Quantification of Glucocorticoid-Associated Morbidity in Severe Asthma Using the Glucocorticoid Toxicity Index

Prospective assessment of glucocorticoid toxicity in rheumatology practice: a focus on the glucocorticoid toxicity index

OBJECTIVE

The glucocorticoid toxicity index (GTI) is developed to measure glucocorticoid (GC)-related morbidity over time. This study aimed to assess GC-toxicity in patients at a rheumatology outpatient clinic by using the GTI and to identify the factors that interfere with the GTI.

METHODS

This prospective study included patients with inflammatory arthritis (IA), connective tissue disease and vasculitis who were newly prescribed GC-treatment (GC-naive) or have been still on GC-treatment for ≤2 years (GC-experienced). Patient demographics and disease characteristics, aggregate improvement score (GTI-AIS), cumulative worsening score (GTI-CWS) and cumulative GC-doses were recorded at baseline, 3rd month and 6th month. Generalized estimating equations (GEE) were used to evaluate the GTI scores and associated factors including cumulative GC-doses.

RESULTS

The study included 156 (48.7% GC-naive) patients with a mean age of 49.1 ± 17.1 years. More than half of the patients in both groups had a diagnosis of vasculitis. A higher cumulative GC-dose was found to be associated with higher GTI-scores in both groups (P < 0.001). In the GC-naive group, patients with vasculitis showed higher GTI-scores than IA patients (P < 0.001); there was also a significant increase in the GTI-CWS at the 6th month compared with the 3rd month. In the GC-experienced group, GTI-AIS and GTI-CWS were significantly different at 3rd and 6th month (P < 0.05).

CONCLUSION

It was shown that GTI scores were associated with cumulative GC-doses and vasculitis patients in the GC-naive patients had higher GTI scores than inflammatory arthritis. The GTI allows individualized assessment and management of adverse effects experienced by patients as a result of GC treatment.

Ten clinical conundrums in the management of eosinophilic granulomatosis with polyangiitis

INTRODUCTION

Eosinophilic granulomatosis with polyangiitis (EGPA) is an immune-mediated, inflammatory, multisystemic disease that is considered a form of ANCA-associated vasculitis and whose association with asthma and blood and tissue eosinophilia differentiate it from other types of vasculitis. Nevertheless, diagnosis of EGPA may be difficult or delayed not only because of the rarity of the disease, but also because other diseases can present with similar manifestations.

AREAS COVERED

We review a series of key areas in EGPA, namely, laboratory and clinical indicators of disease, diagnosis, role of biomarkers, induction and maintenance therapy, and use of traditional and novel drugs. This narrative review was based on a thorough search of PubMed.

EXPERT OPINION

Clinicians should be aware of the limitations of available tools for diagnosing EGPA, and more efforts should be made to identify clinical and laboratory red flags, with the purpose of achieving an early diagnosis before irreversible damage occurs. New effective therapies are available, although future research should target an approach that spares glucocorticoids, reduces the risk of flares and organ damage, and maintains long-term remission with minimum adverse effects.

Longitudinal Assessment of Glucocorticoid Toxicity Reduction in Patients With Severe Asthma Treated With Biologic Therapies

BACKGROUND

Toxicities associated with oral corticosteroids (OCS) are well described. Targeted biologics for severe asthma (SA) substantially reduce OCS exposure with the potential to reduce cumulative OCS-related toxicities. The Glucocorticoid Toxicity Index (GTI) systematically assesses OCS-related toxicity; the GTI Aggregate Improvement Score (AIS) is a bidirectional measure of total toxicity change with a minimal clinically important difference (MCID) of ≤-10.

OBJECTIVE

This study was a longitudinal assessment of patients with SA treated with biologic therapies to assess the trajectory of OCS-related toxicity and predictors of toxicity improvement.

METHODS

A total of 89 patients with SA had GTI assessments at baseline and after 1 and 3 years of biologic therapy.

RESULTS

At 3 years, daily prednisolone use continued to decrease (6.9 mg/day [4.0, 9.4] year 1 vs 0.8 mg/day [0.0, 3.7] year 3, P < .001), OCS-related toxicity continued to decline (AIS at 3 years -36 [-94, 19]), and 61% (54 of 89) met the AIS MCID. There was a significant positive correlation between toxicity outcomes at years 1 and 3 (ρ 0.65, P < .001). Nearly half (49%) met the AIS MCID at both years 1 and 3, but 29% of the cohort did not meet the AIS MCID at either time point. Toxicity change at year 1 was predictive of toxicity change at year 3 for 79%. Toxicity reduction was not proportional to OCS reduction; there were no prebiologic characteristics that predicted toxicity reduction.

CONCLUSIONS

After 3 years of biologic treatment, 61% of patients with SA had clinically significant toxicity improvement. Individual toxicity outcomes at year 1 are associated with longitudinal outcomes, suggesting that for some, additional interventions are needed alongside OCS reduction to decrease morbidity.

Connections and Unmet Needs: Severe Asthma Biologics and Osteoporosis

Asthma is a chronic inflammatory disease with the main anti-inflammatory drugs for better disease control being steroids or corticosteroids. The use of steroids in asthma patients, in particular in uncontrolled asthma patients, is associated with an increased risk of osteoporosis and fragility fractures. A single oral corticosteroid course increases the risk of osteoporosis and the continual use of inhaled corticosteroids is correlated over time to an increased risk for both bone conditions. With the use of new, available biologic therapies for asthma, perhaps even anticipating the times of their use in therapeutic management, in the current guidelines and with targeted strategies of prevention it may be possible to improve asthma management, preventing some comorbidities, such as osteoporosis.

Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa

In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.

Qualitative interviews to support development of a patient-reported companion measure to the Glucocorticoid Toxicity Index

INTRODUCTION

Glucocorticoids (GCs) are associated with multiple toxicities that have substantial impact on patients. We conducted qualitative interviews with patients to identify the toxicities that are most relevant from their perspective, with the goal of creating a patient-reported companion measure to the Glucocorticoid Toxicity Index (GTI), a clinician-facing instrument.

METHODS

Thirty-one patients with recent or current GC use participated in concept elicitation interviews. Participants received GC treatment for myasthenia gravis, chronic inflammatory demyelinating polyradiculoneuropathy, vasculitis, or systemic lupus erythematosus. Transcripts were coded following a thematic analysis approach.

RESULTS

Participants reported more than 100 toxicities they believed to be associated with their GC medications. Common toxicities included weight gain (87%), increased appetite (84%), insomnia/sleep problems (77%), cognitive impairment/brain fog (71%), easy bruising (68%), anxiety (65%), irritability/short temper (65%), and osteoporosis (39%). These toxicities often centered on self-esteem, neuropsychiatric effects, skin toxicities, and musculoskeletal function. They can be categorized into domains such emphasizing neuropsychiatric, metabolic/endocrine, musculoskeletal, and dermatological effects, highlighting aspects of GC toxicity that patients are uniquely positioned to appreciate and report.

CONCLUSION

Our results confirm that the toxicities associated with GCs are pervasive and diverse, with substantial impact on patients' lives. These data will be used to inform the development of a patient-reported outcome measure assessing GC toxicity. This patient-reported instrument will be designed to complement the clinician-reported GTI, facilitating a more detailed understanding of the nuances of change in GC toxicity.

Efficacy and safety of avacopan in patients with ANCA-associated vasculitis receiving rituximab in a randomised trial

OBJECTIVES

To evaluate the efficacy and safety of avacopan in the subgroup of patients with antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis receiving background induction therapy with rituximab in the phase 3 ADVOCATE trial.

METHODS

Key efficacy outcomes were remission at week 26 and sustained remission at week 52. Additional outcomes included the Glucocorticoid Toxicity Index, estimated glomerular filtration rate, urinary albumin to creatinine ratio, health-related quality of life and safety.

RESULTS

Of the 330 patients who received study medication, 214 (64.8%) received rituximab (once weekly for 4 weeks), with a mean age of 59.8 years; 163 (76.2%) had renal vasculitis and 125 (58.4%) were newly diagnosed. Remission at week 26 and sustained remission at week 52 were achieved by 83/107 (77.6%) and 76/107 (71.0%) patients in the avacopan group and 81/107 (75.7%) and 60/107 (56.1%) in the prednisone taper group, respectively. The relapse rate, recovery of renal function, speed of reduction in albuminuria and glucocorticoid toxicity favoured the avacopan group. Serious adverse events occurred in 34.6% and 39.3% of patients in the avacopan and prednisone taper groups, respectively.

CONCLUSIONS

These data suggest that in patients with ANCA-associated vasculitis receiving rituximab, efficacy of treatment with avacopan compared with a prednisone taper was similar at week 26 and greater at week 52, with a favourable safety profile. In addition, avacopan was associated with improved renal outcomes and lower glucocorticoid toxicity. These results demonstrate the efficacy and safety of avacopan in patients receiving background induction therapy with rituximab.

TRIAL REGISTRATION NUMBER

NCT02994927.

Clinical remission in severe asthma with biologic therapy: an analysis from the UK Severe Asthma Registry

BACKGROUND

Novel biologic therapies have revolutionised the management of severe asthma with more ambitious treatment aims. Here we analyse the definition of clinical remission as a suggested treatment goal and consider the characteristics associated with clinical remission in a large, real-world severe asthma cohort.

METHODS

This was a retrospective analysis of severe asthma patients registered in the UK Severe Asthma Registry (UKSAR) who met strict national access criteria for biologics. Patients had a pre-biologics baseline assessment and annual review. The primary definition of clinical remission applied included Asthma Control Questionnaire (ACQ)-5 <1.5 and no oral corticosteroids for disease control and forced expiratory volume in 1 s above lower limit of normal or no more than 100 mL less than baseline.

RESULTS

18.3% of patients achieved the primary definition of remission. The adjusted odds of remission on biologic therapy were 7.44 (95% CI 1.73-31.95)-fold higher in patients with type 2 (T2)-high biomarkers. The adjusted odds of remission were lower in patients who were female (OR 0.61, 95% CI 0.45-0.93), obese (OR 0.49, 95% CI 0.24-0.65) or had ACQ-5 ≥1.5 (OR 0.19, 95% CI 0.12-0.31) pre-biologic therapy. The likelihood of remission reduced by 14% (95% CI 0.76-0.97) for every 10-year increase in disease duration. 12-21% of the cohort attained clinical remission depending on the definition applied; most of those who did not achieve remission failed to meet multiple criteria.

CONCLUSIONS

18.3% of patients achieved the primary definition of clinical remission. Remission was more likely in T2-high biomarker patients with shorter duration of disease and less comorbidity. Further research on the optimum time to commence biologics in severe asthma is required.

The Glucocorticoid Toxicity Index-Metabolic Domains, an abridged version of the Glucocorticoid Toxicity Index: post-hoc analysis of data from the ADVOCATE trial

BACKGROUND

Quantifying glucocorticoid toxicity is crucial to efforts to reduce it. The Glucocorticoid Toxicity Index (GTI) measures toxicity effectively in clinical trials by calculating two scores: the cumulative worsening score (CWS) and the aggregate improvement score (AIS). However, in clinical practice, high patient volumes limit the time available for standardised assessments. We aimed to compare the GTI with an abbreviated version of the GTI, the GTI-Metabolic Domains (GTI-MD), which could help to address this issue by using data that are collected easily at routine visits and do not require additional effort from clinicians.

METHODS

We did a post-hoc analysis of data from ADVOCATE, a randomised, double-blind, double-dummy, phase 3 trial in which avacopan replaced a standard prednisone taper in patients with antineutrophil cytoplasmic antibody-associated vasculitis. We calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each domain of the GTI-MD-comprising the BMI, glucose tolerance, blood pressure, and lipid metabolism domains of the GTI-to test its ability to differentiate the avacopan and prednisone groups by glucocorticoid toxicity. Data from two additional disease cohorts, one comprising patients with asthma and the other comprising patients with autoimmune blistering disease, constituted the validation set.

FINDINGS

Complete data were available for 321 (97%) of the 330 participants comprising the intention-to-treat population in the ADVOCATE trial at week 13, and 307 (93%) at week 26; data from these individuals were included in our post-hoc analysis. In ADVOCATE, 98 (59%) of 166 participants in the avacopan group were men and 68 (41%) were women, 88 (54%) of 164 in the prednisone group were men and 76 (46%) were women; the mean age of participants was 61·2 years [SD 14·6] in the avacopan group and 60·5 years [14·5] in the prednisone group. The validation cohort included 159 patients (89 with glucocorticoid-dependent asthma, of whom 40 [45%] were men and 49 [55%] were women, and 70 with autoimmune blistering disease of the skin, of whom 30 [43%] were men and 40 [57%] were women). The Spearman's rank correlation coefficient in ADVOCATE for the GTI-MD CWS with the GTI CWS for the treatment groups combined was 0·78 (95% CI 0·75-0·81; p<0·0001). The corresponding correlation for the AIS was 0·73 (0·69-0·77, p<0·0001). The GTI-MD distinguished the groups by glucocorticoid toxicity at both 13 weeks and 26 weeks. The mean GTI-MD CWS was lower in the avacopan group than in the prednisone group, consistent with less toxicity (15·9 vs 23·0 at 13 weeks [p=0·0010]; 26·7 vs 31·7 at 26 weeks [p=0·0092]). The GTI-MD AIS values were also consistent with less toxicity in the avacopan group (2·5 vs 13·0 at 13 weeks [p=0·0003], 4·4 vs 10·1 at 26 weeks [p=0·027]). A GTI-MD score of 0 corresponded to a low likelihood of toxicity in the other GTI domains. In the validation set, the Spearman's rank correlation coefficient for the GTI-MD CWS with the GTI CWS was 0·61 (95% CI 0·50-0·70; p<0·0001) and the corresponding correlation for the AIS was 0·58 (0·47-0·68; p<0·0001).

INTERPRETATION

The GTI-MD correlates well with the full GTI and could be incorporated readily into routine clinic workflows without additional input from the clinician. Using the GTI-MD on the background of electronic medical records systems could help clinicians to monitor glucocorticoid toxicity longitudinally, with the goals of preventing the burden of chronic, treatment-related harms and reducing long-term costs to health systems.

FUNDING

ChemoCentryx.

Potential impact of mepolizumab in stepping down anti-osteporotic treatment in corticosteroid-dependent asthma

Oral corticosteroids (OCS) are commonly used for the acute management of severe asthma exacerbations or as maintenance therapy; however, chronic use is associated with significant toxicities, e.g., osteoporosis. In the REal worlD Effectiveness and Safety (REDES) study of mepolizumab in a multicentric Spanish cohort of asthma patients, mepolizumab effectively reduced clinically severe asthma exacerbations and decreased OCS dependence. This post-hoc analysis further evaluates mepolizumab's de-escalation effect on OCS dose. Patients enrolled in REDES who had OCS consumption data available for 12 months pre- and post-mepolizumab treatment were included in this analysis. Primary outcomes were to determine the change in the proportion of patients eligible for anti-osteoporotic treatment due to the changes in OCS consumption before and after 1 year of mepolizumab treatment. All analyses are descriptive. Approximately one-third (98/318; 30.8%) of patients in REDES were on maintenance OCS at the time of mepolizumab treatment initiation. In REDES, mean cumulative OCS exposure decreased by 54.3% after 1 year of treatment. The proportion of patients on high-dose OCS (≥7.5 mg/day) fell from 57.1% at baseline to 28.9% after 12 months of mepolizumab treatment. Thus, 53.6% of OCS-dependent asthma patients treated with mepolizumab would cease to be candidates for anti-osteoporotic treatment according to guidelines thresholds.

Glucocorticoid Toxicity Index scores by domain in patients with antineutrophil cytoplasmic antibody-associated vasculitis treated with avacopan versus standard prednisone taper: post-hoc analysis of data from the ADVOCATE trial

BACKGROUND

The ADVOCATE trial, in which the complement C5a receptor inhibitor avacopan was compared with a standard prednisone taper in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, used the Glucocorticoid Toxicity Index (GTI) to measure glucocorticoid toxicity change. We set out to do a post-hoc analysis of the ADVOCATE data to evaluate changes in individual GTI domains and their ability to differentiate treatment groups.

METHODS

The ADVOCATE trial was a phase 3, double-blind, double-dummy, randomised trial comparing oral avacopan (30 mg) twice daily for 52 weeks plus a prednisone-matching placebo for 20 weeks with oral prednisone tapered over 20 weeks plus an avacopan-matching placebo for 52 weeks in patients with ANCA-associated vasculitis. GTI data were collected within each of the included domains (BMI, blood pressure, glucose tolerance, lipid metabolism, glucocorticoid myopathy, skin toxicity, neuropsychiatric effects, and infections) at baseline, 13 weeks, and 26 weeks. In this post-hoc analysis, we calculated the cumulative worsening score (CWS) and aggregate improvement score (AIS) for each GTI domain, assessed to what extend each domain contributed to the GTI score, and which domains differentiated between the avacopan and prednisone groups. Differences in domain scores between the two groups were compared using Mantel-Haenszel χ2 tests.

FINDINGS

Among the 330 patients included in the intention-to-treat population of the ADVOCATE trial, 321 (97%) had complete data at week 13 (160 in the avacopan group, and 161 in the prednisone group), and 307 (93%) had complete data at week 26 (154 in the avacopan group, and 153 in the prednisone group) and were assessed in this post-hoc study. In ADVOCATE, mean age in both groups was 61 years (61·2 years [SD 14·6] in the avacopan group; 60·5 years [14·5] in the prednisone group); 98 (59%) of 166 patients in the avacopan group were men and 68 (41%) were women; 88 (54%) of 164 patients in the prednisone group were men and 76 (46%) were women. 278 (84%) of 330 patients were White. The mean glucocorticoid use over 26 weeks was lower in the avacopan group than the prednisone group (1073 mg [SD 1669] vs 3192 mg [1174]). Significantly less glucocorticoid toxicity was observed in the avacopan group than the prednisone group by week 13 in four domains of the GTI (BMI, glucose tolerance, lipid metabolism, and skin toxicity), based on both the CWS and AIS. CWS values in the BMI, lipid metabolism, and skin toxicity domains were significantly lower in the avacopan group than the prednisone group at 26 weeks. No domain favoured the prednisone group for glucocorticoid toxicity reduction. 280 (91%) of 307 patients had glucocorticoid toxicity at 26 weeks. Blood pressure (35% in the avacopan group vs 25% in the prednisone group), infection (22% vs 24%), and lipid metabolism (20% vs 15%) contributed the most weight toward CWS values at 26 weeks. 128 (42%) of 307 patients had combinations of improvement and worsening in different domains at 26 weeks.

INTERPRETATION

Replacing a standard prednisone taper with avacopan in patients with ANCA-associated vasculitis reduced glucocorticoid toxicity in multiple GTI domains. For individual patients, glucocorticoid toxicity was often nuanced, improving in some domains while worsening in others. These findings emphasise the value of a composite measure of glucocorticoid toxicity that quantifies cumulative worsening and aggregate change directly.

FUNDING

ChemoCentryx.

Asthma Exacerbations in Severe Asthma: Why Systemic Corticosteroids May not Always Be the Best Treatment Option

Purpose

Advances in the management of severe, eosinophilic asthma have improved, but asthma exacerbations continue to occur. This review aims to look at the evidence we have about why exacerbations may occur; their phenotype and why oral corticosteroids may not always be the best treatment option for all exacerbation of symptoms in individuals with severe asthma.

Recent findings

Studies dating back to the 1990s showed that asthma exacerbations across the spectrum of asthma severity were of different inflammatory endotypes. In addition, there is a wealth of evidence suggesting that eosinophilic inflammation is very responsive to corticosteroid therapy, but that non-eosinophilic inflammation is less so. Two recent UK-based studies have undertaken systematic phenotyping of exacerbations in severe asthma and have shown that there are a significant minority of exacerbation events with an increase in asthma symptoms, fall in lung function, but without evidence of raised T2 biomarkers.

Summary

The evidence to date would suggest that T2 biomarker low asthma exacerbations do not benefit from the administration of oral corticosteroids; in fact, the effect of the oral corticosteroids is harmful. However, there is a paucity of data to answer this question directly. Further research is needed to assess the evolution of non-T2 exacerbations not treated with OCS in a randomised, placebo-controlled, manner.

Estimating glucocorticoid-related morbidity in lupus nephritis using the glucocorticoid toxicity index

OBJECTIVE

Lupus nephritis (LN) is often treated with high doses of glucocorticoids (GCs). The glucocorticoid toxicity index (GTI) was developed by expert consensus to quantify GC toxicity. To date, the GTI has not been shown to correlate with GC exposure in patients with LN.

METHODS

We performed a retrospective cohort study of patients with biopsy-confirmed LN between 2006 and 2016. Cumulative GC exposure and GTI scores were determined via medical record review. Both the aggregate improvement score (GTI-AIS) and the cumulative worsening score (GTI-CWS) were calculated. We performed linear regression to determine the association between GC exposure and GTI scores at 1 year and 5 years following kidney biopsy.

RESULTS

This study included 49 patients with a mean age of 33.3 (SD 9.5) years. Mean GC exposure was 23.0 mg prednisone-equivalents per day through year 1 and 9.9 mg prednisone-equivalents per day through year 5. At 5 years, higher GC exposure was associated with higher GTI-AIS (p < 0.001) and GTI-CWS (p = 0.002), and this association persisted in multivariate analysis adjusting for age, sex, race, induction medication, and nephritis class (p = 0.026 for AIS, p = 0.012 for CWS). At 1 year, GC exposure was not associated with GTI scores (p = 0.70 for AIS; p = 0.58 for CWS).

CONCLUSION

In this cohort study, the GTI was associated with cumulative steroid exposure at 5 years after diagnosis. In patients with LN, the GTI may serve as a useful outcome measure in future LN trials evaluating the steroid sparing effect of novel therapies.

Baseline Glucocorticoid-Related Toxicity Scores in Giant Cell Arteritis: A Post Hoc Analysis of the GiACTA Trial

OBJECTIVE

Giant cell arteritis (GCA) requires treatment with high-dose, long-term glucocorticoids (GCs). A score assessing and quantifying patients' baseline GC-related toxicity may be important to risk stratification and therapeutic decision-making in patients initiating immunosuppression.

METHODS

We analyzed patients with GCA enrolled in the Tocilizumab in Giant Cell Arteritis (GiACTA) trial. Baseline GC-related toxicity scores for 12 domains were derived from the Glucocorticoid Toxicity Index using baseline medications, medical history, vital signs, and laboratory values. The 12 domains examined were body mass index, glucose tolerance, blood pressure, lipid metabolism, bone and/or tendon, GC myopathy, skin toxicity, neuropsychiatric effects, infection, ocular toxicity, gastrointestinal injury, and adrenal function. Potential scores ranged from 0 to 538. We compared differences between those with newly diagnosed versus relapsing disease at baseline.

RESULTS

A total of 250 patients were included (75% female, mean age 69 years). The mean ± SD baseline GC-related toxicity score among all patients was 111.3 ± 53.2. The domains that contributed most to the overall scores were blood pressure (24.0% of the overall score), followed by glucose tolerance (22.6%) and neuropsychiatric effects (15.9%). Baseline GC-related toxicity scores were higher in patients with relapsing disease compared with those with newly diagnosed disease (mean of 122.5 vs. 98.9; P < 0.001). The body mass index and neuropsychiatric domain scores were significantly higher in patients with relapsing disease.

CONCLUSION

This approach to the assessment of baseline GC-related toxicity distinguished patients with relapsing GCA from those with newly diagnosed disease. Baseline GC-related toxicity scores may be useful in therapeutic decision-making for patients beginning immunosuppressive treatment.

Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group

Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.

Applicability of glucocorticoid toxicity index in pemphigus: Comparison between two groups of rituximab-treated and rituximab-naïve patients

Rituximab (RTX) combined with short-term glucocorticoids (GC) is an effective therapeutic option for pemphigus. The newly developed Glucocorticoid Toxicity Index (GTI) tool provides the possibility to measure GC toxicities over time. To compare 1-year GTI between two groups of RTX-treated and RTX-naïve patients with pemphigus. The responsiveness of the GTI was also investigated. A prospective cohort of 129 adults with newly diagnosed pemphigus was conducted. GC-related toxicities were assessed at 3-month intervals according to Composite and Specific lists of the GTI. Of the patients, 76.7% (n = 99) received RTX. Throughout the time intervals, RTX-treated patients had lower GTI compared to RTX-naïve ones (p = 0.036). The mean GTI at 1-year was 34.3 in the RTX-treated group and 50.8 in the RTX-naïve group (p = 0.04). The most commonly observed GC-related toxicity was neuropsychiatric manifestations for 34% (224 events). The relapse rate of RTX-treated patients (1%) was significantly lower than RTX-naïve patients (10%) (p = 0.037). The GTI showed no correlation with cumulative GC consumption in both groups (p > 0.05, both). Patients treated with GC alone had remarkably higher GTI than patients treated with GC plus RTX. The GTI is an applicable tool to quantitatively capture GC toxicities at the patient level in pemphigus.

The glucocorticoid toxicity index: Measuring change in glucocorticoid toxicity over time

Glucocorticoids (GCs) have been the cornerstone of treating dozens of inflammatory conditions for more than seven decades. GC toxicity is ubiquitous in both clinical trials and clinical practice, and toxicities associated with GC use are central to the experience of most patients being treated for immune-mediated conditions. These conditions span the full range of medical specialties, including rheumatology, nephrology, gastroenterology, neurology, pulmonology, ophthalmology, and others. One of the goals of novel therapies for inflammatory disease must be to diminish the effects of GC toxicity in clinically important ways, thereby differentiating these new treatments from existing approaches. Despite the importance of glucocorticoids in the treatment of inflammatory disease for more than 70 years, no reliable means of calculating the degree to which GC toxicity has worsened or improved over the course of treatment has been available. The Glucocorticoid Toxicity Index (GTI), developed by an international group of subspecialty physician experts as a clinician-facing clinical trials outcome measure, is a standardized, validated measure of the phenomenon known as GC toxicity. The purpose of the instrument is to measure change in GC toxicity between two points in time: for example, between the baseline visit and the time of the primary efficacy outcome assessment. The instrument is designed to quantify both worsening and improvement in GC toxicity. The GTI has been validated in both real-world experiences and clinical trials, including a phase 3, label-enabling trial in ANCA associated vasculitis. This article reviews the history and rationale for the development of the GTI, describes key data from validation studies, considers the minimum clinically important difference, and provides instructions for use of the instrument.

The pediatric glucocorticoid toxicity index

OBJECTIVES

To develop a Pediatric glucocorticoid toxicity index (pGTI), a standardized, weighted clinical outcome assessment that measures change in glucocorticoid (GC) toxicity over time.

METHODS

Fourteen physician experts from 7 subspecialties participated. The physician experts represented multiple subspecialties in which GCs play a major role in the treatment of inflammatory disease: nephrology, rheumatology, oncology, endocrinology, genetics, psychiatry, and maternal-fetal medicine. Nine investigators were from Canada, Europe, or New Zealand, and 5 were from the United States. Group consensus methods and multi-criteria decision analysis were used. The pGTI is an aggregate assessment of GC toxicities that are common, important, and dynamic. These toxicities are organized into health domains graded as minor, moderate, or major and are weighted according to severity. The relative weights were derived by group consensus and multi-criteria decision analysis using the 1000Minds^TM software platform. Two quantitative scores comprise the overall toxicity profile derived from pGTI data: (1) the Cumulative Worsening Score; and (2) the Aggregate Improvement Score. The pGTI also includes a qualitative, unweighted record of GC side-effects known as the Damage Checklist, which documents less common toxicities that, although potentially severe, are unlikely to change with varying GC dosing.

RESULTS

One hundred and seven (107) toxicity items were included in the pGTI and thirty-two (32) in the Damage Checklist. To assess the degree to which the pGTI corresponds to expert clinical judgement, the investigators ranked 15 cases by clinical judgement from highest to lowest GC toxicity. Expert rankings were then compared to case ranking by the pGTI, yielding excellent agreement (weighted kappa 0.86). The pGTI was migrated to a digital environment following its development and initial validation. The digital platform is designed to ensure ease-of-use in the clinic, rigor in application, and accuracy of scoring. Clinic staff enter vital signs, laboratory results, and medication changes relevant to pGTI scoring. Clinicians record findings for GC myopathy, skin toxicity, mood dysfunction, and infection. The pGTI algorithms then apply the weights to these raw data and calculate scores. Embedded logic accounts for the impact of age- and sex-related reference ranges on several health domains: blood pressure, lipid metabolism, and bone mineral density. Other algorithms account for anticipated changes in the height Z-scores used in the growth domain, thereby addressing a concern unique to GC toxicity in children. The Damage Checklist ensures comprehensive measurement of GC toxicity but does not contribute to pGTI scoring, because the scored domains emphasize manifestations of GC toxicity that are likely to change over the course of a trial.

CONCLUSIONS

We describe the development and initial evaluation of a weighted, composite toxicity index for the assessment of morbidity related to GC use in children and adolescents. Developing the pGTI digital platform was essential for performing the nuanced calculations necessary to ensure rigor, accuracy, and ease-of-use in both clinic and research settings.

Expert Perspective: Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) comprise a major subset of diseases that cause destructive inflammation of small and medium-sized blood vessels. Although these conditions have a predilection for pulmonary and renal involvement, they are in fact protean diseases that can involve essentially any organ system. AAV is among the most difficult rheumatic diseases to diagnose and treat. Therapy for AAV has evolved over the past two decades. Rituximab, an anti-CD20 monoclonal antibody, is now the preferred agent for remission induction in conjunction with a reduced-dose glucocorticoid taper. Rituximab is also often a key therapy for remission maintenance. Glucocorticoid toxicity reduction has become a major priority for treatment regimens. Avacopan, an important new adjunct to remission induction therapy, may reduce glucocorticoid use and its resulting toxicity. The role of avacopan as a remission maintenance agent requires further study. The duration of immunosuppression following remission is guided by a number of factors, including the patient's overall clinical state, the degree of damage from previous disease activity, the tolerability of remission maintenance medications, and SARS-CoV-2 vaccination and immunity status. Certain features, including history of previous relapse, the presence of ANCA directed against proteinase 3, and a diagnosis of granulomatosis with polyangiitis, favor prolonged remission maintenance therapy. The interval between rituximab doses can usually be lengthened over time during the maintenance phase.

Glucocorticoid toxicity reduction with mepolizumab using the Glucocorticoid Toxicity Index

BACKGROUND

Reduction in glucocorticoid exposure is the primary benefit of new biologic treatments in severe asthma, but there is currently no evidence that reduction in glucocorticoid exposure corresponds to a proportionate reduction in associated toxicity.

OBJECTIVES

To use the validated Glucocorticoid Toxicity Index (GTI) to assess change in glucocorticoid toxicity after 12 months treatment with mepolizumab, and compare toxicity change to glucocorticoid reduction and change in patient-reported outcome measures (PROMs).

METHODS

A longitudinal, real-world prospective cohort of 101 consecutive patients with severe asthma commenced on mepolizumab in a specialist UK regional severe asthma clinic. GTI toxicity assessment, cumulative glucocorticoid exposure and PROMs were recorded on commencing mepolizumab (V1), and after 12 months treatment (V2).

RESULTS

There was significant reduction in oral glucocorticoid exposure (V1 median 4280 mg prednisolone per year (interquartile range 3083-5475 mg) versus V2 2450 mg prednisolone per year (1243-3360 mg), p<0.001). Substantial improvements in individual toxicities were observed, but did not correlate with oral glucocorticoid reduction. Mean±sd GTI aggregate improvement score (AIS) was -35.7±57.8 with a wide range in toxicity change at individual patient level (AIS range -165 to +130); 70% (71 out of 101) had a reduction in toxicity (AIS <0); 3% (three out of 101) had no change (AIS=0); and 27% (27 out of 101) an increase in overall toxicity. 62% (62 out of 101) of patients met the AIS minimally clinically important difference of ≤-10, but AIS did not correlate with glucocorticoid reduction or change in PROMs.

CONCLUSION

Mepolizumab resulted in substantial oral glucocorticoid reduction, but this did not correlate with reduction in oral glucocorticoid toxicity, which varies widely at the individual patient level. Oral glucocorticoid reduction is not a comprehensive measure of response to mepolizumab.

Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand

Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

Glucocorticoid Therapy in ANCA Vasculitis: Using the Glucocorticoid Toxicity Index as an Outcome Measure

Background

ANCA-associated vasculitis (AAV) is an autoimmune disease. Induction remission and maintenance treatment typically includes high-dose, tapering glucocorticoids (GC), in addition to other immunosuppressive medication. The use of theGlucocorticoid Toxicity Index (GTI) provides a global, quantifiable assessment tool in which clinicians can assess GC-associated morbidity. Recent trials in AAV have exposed the need for systemic assessment of GC burden. In this small cohort study, we look to address these issues and the justification of newer GC sparing agents, such as C5a inhibitors.

Methods

A retrospective cohort study of 43 patients with biopsy AAV was constructed from a single center between 2012-2016, and followed up for 48 months. The GTI table made up of adverse features was used to quantify patients' GC toxicity. Electronic patient records were reviewed and scores calculated according to published methods. GTI scores were compared with cumulative steroid doses at separate intervals and incidences of adverse features in relation to the treatment timeline.

Results

The mean age was 65.9 (±11.06) years and treatment regimens consisted of glucocorticoids alongside cyclophosphamide or rituximab. Our results showed statistical significance in the association of cumulative GC doses and GTI scores (P=0.008; 95% CI, 1.31 to 8.05). Adverse features relating to mood disturbance and GC-induced psychosis occurred early, in contrast to adrenal insufficiency, which typically presented later in the follow-up. Infection-related adverse events were consistent throughout.

Conclusions

We demonstrated that higher cumulative doses of steroids in AAV lead to worse glucocorticoid-related toxicity. Using the GTI creates the potential to individualize and quantify the adverse effects patients experience as a result of GC treatment and permits more patient-centered management. Although glucocorticoids remain the main adjunctive immunosuppression of AAV treatment, the narrow therapeutic window supports the need for GC-sparing treatments.

[Safety aspects of the treatment with glucocorticoids for rheumatoid arthritis]

Glukokortikoide (GC) werden für die initiale Therapie der RA nach wie vor empfohlen – zeitlich befristet und in geringstmöglicher Dosierung. Ihre komplexe Wirkweise geht mit Nebenwirkungen einher, die v. a. in der Dauertherapie oberhalb von 5 mg Prednisolon pro Tag eine Rolle spielen. In diesem Dosisbereich begünstigen sie Osteoporose, Diabetes/Hyperglykämie, kardiovaskuläre Ereignisse und Infektionen und tragen damit zu einer vermehrten Frühsterblichkeit bei. Dabei sind die Risiken der GC-Therapie von patientenbezogenen Faktoren abhängig wie Alter, Komorbidität und Begleitmedikation. Ein negativer Einfluss sehr niedriger Steroiddosen auf das Gesamtüberleben ist möglicherweise bei hoher kumulativer Dosis nachweisbar, die Datenlage ist hier jedoch widersprüchlich. Das Monitoring einer GC-vermittelten Toxizität mithilfe eines validierten Index sollte in Zukunft dazu beitragen, die Vorteile einer steroidsparenden Behandlungsstrategie besser zu beschreiben. Selektiver wirkende Substanzen könnten in Zukunft eine Abkopplung der erwünschten Wirkungen von den Nebenwirkungen ermöglichen.