse angioedema. It presented in a cyclical fashion, beginning one to two days before the start of her menstrual cycle, and ending shortly after it was complete. The severity of symptoms increased as time went on, and flare-ups began to also include dyspnea, nausea, vomiting and abdominal pain. After three years of persistent symptoms, the diagnosis of APD was confirmed by a progesterone skin test. Her symptoms were improved with oral prednisone use, however breakthrough episodes still occurred. After multiple failed treatment modalities, she elected bilateral oophorectomy in 2018. However, her symptoms of APD persisted and she still required high-dose oral prednisone. Her condition was further complicated by vasomotor menopausal symptoms and progressive iatrogenic Cushing’s syndrome. She eventually was started on Omalizumab, which helped resolve her APD symptoms and allowed her to wean off prednisone. Vasomotor menopausal symptoms were resolved using conjugated estrogens with bazedoxifene. However, her symptoms of diffuse bony indeterminate bony pain and arthralgias which started whilst on prednisone have persisted in spite of discontinuing prednisone. Conclusion: To our knowledge, this is only the third case of APD which was successfully treated with Omalizumab and the first case where a bilateral oophorectomy failed to resolve symptoms of APD in the literature. Our case also demonstrates the complications of vasomotor menopause symptoms secondary to a bilateral oophorectomy, as well as the adverse effects of long-term glucocorticoid therapy.

Association Between Collagenous and Lymphocytic Colitis and Risk of Severe Coronavirus Disease 2019

Association Between Collagenous and Lymphocytic Colitis and Risk of Severe Coronavirus Disease 2019

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma

BackgroundThe ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma. ObjectiveTo assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction. MethodsPediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale–self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use. ResultsA total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale–self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits. ConclusionASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Newer Biological Agents in the Treatment of Severe Asthma: Real-World Results from a Tertiary Referral Center.

To determine the efficacy of IL-5 inhibitory therapy in severe, refractory asthma in a real-world clinical setting from a tertiary referral center. A retrospective chart review of patients with severe asthma treated with IL-5 biologic therapy for ≥ 6 months at Mayo Clinic in Rochester, Minnesota between January 1, 2013 and August 31, 2019. Over the study period, we identified 63 patients with a mean age of 54 who received an IL-5 inhibitor for ≥ 6 months. A total of 55 patients received mepolizumab, 2 received benralizumab, and 9 patients received both. Patients were followed up for a mean of 25 months. The mean number of months of oral prednisone use prior to biologic initiation was 64. There was a significant reduction in the median dose of prednisone in the 24 months after drug initiation (15 mg vs. 0 mg; p = < 0.0001). Similarly; there was a significant decline in the median number of asthma exacerbations in the 24 months before and after drug initiation (7 vs. 2; p = < 0.0001). The mean number of emergency room (ER) visits and hospitalizations decreased from 5.1 and 2.0 to 1.6 and 0.4 in the 24 months before and after therapy initiation (p < 0.0001 and p = 0.007, respectively) CONCLUSIONS: IL-5 inhibitory therapy is associated with significant and long-term sustained reductions in asthma exacerbation frequency, ER visits, hospitalizations, as well as oral steroid usage in a patient population with refractory steroid-dependent asthma referred to a tertiary referral center.

NEWER BIOLOGICAL AGENTS IN THE TREATMENT OF SEVERE ASTHMA: REAL WORLD RESULTS FROM A TERTIARY REFERRAL CENTER

SESSION TITLE: Asthma: From Blood Biomarkers to Biologics and Disease Burden SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: Biologic pharmacotherapy in the form of anti-interleukin 5 (IL-5) inhibitors (mepolizumab and reslizumab), IL-5 receptor antagonists (benralizumab), and IL-4 and IL-13 inhibitors (dupilumab) are relatively new therapies for the treatment of severe, refractory asthma. The available literature on the efficacy of these agents is mostly limited to the randomized controlled trials performed for drug approval purposes. We report on the usage as well as efficacy of these agents in a real world clinical setting from a tertiary referral center. METHODS: This retrospective chart review of electronic medical records was performed for all patients with severe asthma who underwent biologic pharmacotherapy at Mayo Clinic in Rochester, Minnesota between January 2016 and December 2018. Extracted data included demographic patient information, baseline asthma characteristics, as well as spirometry results. Only patients receiving biologic therapy for ≥ 6 months very included in the study. RESULTS: Over the study period, we identified 50 patients (29 female) receiving one of the newer biologic agents for ≥ 6 months. Median age at treatment onset was 54 (range 22-88 years). A total of 8 patients were initiated on benralizumab and 42 on mepolizumab with a median follow up duration of 9 months post drug initiation. The median number of years of oral prednisone use prior to biologic initiation was two years. There was a significant decline in the median number of asthma exacerbations in the 12 months before and after drug initiation (4 vs. 1; p= 0.0020). Similarly; there was a significant reduction in the median dose of prednisone in the 6 months before and after drug initiation (20mg vs. 5 mg; p= 0.0010). The FEV1 did not change significantly after both 6 and 12 months of biologic therapy compared to baseline FEV1. CONCLUSIONS: We present a long term, real-world clinical experience of the use of newer biological agents in the management of oral steroid dependent asthmatics. We are able to demonstrate significant effectiveness of these agents in reducing asthma exacerbations as well as oral steroid dosages in this difficult patient population. CLINICAL IMPLICATIONS: This study confirms the long term benefit of extended biologic therapy use in severe, refractory oral steroid dependent asthma. DISCLOSURES: No relevant relationships by Megan Dulohery Scrodin, source=Web Response No relevant relationships by Vivek Iyer, source=Web Response pharmaceutical drug trial site invest. relationship with GSK Please note: $1-$1000 Added 03/17/2019 by Karina Keogh, source=Web Response, value=Travel monograph relationship with BMJ Please note: $1-$1000 Added 03/17/2019 by Karina Keogh, source=Web Response, value=Honoraria No relevant relationships by Kaiser Lim, source=Web Response No relevant relationships by Ashokakumar Patel, source=Web Response No relevant relationships by Dayne Voelker, source=Web Response

Corticosteroid use and increased CXCR2 levels on leukocytes are associated with lumacaftor/ivacaftor discontinuation in cystic fibrosis patients homozygous for the F508del CFTR mutation.

Cystic fibrosis (CF) is the most common life-shortening genetic disease and is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Several current therapies aim at improving availability and/or function of the mutant CFTR proteins. The combination therapeutic lumacaftor/ivacaftor (Orkambi, luma/iva) partially corrects folding and potentiates CFTR function impaired by the F508del mutation. Despite the potential for clinical benefit, a substantial number of patients discontinue treatment due to intolerable adverse effects. The aim of the present study is to identify differences between individuals who continued treatment and those who discontinued due to adverse respiratory effects to potentially inform treatment decisions. Clinical data from the year prior to treatment initiation were analyzed from 82 patients homozygous for the F508del mutation treated at the Colorado Adult CF Program. Blood samples were collected from 30 of these subjects before initiation of treatment to examine expression of circulating leukocyte surface antigens and cytokines. Clinical and demographic characteristics were analyzed along with inflammatory markers to determine biomarkers of drug discontinuation. The use of oral prednisone and/or nasal budesonide in the year prior to luma/iva initiation was more prevalent in CF subjects who did not tolerate luma/iva (82% vs. 43%). Increased age, but not gender or initial lung function, was associated with higher probability of discontinuing treatment due to side effects overall. Worse lung function (lower ppFEV1, ppFEF25-75 ≤ 60%) was associated with higher incidence of discontinuing treatment due to pulmonary adverse effects. In a nested cohort of patients, increased surface levels of CXCR2 on CD14+CD16- monocytes were associated with discontinuation. Overall, the patients who tolerated luma/iva were distinguishable from those who did not tolerate the drug based on clinical and cellular markers obtained prior to treatment initiation.

High Recurrence Rate of Oral Ulcers of Unknown Cause: a Challenging Clinical Case

A 54-year-old man showed painful ulcers in the tongue and oropharynx, with 2 months of evolution. The laryngoscopy exam showed ulcers in the pharynx. An intraoral evaluation revealed large and well-delimited ulcers in the tongue, vestibule, and tonsil. Tests for HAV (IgG) and HBV (total anti-HBc) were positive; additionally, the laboratory exams for vitamins A and C were abnormal. Tests for inflammatory bowel diseases yielded non-reagent results. An oral microscopic diagnosis of unspecific chronic ulcer was rendered. An intestinal biopsy showed erosive proctitis; however, Behçet's disease was ruled out. Oral prednisone use improved the oral ulcers after 15 days. Currently, the patient has experienced monthly recurrences of oral ulcers. This does not appear to be an aphthous stomatitis case due to the age of the patient at onset and the severity and frequency of ulcers. The diversity in the causes of oral ulceration can be challenging to diagnose and manage.

Impact of adherence to biological agents on health care resource utilization for patients over the age of 65 years with rheumatoid arthritis.

ObjectivePoor adherence to therapy increases the patient and societal burden and complexity of chronic diseases such as rheumatoid arthritis (RA). In the past 15 years, biologic disease-modifying anti-rheumatic drugs (DMARDs) have revolutionized the treatment of RA. However, little data are available on the impact of adherence to biologics on health care resources. The objective of the study was to determine the long-term health care resource utilization patterns of RA patients who were adherent to biologic DMARD therapy compared to RA patients who were non-adherent to biologic DMARD therapy in an Ontario population and to determine factors influencing adherence.MethodsPatients were identified from the Ontario RA Database that contains all RA patients in Ontario, Canada, identified since 1991. The study population included RA patients, aged 65+ years, with a prescription for a biologic DMARD between 2003 and 2013. Exclusion criteria included diagnosis of inflammatory bowel disease, psoriatic arthritis or psoriasis in the 5 years prior to the index date and discontinuation of biologic DMARD, defined as no subsequent prescription during the 12 months after the index date. Adherence was defined as a medication possession ratio of ≥0.8 measured as the proportion of days for which a patient had biologic treatment(s) over a defined follow-up period. Adherent patients were matched to non-adherent patients by propensity score matching.ResultsA total of 4,666 RA patients were identified, of whom 2,749 were deemed adherent and 1,917 non-adherent. The age (standard deviation) was 69.9 (5.46) years and 75% were female. Relative rates for resource use (physician visits, emergency visits, hospitalization, home care and rehabilitation) for the matched cohort were significantly lower (P⩽0.0001) in adherent patients. Non-adherent patients’ use of oral prednisone (67%) was significantly higher (P⩽0.001) than that of the adherent cohort (56%).ConclusionRA patients adherent to biologic therapy have lower health care resource use and lower steroid use compared to non-adherent patients.

Population Variations in Rheumatoid Arthritis Treatment and Outcomes, Northern California, 1998-2009.

To assess variations in rheumatoid arthritis treatment and outcomes at the community level from 1998 through 2009. The study used computerized data from 16 Kaiser Permanente Northern California Medical Centers. Mixed modeling was used to assess patterns across time and clinic. The analysis accounted for patient demographics, clustering of patients within Medical Centers, and repeated measures of patients over time. The metric used to measure drug use, months of use per patient per year, included both users and nonusers in the denominator, to account for both prevalence and duration of use. Assessment was performed of 28,601 patients with rheumatoid arthritis, with all levels of severity. From 1998 through 2009, methotrexate use doubled in the typical patient to include 23% of the time they were observed; sulfasalazine and hydrochloroquine use declined. By 2008 through 2009, leflunomide and antitumor necrosis factor agents were used by the typical patient 4% and 9% of the time, respectively. Between 1998 and 2009, disease-modifying antirheumatic drug use increased in the typical patient from 38% to 63% of the time, and oral prednisone use declined from 23% to 15% of the time, whereas opioid use initially rose but then fell to 23% of the time. No variations over time were observed for the rate of hospitalized pneumonia or opportunistic infection. Variation across clinics, measured by the difference in drug use between clinics at the 75th and 25th percentiles, was lowest for opioids (25% vs 20% of the time) and greatest for infliximab (< 1% to 3%). Increased use of disease-modifying antirheumatic drugs and declines in prednisone are encouraging. Opioid use may need intervention.

Herpes Esophagitis in an Immunocompetent Teenager

Herpes simplex virus (HSV) esophagitis is a rare infection in the immunocompromised host making it an even more rare condition in the immunocompetent population. Herpes esophagitis usually presents with the constellation of symptoms of odynophagia, dysphagia, fever and retrosternal chest pain. When immunocompetent patients present with odynophagia, the most common etiologies include pill induced esophagitis, toxic ingestion or severe reflux esophagitis. Rarely is infectious esophagitis from HSV, cytomegalovirus or candida considered. HSV is the most common cause of esophagitis typically from a reactivation of prior infection. In very rare cases does it present as a primary infection in the esophagus. We describe a case of HSV esophagitis in an 18-year-old immunocompetent host with no significant past medical history. He presented to his primary care physician with complaints of odynophagia and was prescribed a course of amoxicillin and prednisone syrup. He presented 4 days later to the emergency room with worsening odynophagia, retrosternal chest pain and anorexia. He was evaluated by the gastroenterology team and was taken for esophagogastroduodenoscopy (EGD), which revealed diffuse, bleeding, superficial ulcerations along the entirety of his esophagus. Biopsies were taken and subsequently found to be HSV positive. The patient was treated with intravenous acyclovir, a proton pump inhibitor and sucralfate suspension. HIV was tested and was found to be negative. No other causes of immunosuppression were found. We believe the patients’ initial presentation was in fact a primary infection of HSV esophagitis, which was exacerbated by his oral prednisone use. The purpose of this report was to highlight the rare occurrence of infectious esophagitis with HSV possibly worsened by oral prednisone use in an otherwise healthy, young individual. Also, this report should raise awareness of clinicians to diagnose HSV esophagitis and begin prompt treatment on such patients. EGD with biopsy is the gold standard diagnostic modality for HSV esophagitis and should always be considered in young patients who present with odynophagia even in the absence of other alarm features. There is often a typical mucosal appearance with superficial, well-demarcated, small ulcerations along the mid to distal esophagus. The treatment of choice for HSV esophagitis is acyclovir 5 mg/kg every 8 hours for 7 - 14 days. Symptoms for most immunocompetent patients resolve spontaneously in about 1 - 2 weeks. In confirmed cases of HSV esophagitis, it is important to reassess the patient for any underlying immunodeficiencies. Although rare, HSV esophagitis should be entertained especially given the correct constellation of history and symptoms. J Med Cases. 2015;6(4):173-175 doi: https://doi.org/10.14740/jmc2100w

Discrete and Coalescing Pustules Masking Severe Recalcitrant Rosacea due to Demodex

We describe a clinical case concerning a 36 year old man with a recalcitrant dermatosis involving the face and neck to demonstrate how multiple pathogenic mechanisms may ultimately prohibit disease resolution. This patient’s disease persisted despite multiple standard treatments for the leading differential diagnoses early in the disease course including: topical/systemic corticosteroids for an initially suspected facial dermatitis followed by minocycline and oral ivermectin for granulomatous rosacea with high Demodex burden. These failed therapies prompted the use of oral prednisone and topical pimecrolimus that resulted in some improvement but worsening flares if therapy was discontinued. The leading differential shifted toward rosacea fulminans or an unusual manifestation of immune reconstitution inflammatory syndrome (IRIS) in the setting of possible HIV or iatrogenic immunosuppression. An extensive diagnostic workup was completed and showed isolated IgM deficiency (49 mg/dl, normal range 60 to 300 mg/dl), low levels of 25 hydroxyvitamin D (15 pg/mL, normal range 18 to 64 pg/mL), and low ascorbic acid (0.3 mg/dl, normal range 0.6 to 2.0 mg/dl). The rash finally resolved following a tapering course of cyclosporine and vitamin repletion through supplements and dietary alteration. Our case is one with multiple confounding variables that may have contributed to the recalcitrant nature of this dermatosis: (1) presence of Demodex; (2) iatrogenic immunosuppression due to prolonged systemic and topical steroid use; and (3) vitamin deficiency. It is unclear exactly what role each of these factors played but the purpose of our case is to illustrate these variables can be encountered in regular practice and that sometimes the physician must explore and correct all potential vectors of pathogenesis in order to successfully treat recalcitrant dermatoses.

Muscle Disease

On the basis of strong research evidence, Duchenne muscular dystrophy (DMD), the most common severe childhood form of muscular dystrophy, is an X-linked recessive disorder caused by out-of-frame mutations of the dystrophin gene. Thus, it is classified asa dystrophinopathy. The disease onset is before age 5 years. Patients with DMD present with progressive symmetrical limb-girdle muscle weakness and become wheelchair dependent after age 12 years. (2)(3). On the basis of some research evidence,cardiomyopathy and congestive heart failure are usually seen in the late teens in patients with DMD. Progressive scoliosis and respiratory in sufficiency often develop once wheelchair dependency occurs. Respiratory failure and cardiomyopathy are common causes of death, and few survive beyond the third decade of life. (2)(3)(4)(5)(6)(7). On the basis of some research evidence, prednisone at 0.75 mg/kg daily (maximum dose, 40 mg/d) or deflazacort at 0.9 mg/kg daily (maximum dose, 39 mg/d), a derivative of prednisolone (not available in the United States), as a single morning dose is recommended for DMD patients older than 5 years, which may prolong independent walking from a few months to 2 years. (2)(3)(16)(17). Based on some research evidence, treatment with angiotensin-converting enzyme inhibitors, b-blockers, and diuretics has been reported to be beneficial in DMD patients with cardiac abnormalities. (2)(3)(5)(18). Based on expert opinion, children with muscle weakness and increased serum creatine kinase levels may be associated with either genetic or acquired muscle disorders (Tables 1 and 3). (14)(15)

SAT0084 Effects of different steroid doses on adverse events and radiographic progression of certolizumab pegol-treated rheumatoid arthritis patients

BackgroundUse of oral corticosteroids (CS) in rheumatoid arthritis (RA) remains controversial. While short-term use in early disease or during flares is suggested to reduce inflammation and erosion, side effects and...

Oral prednisone use and risk of keratinocyte carcinoma in non‐transplant population. The VATTC trial

Glucorticosteroids (GC) are potent anti-inflammatory medications with immunosuppressive property. Few retrospective studies have reported the increased risk of development of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) associated with GC use. We aimed to assess the effect of oral GC use on the risk of BCC and SCC using prospective data. We analysed data from the Veterans Affairs Topical Tretinoin Chemoprevention Trial, which followed up patients from 1998 to 2004. Exposure to oral GCs was defined as (1) use of any oral GCs at any point during follow-up and (2) use of GCs for a month or longer. Outcome was occurrence of new BCC or SCC. Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Among the 1051 study participants, 148 patients (14%) had prednisone prescription filled during study period, and 63 (6%) used prednisone for over a month. A total of 472 patients (45%) developed at least one BCC during study: 394 (44%) among non-users of prednisone and 78 (53%) among any time users. The total number of new SCC was 309 (29%): 258 (29%) among non-users of prednisone and 51 (34%) among users. Among any time prednisone users, the adjusted HR was 1.11 (95% CI, 0.87-1.42) for BCC, and 1.05 (95% CI, 0.76-1.45) for SCC. Among those who used prednisone for 30 or more days, the HR was 1.26 (95% CI, 0.90-1.78) for BCC, and 1.03 (95% CI, 0.66-1.60) for SCC. This study does not support the existence of association between use of oral GCs and risk of BCC or SCC.

Lichen planus

Lichen planus

Attenuation of the September Epidemic of Asthma Exacerbations in Children: A Randomized, Controlled Trial of Montelukast Added to Usual Therapy

Johnston N, Mandhane P, Dai J, et al. Pediatrics. 2007;120(3). Available at: www.pediatrics.org/cgi/content/full/120/3/e702 PURPOSE OF THE STUDY. To evaluate whether montelukast, when added to usual asthma therapy, would affect the asthma symptoms experienced during the annual asthma epidemic occurring each year when school resumes after summer vacation. STUDY POPULATION. Participants included 194 subjects from 2 to 14 years of age with physician-diagnosed asthma. More than 90% of the children had prescriptions for an inhaled corticosteroid (ICS). METHODS. Children were randomly assigned to receive either an age-appropriate dose of montelukast (n = 98) or placebo (n = 96). The first tablet was taken the evening of September 1 and continued nightly for 45 days. Asthma symptoms, cold symptoms, use of oral prednisone, and unscheduled physician visits resulting from asthma were recorded daily. Subjects were instructed to take the tablet in addition to their usual asthma therapy. RESULTS. Children who received montelukast experienced 53% fewer days with “worse asthma symptoms” compared with children who received placebo (3.9% vs 8.3%; P &amp;lt; .02). In addition, there was a 78% reduction in the number of unscheduled visits to a physician for asthma (4 vs 18; P = .011). These improvements were seen in patients with and without cold symptoms. Among boys, the greatest benefit from montelukast was seen in those aged 2 to 5 years. Girls benefited most from montelukast when they were between the ages of 10 and 14 years. CONCLUSIONS. Montelukast, when added to usual asthma therapy, reduced the risk of worsening asthma symptoms and unscheduled physician visits during the annual September asthma epidemic. REVIEWER COMMENTS. It has long been recognized that epidemics of asthma exacerbations occur annually after students return to school after summer vacation. This study demonstrates that montelukast, a leukotriene-receptor antagonist, could be used in conjunction with usual asthma medications to attenuate some of these annual symptoms. The study population enrolled in this study was composed largely of persistently asthmatic children, based on the fact that &amp;gt;90% were prescribed ICSs. Additional studies are needed to investigate whether a similar reduction in asthma symptoms would be seen in subjects with less-severe asthma. In addition, compliance with the use of prescribed ICS in this study was relatively poor, with only 47% of subjects using an ICS routinely. This is in agreement with other studies that have shown that ICS prescription filling is at its lowest just before the return to school. It remains to be seen whether simply improving compliance with prescribed ICSs at the start of the academic school year would also lead to a significant reduction in asthma symptoms.

Course, complications, and outcome of juvenile arthritis–related uveitis

To describe the clinical features of uveitis in patients with juvenile idiopathic arthritis (JIA). Retrospective chart review of a subset of 1,081 consecutive JIA patients who were younger than 18 years of age and had uveitis, with a minimum of 1-year follow-up at a single center. One hundred forty-two patients (13.1%) developed uveitis after a mean follow-up of 6.3 years (range, 0.10-23.2). Uveitis types were chronic anterior (97/142, 68.3%), acute anterior (23/142, 16.2%), recurrent anterior (17/142, 12%), and panuveitis (5/142, 3.5%). Uveitic complications were observed in 37.3% of cases (53/142) and 32.5% of eyes (74/228). When we compared uveitic eyes with complications to uveitic eyes without complications, we found the following significant differences: time interval from diagnosis of JIA to diagnosis of uveitis was shorter (mean, 1.3 years vs. 2.2 years; p = 0.003) and use of oral prednisone was greater (59.1% vs 15.6%; p < 0.0001) in the eyes with complications. Twenty-one children (21/142, 14.8%) with uveitis underwent a total of 62 ocular surgeries. Good visual acuity (20/40 or better) was found in 90.8% of eyes (159/175) and in both eyes of 87% of cases (94/108), impaired visual acuity in 6 eyes of 4 cases (6/175, 3.4%), and blindness in 10 eyes of 10 cases (10/175, 5.7%). Only 2 patients had reduced visual acuity in both eyes. Surgery was the single most important risk factor for reduced visual acuity at the last follow-up (p = 0.0086). Most uveitic eyes with JIA achieved good visual outcome despite uveitic complications.