Short Course Of Oral Corticosteroids Research Articles

Chronic cough and sputum production are associated with worse clinical outcomes in stable asthma

Chronic cough and sputum production (chronic mucus hypersecretion) is a poorly described clinical feature of asthma. Our objective was to identify clinical, immunological and computed tomography (CT) measures of airway wall dimensions associated with these symptoms in smokers and never smokers with asthma. Cross-sectional data was analysed from 120 smokers and never smokers with asthma. Participants with and without a history of chronic mucus hypersecretion were compared for clinical outcomes, sputum differential cell counts and CT measures of airway dimensions (wall thickness, luminal area and percent wall area). Chronic mucus hypersecretion occurred in a higher proportion of smokers with asthma (56%) than never smokers with asthma (20%), (p<0.001) and the proportion of patients with these symptoms increased with asthma severity (p=0.003). Smokers with asthma and chronic mucus hypersecretion had worse current clinical control than smokers without those symptoms [ACQ score 2.3 versus 1.6, p=0.002]. A greater proportion of never smokers with chronic mucus hypersecretion required short courses of oral corticosteroids in the last year (58% versus 19%, p=0.011). Sputum neutrophil and eosinophil counts were similar in asthma patients with or without chronic mucus hypersecretion. Of those with severe asthma and chronic mucus hypersecretion, a CT measure of airway lumen area was reduced in smokers compared to never smokers (11.4mm(2) versus 18.4mm(2); p=0.017). Chronic mucus hypersecretion occurs frequently in adults with stable asthma, particularly in smokers with severe disease and is associated with worse current clinical control in smokers and more exacerbations in never smokers.

The pharmacists’ potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma

Despite of pharmacists' specialized knowledge of medication and his/her regular contact with patients, the expertise of the pharmacist may not be used enough yet. Furthermore, the potential of pharmacy dispensing data is underestimated. To provide targets for tailored interventions in asthma patients and to illustrate the potential value of pharmacists in the identification of these targets using individual pharmacy dispensing data. We performed a cross sectional retrospective analysis assessing the quality of asthma patients' pharmacotherapeutic treatment. Drug dispensing data from 2008 to 2009 were retrieved from a Dutch pharmacy database. All asthma patients were screened for potential suboptimal pharmacotherapy in 2009. Results were projected to a single community pharmacy to provide an estimate of the number of patients eligible for potential interventions. (1) frequent use of short-acting β-agonists without preventive medication, (2) concomitant use of β-blockers, (3) multiple short courses of oral corticosteroids without using inhaled corticosteroids and 4) use of long-acting β-agonist without inhaled corticosteroids. A total of 8,504 patients were eligible for analysis of the quality of their asthma treatment. 20.9 % of all asthma patients used >100 DDD short-acting β-agonists per year, whereas between 21.2 % (≥ 400 DDD) and 31.4 % (100-199 DDD) of these patients did not receive preventive medication. Approximately 5.2 % of the asthma patients are using β-blockers concomitantly and 21.8 % of them received non-cardioselective β-blockers. 6.3 % of the asthma patients received two or more oral courses of corticosteroids in 2008 and 17.4 % of these patients did not receive inhaled corticosteroids in 2009. 2.9 % of the patients used a long-acting β-agonists without inhaled corticosteroids. 8.4 % of the asthma patients using both long-acting β-agonists and inhaled corticosteroids received these drugs in two separate inhalers. We estimated that about 400 asthma patients could be identified in an average pharmacy population (8,000 patients) and 33 (95 % CI 22-44) of these patients would be eligible for interventions. This study shows the potential for pharmacists to use their own pharmacy records to identify suboptimal therapy of asthma patients, who may be targets for tailored interventions.

Chapter 6: Nasal polyps.

Nasal polyps occur in 1-4% of the population, usually occurring in the setting of an underlying local or systemic disease. The most common associated condition is chronic rhinosinusitis (CRS). A high prevalence of nasal polyps is also seen in allergic fungal rhinosinusitis, aspirin-exacerbated respiratory disease, Churg-Strauss syndrome, and cystic fibrosis. In the setting of CRS, nasal polyps are not likely to be cured by either medical or surgical therapy; however, control is generally attainable. The best medical evidence supports the use of intranasal corticosteroids for maintenance therapy and short courses of oral corticosteroids for exacerbations. The evidence for short- and long-term antibiotics is much less robust. For patients with symptomatic nasal polyposis nonresponsive to medical therapies, functional endoscopic sinus surgery provides an adjunctive therapeutic option.

Herpesviruses and the microbiome

The focus of this article will be to examine the role of common herpesviruses as a component of the microbiome of atopic patients and to review clinical observations suggesting that atopic patients might be predisposed to more severe and atypical herpes-related illness because their immune response is biased toward a TH2 cytokine profile. Human populations are infected with 8 herpesviruses, including herpes simplex virus HSV1 and HSV2 (also termed HHV1 and HHV2), varicella zoster virus (VZV or HHV3), EBV (HHV4), cytomegalovirus (HHV5), HHV6, HHV7, and Kaposi sarcoma-associated herpesvirus (termed KSV or HHV8). Herpesviruses are highly adapted to lifelong infection of their human hosts and thus can be considered a component of the human "microbiome" in addition to their role in illness triggered by primary infection. HSV1 and HSV2 infection and reactivation can present with more severe cutaneous symptoms termed eczema herpeticum in the atopic population, similar to the more severe eczema vaccinatum, and drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) is associated with reactivation of HSV6 and possibly other herpesviruses in both atopic and nonatopic patients. In this review evidence is reviewed that primary infection with herpesviruses may have an atypical presentation in the atopic patient and conversely that childhood infection might alter the atopic phenotype. Reactivation of latent herpesviruses can directly alter host cytokine profiles through viral expression of cytokine-like proteins, such as IL-10 (EBV) or IL-6 (cytomegalovirus and HHV8), viral encoded and secreted siRNA and microRNAs, and modulation of expression of host transcription pathways, such as nuclear factor κB. Physicians caring for allergic and atopic populations should be aware of common and uncommon presentations of herpes-related disease in atopic patients to provide accurate diagnosis and avoid unnecessary laboratory testing or incorrect diagnosis of other conditions, such as drug allergy or autoimmune disease. Antiviral therapy and vaccines should be administered promptly when indicated clinically.

Management of Asthma in School age Children On Therapy (MASCOT): a randomised, double-blind, placebo-controlled, parallel study of efficacy and safety

Asthma affects one in eight children in the UK. National management guidelines have been available for many years but, unlike in adults, studies in children have been few, with their methodologies often based on inappropriate adult models. Sound medical evidence in support of the national guidelines for asthma management in children is lacking. The MASCOT study has been developed to address this need. To determine whether adding salmeterol or montelukast to low-dose inhaled corticosteroids (ICSs) can reduce the number of exacerbations requiring treatment with oral corticosteroids in children with uncontrolled asthma. A randomised, double-blind, placebo-controlled trial with a 4-week run-in period on a fluticasone propionate inhaler (100 µg twice daily) with inhaler technique correction. Patients who met the post run-in period eligibility criteria were randomised in the ratio of 1 : 1 : 1 and were followed for 48 weeks. Secondary care hospitals based in England and Scotland with recruitment from primary and secondary care. Children aged 6-14 years with asthma requiring frequent short-acting beta-2 agonist relief, with symptoms of asthma resulting in nocturnal wakening and/or asthma that has interfered with usual activities. Three groups were compared: (1) inhaled fluticasone propionate 100 µg twice daily plus placebo tablet once daily; (2) inhaled fluticasone propionate 100 µg and salmeterol 50 µg twice daily (combination inhaler) plus placebo tablet once daily; and (3) inhaled fluticasone propionate 100 µg twice daily plus montelukast 5-mg tablet once daily. The primary outcome was the number of exacerbations requiring treatment with oral corticosteroids over 48 weeks. Secondary outcome measures included quality of life as measured by the Paediatric Asthma Quality of Life Questionnaire with Standardised Activities [PAQLQ(S)] and the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ); time from randomisation to first exacerbation requiring treatment with a short course of oral corticosteroids; school attendance; hospital admissions; amount of rescue beta-2 agonist therapy prescribed; time from randomisation to treatment withdrawal (because of lack of efficacy or side effects); lung function at 48 weeks (as assessed by spirometry); cost-effectiveness; adverse events. The study was closed prematurely because of poor recruitment and the target sample size of 450 was not achieved. In total, 898 children were screened to enter the trial, 166 were registered for the 4-week run-in period and 63 were randomised (group 1: 19, group 2: 23, group 3: 21), with 38 contributing data for the primary outcome analysis. There were no significant differences between groups for any of the outcomes. Adverse events were similar between the groups except for nervous system disorders, which were more frequently reported on fluticasone plus montelukast. Based on the results of the MASCOT study it is not possible to conclude whether adding salmeterol or montelukast to ICSs can reduce the number of exacerbations requiring treatment with oral corticosteroids in children with uncontrolled asthma. Current Controlled Trials ISRCTN03556343. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 4. See the HTA programme website for further project information.

Bronchial rupture related to endobronchial stenting in relapsing polychondritis

To the Editor: Relapsing polychondritis is a rare multi-systemic disease characterised by recurrent episodes of inflammation and destruction of cartilaginous structures [1]. Airway involvement by relapsing polychondritis, which results in tracheobronchomalacia and airway stenosis, is associated with a poor prognosis. Several reports have suggested that endobronchial intervention can be beneficial in these subjects [2, 3]. Herein, we describe a case of bronchial rupture related to endobronchial intervention in a patient with relapsing polychondritis. A 47-yr-old male nonsmoker was referred for management of progressive dyspnoea, stridor and cough evolving over 12 months. He had been considered to have severe asthma and was treated with a fixed combination of inhaled corticosteroids and long-acting β-agonists, and short courses of oral corticosteroids. Spirometry showed fixed airflow limitation with a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity of 22% and an FEV1 of 22% predicted. A thoracic computed tomography (CT) scan revealed marked thickening and narrowing of trachea and mainstem bronchi (fig. 1). A diagnosis of relapsing polychondritis was suggested; the patient had no auricular or nasal chondritis and no ocular symptoms. Fluorodeoxyglucose positron emission tomography showed no cartilaginous tracer uptake. Bronchoscopy showed marked thickening and inflammation of airway mucosa. Severe tracheobronchomalacia, …

Chapter 16: Asthma in pregnancy

The course of asthma during pregnancy may be affected by maternal physiological changes and triggers of asthma such as viral infections, exposure to allergens, and nonadherence with therapy. If asthma is uncontrolled, there are recognized harmful effects not only to the mother but also to the fetus. However, with effective asthma control, most women have outcomes, at or near that of the general population. Many medications are considered appropriate for use in pregnancy including inhaled corticosteroids (ICSs) such as budesonide, beclomethasone dipropionate, and fluticasone and the leukotriene receptor antagonists montelukast and zafirlukast. When ICSs or ICS/long-acting beta(2)-adrenergic agonist combinations are not effective during exacerbations of asthma, short courses of oral corticosteroids should be administered earlier rather than later. Spirometry and flow volume loop tracings are useful measures of pulmonary function for gravidas. Results may be compared with nonpregnant reference values. Vocal cord dysfunction may be suspected when the inspiratory loop is truncated. The gravida does not reject the fetus because of lack of vascular continuity, a trophoblast layer causing separation, and suppressive mechanisms at the placental interface. The secretion of IL-10 increases in pregnancy and is lower in women with recurrent spontaneous abortions. Only immunoglobulin G (IgG) subclasses are transported across the placenta, especially IgG1, IgG3, and IgG4. Fetal B cells can produce endogenous IgE by 20 weeks of gestation.

Cardiac arrest and myocardial pseudoinfarction

A 48-year-old Asian woman collapsed at home without prodrome in May, 2010. Her husband started basic life support, and paramedics successfully cardioverted her from ventricular fibrillation. History included pulmonary sarcoidosis diagnosed 9 years previously after a presentation with breathlessness, erythema nodosum, and mildly raised serum angiotensin converting enzyme (ACE) concentration (82 u/L, normal <70 u/L). She was treated with a short course of oral corticosteroids, but had declined biopsy or further treatment and had been symptom-free for 2 years.

Asymptomatic bilateral pulmonary embolism in Churg-Strauss syndrome

To the Editor: Churg–Strauss syndrome (CSS) is a systemic small-sized vessel vasculitis, characterised by severe asthma, transient pulmonary infiltrates, and blood and tissue eosinophilia [1]. CSS can affect several organs, including the lungs, heart, kidneys and peripheral nervous system. Anti-neutrophil cytoplasm autoantibodies (ANCA) mainly directed against myeloperoxidase (MPO) are detected in ∼40% of patients and are associated with renal involvement. Several studies have focused on venous thromboembolic events (VTE), which are an emerging clinical condition in ANCA-associated vasculitides (AAV) [2, 3]. Herein, we report the case of a patient with newly diagnosed CSS and totally asymptomatic pulmonary embolism, and discuss the features, pathogenesis and management of VTE in CSS. In February 2011, a 61-yr-old male was referred for recent asthenia, diffuse arthromyalgia and blood eosinophilia. His past medical history included high blood pressure treated with amlodipine. There were no other risk factors for VTE other than age and inflammatory state. His recent history included late-onset asthma, which started 1 yr earlier and required various combined inhaled corticosteroids, bronchodilators and several short courses of oral corticosteroids. In early December 2010, the patient complained of general weakness, weight loss and diffuse myalgia. In late December, another asthma flare-up was successfully treated with a course of oral prednisolone (1 mg·kg−1 per day for 5 days), which was effective for both myalgia and weakness. Unfortunately, muscle and joint pain immediately relapsed as soon as corticosteroids were discontinued, while respiratory symptoms had improved. In February 2011, a thoracic computed tomography (CT) scan was performed, focusing on the parenchyma not vessels. No lesions were reported. At the same time, distal paresthesia appeared and subsequently concerned the lower left and upper right limbs. Following this, the patient was referred to our department (Internal Medicine …

Systemic Mycobacterium avium Complex Infection During Antitumor Necrosis Factor‐α Therapy in Pediatric Crohn Disease

Systemic <i>Mycobacterium avium</i> Complex Infection During Antitumor Necrosis Factor‐α Therapy in Pediatric Crohn Disease

Practice patterns for oral corticosteroid burst therapy in the outpatient management of acute asthma exacerbations

The use of a short course of oral corticosteroids (OCS), or "steroid burst," is standard practice in the outpatient management of acute severe exacerbations of asthma. Despite published guidelines, the actual practice patterns are unknown. A Web-based survey about typical patterns of OCS administration and total steroid burst dose was administered to pulmonologists (n = 150), allergists (n = 150), primary care physicians (n = 153), and pediatricians (n = 150). No predominant dosing regimen was observed, although a fixed single daily dose was the most commonly prescribed regimen (59%). The majority of physicians treating patients ≥12 years of age prescribed a total burst dose of ≤200 mg and essentially all (99.7%) prescribed ≤600 mg. Among physicians treating younger children, approximately one-quarter prescribed ≤1 mg/kg per day for 3 days (27.8% for children aged 5-11 years of age and 28.1% for children aged <5 years, respectively) and essentially all prescribed ≤2 mg/kg per day for 10 days (99.8% for children aged 5-11 years and 100% for children aged <5 years of age). When prescribing OCS burst therapy for asthma exacerbations, physicians tend to prescribe less than the upper dose recommended in the guidelines; with many physicians prescribing a total steroid burst dose below the lower end of the recommended dose range. Additional study is needed to determine the optimal dose and duration for treating exacerbations of asthma with OCS to minimize both side effects and time to reestablishing asthma control.

(Stereotactic) radiosurgery XIX: spinal radiosurgery – two year experience in a UK centre

Introduction. Modern radiotherapy image guidance enables the treatment of extracranial targets with the required accuracy for safe delivery of radiosurgical treatments. The first two years’ experience of spinal radiosurgery in a UK radiotherapy centre is reported. Materials and methods. Patients with primary or metastatic spinal lesions were treated using the CyberKnife stereotactic radiotherapy system. Xsight Spine (fiducial-free) tumour tracking software was used in all cases. Treatment was delivered using either a single or a three-fraction schedule, between February 2009 and March 2011. Results. Fifty-three spinal lesions were treated, comprising 14 primary lesions in 12 patients, and 39 metastases in 29 patients. The prescription dose ranged from 8 to 30 Gy in 1–3 fractions. Fifty-nine percent of patients experienced no acute side effects from treatment. There were three cases of acute grade 3 back or nerve root pain, all of which responded to a short course of oral corticosteroids. At a median follow-up of 11.1 months, local control and overall survival were 91 and 65%, respectively. Pain improvement was seen in 75% of symptomatic metastases at 6 months post treatment. Conclusions. Early UK experience confirms that radiosurgery is well tolerated with excellent local control rates. Longer-term prospective data are needed to clarify the role of spinal radiosurgery for patients in this country.

Cyclophosphamide-refractory scleroderma-associated interstitial lung disease: remarkable clinical and radiological response to a single course of rituximab combined with high-dose corticosteroids

We would like to report our experience of using rituximab in cyclophosphamide refractory, rapidly progressive interstitial lung disease (ILD) in a patient with limited scleroderma. A 40-year-old man presented with 10-week history of inflammatory polyarthritis, which responded to a short course of oral corticosteroids. However, 3 weeks later, he developed new onset of exertional dyspnoea. High-resolution CT of the thorax was suggestive of early ILD. Surgical lung biopsy showed features of fibrotic non-specific interstitial pneumonia. He was diagnosed with scleroderma on the basis of: presence of anticentromere antibodies, Raynaud's phenomenon, pulmonary fibrosis, digital oedema and hypomotility along with a dilated oesophagus. He was treated aggressively with pulse doses of corticosteroids and cyclophosphamide; however, his ILD continued to deteriorate. At this stage, he received rituximab (two pulses of 1 g each), which led to a gradual clinical improvement. Now, 12 months since his rituximab infusion, he walks 2 miles daily without any exertional dyspnoea.

Oral and Nasal Steroids for Nasal Polyps

Oral and Nasal Steroids for Nasal Polyps

A Short Burst of Oral Corticosteroid for Children with Acute Asthma: Is There an Impact on Immunity?

Background: We wished to examine the impact of a short course of oral corticosteroids on the immune function of children with acute asthma and explore the mechanism of immune suppression, if any. Methods: We conducted a prospective cohort study of children aged 3–17 years presenting with acute asthma to the emergency department. The exposure of interest was a short course of systemic corticosteroids. In emergency department, corticosteroid-treated and nonexposed children were immunized with 3 antigens, namely, a neoantigen (Bacteriophage φX 174) and 2 recall antigens (diphtheria and tetanus). After 5 ± 1 weeks, children were reimmunized with Bacteriophage φX 174. Antibody titers were measured 1, 2 (peak), and 5 weeks after the primary immunization, and 1 week (peak) after the secondary one. Results: We enrolled 41 children, 27 treated with and 14 unexposed to oral corticosteroids. Corticosteroid-treated children displayed an 85% lower adjusted total (IgG and IgM) peak titers to the primary Bacteriophage immunization compared to controls [ratio of geometric means (95% confidence interval): 15% (5% to 43%)]. There were no group differences in the rise of diphtheria or tetanus antibodies. After the secondary Bacteriophage immunization, corticosteroid-treated patients showed no significant group difference in peak total titers [ratio of geometric means (95% confidence interval): 1.84% (0.66%, 5.10%)], amplification and absolute, and percent IgG titers as compared to unexposed children. Conclusions: In children with acute asthma, a short course of oral corticosteroids may be associated with depressed immune response to a new antigen, with recovery within 6 weeks and no apparent impact on response to known antigens.

P74 British asthma guideline revision does affect prescribing patterns in children

BackgroundAlthough audits of prescribing practice referenced to the British asthma management guidelines have been reported little is known on the impact of guideline revisions. Concerns about the use of high...

Type 1 and type IV hypersensitivity to nickel

We report a case of type 1 and type IV contact hypersensitivity to nickel. Very few cases of immediate contact urticaria to nickel have been reported. The mechanism behind this is not fully understood, although it has been postulated that nickel may act as a mast cell discharger on a non-immunological basis. Nickel is found in varying concentrations in stainless steels; its biological availability varies depending on the alloy composition. Our patient has adapted her lifestyle to minimize her contact with household appliances containing nickel. If medical or dental treatment using stainless steel equipment is required, we recommend a short course of oral corticosteroids and antihistamines.

697 The Most Frequent Flaws Regarding the Tending of the Asthma Attack in Children in France

Context: Seemingly emergency treatment of episodes of asthma attack suffers from therapeutic attitudes which do not match usual international recommendations. Purpose: During specialised consultations we have aimed to assess the most common flaws regarding the tending of children's asthma exacerbations by our local care dispensers. Method: We opened a prospective data collection of 100 children who had had an asthma attack in the weeks befor the consultation, during the winter 2007/2008. The children are between 2 and 16 years old(average age of 6 years 4 months). The gender ratio is 60% male and 40% female. 49% of them have had their persistent asthma confirmed for more than 6 months, 35% for more than 2 years and the remaining 16% for as long as 5 years. Results: In 39% of cases, short-acting inhaled Beta2-agonists are neither prescribed nor advised. In 68% short course of oral corticosteroids are not resorted to. Combination of long-acting inhaled Beta2-agonist and inhaled corticosteroids are used for treating the attack in 21% of children, usually over a few days long. Several other, non-accredited, alternative treatments(e.g. antihistamins, leukotrien-antagonists, homeopathy) are used in 24% of cases. Conclusions: The tending of asthma exacerbations in children in our area shows: Practical implications: It seems important during Continual Medical Education sessions on child asthma to insist on the distinction to be made between emergency treatment and long-standing medications

Traitement de la maladie de Darier par 5-fluorouracile topique : quelle efficacité, quels risques ?

Darier's disease, an autosomal dominant disorder, is often resistant to therapy. There have been few encouraging reports in recent years of treatment using topical 5-fluorouracil (5FU) in this indication. We describe three cases of Darier's disease treated with Efudix: though it initially proved very effective, after several months this treatment became inefficacious. Case 1: a 16-year-old girl with Darier's disease refractory to conventional treatments. Treatment with topical 5FU was initiated. After 3 weeks, her cutaneous lesions had practically disappeared, leaving only pigmented scars. At 6 months, worsening of the disease was controlled by increasing 5FU. At 11 months, the disease worsened and 5FU, which proved inefficient, was stopped. Case 2: a 59-year-old woman presenting treatment-resistant Darier's disease was given 5FU. After 1 week, improvement began and was evident at 4 months. However, after 13 months of treatment, the disease progressed, and increased 5FU proved completely ineffective. Case 3: a 29-year-old woman was hospitalized for inflammatory Darier's disease. Topical 5FU was applied to the left half of the body and a short course of oral corticosteroids was prescribed. After 10 days of treatment, there was a clear improvement. After 6 weeks, the patient showed episodes of healthy skin. However after 3 months, the patient stopped taking her treatment due to inefficacy. While topical 5FU seems to be effective initially in treating Darier's disease, this efficacy subsides over time. Although no adverse effects were noted in our patients, use of 5FU can result in serious adverse reactions. Because of the loss of efficacy of this treatment following initial success, coupled with its poorly evaluated safety, caution must be exercised when prescribing it, particularly in patients with dihydropyriminidine dehydrogenase (DPD) deficiency or for use on damaged skin.

Advances in pediatric asthma in 2009: Gaining control of childhood asthma

This year's summary will focus on recent advances in pediatric asthma as reported in Journal of Allergy and Clinical Immunology publications in 2009. New National Asthma Education and Prevention Program asthma guidelines were released in 2007, with a particular emphasis on asthma control. Now that we have worked with the principals of the guidelines for 2 years, new insights are reported on how to implement the guidelines into clinical practice. This year's report will focus on gaps in management that need to be addressed, including health disparities, methods to improve asthma management through opportunities available in school-based asthma programs, and more information on the development of asthma in childhood. This information brings us closer to the point of managing children with controllable asthma and understanding reasons why asthma is not controlled in the remaining children. If we can close these gaps through better communication, improvements in the health care system, and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children.