Systemic Corticosteroids In Patients Research Articles

Anti-tuberculous therapy combined with systemic corticosteroids improves retinal sensitivity in patients with active presumed tuberculous choroiditis

To investigate the efficacy of anti-tuberculous therapy and systemic corticosteroids in patients suffering from active presumed tuberculous choroiditis by the assessment of central retinal sensitivity and fixation characteristics. Six patients (six eyes) with active presumed tuberculous choroiditis were treated with anti-tuberculous therapy and systemic corticosteroids. Mean central retinal sensitivities and fixation stability and location were investigated with MP-1 microperimetry before and after treatment. After a mean follow-up of 11.33 ± 7.53 months (range 6-24 months), all eyes showed resolution of inflammation, with no recurrences, associated with a significant improvement in visual acuity (P = 0.003). At the baseline, mean central retinal sensitivities were 2.03 ± 2.46 dB (range 0.0-6.6 dB). Fixation was stable and predominantly central in three eyes, and unstable and predominantly eccentric in three eyes. After treatment at a mean of 9.33 ± 6.56 months (range 4-20 months), mean central retinal sensitivities improved to 9.65 ± 5.35 dB (range 2.4-15.2 dB) (P = 0.004) and fixation became predominantly central and stable in all eyes. Anti-tuberculous therapy combined with systemic corticosteroids improves central retinal sensitivity and fixation characteristics in patients with presumed tuberculous choroiditis.

Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma.

In asthmatic patients inadequately controlled on inhaled corticosteroids and/or those with moderate persistent asthma, two main options are recommended: the combination of a long-acting inhaled ss2 agonist (LABA) with inhaled corticosteroids (ICS) or use of a higher dose of inhaled corticosteroids. To determine the effect of the combination of long-acting ss(2) agonists and inhaled corticosteroids compared to a higher dose of inhaled corticosteroids on the risk of asthma exacerbations, pulmonary function and on other measures of asthma control, and to look for characteristics associated with greater benefit for either treatment option. We identified randomised controlled trials (RCTs) through electronic database searches (MEDLINE, EMBASE and CINAHL), bibliographies of RCTs, clinical trial registries and correspondence with manufacturers until May 2008. RCTs that compared the combination of inhaled LABA and ICS to a higher dose of inhaled corticosteroids, in children and adults with asthma. Two authors independently assessed methodological quality and extracted data. We obtained confirmation from the trialists when possible. The primary endpoint was the number of patients experiencing one or more asthma exacerbations requiring oral corticosteroids. This review included 48 studies (15,155 participants including 1155 children and 14,000 adults). Participants were inadequately controlled on their current ICS regimen, experiencing ongoing symptoms and with generally moderate (FEV1 60% to 79% of predicted) airway obstruction. The studies tested the combination of salmeterol or formoterol with a median dose of 400 mcg/day of beclomethasone or equivalent (BDP-eq) compared to a median of 1000 mcg/day of BDP-eq, usually for 24 weeks or less. There was a statistically significantly lower risk of exacerbations requiring systemic corticosteroids in patients treated with LABA and ICS (RR 0.88, 95% CI 0.78 to 0.98, 27 studies, N = 10,578) from 11.45% to 10%, with a number needed to treat of 73 (median study duration: 12 weeks). The study results were dominated by adult studies; trial data from three paediatric studies showed a trend towards increased risk of rescue oral steroids (RR 1.24, 95% CI 0.58 to 2.66) and hospital admission (RR 2.21, 95% CI 0.74 to 6.64) associated with combination therapy. Overall, there was no statistically significant difference in the risk ratios for either hospital admission (RR 1.02, 95% CI 0.67 to 1.56) or serious adverse events (RR 1.12, 95% CI 0.91 to 1.37). The combination of LABA and ICS resulted in significantly greater but modest improvement from baseline in lung function, symptoms and rescue medication use than with higher ICS dose. Despite no significant group difference in the risk of overall adverse events (RR 0.99, 95% CI 0.95 to 1.03), there was an increase in the risk of tremor (RR 1.84, 95% CI 1.20 to 2.82) and a lower risk of oral thrush (RR 0.58, 95% CI 0.40 to 0.86)) in the LABA and ICS compared to the higher ICS group. There was no significant difference in hoarseness or headache between the treatment groups. The rate of withdrawals due to poor asthma control favoured the combination of LABA and ICS (RR 0.65, 95% CI 0.51 to 0.83). In adolescents and adults with sub-optimal control on low dose ICS monotherapy, the combination of LABA and ICS is modestly more effective in reducing the risk of exacerbations requiring oral corticosteroids than a higher dose of ICS. Combination therapy also led to modestly greater improvement in lung function, symptoms and use of rescue ss(2) agonists and to fewer withdrawals due to poor asthma control than with a higher dose of inhaled corticosteroids. Apart from an increased rate of tremor and less oral candidiasis with combination therapy, the two options appear relatively safe in adults although adverse effects associated with long-term ICS treatment were seldom monitored. In children, combination therapy did not lead to a significant reduction, but rather a trend towards an increased risk, of oral steroid-treated exacerbations and hospital admissions. These trends raised concern about the safety of combination therapy in view of modest improvement in children under the age of 12 years.

Effect of a 14-day course of systemic corticosteroids on the hypothalamic-pituitary-adrenal-axis in patients with acute exacerbation of chronic obstructive pulmonary disease

BackgroundAs supra-physiological intake of corticosteroids is a well known risk factor for the development of adrenal insufficiency, we investigated the function of the hypothalamic-pituitary-adrenal (HPA) axis during a 14-day course of systemic corticosteroids in patients with acute exacerbation of chronic obstructive pulmonary disease using clinical and laboratory measures.MethodsA systematic clinical and laboratory assessment including measurement of basal cortisol levels and the response to low dose (1 μg) ACTH stimulation was performed in nine patients before, on the first and the last day of treatment, as well as 2, 7 and 21 days after corticosteroid withdrawal.ResultsAt baseline, all nine patients had normal responses to 1 μg ACTH. On the first day of steroid treatment, 78% had a blunted peak cortisol response. This percentage increased to 89% after 14 days of steroid treatment. 78%, 33% and 33% of the patients had a blunted cortisol response to ACTH 2, 7, and 21 days after corticosteroid withdrawal, respectively. ROC curve analysis revealed that only basal cortisol concentrations (AUC 0.89), but not ACTH concentrations (AUC 0.49) or clinical signs (AUC 0.47) were predictive of an impaired function of the HPA axis. Basal cortisol levels of > 400 and < 150 nmol/l were 96% and 100% sensitive for a normal or pathological response to the ACTH stimulation test, respectively.ConclusionImmediate and prolonged suppression of the HPA axis is a common finding in otherwise asymptomatic patients undergoing systemic steroid treatment for acute exacerbation of chronic obstructive pulmonary disease and can reliably be assessed with the low-dose ACTH test.

Morbidity associated with systemic corticosteroid preparation for coronary artery bypass grafting in patients with chronic obstructive pulmonary disease: a case control study

BackgroundCoronary artery bypass grafting (CABG) is associated with high morbidity in patients with chronic obstructive pulmonary disease (COPD).We examine the effect of preoperative systemic corticosteroids on morbidity in this setting.MethodsNinety candidates for elective CABG participated in a prospective, open randomized trial, including 30 patients with COPD who received a single injection of a long-acting corticosteroid, 30 with COPD who received placebo, and 30 without COPD who served as controls. Primary end-points were postoperative pulmonary and nonpulmonary complications. Secondary end-points were length of hospital stay (LOS), ICU stay of less than 24 hours and more than 48 hours, duration of mechanical ventilation, and time to walking and sitting.ResultsThe rate of pulmonary complications was similar in the two COPD groups and in the COPD patients and controls. The placebo group had more major nonpulmonary complications than the treatment group, but the difference was not statistically significant (26% vs. 17%, P = NS). The non-COPD control group had significantly fewer nonpulmonary complications than the COPD patients (treatment+placebo) (33% vs 70%, P = 0.014) and a similar rate of pulmonary complications. There was a statistically significant difference between the treated and placebo COPD groups in ICU stay less than 24 hours (P ≤ 0.001) and more than 48 hours (P = 0.03) and hospital stay (P = 0.013). On stepwise analysis, only age and number of coronary grafts were predictors of pulmonary complications.ConclusionThe use of preoperative systemic corticosteroids in patients with COPD undergoing CABG may shorten ICU and hospital stay.

Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations of chronic obstructive pulmonary disease

The use of systemic corticosteroids for the management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) was studied. Medical charts of patients admitted to the hospital between July 2002 and November 2003 with a primary diagnosis of AECOPD were retrospectively reviewed. The primary objective was to characterize the drug, dosage, route, frequency, and duration of systemic corticosteroids prescribed for the management of AECOPD. The secondary objective was to compare the mean length of stay (LOS) and 30-day relapse rate between patients who received lower and higher dosages of corticosteroids. One hundred forty-five admissions (123 patients) for AECOPD (mean +/- S.D. age, 65 +/- 11 years) were evaluated. Higher dosages of systemic corticosteroids (>80 mg of prednisone equivalent [PE] per day) were prescribed for 51% and i.v. therapy for 56% of admissions. The mean +/- S.D. total systemic corticosteroid exposure during hospitalization for all admissions was 759 +/- 971 mg of PE (mean +/- S.D. daily exposure = 134 +/- 111 mg of PE per day). The mean LOS was significantly longer for the higher-dosage group than for the lower-dosage group (6.1 versus 4.2 days, p = 0.0004). A tapered regimen was prescribed for 79% of discharges. Twenty-seven percent of the discharges with routine follow-up care had a relapse of disease within 30 days. This retrospective observational study confirmed a wide variability in the dosages of systemic corticosteroids for the inpatient management of AECOPD, including the use of higher dosages and tapered regimens. Prospective randomized studies are needed to determine the most effective regimen of systemic corticosteroids in patients with AECOPD.

Lack of Response to Systemic Corticosteroids in Patients with Lymphangioma

Lymphangioma is a benign nonencapsulated orbital tumor that is difficult to treat. Recently, systemic corticosteroids were advocated as a safe and effective alternative to surgical drainage of the cysts. We describe our experience with 3 cases in which proptosis progressed or did not improve despite the exclusive use of systemic steroids for 1 week, necessitating urgent surgical intervention. These three cases demonstrate that at least in some cases, steroids alone may be ineffective, and alternative interventions must be undertaken.

A Rational Approach to the Management of Severe Refractory Asthma

Severe refractory asthma is a heterogeneous condition with different patterns of severity and different reasons for loss of asthma control. The three main patterns include asthma with frequent exacerbations, asthma with irreversible airway obstruction, and asthma with reduced sensitivity or resistance to corticosteroids. Each of these patterns has distinct risk factors. The assessment of patients with severe asthma requires a systematic, diagnostic and management protocol. The majority of patients will benefit from thorough analysis and treatment of aggravating factors. In some patients with severe refractory asthma, in particular those with concomitant chronic rhinosinusitis, long-term administration of systemic corticosteroids may be necessary. In these patients all efforts should be directed towards reducing the dose of corticosteroids as much as possible. Although several corticosteroid-sparing agents and immunosuppressants have been proposed in the literature, none of these has gained complete acceptance in clinical practice, either because of limited efficacy or unacceptable adverse effects. Novel potent anti-inflammatory therapies aimed at reducing the need for systemic corticosteroids in patients with severe, refractory asthma are urgently needed.

Corticosteroids for maintaining remission of Crohn's disease.

To evaluate the effectiveness and safety of conventional systemic corticosteroid therapy in maintaining clinical remission in Crohn's disease. A computer-assisted search of the on-line bibliographic database MEDLINE of studies published in English, French, Spanish, Italian and German between 1966 and May, 1998. Manual searches of the reference lists from the potentially relevant studies were performed in order to identify additional studies that may have been missed using the computer-assisted search strategy. Proceedings from major gastrointestinal meetings were also manually searched from 1985 to 1997 in order to identify unpublished studies. The Cochrane Controlled Trials Register and the Inflammatory Bowel Disease Review Group Trials Register were also searched. Randomized double-blind placebo-controlled trials involving patients of any age with Crohn's disease in clinical remission as defined by a CDAI < 150 or by the presence of no symptoms or only mild symptoms at the time of entry into the trial. The experimental treatment consisted of oral conventional corticosteroid therapy (excluding budesonide, fluticasone, etc). Clinical disease relapse was used as the outcome measure of interest. Eligible studies were selected by 4 reviewers and data were extracted onto standardized data extraction forms. Disagreements in eligibility or data extraction were resolved by consensus. Data were converted into individual 2x2 tables for each study. The presence of significant heterogeneity among studies was tested using the chi-square test. The 2x2 tables were synthesized into a summary test statistic using the pooled odds ratio and 95% confidence intervals as described by Cochran and Mantel and Haenszel (the 'odds ratio' in MetaView). A fixed effects model was used for the pooling of data. Four studies were initially judged as being eligible for inclusion. After obtaining additional information on one of the studies it was excluded because it was not double-blind. The total number of subjects included in the analysis at the time points of 6, 12 and 24 months were 142, 131 and 95 for the corticosteroid group and 161, 138 and 87 for the control group. The odds ratios for relapse on active treatment and the corresponding 95% confidence intervals were 0.71 (0.39, 1.31), 0.82 (0.47, 1.43) and 0.72 (0.38, 1.35) at 6, 12 and 24 months. The numbers needed to treat with corticosteroids to prevent one additional relapse were 24, 35, 15 respectively. The use of conventional systemic corticosteroids in patients with clinically quiescent Crohn's disease does not appear to reduce the risk of relapse over a 24 month period of follow-up.

Long-term treatment with aspirin desensitization in asthmatic patients with aspirin-exacerbated respiratory disease

Background: Aspirin desensitization treatment is an option to decrease disease activity and reduce the need for systemic corticosteroids in patients with aspirin-exacerbated respiratory disease (AERD). Objective: This study was designed to determine whether the clinical courses of patients with AERD improved as early as 6 months after starting aspirin desensitization and to compare this with follow-up evaluations after at least a year. Methods: Between 1995 and 2000, 172 patients with AERD were admitted to our General Clinical Research Center, were desensitized to and treated with aspirin, were discharged to their home communities, and participated in follow-up interviews and written assessments of their clinical courses. Results: By the first 6 months of aspirin treatment, there were significant reductions in sinus infections and numbers of short courses of prednisone and improvements in sense of smell and general assessment of nasal-sinus and asthma symptoms (P < .0001). These results persisted for 1 to 5 years (P < .0001). Mean prednisone doses decreased from 10.8 mg/d to 8.1 and 3.6 mg/d at 6 months and greater than 1 year, respectively. Of the 172 patients, 24 (14%) discontinued aspirin treatment because of side effects, and 115 (67%) responded to aspirin treatment. After eliminating those who discontinued aspirin treatment because of side effects, the improvement rate was 115 (78%) of 148 patients. Of the 126 patients who completed a year or more of aspirin treatment, 110 (87%) experienced improvement. Conclusion: Aspirin desensitization followed by daily aspirin is efficacious by at least the first 6 months of treatment and continues to be effective for up to 5 years of follow-up. (J Allergy Clin Immunol 2003;111:180-6.)

The role of systemic corticosteroids in acute exacerbation of chronic obstructive pulmonary disease.

The administration of systemic corticosteroids for patients with exacerbations of chronic obstructive pulmonary disease (COPD) has become common practice over the past 25 years. This practice remained somewhat controversial because corticosteroids can have serious adverse effects and initial clinical trials provided inconclusive evidence concerning their efficacy. Results from recent clinical trials indicate that systemic corticosteroids are modestly effective in shortening the duration of severe exacerbations of COPD. Systemic corticosteroids administered intravenously or orally to hospitalized patients with exacerbations of COPD reduced the absolute treatment failure rate by about 10%, increased the forced expiratory volume in 1 second (FEV1) by about 100 ml, and shortened the hospital stay by 1 to 2 days. Oral corticosteroids probably confer similar benefits when used for treating moderately severe COPD exacerbations in an out-patient setting. The optimal starting dose of corticosteroids is not known, but the duration of treatment should not extend longer than 2 weeks. Hyperglycemia is the most common adverse event, but secondary infections, mental disturbances, and myopathies may also occur.

Withdrawal of Chronic Systemic Corticosteroids in Patients with COPD.

Rice, K L; Rubins, J B; Lebahn, F; Parenti, C M; Duane, P G; Kuskowski, M; Joseph, A M; Niewoehner, D E.

Inhaled mometasone furoate reduces oral prednisone requirements while improving respiratory function and health-related quality of life in patients with severe persistent asthma

Background: Inhaled corticosteroid therapy in severe persistent asthma has been shown to reduce or eliminate oral corticosteroid (OCS) use while retaining effective asthma control. Objective: We sought to evaluate the ability of mometasone furoate (MF) delivered by means of dry powder inhaler to reduce daily oral prednisone requirements in OCS-dependent patients with severe persistent asthma. Methods: We performed a 12-week, double-blind, placebocontrolled trial (21 centers, 132 patients) comparing 2 doses of MF (400 and 800 μg administered twice daily) with placebo, followed by a 9-month open-label phase in which 128 patients received treatment with MF. Results: At the endpoint of the double-blind trial, MF 400 and 800 mg twice daily reduced daily OCS requirements by 46.0% and 23.9%, respectively, whereas placebo increased OCS requirements by 164.4% (P < .01). Oral steroids were eliminated in 40%, 37%, and 0% of patients in the MF 400 and 800 mg twice daily and placebo groups, respectively. Pulmonary function and quality of life significantly increased for MF-treated patients. Further reductions in OCS requirements were achieved with long-term MF treatment in the open-label phase. Conclusion: MF inhaled orally as a dry powder is an effective alternative to systemic corticosteroids in patients with severe persistent asthma. (J Allergy Clin Immunol 2000;106:852-60.)

Controlled Short-term Trial of Fluticasone Propionate in Ventilator-Dependent Patients With COPD

There is no agreement about the efficacy of systemic corticosteroids in patients with COPD, but corticosteroids often are employed during exacerbations of the disease. The use of systemic or inhaled corticosteroids in patients in stable condition is even more controversial, even though the more severely affected patients seem to respond better. Unfortunately, in this subset of patients, the use of forced expiratory maneuvers frequently fails to detect significant functional response. We evaluated the short-term effects of an inhaled corticosteroid, fluticasone propionate (FP), on FEV(1) and on the mechanical properties of patients in stable condition with severe COPD and chronic hypercapnic respiratory failure who were receiving long-term ventilatory support. This allowed us to measure respiratory mechanics (RM) passively, thereby avoiding any problems linked with voluntary maneuvers. Randomized, placebo-controlled, crossover study. A respiratory ICU. Twelve hypercapnic COPD patients (mean [+/- SD] PaCO(2), 60+/-11 mm Hg; mean FEV(1), 13+/-5% predicted; and mean FEV(1)/FVC, 31 +/- 7%) were enrolled. A daily dose of 2,000 microg FP or placebo was administered via metered-dose inhaler during mechanical ventilation for 5 consecutive days. A washout of 72 h was allowed between regimens. End-expiratory and end-inspiratory airway occlusions were performed to assess static intrinsic positive end-expiratory pressure (PEEPi,st), static compliance of the respiratory system (Cst,rs), maximal respiratory resistance (Rmax, rs), and minimal respiratory resistance (Rmin,rs). The bronchodilator response also was assessed by FEV(1) level. No significant changes were found in RM after administration of the placebo. By day 6, FP had induced the following significant decreases: PEEPi,st, 4.3+/-2.4 to 3.1+/-1.7 cm H(2)O (p<0.01); Rmax,rs, 19.0+/-6.5 to 14.6+/-6 cm H(2)O/L/s (p<0.001); and Rmin,rs, 14.8+/-4.2 to 10.5+/-3.4 cm H(2)O/L/s (p<0.001). The Cst,rs and the effective additional resistance of the respiratory system did not change significantly, the latter suggesting that the major effect of FP was on the airway caliber (Rmin,rs). FEV(1) changes significantly (p<0.01) underestimated the bronchodilator response, as compared with changes in Rmin,rs. We conclude that in patients in stable condition with severe COPD and chronic hypercapnic respiratory failure, a brief trial of FP may induce a bronchodilator response, mainly related to a reduction in airway resistances, that is not detected by the usual pulmonary function tests.

Efficacy of unilateral versus bilateral temporal artery biopsies for the diagnosis of giant cell arteritis

PURPOSE: To determine the utility of unilateral versus bilateral temporal artery biopsies in detecting the pathologic changes of giant cell arteritis. METHODS: We performed a retrospective study to determine the utility of unilateral versus bilateral temporal artery biopsies in detecting the pathologic changes of giant cell arteritis. The pathologic reports of consecutive temporal artery biopsy specimens received at the Wilmer Ocular Pathology Laboratory over a 28-year period from 1968 to 1996 were reviewed. RESULTS: Of 908 specimens examined from 758 patients, 300 specimens were simultaneous bilateral biopsies from 150 patients, 72 specimens were bilateral sequential biopsies from 36 patients, and the remaining 536 specimens were unilateral biopsies from 536 patients. Of the 186 patients who had bilateral simultaneous or nonsimultaneous biopsies, 176 had identical diagnoses on both sides. In four patients, no artery was obtained on one side. In each of the remaining six patients, five of whom had bilateral simultaneous biopsies and one of whom had bilateral sequential biopsies performed 8 days apart, the biopsy specimen from one side was interpreted as showing only arteriosclerotic changes with no evidence of active or healed arteritis, whereas the other specimen was interpreted as showing either probable healed arteritis (three specimens) or possible early arteritis (three cases). In none of the six patients with differing diagnoses between the two sides was one side interpreted as showing definite, active giant cell arteritis. Five of the six patients were subsequently determined to have giant cell arteritis, based on a combination of clinical findings, erythrocyte sedimentation rate, and response to treatment with systemic corticosteroids. CONCLUSIONS: The results of this study indicate that performing a bilateral simultaneous or sequential temporal artery biopsy improves the diagnostic yield in at least 3% of cases of giant cell arteritis, whereas in 97% of cases, the two specimens show the same findings. Thus, in patients in whom only one artery can be biopsied, there is a high probability of obtaining the correct diagnosis. Nevertheless, although the improvement in diagnostic yield of bilateral temporal artery biopsies is low, the consequences of both delayed diagnosis and treatment of giant cell arteritis as well as the use of systemic corticosteroids in patients who do not have giant cell arteritis are of such potential severity that consideration should always be given to performing bilateral temporal artery biopsies in patients suspected of having the disease.

Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations (SCCOPE): Rationale and Design of an Equivalence Trial

The Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations Trial (SCCOPE) was a randomized, double-blind, placebo-controlled, multicenter trial sponsored by the U.S. Department of Veterans Affairs Cooperative Studies Program. Its principal purpose was to determine whether withholding systemic corticosteroids in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD) who were treated with other usual therapy resulted in a clinically significant increase in the rate of treatment failure. Because placebo was compared to a standard therapy, the study was designed as an equivalence trial. If corticosteroids proved effective, the study would also determine whether a short course was as effective as a long one. SCCOPE was to enroll up to 1100 subjects from more than 20 Veterans Administration Medical Centers over 3 years. Patients were screened shortly after hospital admission for acute exacerbation of COPD. Principal criteria for eligibility were age of 50 years or older, smoking history of 30 pack-years or more, clinical diagnosis of COPD as opposed to asthma, nonuse of systemic corticosteroids in the previous 30 days, and forced expiratory volume in 1 sec (FEV 1) of 1500 ml or less. Eligible subjects were randomized to one of three treatment arms: (1) short course (2 weeks) of systemic corticosteroids, (2) long course (8 weeks) of systemic corticosteroids, or (3) placebo. We standardized most other aspects of care. We followed patients for 6 months. The primary endpoint of the study was treatment failure, defined as death, intubation with mechanical ventilation, hospital readmission for COPD, or intensification of pharmacologic therapy. Secondary endpoints included length of hospital stay, changes in FEV 1, and changes in dyspnea score. We also evaluated possible adverse effects from systemic corticosteroids.

Vogt-Koyanagi-Harada Syndrome

We reviewed data from 26 patients with Vogt-Koyanagi-Harada syndrome who presented at the Bascom Palmer Eye Institute between March 1969 and February 1990. Visual outcomes were good, with final visual acuity of better than 20/30 in 29 (66%) of 44 eyes and of worse than 20/400 in only three (7%) of 44 eyes. A poor prognosis was associated with the development of choroidal neovascular membranes or chronic uveitis. All patients were treated with systemic corticosteroids. Corticosteroid therapy averaged 6 months, but was prolonged (48 months) in patients who developed chronic uveitis. Disease recurred in nine (43%) of 21 patients in the first 3 months, usually in association with a rapid tapering of steroid dosage. We recommend the early, aggressive use of systemic corticosteroids in patients with Vogt-Koyanagi-Harada syndrome and a gradual tapering of drug dosage for 6 months after presentation.

EFFECT OF BECLOMETHASONE DIPROPIONATE DELIVERED BY AEROSOL IN PATIENTS WITH ASTHMA

Beclomethasone dipropionate has been inhaled from a pressurised aerosol by seventeen patients with asthma and has provided the only form of corticosteroid treatment in these patients for 2 to 6 months. Nine patients were not taking systemic corticosteroids when the steroid aerosol treatment was started, and eight others were transferred from prednisolone to the new treatment. The steroid aerosol seemed to exert a significant topical corticosteroid action on the airways and provided the expected clinical benefits of corticosteroids seen in many patients with asthma. The therapeutic results were confirmed by measurements of forced expired volume in one second. Basal plasma-hydrocortisone levels did not become low in any patient, and in those transferred from prednisolone the plasma-hydrocortisone rose to normal. This apparent return of adrenal responsiveness was confirmed by measuring the response to tetracosactrin stimulation in eight patients. The results support the idea that inhaled beclomethasone dipropionate acts in a similar way to systemic corticosteroids in patients with asthma but seems to have less systemic effect. Systemic corticosteroids had to be given on occasion to six patients over the period of study, and this indicates the need to compare the therapeutic potency of the steroid aerosol with systemic corticosteroids to confirm that beclomethasone-dipropionate aerosol treatment does have a significant topical action.