Adrenal suppression among asthmatic children receiving chronic therapy with inhaled corticosteroid with and without spacer device

A review of the in vitro and in vivo valved holding chamber (VHC) literature with a focus on the AeroChamber Plus Flow-Vu Anti-static VHC

Valved holding chambers (VHCs) reduce the need for inhalation-actuation coordination with pressurized metered dose inhalers (pMDIs), reduce oropharyngeal drug deposition and may improve lung deposition and clinical outcomes compared to pMDIs used alone. While VHCs are thus widely advocated for use in vulnerable patient groups within clinical and regulatory guidelines, there is less consensus as to whether the performance differences between different VHCs have clinical implications. This review evaluates the VHC literature, in particular the data pertaining to large- versus small-volume chambers, aerosol performance with a VHC adjunct versus a pMDI alone, charge dissipative/conducting versus non-conducting VHCs, and facemasks, to ascertain whether potentially meaningful differences between VHCs exist. Inconsistencies in the literature are examined and explained, and relationships between in vitro and in vivo data are discussed. A particular focus of this review is the AeroChamber Plus® Flow-Vu® Anti-static VHC, the most recent iteration of the AeroChamber VHC family.

Systemic activity of inhaled beclomethasone dipropionate: a double-blind comparison of volume spacers

BACKGROUND

To which extent volume spacers may influence systemic activity of inhaled beclomethasone dipropionate (BDP) has not been evaluated.

AIM

To assess whether the AeroChamber Plus™ spacer is equivalent to the Volumatic™ spacer for administration of inhaled hydroflouroalkane 134a propelled BDP in terms of lower leg growth rate (LLGR).

PATIENTS AND METHODS

Prepubertal children with mild asthma (n = 26, aged 6-14 years) were included in a 3-time periods of 2 weeks duration randomized double-blind cross-over study with a single-blind placebo run-in and two washout periods. LLGR was measured with the knemometer. Interventions were inhaled BDP hydroflouroalkane 134a pressurized metered dose inhaler 100 μg and 200 μg b.i.d. with the AeroChamber Plus and 200 μg b.i.d. with the Volumatic spacer.

RESULTS

Beclomethasone dipropionate 200 μg b.i.d. from the AeroChamber Plus was non-inferior to BDP 200 b.i.d. from the Volumatic spacer as the lower margin of confidence interval of the difference between treatments (-0.18 to 0.13 mm/week) was greater than the prespecified lower limit for non-inferiority (-0.20 mm/week). UFC/creatinine data showed no statistically significant variations.

CONCLUSION

The systemic activity of BDP, via the Volumatic™, and AeroChamber Plus™ spacers is similar. The AeroChamber Plus spacer may be used in children without risk of increasing systemic activity of BDP.

Efficacy of fluticasone metered-dose inhaler and dry powder inhaler for pediatric asthma

BACKGROUND

For the treatment of bronchial asthma, two types of fluticasone inhaler devices are available, namely, metered-dose inhaler with spacer (MDI-S) and the dry powder inhaler (DPI). The former is recommended for young children with a low peak inspiratory flow (PIF) and the latter for adolescents and adults. But the difference in the therapeutic efficacy between them has been studied only rarely in adolescent patients.

METHODS

In the present study, 21 post-elementary school-age patients with moderate persistent bronchial asthma (age 8-15 years, 10.3 +/- 2.1 years), who all had a sufficient PIF of 114 +/- 29 L/min, were examined in order to compare the two types of fluticasone inhalers. Eleven of 21 patients inhaled 200 microg/day Flutide using the MDI-S twice daily for 1 month in the first month, and the same dose using the DPI for the next month. The other 10 patients inhaled the opposite regimens. At the end of the each treatment, spirometry was examined.

RESULTS

Measurements done before therapy and then at the end of MDI-S and DPI therapy, respectively, were as follows: forced expiratory volume in 1 s (FEV(1.0)), 72.4 +/- 18.2%, 91.5 +/- 18.2% and 84.1 +/- 16.3% (MDI-S vs DPI, P > 0.040); maximal mid-expiratory flow (MMEF), 62.0 +/- 23.6%, 88.7 +/- 26.5%, 79.3 +/- 33.4% (P > 0.044) and the peak expiratory flow (PEF) was 73.9 +/- 25.0%, 95.6 +/- 32.8%, and 90.5 +/- 29.5%, respectively (n.s.). MDI-S was thus found to be more effective in terms of %FEV(1.0) and in %MMEF.

CONCLUSIONS

High therapeutic efficacy was obtained with the use of the MDI-S in fluticasone inhalation for post-elementary school-age patients with sufficient inspiration ability.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

The effects of long term use of inhaled corticosteroids on linear growth, adrenal function and bone mineral density in children

In this study we aimed to investigate the long term effects of inhaled steroids on linear growth, adrenal function and bone mineral density. Thirty children with moderate asthma were randomly divided into two groups. Fifteen children (8 boys, 7 girls mean age; 10.6 +/- 2.1) were treated with budesonide (group 1), and 15 (9 boys, 6 girls, mean age; 9.6 +/- 2.4). with fluticasone propionate (group 2). Control group included 30 children. Anthropometric assessment, symptom and medication scores, pulmonary functions, bone mineral density, serum and urine cortisol levels and ACTH stimulation test were evaluated at the beginning of the study and after one year period. Symptom and medication scores, pulmonary functions improved significantly in both groups (p < 0.05). The mean annual growth was similar in group 1 and 2 and control group. Bone mineral density was comparable with control group at the beginning of the study and after one year. Mean serum cortisol level diminished at the end of the therapy but no significant differences were found between the initial and end values in respect to urine cortisol levels and cortisol/creatinine ratio. Of three groups ACTH stimulation test revealed that there were no significant difference between study and control groups. In conclusion, although we did not observed any side effects of inhaled corticosteroids we suggest that children treated with inhaled corticosteroids for a long time should be followed closely with respect to side effects.

The effect of inhaled corticosteroids on the urinary calcium to creatinine ratio in childhood asthma

BACKGROUND

The use of inhaled corticosteroids (ICS) via spacers in childhood asthma is increasing. However, concern has been raised about its long-term impact. Hypercalciuria is a known adverse effect of treatment with systemic corticosteroids. The urinary calcium to creatinine ratio (UCa:Cr) is a simple, reliable and non-invasive tool for evaluation of hypercalciuria.

AIM

To determine whether ICS can induce hypercalciuria in children with asthma.

SETTING

Outpatient clinic in a referral hospital.

METHODS

The UCa:Cr was determined in 25 children aged 3-6 years with mild-to-moderate persistent asthma before and after a 2-month course of inhaled budesonide 400 micrograms/day via an aerochamber. Children who had received oral corticosteroids, diuretics, antibiotics or theophylline were excluded.

STATISTICS

Paired Student's t-test and Fisher's exact test.

RESULTS

The mean UCa:Cr was similar in the children with asthma before and after 2 months' administration of budesonide (0.10 +/- 0.10 and 0.11 +/- 0.08, respectively; p = 0.601). The numbers of hypercalciuric children were two and five, respectively (p = 0.417). In 68% of patients, the UCa:Cr increased and in 16% the increase indicated hypercalciuria (UCa:Cr > 0.2).

CONCLUSIONS

Although the treatment of childhood asthma with budesonide 400 micrograms/day via an aerochamber does not appear to be associated with hypercalciuria, the existence of a subgroup of patients in whom ICS may induce hypercalciuria is plausible. This needs to be further evaluated in a larger study.

Inhaled corticosteroids in childhood asthma: long-term effects on growth and adrenocortical function

Inhaled corticosteroids (ICS) are the most potent of all the available inhaled treatments, and are effective medications for long-term control of asthma. However, their use in children is limited by the risk of systemic adverse effects. Although results reported in the literature on the adverse effects of ICS are conflicting and often restricted to a small number of cases with a limited follow-up, most of them show an early decrease in growth velocity without significant influence on final adult height. Partial adrenal suppression has also been demonstrated in children treated with ICS for more than 2 months. Only children with mild persistent, moderate, or severe asthma not controlled by non-corticosteroid drugs should be treated with ICS for long periods. The dose of ICS must be individually adjusted to minimize the possible adverse effects on growth, and all children with asthma receiving long-term treatment with ICS must be regularly evaluated for growth impairment, which may necessitate dose reduction or drug replacement.

Adrenal suppression in asthmatic children receiving low-dose inhaled budesonide: comparison between dry powder inhaler and pressurized metered-dose inhaler attached to a spacer

BACKGROUND

Dry powder inhalers (DPI) have in recent years become a common mode for administration of inhaled corticosteroids for preventive therapy of asthma. Inhaled steroids delivered by DPI achieve increased lung deposition compared with pressurized metered-dose inhalers (pMDI), which is associated with increased therapeutic effect. This may be associated with increased systemic absorption.

OBJECTIVE

The purpose of this study was to evaluate the prevalence of adrenal suppression in children using low-dose budesonide given by DPI, as compared with pMDI attached to a large-volume spacer device (pMDI + spacer).

METHODS

In an open-labeled crossover study, 15 asthmatic children aged 5 to 15 years received 200 microg of inhaled budesonide twice daily by DPI (Turbuhaler, Astra, Draco AB, Lund, Sweden) and by pMDI + spacer, 1 month each, in a randomized order. Twenty-four-hour urine collections were performed at baseline and at the end of each of the 2 months of the study period, and urinary cortisol and creatinine were measured.

RESULTS

Baseline urinary cortisol:creatinine was 0.038 +/- 0.012 microg/mg, similar in both groups. After 1 month of DPI therapy, urinary cortisol:creatinine was reduced by 27 +/- 16% to 0.028 +/- 0.012 microg/mg (P = 0.018). Urinary cortisol:creatinine after 1 month of pMDI + spacer therapy was similar to baseline 0.037 +/- 0.019 microg/mg (P = 0.78).

CONCLUSIONS

Treatment of asthmatic children with budesonide 400 microg daily given via a DPI for 1 month was associated with hypothalamic-pituitary-adrenal axis suppression. This effect was not observed with the same dose of budesonide administered via pMDI + spacer. This indicates that systemic absorption might be reduced with pMDI + spacer therapy.

Inhaled steroids and the risk of adrenal suppression in children

Corticosteroids are the mainstay of treatment of all asthma severity levels in adults and children. With their widespread use comes a responsibility to monitor, understand, and balance their efficacy and safety. Systemic adverse effects such as adrenal suppression have been clearly associated with the use of oral corticosteroids and to a lesser degree with the use of inhaled corticosteroids (ICS). In clinical trials, adrenal suppression is more evident when ICS are used in long-term therapy and at higher doses. However, monitoring adrenal suppression during short-term therapy and at lower doses is still of value in order to ascertain the lower limit of an inhaled corticosteroid's safety profile. Significant adrenal suppression at conventional ICS doses appears to be rare in clinical practice. When evaluating the effect of ICS on the hypothalamo-pituitary-adrenal-axis (HPA-axis), one must consider sources of variability both within and among trials including test sensitivity, systemic bioavailability, degree of airway obstruction, and delivery devices. All of these factors have the potential to effect the level of adrenal suppression detected and must be considered when interpreting HPA-axis test results in research or practice. This review will discuss adrenal suppression found with common ICS.

Inhaled corticosteroids and the risk of diabetes among the elderly

AIMS

There is evidence that large doses of inhaled corticosteroids lead to an increased risk of glaucoma, cataracts and other problems associated with oral corticosteroid use. However, no formal investigation so far has been conducted into the relationship between inhaled corticosteroids and diabetes.

METHODS

Our nested case-control design studied the association between current use of inhaled corticosteroids and the risk of using antidiabetic medications among a cohort of 21 645 elderly subjects. We also investigated the possibility of a dose-response relationship in users of beclomethasone. Data were obtained from the medical and pharmaceutical databases of the Regie de l'assurance maladie du Québec.

RESULTS

Within the cohort, we identified 1494 cases and we selected 14 931 controls using density sampling. The unadjusted rate ratio (and 95% confidence interval, CI) for developing diabetes among current users of inhaled corticosteroids was 1.4 (1.2, 1.5). After adjusting for covariates, the rate ratio (95% CI) decreased to 0.9 (0.8, 1.1). The loss of statistical significance was due in large part to adjusting for the current use of oral corticosteroids. We also did not observe a statistically significant increase in risk among users of high-dose beclomethasone compared to nonusers, after adjusting for covariates.

CONCLUSIONS

Our results do not indicate an increased risk of diabetes among current users of inhaled corticosteroids.

A comparison of the efficacy and safety of a half dose of fluticasone propionate with beclamethasone dipropionate and budesonide in childhood asthma

This study was carried out in an attempt to compare the efficacy and safety of fluticasone propionate (FP) at the half dose of budesonide (BUD) and beclamethasone dipropionate (BD) in childhood asthma. Ninety-six children with moderate to severe asthma (9.6 +/- 2.17 years) whose asthma was already controlled on BUD (n = 52) or BD (n = 44) were recruited into the study. In the first part of the study (the first 12 weeks) each group was followed with three weekly lung function measurements, daily diary records, and peak expiratory flow (PEF) measurements on the initial medication. At the end of 6 weeks, drugs were switched to a half dose of FP, and the subjects were followed for another 6 weeks. Blood samples were obtained for osteocalcin and plasma cortisol levels after each treatment period. In the second part of the study, 50 patients continued to take FP at the half dose of BUD or BD for another 30 weeks. Clinic visits, including lung function and PEF measurements, were conducted every 10 weeks. After 6 weeks of FP treatment, there was a small but statistically significant decrease in FEV1 and FEF(25-75) in both groups (BUD and BD) without any significant obstruction. These mild changes in lung function measurements continued during long-term follow-up. However, there was no statistically significant further decrease in any lung function parameters while receiving FP (visits 3-8) (coefficient = -0.00751 L/day, p = 0.39 for FEF(25-75) and coefficient = -0.00910 L/sec/day, p = 0.055 for FEV1). There were no significant changes in the morning and evening PEF measurements and diurnal PEF variations after 6 weeks of treatment with FP compared with BUD and BD treatments. There were no significant changes in basal cortisol and osteocalcin levels before or after 6 weeks of FP treatment (p > 0.05). The present study concluded that, although FP at the half dose of BUD or BD seems to maintain reasonable control of the disease symptoms, a mild but significant and persistent decrease in lung function parameters may indicate that FP may not be twice as potent as BUD or BD in childhood asthma by evaluation of lung functions. This conclusion must be further verified with long-term studies.

Comparison of efficacy and safety between flunisolide/AeroChamber and budesonide/turbuhaler in patients with moderate asthma. AER-MD-04 Study Group

BACKGROUND

There is a limited body of evidence comparing the clinical effects of different inhaled corticosteroids in the treatment of asthma. This study compared the safety and efficacy of inhaled flunisolide and budesonide, both with unique delivery systems that may affect clinical response.

OBJECTIVE

This multicenter study was carried out to compare the efficacy and safety of flunisolide, administered via AeroChamber, with budesonide, administered via Turbuhaler, in the treatment of moderate asthma.

METHODS

Patients with moderate asthma, defined as an FEV1 of 40% to 85% of predicted, underwent a 2-week run-in period during which beclomethasone, 750 microg twice daily by MDI, was administered, along with salbutamol prn. Patients (n = 176) were then randomized into two groups. One group received flunisolide administered via AeroChamber, 750 microg (3 puffs), twice daily. The second group received budesonide administered via Turbuhaler, 600 microg (3 puffs), twice daily. All patients took salbutamol prn.

RESULTS

At the end of the 6-week treatment period, there were no significant differences (P > .05 for all comparisons) in efficacy between the groups as evaluated by any efficacy parameter. The treatment groups also did not differ significantly in the number of adverse events or in the incidence of oropharyngeal Candida infection.

CONCLUSION

Flunisolide administered by AeroChamber and budesonide administered via Turbuhaler demonstrate similar efficacy and safety in the treatment of moderate asthma.

Measures of hypothalamic-pituitary-adrenal function in patients with asthma treated with inhaled glucocorticoids: clinical and research implications

In asthmatic patients treated with inhaled glucocorticoids there may be a risk of suppression of hypothalamic-pituitary-adrenal (HPA) function. The aim of the present study was to review peer-refereed data on HPA function in asthmatic patients taking inhaled glucocorticoids, and to discuss the value of HPA function measures in clinical practice and research. There is no evidence that inhaled glucocorticoids in recommended doses cause clinically significant HPA insufficiency. If sensitive measures of basal adrenal activity are used, however, dose-related suppressive effects with specific drugs and application systems can be detected. In adults, fluticasone propionate appears to be more potent than budesonide or triamcinolone acetonide in suppressing measures of basal adrenal activity. Measures of basal adrenal activity are useful in clinical trials that assess and compare systemic activity of specific drugs, application devices, and administration regimens, but have no place in the management of asthma.

A pharmacokinetic/pharmacodynamic approach to predict the cumulative cortisol suppression of inhaled corticosteroids

The suppression of endogenous cortisol release is one of the major systemic side effects of inhaled corticosteroids in the treatment of asthma. The circadian rhythm of the endogenous cortisol release and the resulting plasma concentrations as well as the release suppression during corticosteroid therapy could previously be described with an integrated PK/PD model. Based on this model, a PK/PD approach was developed to quantify and predict the cumulative cortisol suppression (CCS) as a surrogate marker for the systemic activity of inhaled corticosteroid therapy. The presented method was applied to predict CCS after single doses and during short-term multiple dosing of the inhaled corticosteroids flunisolide (FLU), fluticasone propionate (FP), and triamcinolone acetonide (TCA), and after oral methylprednisolone as systemic reference therapy. Drug-specific PK and PD parameters were obtained from previous single-dose studies and extrapolated to the multiple-dose situation. For single dosing, a similar CCS within the range of 16-21% was predicted for FP 250 micrograms, FLU 500 micrograms, and TCA 1000 micrograms. For multiple dosing, a respective CCS of 28-33% was calculated for FLU 500 micrograms bid, FP 250 micrograms, bid, and TCA 1000 micrograms bid. Higher cortisol suppression compared to these single and multiple dosing regimens of the inhaled corticosteroids was predicted after oral doses of only 1 mg and 2 mg methylprednisolone, respectively. The predictive power of the approach was evaluated by comparing the PK/PD-based simulations with data reported previously in clinical studies. The predicted CCS values were in good correlation with the clinically observed results. Hence, the presented PK/PD approach allows valid predictions of CCS for single and short-term multiple dosing of inhaled corticosteroids and facilitates comparisons between different dosing regimens and steroids.