Short Course Of Oral Corticosteroids Research Articles

Inhaled Corticosteroids Should Be Initiated Before Discharge from the Emergency Department in Patients with Persistent Asthma

National and International Guidelines concur that inhaled corticosteroids (ICS) are the preferred long-term maintenance drug therapy for mild persistent asthma for all ages. For moderate and severe persistent asthma, ICS are essential to optimal management, often concurrent with other key therapies. Despite strong evidence and consensus guidelines, ICS are still underused. While some patients who are treated in the emergency department (ED) have intermittent asthma, most have persistent asthma and need ICS for optimum outcomes. Failure to initiate ICS at this critical juncture often results in subsequent lack of ICS therapy. Along with a short course of oral corticosteroids, ICS should be initiated before discharge from the ED in patients with persistent asthma. Although the NIH/NAEPP Expert Panel Report 3 suggests considering the prescription of ICS on discharge from the ED, The Global Initiative for Asthma (GINA) 2008 guidelines recommend initiation or continuation of ICS before patients are discharged from the ED. The initiation of ICS therapy by ED physicians is also encouraged in the emergency medicine literature over the past decade. Misdiagnosis of intermittent asthma is common; therefore, ICS therapy should be considered for ED patients with this diagnosis with reassessment in follow-up office visits. To help ensure adherence to ICS therapy, patient education regarding both airway inflammation (show airway models/colored pictures) and the strong evidence of efficacy is vital. Teaching ICS inhaler technique, environmental control, and giving a written action plan are essential. Lack of initiation of ICS with appropriate patient education before discharge from the ED in patients with persistent asthma is common but unfortunately associated with continued poor patient outcomes.

PRACTICE PATTERNS IN THE PRESCRIPTION OF ORAL CORTICOSTEROID BURST THERAPY IN THE OUTPATIENT MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS

PURPOSE: The use of a short course of oral corticosteroids (OCS), or steroid burst, is standard practice in outpatient management of acute asthma exacerbations. Although there are published guidelines on the use of OCS in asthma exacerbations, actual practice patterns in this clinical setting are unknown. This study was designed to evaluate the pattern of OCS administration and typical total OCS burst doses used in different physician groups.

Nonoperative management of adhesive capsulitis of the shoulder: Oral cortisone application versus intra-articular cortisone injections

Oral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder. In a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used. In the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P < .0001), SST (P=.035), VAS (P < .0001), and range of motion (P < .05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P < .0001), SST (P < .0001), the VAS (P < .0001), and range of motion (P < .05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P < .05). Differences in the VAS for pain and function were not significant (P > .05). The use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids.

Do short courses of oral corticosteroids and use of inhaled corticosteroids affect bone health in children?

This Practice Point commentary discusses the findings of a prospective study by Kelly et al. that evaluated the effect of multiple short courses of oral corticosteroids and use of inhaled corticosteroids on bone accrual in children with asthma. The researchers determined the cumulative number of short courses of oral corticosteroids and the cumulative dose of inhaled corticosteroids over a 7-year study period. Multiple short courses of oral corticosteroids in boys, but not girls, were a dose-dependent risk factor for decreased bone-mineral accrual and osteopenia. Inhaled corticosteroid use in boys, but not girls, was also associated with decreased bone accrual, but the association was not dose-dependent. However, no effect of corticosteroids on fracture risk was found. Here, I discuss the relevance of these findings in relation to attainment of peak bone mass and outline how the findings could be complicated by disease-related effects of asthma on bone health.

Coccydynia Related to Calcium Crystal Deposition

Study of 4 cases of severe coccydynia revealing calcium deposits in the sacrococcygeal and intercoccygeal joints. To highlight calcium crystal deposition as a cause of sudden-onset coccydynia. Intervertebral disc calcification in the cervical, thoracic, or lumbar spine is well known, but calcifications in the sacrococcygeal or intercoccygeal joints with symptoms have never been reported. All 4 patients presented with severe, sudden-onset coccydynia. Radiographs of the coccygeal area showed calcific deposits in the sacrococcygeal or intercoccygeal joints. Patients received a short course of oral corticosteroids or steroid injections. Conservative management provided prompt relief in all but one case. In 2, the resolution of the calcific deposits as seen on follow-up radiography was highly suggestive of their apatite origin. Calcium crystal deposition in the sacrococcygeal or intercoccygeal joints can cause coccydynia. Conservative treatment is effective as a first-line approach.

Effect of long-term corticosteroid use on bone mineral density in children: a prospective longitudinal assessment in the childhood Asthma Management Program (CAMP) study.

Systemic corticosteroids are known to induce osteoporosis and increase the risk for fractures in adults and children. Inhaled corticosteroids have been shown to increase the risk for osteoporosis and fractures in adults at risk; however, long-term prospective studies of children to assess risks of multiple short courses of oral corticosteroids and chronic inhaled corticosteroids have not been performed. Thus, we assessed the effects of multiple short courses of oral corticosteroids and long-term inhaled corticosteroids on bone mineral accretion over a period of years. This was a cohort follow-up study for a median of 7 years of children who had mild-to-moderate asthma and initially were randomly assigned into the Childhood Asthma Management Program trial. Serial dual-energy radiograph absorptiometry scans of the lumbar spine for bone mineral density were performed for all patients. Annual bone mineral accretion was calculated for 531 boys and 346 girls who had asthma and were aged 5 to 12 years at baseline (84% of the initial cohort). Oral corticosteroid bursts produced a dosage-dependent reduction in bone mineral accretion (0.052, 0.049, and 0.046 g/cm(2) per year) and an increase in risk for osteopenia (10%, 14%, and 21%) for 0, 1 to 4, and >or=5 courses, respectively, in boys but not girls. Cumulative inhaled corticosteroid use was associated with a small decrease in bone mineral accretion in boys but not girls but no increased risk for osteopenia. Multiple oral corticosteroid bursts over a period of years can produce a dosage-dependent reduction in bone mineral accretion and increased risk for osteopenia in children with asthma. Inhaled corticosteroid use has the potential for reducing bone mineral accretion in male children progressing through puberty, but this risk is likely to be outweighed by the ability to reduce the amount of oral corticosteroids used in these children.

A case of adult blaschkitis with features of interface dermatitis

Conflicts of interest: none declared. Sir, Adult blaschkitis is a rare, relapsing linear eruption of pruritic papules and vesicles. The lesions involve multiple sites, particularly the trunk, and follow Blaschko’s lines.1 2–3 Blaschkite de l’adulte and acquired relapsing self‐healing Blaschko dermatitis have been suggested as alternative names for this condition.1, 2 Seven cases have been reported in the literature since it was first described in 1990 by Grosshans and Marot, and the histopathological findings were those of spongiotic dermatitis.1 2–3 We present a case of adult blaschkitis with the histopathological features of interface dermatitis. A 31‐year‐old man presented with a 1‐month history of unilateral pruritic skin disease. He had no history of atopic dermatitis, psoriasis, or any other dermatitis. He had no significant past medical or drug use history. Physical examination revealed discrete erythematous grouped papules and vesicles on the left sides of the trunk and upper and lower limbs. The skin lesions formed whorls and streaks along Blaschko’s lines (Fig. 1). A punch biopsy from an abdominal lesion revealed hyperkeratosis, focal parakeratosis, acanthosis, and scattered dyskeratotic cells with basal cell vacuolar degeneration in the epidermis. Spongiosis and lymphocyte exocytosis were also found. Superficial perivascular lymphocytic infiltrates were seen in the dermis (Fig. 2). A short course of oral corticosteroids (20 mg daily) and topical corticosteroid lotion were prescribed. The existing skin lesions improved; however, new lesions developed. His skin lesions cleared with the addition of narrowband ultraviolet B phototherapy (total 6250 mJ, twice a week for 2 months).

Extent of uncontrolled disease and associated medical costs in severe asthma – a PHARMO study

ABSTRACTObjective: Asthma is a major public health problem with considerable economic impact. The highest costs being observed in patients with severe asthma. Furthermore, despite the use of recommended therapies, asthma control can still be poor. Therefore, the objective of this study was to assess the extent of uncontrolled disease and associated medical costs in severe asthma.Methods: The PHARMO Record Linkage System includes among others drug dispensing and hospitalizations for ≥ 2 million subjects in The Netherlands. Severe asthma patients used long-acting beta-agonists and inhaled corticosteroids for over 200 days and short-acting beta-agonists for at least 100 days in 2004. Severe uncontrolled asthma was defined as a hospitalization for asthma or use of multiple short courses of oral corticosteroids assessed in 2004. Reimbursed costs of asthma drugs and hospitalizations were calculated during this year. A matched nested-case control study was performed to identify treatment-related risk factors for uncontrolled disease. Information on clinical diagnosis of (severity of) asthma was not available.Results: About 17% of patients with severe asthma aged 12–49 years (N = 1158) showed lack of control. Excess drug costs for severe uncontrolled asthma with hospitalization mounted up to 700 Euro per patient per year and 300 Euro per patient per year for patients without hospitalization. Including hospital admission costs, excess costs mounted up to over 10 000 Euro per patient per year. Lack of control did not seem to be caused by under-treatment.Conclusion: Poor control of severe asthma leads to disproportionately increased direct costs compared to severe controlled asthma, especially when hospital admission is required.

Asthma Control Score Based on Filled Medication Prescriptions: A Validation Study

Periodic measurement of disease control is recommended to characterize asthma and monitor treatment. To elaborate and validate an asthma control score (ACS) for use in studies based on administrative health databases. Adult patients with asthma were recruited from a clinic. The ACS is based on the average number of doses of short-acting inhaled beta(2)-agonists taken per week and short courses of oral corticosteroids dispensed over a three-month period. Data were obtained from the Régie de l'assurance maladie du Québec database in Canada. The ACS was compared with the asthma control questionnaire and the use of health care services for asthma over a 12-month period. A total of 60 patients were enrolled. They had a mean (+/- SD) age of 50.4+/-13.9 years, and 43.3% were male. Patients had had asthma for 20.8+/-15.1 years on average and had a mean prebronchodilator forced expiratory volume in 1 s of 77.0% of the predicted value. The mean ACS was 8.3+/-11.6, with a range of 0 to 60. The ACS was not found to be correlated with the asthma control questionnaire, but it was significantly associated with health care services used. For each additional point in the ACS, patients were 2% more likely to need acute care for asthma (rate ratio 1.02; P=0.02). Further studies including patients followed by general practitioners are required before the general use of this score. This innovative score is useful to rapidly assess the control of asthma over long periods of time and at a low cost in studies using administrative drug databases.

Analysis of Steroid Treatment of First Wheezing Episode

Analysis of Steroid Treatment of First Wheezing Episode

Pharmacotherapy options for complex regional pain syndrome

Complex regional pain syndrome is a painful disorder of unclear etiology, typically involving the distal part of one limb, represented by spontaneous and evoked pain as well as autonomic, motor and trophic abnormalities. It can be incapacitating and severely affect function and quality of life. Although full-blown complex regional pain syndrome can be diagnosed easily, less fulminate forms of the syndrome often remain undiagnosed. Controlled trials have demonstrated that a short course of oral corticosteroids, intranasal or intramuscular calcitonin, intravenous bisphosphonates, free-radical scavengers, gabapentin, regional intravenous sympathetic blocks with bretylium and spinal cord stimulation or physical therapy and occupational therapy can be efficacious for complex regional pain syndrome. Nonetheless, the management of this syndrome is difficult because currently available drugs and technologies do not provide adequate pain relief for a considerable percentage of sufferers. The present review focuses primarily on the pharmacotherapy of complex regional pain syndrome and describes briefly the epidemiology, pathogenesis and clinical manifestations of the syndrome.

Decision making in asthma exacerbation: a clinical judgement analysis

Background: Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors based on their knowledge and experience. Decisions include...

Management approaches to intermittent wheezing in young children

To review the recently published studies addressing various treatment approaches for episodic wheezing in young children. A landmark study demonstrated that short courses of oral corticosteroids initiated at the first sign of an upper respiratory tract infection decreased wheezing episode frequency and severity. Since then, alternative treatment strategies have been investigated. Montelukast decreased short-term daytime cough and delayed exacerbations following hospitalization for respiratory syncytial virus bronchiolitis, and led to fewer exacerbations without decreasing oral corticosteroids use among children with intermittent asthma. Preschool children with frequent wheezing at high risk for asthma receiving daily inhaled corticosteroids experienced lower rates of exacerbations requiring oral corticosteroids. Episodic use of inhaled corticosteroids, initiated at the early signs of an upper respiratory infection, led to modest reduction in symptoms, but not oral corticosteroid use. Among young children with 'preasthma', inhaled corticosteroids initiated after 3 days of wheezing did not affect the frequency or severity of wheezing episodes. Evidence for the preferred treatment strategies for intermittent wheezing in young children remains incomplete. Most of the studies represent heterogeneous populations and lack adequate statistical power to evaluate relevant outcomes. Based on the evidence, there is rationale for further investigation of several management strategies, including corticosteroids and/or leukotriene receptor antagonists administered daily or episodically.

Anti‐inflammatory pharmacotherapy for wheezing in preschool children

Accumulating evidence indicates that there are at least two phenotypes of wheezing in preschool years with distinct natural history. Frequent wheezing in the first 3 years of life with risk factors for asthma (e.g., eczema, maternal asthma) predicts symptoms in older age, while infrequent viral-associated wheezing without risk factors for asthma has a benign prognosis. This systematic review summarizes evidence on the use of anti-inflammatory medications in preschool children with wheezing. Literature search was performed using Medline and the Cochrane Library. Retrieved articles were critically appraised. Episodic use of high-dose inhaled corticosteroids (>1,600 mcg/day of beclomethasone) may ameliorate severity of intermittent viral-associated wheezing. Maintenance inhaled corticosteroids can control symptoms in children with frequent wheezing associated with risk factors for asthma. Inhaled corticosteroids do not alter the natural history of wheezing even when started early in life and could have a negative impact on linear growth rate. Short courses of oral corticosteroids have been proposed as an effective measure to control exacerbations of symptoms although there is little evidence supporting their use. Some studies support the administration of non-steroidal anti-inflammatory medications (leukotriene pathway modifiers, cromones, methylxanthines) for mild frequent wheezing. Maintenance inhaled corticosteroids is the most effective measure for controlling frequent wheezing in preschool children, especially when accompanied by risk factors for asthma. This treatment does not affect the natural history of wheezing, although deceleration of linear growth rate is the most commonly recognized systemic adverse effect.

A 63-year-old man with headaches and behavioral deterioration

A 63-year-old, right-handed man presented to his local hospital with headaches and recent behavioral and cognitive deterioration. One year prior to presentation, he noted nonspecific increasing fatigue and sinus problems that he attributed to recent woodworking with moldy wood and exposure to fine dust. In early February 2000, he developed headaches, which he identified as being different from his usual “migraine headache.” They were frontal, throbbing, and severe, classified as “10 out of 10” on a pain scale and they occasionally awoke him from sleep. He was evaluated by local physicians, including a neurologist, ophthalmologist, and otolaryngologist, was diagnosed with sinus headaches, and was treated unsuccessfully with antihistamines, antibiotics, and a short course of oral corticosteroids of unknown dose. The headaches continued and he was seen in a local emergency room on two separate occasions and treated with neuroleptics and sumatriptan without benefit. A sedimentation rate was normal. In March 2000, the patient had imbalance and was noted to veer often to the left. Prominent behavioral changes also were identified in that he was more irritable, disinhibited, impatient, and oppositional. He had less interest in his hobbies, was more forgetful, and was fidgety. Superimposed on these changes were episodes of more marked confusion. He voluntarily stopped driving as he felt he was unable to make quick decisions. The patient also experienced nausea and vomiting on a nearly daily basis. He would not eat for up to 2 days because of these symptoms and lost 20 pounds in 2 months. During the first week of March, he was hospitalized locally in Arizona. Erythrocyte sedimentation rate, antinuclear antibodies, fungal serology, serum protein electrophoresis, B12, and folate were tested and were normal or negative. MRI of the brain revealed scattered T2 hyperintensities in the bilateral subcortical and deep white matter, some of which …

Antileukotrienes as Adjunctive Therapy in Acute Asthma

The leukotriene receptor antagonists (LTRAs) are a comparatively new class of asthma drugs that exhibit both bronchodilator and anti-inflammatory properties. There is a substantial body of evidence for their benefit in the management of chronic asthma in both adults and children, and particularly in specific types of asthma such as exercise-induced and aspirin-sensitive asthma. Despite best practice using current treatment guidelines for the management of acute asthma, a significant proportion of patients require continued treatment and are unable to be discharged from the emergency department; many require a short course of oral corticosteroids. The relatively rapid onset of action of LTRAs after oral administration and their additive effect to beta(2)-adrenoceptor agonists led to the hypothesis that they might be of benefit in acute asthma. This review examines the available evidence for the effect of LTRAs in acute asthma. Although the evidence is limited, it suggests that treatment with LTRAs provides additional bronchodilator effect to nebulised and inhaled beta(2)-adrenoceptor agonists. Short-term therapy with LTRAs results in fewer treatment failures and readmissions for patients with acute asthma, and less need for additional therapies such as nebulisers and corticosteroids.

A 77-Year-Old Farmer With Respiratory Failure and Thrombocytopenia

A 77-year-old farmer presented with a 3-month history of progressive dyspnea. His symptoms started with anorexia, malaise, fever, and dry cough. He was initially treated with azithromycin and a short course of oral corticosteroids for COPD exacerbation. Two days after finishing the treatment, his symptoms progressed, and he was admitted to a local hospital with respiratory distress, altered mental status, hypotension, and abnormal chest radiograph findings. Bronchoscopy showed normal airways, and the BAL fluid sample revealed lymphocytosis with negative culture results.

Short course of prednisolone in patients with solitary cysticercus granuloma: A double blind placebo controlled study

The study was conducted to confirm the role of a short course of oral corticosteroids in patients with solitary cysticercus granuloma with seizures by a double-blind placebo-controlled study. In an open-label trial we, in past, had demonstrated a beneficial role of prednisolone. A short course of prednisolone helped in early resolution of solitary cysticercus granuloma. In this double-blind placebo-controlled randomized study, 60 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either anti-epileptic monotherapy with prednisolone (n=30) or anti-epileptic monotherapy along with placebo (n=30). The patients received prednisolone, 1mg/kg/day for 10 days, followed by tapering over next 4 days. None of the patients received albendazole therapy. The patients were followed up monthly, at least for 9 months. A repeat CT scan was performed after 6 months. The data were analysed by chi-square test. The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 6 months demonstrated non-significantly better response for prednisolone treated patients. In prednisolone group the lesion disappeared in 52% of patients and in 48% patients who received placebo. However, a significantly lesser number of prednisolone treated patients (n=12%) than controls (n=48%), had seizure recurrence. Our study suggests that short-term prednisolone therapy may not help in rapid resolution of solitary cysticercus granuloma, however, prednisolone therapy improves seizure-related prognosis.

Orbital Pseudotumor as an Initial Manifestation of Multicentric Castleman's Disease

To report on a patient with multicentric Castleman's disease (MCD) who showed an orbital pseudotumor as an initial manifestation. A Japanese male patient, 65 years old, initially exhibited swelling of the left eyelid. Computed tomography and magnetic resonance imaging showed an infiltrating orbital mass around the left eye. The patient was treated several times with short courses of oral corticosteroids without significant response. Eight years after the first examination, he was referred to our neuroophthalmology clinic owing to persistent eyelid swelling. He exhibited an accelerated erythrosedimentation rate, polyclonal hypergammaglobulinemia, and multiple cervical and thoracic mediastinal lymphadenopathies. Histopathological examination revealed mixed-type MCD from a cervical lymph node and chronic inflammatory cell infiltration from eyelid swelling. Four months after his first visit, the patient's condition was complicated by fever, general fatigue, and hypoxemia. A cell marker study of the swollen lymph node showed monoclonality, indicating the development of non-Hodgkin's lymphoma. The clinical course in this case suggests that an inflammatory reaction in the orbital tissue was initially present, before MCD, and that non-Hodgkin's lymphoma subsequently developed.

Histiocytic necrotising lymphadenitis (Kikuchi's disease): A rare cause of cervical lymphadenopathy

Both Head and Neck Surgeons and General Surgeons are frequently referred patients with cervical lymphadenopathy. An uncommon but important cause is histiocytic necrotising lymphadenitis. This is a benign self-limiting disease that has been confused with malignant lymphomas. Some patients may also experience distressing and debilitating symptoms which can last for months. We describe four cases to illustrate the varied clinical presentation of this disease and present new signs seen in association with it. A remarkable therapeutic response to a short course of oral corticosteroids was observed in one case.