Steroid Prescription Research Articles

Risk factors associated with acute exacerbation of chronic obstructive pulmonary disease in HIV-infected and uninfected patients.

To determine the association between HIV infection and other risk factors for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Longitudinal, national Veterans Aging Cohort Study including 43 618 HIV-infected and 86 492 uninfected veterans. AECOPD was defined as an inpatient or outpatient COPD ICD-9 diagnosis accompanied by steroid and/or antibiotic prescription within 5 days. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) for first AECOPD over 2 years and used Poisson regression models to adjust for risk factors. Over 234 099 person-years of follow-up, 1428 HIV-infected and 2104 uninfected patients had at least one AECOPD. HIV-infected patients had an increased rate of AECOPD compared with uninfected (18.8 vs. 13.3 per 1000 person-years, P < 0.001). In adjusted models, AECOPD risk was greater in HIV-infected individuals overall (IRR 1.54; 95% CI 1.44-1.65), particularly in those with more severe immune suppression when stratified by CD4 cell count (cells/μl) compared with uninfected (HIV-infected CD4 < 200: IRR 2.30, 95% CI 2.10-2.53, HIV-infected CD4 ≥ 200-349: IRR 1.32, 95% CI 1.15-1.51, HIV-infected CD4 ≥ 350: IRR 0.99, 95% CI 0.88-1.10). HIV infection also modified the association between current smoking and alcohol-related diagnoses with risk for AECOPD such that interaction terms for HIV and current smoking or HIV and alcohol-related diagnoses were each significantly associated with AECOPD. HIV infection, especially with lower CD4 cell count, is an independent risk factor for AECOPD. Enhanced susceptibility to harm from current smoking or unhealthy alcohol use in HIV-infected patients may also contribute to the greater rate of AECOPD.

The effect of an integrated syndromic respiratory disease guideline in primary health care settings

The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC. The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details. During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled β-agonist prescription increased. The average cost of drug prescription was reduced by 19%. Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.

Diabetes and the risk of infections with immunomodulator therapy in inflammatory bowel diseases

Infections are an important concern in patients using immunosuppressive therapy for their inflammatory bowel disease (IBD). Diabetes affects nearly 10% of Americans. Whether it confers an additional risk with immunosuppression in IBD has not been examined previously. To examine the association between diabetes and infections with immunomodulator use in IBD METHODS: Using a validated, multi-institutional IBD cohort, we identified all patients who received at least one prescription for immunomodulators (thiopurines, methotrexate). Our primary outcome was infection within 1year of the prescription of the immunomodulator. Multivariable logistic regression adjusting for relevant confounders was used to estimate the independent association with diabetes. Our study included 2766 patients receiving at least one prescription for immunomodulators among whom 210 (8%) developed an infection within 1year. Patients who developed an infection were likely to be older, have more comorbidities, more likely to have received a prescription for steroids but similar in initiation of anti-TNF therapy within that year. Only 8% of those without an infection had diabetes compared to 19% of those who developed an infection within 1year [odds ratio (OR) 2.74, 95% confidence interval (CI) 1.88-3.98, P<0.001]. On multivariate analysis, diabetes was independently associated with a nearly two-fold increase in risk of infections (OR: 1.80, 95% CI: 1.20-2.68). There was no increase in risk of infections with addition of anti-TNF therapy (OR: 1.14, 95% CI: 0.80-1.63). Diabetes is an independent risk factor for infection in IBD patients using immunomodulator therapy.

Sa1121 Diabetes Is an Independent Risk Factor for Immunosuppression-Related Infections in Patients With Inflammatory Bowel Diseases

Introduction: Infections are an important concern in patients with inflammatory bowel diseases (IBD; Crohn's disease (CD), ulcerative colitis (UC)) treated with immunosuppressive therapy. This is particularly so in those with significant co-morbidity, a population commonly excluded from clinical trials. Diabetes affects 9.3% of Americans and in increasing in prevalence. Infections commonly complicate diabetes which has itself been hypothesized to have an immunosuppressive effect. However, whether it confers additional risk of infections over immunomodulator therapy has not been examined previously. Methods: Using a validated, multi-institutional IBD cohort, we identified all patients who received at least one prescription for immunomodulators (azathioprine, 6-mercaptopurine, and methotrexate). We identified diabetes and infections according to the corresponding ICD-9 codes. Our primary outcome was infection within 1 year of the first prescription of the immunomodulator. Multivariate logistic regression was used to estimate the independent association between diabetes and infection adjusting for relevant confounders including age, gender, comorbidity, and confounding medications. Results: Our study included 2,766 patients receiving at least one prescription for immunomodulators among whom 210(8%) developed an infectious complication within 1 year of the first prescription. Patients who developed an infection were likely to be older (46 years vs. 41 years, p < 0.001), female (58% vs. 52%), and have one or more additional comorbidity (95% vs. 70%). They were also more likely to have received a prescription for steroids (62 vs. 31%) but similar in initiation of anti-TNF therapy within that year (22% vs. 19%). Only 8% of those without an infection had diabetes compared to 19% of those who developed an infection within 1 year (p < 0.001) ( Figure). The most common infections in both groups were sepsis, pneumonia, cellulitis, and urinary tract infection. In multivariate analysis, diabetes was independently associated with a nearly twofold increase in risk of infections (OR 1.76, 95% CI 1.17 2.64) despite adjusting for age, other comorbidity, and medications. Conclusions: Diabetes is an independent risk factor for infection in IBD patients using immunomodulator therapy. Counseling and monitoring for such risks in addition to ensuring appropriate prophylaxis against preventable infections may help improve patient outcomes.

924 Long-Term Outcomes of Top-Down Versus Step-up Treatment in Newly Diagnosed Crohn's Disease: Final Data

G A A b st ra ct s variables, healthcare utilization, comorbidities and baseline immunosuppressive medication use, to assess the relative effectiveness and safety of IFX and ADA. Results: Our cohort comprised 1869 biologic-naive UC pts (age, 42.3±16.0y; 50.8% males) who were prescribed IFX (n=1470) or ADA (n=399) as first-line anti-TNF agents, and followed over median of 1.7 years (IQR, 0.9-3.0). Baseline demographics, healthcare utilization (outpatient, inpatient or emergency room visits; imaging and endoscopic procedures), comorbidities and prior medication exposure was comparable between the two groups (Table 1). As compared to ADA, pts treated with IFX were significantly less likely to require IBD-related hospitalization and new steroid prescription, after adjusting for baseline demographic variables, healthcare utilization, comorbidities and baseline immunosuppressive medication use (Table 2). There was no significant difference in the risk of abdominal surgery, though the number of events was small. Persistence on therapy at 6 months was significantly higher for IFX (61.4%) compared to ADA (14.8%). The incidence of serious infections was comparable between IFXand ADA-treated pts (incidence rate per 100 patient years: IFX vs. ADA, 1.49 vs. 2.25). Conclusion: In a large cohort of biologic-naive UC pts, IFX appears superior to ADA as first-line anti-TNF agent for important clinically relevant outcomes, without increased risk of serious infections. This requires further validation in randomized trials. Baseline characteristics of biologic-naive patients with ulcerative colitis.

Sa1123 Infusion-Related Reactions With Vedolizumab Treatment in Patients With UC or CD During the GEMINI 1 and GEMINI 2 Clinical Trials

Introduction: Infections are an important concern in patients with inflammatory bowel diseases (IBD; Crohn's disease (CD), ulcerative colitis (UC)) treated with immunosuppressive therapy. This is particularly so in those with significant co-morbidity, a population commonly excluded from clinical trials. Diabetes affects 9.3% of Americans and in increasing in prevalence. Infections commonly complicate diabetes which has itself been hypothesized to have an immunosuppressive effect. However, whether it confers additional risk of infections over immunomodulator therapy has not been examined previously. Methods: Using a validated, multi-institutional IBD cohort, we identified all patients who received at least one prescription for immunomodulators (azathioprine, 6-mercaptopurine, and methotrexate). We identified diabetes and infections according to the corresponding ICD-9 codes. Our primary outcome was infection within 1 year of the first prescription of the immunomodulator. Multivariate logistic regression was used to estimate the independent association between diabetes and infection adjusting for relevant confounders including age, gender, comorbidity, and confounding medications. Results: Our study included 2,766 patients receiving at least one prescription for immunomodulators among whom 210(8%) developed an infectious complication within 1 year of the first prescription. Patients who developed an infection were likely to be older (46 years vs. 41 years, p < 0.001), female (58% vs. 52%), and have one or more additional comorbidity (95% vs. 70%). They were also more likely to have received a prescription for steroids (62 vs. 31%) but similar in initiation of anti-TNF therapy within that year (22% vs. 19%). Only 8% of those without an infection had diabetes compared to 19% of those who developed an infection within 1 year (p < 0.001) ( Figure). The most common infections in both groups were sepsis, pneumonia, cellulitis, and urinary tract infection. In multivariate analysis, diabetes was independently associated with a nearly twofold increase in risk of infections (OR 1.76, 95% CI 1.17 2.64) despite adjusting for age, other comorbidity, and medications. Conclusions: Diabetes is an independent risk factor for infection in IBD patients using immunomodulator therapy. Counseling and monitoring for such risks in addition to ensuring appropriate prophylaxis against preventable infections may help improve patient outcomes.

Paralysie faciale idiopathique de l’enfant

Idiopathic facial palsy is the most common cause of facial nerve palsy in children. Controversy exists regarding treatment options. The objectives of this study were to review the epidemiological and clinical characteristics as well as the outcome of idiopathic facial palsy in children to suggest appropriate treatment. A retrospective study was conducted on children with a diagnosis of idiopathic facial palsy from 2007 to 2012. A total of 37 cases (13 males, 24 females) with a mean age of 13.9 years were included in this analysis. The mean duration between onset of Bell's palsy and consultation was 3 days. Of these patients, 78.3% had moderately severe (grade IV) or severe paralysis (grade V on the House and Brackmann grading). Twenty-seven patients were treated in an outpatient context, three patients were hospitalized, and seven patients were treated as outpatients and subsequently hospitalized. All patients received corticosteroids. Eight of them also received antiviral treatment. The complete recovery rate was 94.6% (35/37). The duration of complete recovery was 7.4 weeks. Children with idiopathic facial palsy have a very good prognosis. The complete recovery rate exceeds 90%. However, controversy exists regarding treatment options. High-quality studies have been conducted on adult populations. Medical treatment based on corticosteroids alone or combined with antiviral treatment is certainly effective in improving facial function outcomes in adults. In children, the recommendation for prescription of steroids and antiviral drugs based on adult treatment appears to be justified. Randomized controlled trials in the pediatric population are recommended to define a strategy for management of idiopathic facial paralysis.

The efficacy of systemic corticosteroids in treatment of respiratory tract infections during hajj 2012.

Background:Diagnosis and treatment of respiratory tract infections (RTI) in a mass-gathering situation such as hajj is a medical challenge that requires quick decision-making and considerable knowledge about its etiology and treatment methods. High prevalence of RTI during Hajj and tendency of caravan physicians to treat of patients quickly in such situation lead to prescription of parenteral steroids. Nonetheless, no study has focused on the short-term and long-term effects of systemic steroids in Hajj pilgrims with RTI.Objectives:This study focuses on efficacy of systemic consumption of corticosteroids in alleviating symptoms of RTI.Patients and Methods:This clinical trial was included 1671 pilgrims in Hajj 2012 who had symptoms of RTI based on caravan physician’s findings. The patients were divided to two groups to receive either parenteral corticosteroid or other drugs. Patients who received antibiotics for bacterial infections were excluded. This survey concentrated on general symptoms of RTI during Hajj such as fever, musculoskeletal pain, coryza, sore throat, cough, dyspnea, and hoarseness before, 24 hours after, and five days after drug consumption. For classification and analysis of data, SPSS 17 was used. Descriptive statistical and Chi square test were used to compare variables.Results:In comparison to corticosteroid injection, treatment without systemic corticosteroids could reduce the fever more significantly within five days (P < 0.05), while it had no effect after 48 hours (P > 0.05). Although corticosteroids alleviated the symptoms during the first 48 hours (P > 0.05), they had no more effect after five days of consumption (P > 0.05). Treatment with medications other than corticosteroid had less effect on reducing coryza (P > 0.05) while corticosteroids had significant alleviating effect on coryza, cough, and musculoskeletal pain (P < 0.05).Conclusions:There is a need to conduct more comprehensive studies on effect of combination therapy with corticosteroids and antibiotics as well as their short-term and long-term adverse effects on the immune system. While injecting corticosteroids is commonly administered in patients with RTI, they are not recommended due to the lack of data on their long-term therapeutic and adverse effects.

A survey of analgesic and anti-inflammatory drug prescription for oral implant surgery

Aim: This study was conducted to determine the preferred analgesic and anti-inflammatory drugs prescribed by oral implantologists in India. Methods: A structured questionnaire was distributed to 332 dentists to gather information regarding their prescription habits for analgesics and anti-inflammatory drugs. Frequency distributions were computed by type of drug being prescribed and the protocol followed. Results: Analysis of data showed that majority of dentists (85.8%, n = 285) prescribed conventional non-steroidal anti-inflammatory drugs (NSAIDs) for implant surgery. The most common prescription was ibuprofen with paracetamol combination (32.2%, n = 107) followed by diclofenac (20.2%, n = 67). Most dentists reported prescribing different NSAIDs for the same procedure in different patients (64.7%, n = 215). Only, 35.5% ( n = 118) followed the peri-operative protocol. Adjunctive prescription of steroids was done by only 33.7% ( n = 112). Conclusion: Our study illustrates that the general trend of analgesic and anti-inflammatory drug prescription for dental implant surgery among Indian dentists is mostly in accordance with the guidelines for pain management worldwide. However, it is noteworthy that a few dentists do prescribe drugs not primarily indicated for dental pain management and use widely varying protocols for the same. Therefore, in order to avoid potential complications, it is essential to raise awareness of among the dental practitioners of the appropriate indications and dosage regimen of specific drugs.

Gaps in the inpatient management of chronic obstructive pulmonary disease exacerbation and impact of an evidence-based order set.

Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions. To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD. The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario. A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5 ± 7.7 days before order sets to 4.1 ± 5.0 days with order sets (P=0.017). Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.

Use of traditional Chinese medicine reduces exposure to corticosteroid among atopic dermatitis children: A 1-year follow-up cohort study

Ethnopharmacological relevanceAtopic dermatitis is a prevalent dermatologic disease in children. Corticosteroid is an important treatment but side effects caused by long-term and excessive use heavily concern patients. Traditional Chinese medicine (TCM) is potentially an alternative treatment and might cause less adverse effects. This nationwide retrospective cohort study aimed to examine the hypothesis that TCM use is associated with lower exposure to corticosteroid. Materials and methodsChildren under 12 years of age with ICD-9 codes 691.8 and 692.x were identified as atopic dermatitis patients from 2007/1/1 to 2007/12/31. Corticosteroid use was compared between TCM users and non-users for one-year follow-up by using a general estimation equation model with propensity-score matching. ResultsA total of 9012 TCM users were identified and the use of corticosteroid after treatment was compared with matched TCM non-users. Use of TCM significantly reduced exposure to corticosteroids after 1-year follow-up. Among TCM users, the exposure to any corticosteroids was lower (42.1% reduction in TCM users versus 34.5% increase in TCM non-users, relative risk: 0.36; p-Value<0.001), the duration was shorter (relative risk for using corticosteroid more than 14 days: 0.37; p-Value<0.001), and the rate of frequent visits with steroid prescription was also lower. CHM was the most commonly used TCM modality (98.5% of all visits) and Xiao-Feng-San was the most commonly used CHM (33% of all prescriptions) with extensive coverage for pathogenesis of atopic dermatitis. ConclusionsLower use rate of corticosteroid can be found after TCM treatment, which can be considered as an integrative therapy for atopic dermatitis. Further studies are warranted on the basis of this study.

P50 Difficult Asthma Clinics: Are They Effective?

Background “Difficult asthma” is defined as persistent symptoms and/or frequent exacerbations in patients with a diagnosis of asthma, despite treatment at step 4 or 5 of the BTS/SIGN guidelines 1 . “Difficult asthma” clinics have been set up in many UK hospitals, but there is no published evidence to suggest their effectiveness at reducing exacerbations or hospital admissions. Aims To determine whether a regional difficult asthma clinic led to a reduction in prescription of oral steroid for exacerbations and a reduction in hospital admissions for asthma. Methods A retrospective analysis of patients who attended this regional difficult asthma clinic between August 2009 and May 2013 was performed. Medical notes and GP letters were scrutinised to ascertain the number of hospital admissions two years before and two years after the first clinic appointment. For oral steroids, one year before and after was used. To compare these data Wilcoxon tests were used due to the skewed data. Results For hospital admissions, data was available for 44 patients, mean (SD) age 44.2 (14.1) and 66% female. The median (inter-quartile range (IQR)) number of hospital admissions in the two years prior to clinic was 2 (0,3) compared to 0 (0,1) in the two years following clinic visit (p = 0.014). Oral steroid prescription data was available for 54 patients, mean (SD) age 43.5 (14.4), 70% female. The median (IQR) number of oral steroid courses required in the year prior to first clinic appointment was 6 (3.75,10), which reduced to 2 (0,4) in the year after first appointment (p Conclusion Our regional difficult asthma clinic significantly reduced both hospital admissions for asthma two years after first clinic appointment and number of oral steroid prescriptions one year after first clinic appointment. This study, although small, highlights the benefit of such clinics to patients and the potential for the reduction in use of NHS resources. They should be encouraged in all major centres. Reference Prys-Picard CO, Campbell SM, Ayres JG, Miles JF, Niven RM. Consensus Difficult Asthma Consortium UK. Defining and investigating difficult asthma: developing quality indicators. Respiratory Medicine 2006;100(7):1254–61

P33 'light Touch' Telemonitoring For People With Copd In Lothian: A Pilot Evaluation With Nested Qualitative Study

Background and aim Professionally monitored telehealthcare has significant workload implications, but qualitative work suggested that pulse oximetry could potentially contribute to self-monitoring. We aimed to evaluate the acceptability and perceived utility of a COPD ‘Light Touch’ service. ‘Light Touch’ intervention People with COPD used a pulse oximeter and symptom diary to self-monitor and self-refer according to a self-management plan. The service was overseen (though not actively monitored) by community-based respiratory/long-term conditions teams who were contactable by a telephone helpline. Method We undertook a before-and-after study with quantitative data collection at baseline and six-months. Outcomes were St George’s Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS) and service use. Nested semi-structured interviews with patients (at baseline and six-months) and managers, and a focus group of healthcare professionals explored perceptions of the service. Results We recruited 51 patients. Quality-of-Life (SGRQ): 21 (46%) participants improved by ≥4 (the minimum important difference); 12 (26%) deteriorated by ≥4. HADS improved: more participants had normal scores for anxiety (65%) and depression (80%) at 6 months than at baseline (51% and 64%). There were fewer surgery consultations and more telephone consultations, antibiotic, oral steroid and nebulised therapy prescriptions recorded during the study period compared to the previous year. Only 18 (39%) contacted the Light-Touch Helpline. We conducted interviews with 20 participants (36 interviews), 6 managers, and a focus group of 8 clinicians. Patients were generally positive and embraced ‘Light-Touch’ telemonitoring as part of their daily self-surveillance. The readings were reassuring and gave them confidence to make self-management decisions. Most patients did daily checks though several had stopped routine monitoring preferring to ‘check their readings as and when the need arises’. Healthcare professionals were concerned that patients had disengaged with their service. Few patients contacted the clinical teams for help or advice during the study and 6-monthly telephone reviews were introduced to maintain contact. Conclusion ‘In contrast to professionally-monitored telehealthcare, ‘Light-Touch’ seemed to reduce the contacts between patients and professionals. Whilst this may represent effective self-management, there were concerns that loss of engagement with healthcare services may be detrimental to achieving prompt management of exacerbations.

Evaluating the Accuracy of Drug Dosing in the Prescriptions for Children under 5 Years Old from Non Pediatric Physicians in Outpatient Clinics

<b>Background:</b> Pediatric patients are more vulnerable to the effects of a medication error and may experience a more serious adverse drug reaction than adults. Dosing errors represent the most common medication errors that occur in pediatric prescriptions. This study aimed to evaluate the accuracy of drug dosing that prescribed for children under 5 years by non paediatric specialist physicians in their outpatient clinic setting. <b>Methods: </b>An observational study was done in a single outpatient pharmacy located in Al - Amria at Baghdad/ Iraq from May to August 2014. 24 prescriptions to children less than 5 years old from non pediatric physicians were included in this study. Each prescription will be carefully examined to collect the following data: age and weight of the patient, diagnosis of the case, the name of the prescribed drugs with their strength, dose, route of administration and frequency of usage. All children were weighted in the pharmacy. Determination of the accuracy of drug dosing for each drug in all prescriptions was based mainly on drug dosing that stated in BNF for children. <b>Results: </b>The percent of correct dosing in the prescriptions of non pediatricians in their outpatient clinics to children below 5 years old is only 31%. Dosing error was more common (90%) in infants than in older children (64.5%). antibiotics were the most common class of drugs that prescribed to children, while the highest percent of dosing error was related to steroid, antipyretic and analgesic prescribing. <b>Conclusion:</b> Dosing error is a common problem in the Rx of non pediatrician in outpatient clinics for preschool children in general and for infants specially.

Thiazolidinediones and the risk of asthma exacerbation among patients with diabetes: a cohort study.

BackgroundThiazolidinediones are oral diabetes medications that selectively activate peroxisome proliferator-activated receptor gamma and have potent anti-inflammatory properties. While a few studies have found improvements in pulmonary function with exposure to thiazolidinediones, there are no studies of their impact on asthma exacerbations. Our objective was to assess whether exposure to thiazolidinediones was associated with a decreased risk of asthma exacerbation.MethodsWe performed a cohort study of diabetic Veterans who had a diagnosis of asthma and were taking oral diabetes medications during the period of 10/1/2005 – 9/30/2006. The risk of asthma exacerbations and oral steroid use during 10/1/2006 – 9/30/2007 was compared between patients who were prescribed thiazolidinediones and patients who were on alternative oral diabetes medications. Multivariable logistic regression and negative binomial regression analyses were used to characterize this risk. A sensitivity analysis was performed, restricting our evaluation to patients who were adherent to diabetes therapy.ResultsWe identified 2,178 patients who were on thiazolidinediones and 10,700 who were not. Exposure to thiazolidinediones was associated with significant reductions in the risk of asthma exacerbation (OR = 0.79, 95% CI, 0.62 – 0.99) and oral steroid prescription (OR = 0.73, 95% CI 0.63 – 0.84). Among patients who were adherent to diabetes medications, there were more substantial reductions in the risks for asthma exacerbation (OR = 0.64, 95% CI 0.47 – 0.85) and oral steroid prescription (OR = 0.68, 95% CI 0.57 – 0.81).ConclusionsThiazolidinediones may provide a novel anti-inflammatory approach to asthma management by preventing exacerbations and decreasing the use of oral steroids.

Improvement in COPD management by access to asthma/COPD clinics in primary care: Data from the observational PATHOS study

Chronic obstructive pulmonary disease (COPD) guidelines emphasize the importance of patient education to improve quality of life and avoid exacerbations. Longitudinal evaluations of structured management of COPD in primary care are lacking. To evaluate the impact of primary care asthma/COPD clinics on exacerbations, hospitalizations, and associated costs in COPD. This population-based, retrospective, observational study, linking primary care medical records data to mandatory Swedish national registries, included patients with COPD from 76 primary healthcare centers (1999-2009). A questionnaire on access to an asthma/COPD clinic was retrospectively answered. Propensity score matching was performed at index (COPD diagnosis) by center type (with and without an asthma/COPD clinic). Poisson regression was used to compare the yearly rate of exacerbations (hospitalization, emergency visits, or prescription for oral steroids or antibiotics) and COPD-related prescriptions at the centers. An economic analysis was performed from the Swedish healthcare perspective using 2011 unit costs and the incremental cost-effectiveness ratio was calculated. The study included 21,361 patients (mean age, 68.0 years; 53% female). Access to asthma/COPD clinics increased from 34% to 85% during the study period. Patients at primary healthcare centers with asthma/COPD clinics had 27% fewer exacerbations (0.71 vs. 0.98) and 37% fewer hospitalizations annually (0.36 vs. 0.58) (p<0.0001). Asthma/COPD clinics reduced the annual cost of medication and healthcare contacts by 37% (SEK 52,892 [€5858] to SEK 33,410 [€3700] per patient). Patients at primary healthcare centers with asthma/COPD clinics experienced fewer COPD exacerbations and hospitalizations, and overall treatment costs were substantially reduced. ClinicalTrials.gov identifier: NCT01146392.

Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease.

Various causes can contribute to the high rates of readmission among patients hospitalized with chronic obstructive pulmonary disease (COPD). To determine the frequency and predictors of early readmission among patients aged 40-64 years, hospitalized with COPD. In a retrospective cohort study, using a large national commercial insurance database, we obtained the clinical information within 12 months of the index hospitalization and 30 days after discharge. Primary outcome was early readmission, defined as hospitalization within 30 days of discharge. We categorized predictor variables as patient, provider, and system factors, and compared these variables between patients readmitted and those not readmitted. Logistic regression was used for multivariable analysis. Of 8,263 patients who met the inclusion criteria, 741 (8.9%) had early readmission. Multivariable analysis showed patient factors (male, history of heart failure, lung cancer, osteoporosis, and depression), provider factors (no prior prescription of statin within 12 mo of the index hospitalization and no prescription of short-acting bronchodilator, oral steroid and antibiotic on discharge), and system factors (length of stay, <2 or >5 d and lack of follow-up visit after discharge) were associated with early readmission among patients hospitalized with COPD. The C-statistic of the model including patient characteristics was 0.677 (95% confidence interval, 0.656-0.697), which was improved to 0.717 (95% confidence interval, 0.702-0.732) after addition of provider- and system-based factors. One of 11 patients hospitalized with COPD is readmitted within 30 days of discharge. Provider and system factors are important modifiable risk factors of early readmission.

Topiramate Use Does Not Reduce Flares of Inflammatory Bowel Disease

Additional medications are needed for inflammatory bowel disease (IBD) as existing therapies are incompletely effective and can be costly and toxic. Preclinical studies suggest that topiramate (an anticonvulsant) may have disease-modifying properties in IBD, but its efficacy in humans is unknown. To evaluate whether topiramate use is associated with clinical benefit in IBD patients. We conducted a retrospective cohort study using administrative claims data from the MarketScan databases. Persons with IBD were identified between 2000 and 2010. New users of topiramate were compared with users of other anticonvulsant and anti-migraine medications. The primary outcome was a new prescription for an oral steroid (≥14 days). Secondary outcomes included initiation of biologic agents, abdominal surgery, and hospitalization. Cox proportional hazard modeling was used to adjust for potential confounders. We identified 773 new users of topiramate and 958 users of comparator drugs. After adjusting for potential confounders, topiramate use was not associated with the primary outcome of steroid prescriptions [hazard ratio (HR) 1.14, 95 % confidence interval (CI) 0.74, 1.73]. Results did not differ significantly by IBD subtype. There was no difference between topiramate users and users of comparator drugs with respect to post-exposure initiation of biologic agents (HR 0.93, 95 % CI 0.39, 2.19), abdominal surgery (HR 1.04, 95 % CI 0.17, 6.41), or hospitalization (HR 0.86, 95 % CI 0.62, 1.19). In this large U.S. administrative claims study, topiramate use was not associated with markers of IBD flares. These results cast doubt on whether topiramate may be an effective adjunct to current IBD therapy.

P-062 Clinical and Demographics Features Associated with the Use of Steroids in UC Patients from Two References Centers in Salvador-Bahia-Brazil

The steroids are effective treatment for activity of Ulcerative Colitis (UC). These medications are indicated during moderate or severe clinical activity. Cross-sectional study performed from January of 2011 until September of 2012 in 2 references centers in Salvador. Interviews and chart review were conducted. The prevalence ratio (PR) and evaluation of the association between the use of corticosteroids and independent variables were performed through multivariate Poisson regression model. The study was approved by the ethics and research committee of the University Hospital Professor Edgard Santos. Among the 267 patients enrolled, 180 (67.4%) were women. The average age at diagnosis was 39.4 years. The mean disease duration from diagnosis was 7.56 years. Multivariate Poisson regression model demonstrated that prescription of systemic steroids was associated with weight loss (PR = 1.29) and diarrhea (PR = 1.27) at diagnosis, extraintestinal manifestation (PR = 1.32) and hospitalization (PR = 1.67). Living in countryside was associated with less prescription of steroids (PR = 0.74). Weight loss and diarrhea at diagnosis, extraintestinal manifestation, need of hospitalization during the disease and urban procedence were factors associated with increased need of steroid therapy for UC. New and prospective studies are needed to confirm the association of these factors with severity of the disease.

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Introduction: Contradictory evidence regarding the use of low dose steroids in septic shock is a challenge for physicians. Recent published guidelines attempt to address this, yet leave clinicians with recommendations that are subject to interpretation. Methods: The purpose of this study was to pilot test a questionnaire we developed to evaluate how clinicans' interpret and implement the current recommendations around the use of corticosteroids in septic shock. Results: Pulmonary and Critical Care physicians in Providence, RI (N = 27; 50% response rate) were asked to complete an electronic questionnaire in which they were presented with scenarios regarding patients with septic shock and asked to select various treatment options. Physicians in-training (ie, fellows), academic physicians and those in private practice were all included. Overall among attending physicians academic physicians versus private practioner's were more likely to prescribe steroids for patients on high dose vasopressors (defined as > 15mcg/min of norepinephrine). In addition regardless of fluid status, co-morbidities (including HIV, end stage renal disease, or diabetes mellitus) or the presence of chronic steroids, academic physicians were more likely to prescribe low dose steroids, (p <.05). While these findings did not reach statistically significance physicians-in-training (vs. attendings) appear more likely to prescribe steroids for patients in septic shock. For patients with HIV and diabetes mellitus, steroid prescription rates appeared to be less than for other defined conditions but again did not reach statistical significance. Patients on chronic steroids appeared more likely to receive low dose steroids. The use of cosyntropin stimulation testing did not differ between academic and private physicians. Conclusions: Critical care physicians vary in the use of low dose steroids for patients in septic shock. A large national survey will help to elucidate our findings and may lead to clear clinical guidelines for the treatment of patients in septic shock.