Short Course Of Oral Steroids Research Articles

The child with multiple short courses of steroid therapy

Glucocorticosteroids are potent drugs that are important parts of rational therapy for a number of common diseases in paediatrics. While long term steroid use is associated with both adrenal and immune suppression, short courses of oral steroids (1 to 2 mg/kg of prednisolone or prednisone for three to five days) are not associated with these effects, even when used on several occasions over the course of one year. Chronic low or moderate dose inhaled steroid therapy is not associated with untoward systemic effects.

A Retrospective Analysis of Treatment Outcomes and Time to Relapse after Intensive Medical Treatment for Chronic Sinusitis

Despite the high prevalence of chronic sinusitis, there are few published studies assessing its response to medical treatment. We analyzed, retrospectively, 40 patients seen in our center who were treated for chronic sinusitis with a protocol of intensive medical therapy. Both symptomatic and radiographic improvements were assessed as well as factors associated with early relapse. Intensive medical treatment consisted of 1 month of antibiotics, a short course of oral steroids, and adjunctive therapy (e.g., nasal irrigations plus intranasal steroids). After intensive medical therapy, adjunctive medical therapy was continued. A sinus computed tomography was performed at baseline and 6-8 weeks later and scored for extent of disease. Pre- and posttreatment symptom scores also were assessed. Time to relapse was defined as the time interval after antibiotic treatment at which a recurrence of symptoms necessitated reinstitution of antibiotics and/or oral steroids. Thirty-six of the 40 patients improved either symptomatically, radiographically, or both following the medical regimen. Twenty-six patients had sustained symptomatic benefit beyond 8 weeks after initial treatment. A statistically significant correlation was found between the change in pre- to posttreatment symptom scores and computed tomography scores. Using a log-rank test to compare rates of sinusitis relapse, nasal polyposis and a history of sinus surgery were significantly associated with earlier relapse (p = 0.006 and 0.018, respectively). In contrast, atopy, asthma, and persistent obstruction of the ostiomeatal unit were not associated with early relapse. Intensive medical treatment resulted in symptomatic and radiographic improvement in chronic sinusitis, and the majority of patients remained free of a relapse for >8 weeks. A history of nasal polyposis or previous sinus surgery was associated with earlier relapse of sinusitis symptoms. In contrast, the presence of atopy, a history of asthma, or persistent OMU obstruction was not associated with earlier relapse. Although long-term benefits have not been established, a prospective study of treatment outcomes from intensive medical treatment appears to be warranted.

Cutaneous lupus erythematoses

The clinical features of the major types of cutaneous lupus arewell known. The three broad categories of discoid lupus, subcutaneous lupus and acute cutaneous lupus describe particular entities with generally discreet clinical features. However there is considerable overlap between these forms and the initial focus of management of patients presenting with cutaneous signs of lupus erythematosus consists of establishing the degree of systemic involvement present. In those patients with systemic disease the over-riding therapeutic need is for control of the systemic features of the condition. Cutaneous disease will normally respond at the same time. However there are many patients who have cutaneous disease as their major disease presentation. In these, choice of therapeutic option depends on the extent of cutaneous involvement, the time course of disease and the presence or absence of scarring. Whilst there is general agreement that first-line therapy with sunscreen, topical steroids and then if necessary anti-malarials is effective in the majority of patients (around two-thirds), subsequent therapy is based more on anecdote and experience than hard evidence. Being female, smoking and having extensive disease are features that often go together and lead to relative resistance to therapy. Once a single anti-malarial has failed in treatment, combination anti-malarials, dapsone, oral gold, methotrexate, thalidomide and many other agents have all been used though clinical evidence in support of their use is noticeable by its absence. Short courses of oral steroids are also often necessary in patients with severe and extensive disease as well as those with scarring. This talk will review the spectrum of disease, and the available treatment options.

Therapy of allergic rhinitis

Allergic rhinitis is a common disease with a prevalence of 10-20% in western countries. Allergic rhinitis may be complicated by the possible restriction of quality of life and can lead to sequelae like sinusitis, headache or even allergic asthma. The treatment of allergic rhinitis is mainly based on allergen avoidance, pharmacological treatment and specific immunotherapy. For mild symptoms of seasonal or perennial allergic rhinitis topical or nonsedating second generation oral H1-antihistamines or chromones are advised. If the patient presents symptoms of long duration or nasal obstruction is dominant, intranasal steroids should be used, which have proved to be an effective and safe form of therapy for allergic rhinitis. A combination of oral antihistamines and steroids are possible and recommended if one of these agents alone does not provide sufficient relief. If necessary this regimen is supplemented with topical antihistamines or chromone eyedrops. In cases of severe nasal obstruction, a short course of oral steroids or topical decongestants, which both should not be given longer than ten days, is recommended. Intramuscular corticosteroids should not be given, due to the suppression of adrenal glands. In addition it is important to prevent exposure to the allergen. If the treatment is not effective, further investigations should be done to exclude other nasal diseases (polyposis nasi, anatomical anomalies, chronic sinusitis). This article summarizes the recommended medications with their possible side-effects and their place in therapy management of allergic rhinitis in adults and children.

Association of Being Overweight with Greater Asthma Symptoms inInner-City Black and Hispanic Children

Luder E, Melnik TA, DiMaio MJ Pediatr.1321998699703The prevalence of both asthma and obesity have been increasing over recent years, and are higher among minorities. The aim of this study was to observe whether the weight status of inner-city minority asthmatic children differed from that of their nonasthmatic peers, and to determine if overweight asthmatic children experienced more severe asthma.The study group was composed of 209 black and Hispanic children between the ages of 2 and 18 who carried the single diagnosis of asthma, and who had not received chronic oral steroids or more than 4 short courses of oral steroids within the past year. The control group consisted of 1017 black and Hispanic children enrolled in New York City schools.Information obtained from the patient record and an interview was used to determine asthma severity. This information included peak expiratory flow (PEF) records, number of medications used, number of emergency visits or hospitalizations, number of school days missed, and ability to participate in play or sports activities. PEF rate was measured at enrollment in patients who were at least 6 years old and could perform a good effort. Standing height and weight were measured in the patients. Height and weight measurements for the control group were available for comparison. Body mass index (BMI) was calculated and used as the indicator of weight status. Differences in BMI between the asthmatic children and their peers were determined, and the relationship between high BMI and the various measures of asthma severity was examined.The percentile distribution of BMI for the children with asthma was compared with that of the control group as well as the established reference population. The BMI distribution for the asthmatic patients as well as the controls was skewed towards the higher percentiles compared with the reference population, but was skewed to a greater extent for the asthmatics. The asthmatic children had a relative risk of 1.34 of having a BMI at 85th percentile or greater compared with the peer group (P = .06). The relative risk for asthmatics of having a BMI at 95th percentile or greater was 1.51 (P = .03). The risk of being overweight (based on a BMI of 85th percentile or greater) was found to be significantly associated with days of school missed (30 days or more missed per year), PEF rate of ≤60% predicted, and three or more prescribed asthma medications. The risk of being overweight was not significantly associated with number of hospitalizations, number of emergency visits, or level of sports participation.The prevalence of being overweight was significantly higher in asthmatic children compared with their peers. Being overweight was significantly associated with severity of asthma as measured by PEF rate, days of school missed, and number of asthma medications.The authors mention that the findings of this study do not allow us to determine whether asthmatic children are more overweight because of a decreased activity level, or if being overweight actually leads to increased severity of asthma. Asthmatic children may be held back from participating in sports by their parents and thus become overweight because of inactivity. Alternatively, overweight children might spend more time indoors, thereby being exposed to greater amounts of indoor allergens, leading to increased asthma. The latter explanation might be more of an issue in inner-city environments.

ENDOCRINE-METABOLIC EFFECTS OF ASTHMA TREATMENT: The Impact of Glucocorticoid Therapy in the Elderly

Asthma is a chronic inflammatory disease of the airways, well recognized to affect millions of children and young adults in the United States. However, it is also a disease that is often underdiagnosed and underemphasized in the elderly population, in which many unique considerations become significant. The prevalence of asthma in persons over age 65 has been reported to range from 6.5% to 40%. 17 , 50 , 77 The incidence rate for newly diagnosed asthma is about 100 cases per 1000 population over age 65, little changed from earlier adulthood. 21 , 177 Not surprisingly, there is evidence that the mortality rate associated with asthma is much higher in the elderly population. 36 , 177 Likewise, increased hospitalization rates and cost of care are important considerations in this portion of the asthmatic population. 152 , 176 The challenges of diagnosis and optimal treatment of asthma in the elderly have therefore gained increased attention, recognizing the implications of chronic disease in this growing segment of our society. 112 , 152 Presently, there are no unique pharmacologic recommendations for elderly patients with asthma. The most frequently prescribed medications include inhaled β 2 -agonists (short-acting and long-acting) and inhaled glucocorticoids (GC). A short course of oral steroids is often indicated for acute exacerbations and long-term oral steroids are occasionally necessary for severe, persistent asthma. Other useful agents include oral β agonists, cromones (cromolyn and nedocromil), theophylline, leukotriene modifiers and inhaled anticholinergics. The usual therapeutic implementation of these medications follows the same guidelines applied to younger populations, although there are additional cautionary recommendations regarding diagnosis, implications of polypharmacy, technical issues of drug administration and the potential for therapy to aggravate coexisting conditions. 14 , 113 Among the most significant potential ramifications for asthma therapy in elderly patients is the impact on the endocrine system. Most of the proposed endocrinologic and metabolic systemic effects of asthma therapy have particular relevance to the elderly. Among the most frequently used agents are glucocorticoids, which carry the greatest possibility for such adverse effects and deserve special deliberation. In doing so, one finds some answers and many unresolved issues.

Bone mineral density in asthmatic patients treated with inhaled corticosteroids: a case-control study.

Recent studies suggest that inhaled corticosteroids can adversely affect bone metabolism. The objective of this study was to evaluate the importance of these adverse effects in a case-control study. Bone mineral density (BMD) was measured in 48 asthmatic adults (15 males and 33 females) treated with inhaled steroids (beclomethasone or budesonide) and in 48 gender and age-matched healthy subjects at baseline and at 2 yrs. Vertebral BMD was measured by dual energy X-ray densitometry. Patients had been treated with a dose of 662 +/- 278 micrograms (range 300-1,000 micrograms) of beclomethasone dipropionate or budesonide for more than 1 yr (mean duration of treatment 10.6 yrs, range 1-16 yrs). Twenty four patients had needed 1-6 short courses of oral steroids and seven had received oral corticosteroids (mean daily dose 6.2 mg prednisone) for 2-15 yrs more than 4 yrs prior to the BMD measurements. During the follow-up, 14 patients required 1-3 short courses of oral steroids. There was no correlation either between inhaled corticosteroid doses or duration of treatment and BMD values. There were no significant differences in BMD baseline values between patients and healthy controls. BMD significantly decreased in both groups at 2 yrs, from 1.08 +/- 0.19 to 1.05 +/- 0.19 g.cm-2 (p = 0.002) in asthmatics versus 1.12 +/- 0.17 to 1.09 +/- 0.18 g.cm-2 (p = 0.008) in controls. There were no significant differences in BMD loss between patients and healthy controls. Furthermore, no differences were found in bone loss when pre- and postmenopausal women were compared with their healthy control counterparts. No differences in baseline BMD were found between patients who had received regular oral corticosteroid therapy or booster courses of oral corticosteroids and those who had not. Inhaled corticosteroid treatment at a mean dose of 662 micrograms.day-1 and sporadic booster courses of oral corticosteroids do not further increase bone mass loss with respect to that expected from natural bone mass loss.

Compliance with inhaled medication and self-treatment guidelines following a self-management programme in adult asthmatics

Two of the principal components of self-management are compliance with medication and adherence to self-treatment guidelines. The aim of this study was to evaluate compliance objectively. Twenty two adult asthmatics attended a self-management programme. During a 2 week run-in period, compliance with inhaled steroids and peak expiratory flow (PEF) were electronically-registered. For PEF this resulted in a personal best value (PBV). Subsequently, patients attended four educational group sessions. During the four weeks of follow-up, patients were instructed to measure their PEF on a fixed day of the week and when they experienced an increase in symptoms. If PEF fell below 80% of PBV, patients had to double their use of inhaled steroids; if PEF fell below 60%, they had to start a short course of oral steroids. During run-in, mean compliance was 83% and compliance per patient varied from 6 to 106%. During follow-up, on days without exacerbation, compliance with inhaled steroids increased by 12% (95% confidence interval (95% CI) 3-21%) compared to run-in, ranging 21-200%. On days when patients should have doubled their inhaled steroids, compliance decreased by 28% (95% CI -39 to -17), and compliance ranged 46-94%. Of the 10 patients who should have doubled their medication, only three did so, whilst four increased the use of inhaled steroids but only by one or two puffs; three patients did not alter their behaviour. In five patients (24%) PEF fell below 60% of their PBV, after which four started prednisolone (self-report). In conclusion, even after a formal self-management programme, patients with asthma comply only partially to self-treatment guidelines. Most are willing to increase, but not double, their inhaled steroids. This suggests that more emphasis is needed to reassure patients about the safety of inhaled steroids.

Pemphigus foliaceus induced by nifedipine.

We report a case of pemphigus foliaceus caused by nifedipine. In this case casual rechallenge with nifedipine confirmed that this drug was the causative agent. The skin lesions cleared quickly after withdrawal of the drug and treatment with a short course of oral steroids. To our knowledge, this is the first reported patient with nifedipine-induced pemphigus.

Penicillamine-Induced Pemphigus Foliaceus

Penicillamine-induced pemphigus is an uncommon but well-recognized phenomenon. It has been generally believed to be a benign disease responding to withdrawal of the drug or to treatment with a short course of oral steroids. In the hope that it will increase awareness of the potential severity of this disease, we report herein a case of penicillamine-induced pemphigus foliaceus with fatal termination.