Inhaled corticosteroid therapy is safe in tuberculin-positive asthmatic children

Impact of Allergic Disease on the Risk of Mycobacterial Disease

BACKGROUND

The association between allergic diseases and the risk of mycobacterial disease is unclear.

OBJECTIVE

To evaluate the association between allergic diseases and mycobacterial diseases.

METHODS

This was a population-based cohort study of 3,838,680 individuals, without prior mycobacterial disease, who participated in the 2009 National Health Screening Exam. We evaluated the incidence of mycobacterial disease (tuberculosis or nontuberculous mycobacterial infection) in participants with allergic disease (asthma, allergic rhinitis, or atopic dermatitis) and those without allergic disease. We followed the cohort up until the date of mycobacterial disease diagnosis, follow-up loss, death, or December 2018.

RESULTS

During a median follow-up of 8.3 (interquartile range, 8.1-8.6) years, 0.6% of participants developed mycobacterial disease. The incidence of mycobacterial disease was significantly higher in those with allergic diseases than in those without allergic diseases (1.0 vs 0.7/1000 person-years; P < .001), with an adjusted hazard ratio of 1.13 (95% CI, 1.10-1.17). Asthma (adjusted hazard ratio, 1.37; 95% CI, 1.29-1.45) and allergic rhinitis (adjusted hazard ratio, 1.07; 95% CI, 1.04-1.11) increased the hazard of mycobacterial disease, whereas atopic dermatitis did not. The association between allergic diseases and hazard of mycobacterial disease was more prominent in older (age ≥ 65 years, P for interaction = .012) and obese (body mass index ≥ 25 kg/m2, P for interaction < .001) participants.

CONCLUSION

Allergic diseases including asthma and allergic rhinitis were associated with an increased risk of mycobacterial disease, whereas atopic dermatitis was not.

Evaluation of Glucocorticoid Therapy in Asthma Children with Small Airway Obstruction Based on CT Features of Deep Learning

This study was aimed at exploring the treatment of asthma children with small airway obstruction in CT imaging features of deep learning and glucocorticoid. A total of 145 patients meeting the requirements in hospital were included in this study, and they were randomly assigned to receive aerosolized glucocorticoid (n = 45), aerosolized glucocorticoid combined with bronchodilator (n = 50), or oral steroids (n = 50) for 4 weeks after discharge. The lung function and fractional exhaled nitric oxide (FENO) indexes of the three groups were measured, respectively, and then the effective rates were compared to evaluate the clinical efficacy of glucocorticoids with different administration methods and combined medications in the short-term maintenance treatment after acute exacerbation of asthma. Deep learning algorithm was used for CT image segmentation. The CT image is sent to the workbench for processing on the workbench, and then the convolution operation is performed on each input pixel point during the image processing. After 4 weeks of maintenance treatment, FEF50 %, FEF75 %, and MMEF75/25 increased significantly, and FENO decreased significantly (P < 0.01). The improvement results of FEF50 %, FEF75 %, MMEF75/25, and FENO after maintenance treatment were as follows: the oral hormone group was the most effective, followed by the combined atomization inhalation group, and the hormone atomization inhalation group was the least effective. The differences among them were statistically significant (P < 0.05). The accuracy of artificial intelligence segmentation algorithm was 81%. All the hormones were more effective than local medication in the treatment of small airway function and airway inflammation. In the treatment of aerosol inhalation, the hormone combined with bronchiectasis drug was the most effective in improving small airway obstruction and reducing airway inflammation compared with single drug inhalation. Deep learning CT images are simple, noninvasive, and intuitively observe lung changes in asthma with small airway functional obstruction. Asthma with small airway functional obstruction has high clinical diagnosis and evaluation value.

Inhaled Corticosteroid-Related Tuberculosis in the Real World Among Patients with Asthma and COPD: A 10-Year Nationwide Population-Based Study

BACKGROUND

There have been concerns about the risk of inhaled corticosteroid (ICS)-related tuberculosis (TB) development.

OBJECTIVE

We investigated the occurrence of TB among ICS users according to underlying respiratory diseases and type of ICS.

METHODS

A 12-year population cohort comprising approximately 1 million subjects collected from the Korean claims database were used. Adult ICS users (budesonide or fluticasone) were enrolled. The temporal relationship between TB development and the last ICS prescription before TB development was evaluated. A nested case-control study was performed with 1:4 matching for age, sex, and the initiation date of the ICS.

RESULTS

There were 17,991 ICS users, and 175 developed TB during the study period. Approximately 80% (140/175) of patients who developed TB were diagnosed within 3 years after the last ICS prescription. In the nested case-control study, the occurrence of TB was not related to the type of ICS, but was related to a higher annual admission rate and a higher comorbidity score. The risk of TB was higher in patients with chronic obstructive pulmonary disease (COPD) than in those with asthma (odds ratio: 2.31; CI 95%: 1.39-3.38; P = .0011) after adjusting for covariates. The subgroup analysis revealed no difference between budesonide and fluticasone with respect to the risk of developing TB in patients with asthma, COPD, or asthma-COPD overlap syndrome.

CONCLUSION

An increased risk of TB development may persist for 3 years after stopping the ICS and the risk is higher in patients with COPD regardless of the type of ICS used.

Endocrine and Metabolic Aspects of Tuberculosis

Endocrine and metabolic derangements are infrequent in patients with tuberculosis, but they are important when they occur. The basis for these abnormalities is complex. While Mycobacterium tuberculosis has been described to infect virtually every endocrine gland, the incidence of gland involvement is low, especially in the era of effective antituberculosis therapy. Furthermore, endocrine and metabolic abnormalities do not always reflect direct infection of the gland but may result from physiological response or as a consequence of therapy. Metabolic disease may also predispose patients to the development of active tuberculosis, particularly in the case of diabetes mellitus. While hormonal therapy may be necessary in some instances, frequently these endocrine complications do not require specific interventions other than antituberculous therapy itself. With the exception of diabetes mellitus, which will be covered elsewhere, this chapter reviews the endocrinologic and metabolic issues related to tuberculosis.

Effects of the inhaled treatment of liriope radix on an asthmatic mouse model

As a treatment for allergic asthma, inhaled treatments such as bronchodilators that contain β2-agonists have an immediate effect, which attenuates airway obstructions and decreases airway hypersensitivity. However, bronchodilators only perform on a one off basis, but not consistently. Asthma is defined as a chronic inflammatory disease of the airways accompanying the overproduction of mucus, airway wall remodeling, bronchial hyperreactivity and airway obstruction. Liriope platyphylla radix extract (LPP), a traditional Korean medicine, has been thoroughly studied and found to be an effective anti-inflammatory medicine. Here, we demonstrate that an inhaled treatment of LPP can attenuate airway hyperresponsiveness (AHR) in an ovalbumin-induced asthmatic mouse model, compared to the saline-treated group (p < 0.01). Moreover, LPP decreases inflammatory cytokine levels, such as eotaxin (p < 0.05), IL-5 (p < 0.05), IL-13 (p < 0.001), RANTES (p < 0.01), and TNF-α (p < 0.05) in the bronchoalveolar lavage (BAL) fluid of asthmatic mice. A histopathological study was carried out to determine the effects of LPP inhalation on mice lung tissue. We performed UPLC/ESI-QTOF-MS, LC/MS, and GC/MS analyses to analyze the chemical constituents of LPP, finding that these are ophiopogonin D, spicatoside A, spicatoside B, benzyl alcohol, and 5-hydroxymethylfurfural. This study demonstrates the effect of an inhaled LPP treatment both on airway AHR and on the inflammatory response in an asthmatic mouse model. Hence, LPP holds significant promise as a nasal inhalant for the treatment of asthmatic airway disease.

Inhaled corticosteroids and the increased risk of pulmonary tuberculosis: a population-based case-control study

AIMS

The association between inhaled corticosteroid (ICS) use and pulmonary tuberculosis (TB) development is uncertain. We conducted a population-based case-control study to investigate whether ICS use increases the risk of developing TB.

METHODS

Tuberculosis patients aged 18 years and older were identified using the National Health Insurance Research Database (NHIRD) in Taiwan between 2002 and 2010. Each TB patient was frequency matched to four control patients according to age, sex and index year. We retrospectively followed up the medications and comorbid medical conditions for the 5 years prior to the index date. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) of TB development using multiple logistic regression models.

RESULTS

Most of the study participants were men (68.7%), and the mean age among the 8091 TB patients and 32,364 comparison participants was 61.3 ± 18.6 years. After adjusting for potential covariates, ICS use caused a 2.04-fold increased risk of developing TB (adjusted OR: 2.04, 95% CI: 1.78-2.33). When considering dose-response and adjusting for potential covariates, ICS and oral corticosteroids (OCS) use remained independent risk factors and exhibited a dose-response relationship of TB development. The multiplicative increased risk of TB was also significant in patients using ICS and OCS compared with patients not using ICS and OCS (adjusted OR: 4.31, 95% CI: 3.39-5.49). Previous TB history exhibited the greatest risk of TB development among the comorbidities (adjusted OR: 8.50, 95% CI: 7.52-9.61).

CONCLUSION

Long-term ICS use may increase the risk of TB.

Inhaled corticosteroids (ICS) and risk of mycobacterium in patients with chronic respiratory diseases: a meta-analysis

BACKGROUND

Studies have indicated that therapy with inhaled corticosteroids (ICS) can be associated with a higher risk of pneumonia. However, it is not known whether ICS increases the risk of mycobacterium. Most of these published studies were small, and the conclusions were inconsistent.

METHODS

A meta-analysis was conducted into whether ICS increases the risk of mycobacterium in patients with chronic respiratory diseases. PubMed, OVID, EMBASE and Cochrane Library databases were searched.

RESULTS

Five studies involving 4,851 cases and 28,477 controls were considered in the meta-analysis. From the pooled analyses, there was significant association between ICS and risk of mycobacterium in all patients with chronic respiratory diseases [risk ratio (RR) =1.81; 95% confidence interval (CI), 1.23-2.68; P=0.003]. Among patients with chronic respiratory diseases, the relationship between ICS and risk of tuberculosis (TB) was also significant (RR =1.34; 95% CI, 1.15-1.55; P=0.0001). And meta-analysis of four studies in patients with chronic obstructive pulmonary disease (COPD) (RR =1.42; 95% CI, 1.18-1.72; P=0.0003) or two studies in patients who have prior pulmonary TB (RR =1.61; 95% CI, 1.35-1.92; P<0.00001) or three studies in patients with high-dose ICS (RR =1.60; 95% CI, 1.28-1.99; P<0.0001) showed a relationship between ICS and risk of mycobacterium.

CONCLUSIONS

Significant relationship has been shown between ICS use and risk of mycobacterium in all patients with chronic respiratory diseases. ICS use also increases the risk of TB among the patients with chronic respiratory diseases. Use of ICS increases the risk of mycobacterium in patients with COPD or patients with prior pulmonary TB or patients inhaling high-dose corticosteroids. Further research is required to establish the potential adverse effect of ICS as a therapy for chronic respiratory diseases.

Inhaled corticosteroids and risk of tuberculosis in patients with respiratory diseases

RATIONALE

Treatment with substantial doses of oral corticosteroids (OCS) for prolonged periods increases the risk of tuberculosis (TB). However, little is known about the effect of inhaled corticosteroids (ICS) in this respect.

OBJECTIVES

We quantified the independent contribution of ICS to the risk of TB in a population of patients with airway diseases.

METHODS

A population-based cohort design with a nested case-control analysis was used. A cohort of patients with airways disease was formed using the Quebec databases. TB cases were identified and age-matched control subjects were selected from all subjects who entered the cohort in the same month as the cases. TB incidence among the cohort was compared with the general population of Quebec using the standardized incidence ratio.

MEASUREMENTS AND MAIN RESULTS

The cohort consisted of 427,648 subjects. There were 564 cases of TB identified between 1990 and 2005. The standardized incidence ratio was 3.9 (95% confidence interval [CI], 2.6-5.4). Any and current users of ICS are at an increased risk of TB (rate ratio [RR], 1.27; 95% CI, 1.05-1.53; and RR, 1.33; 95% CI, 1.04-1.71, respectively). Among users of OCS, no significant relationship could be demonstrated. Among subjects without OCS exposure, adjusted RRs were significant for any ICS use (RR, 1.26; 95% CI, 1.02-1.56) and current use (RR, 1.48; 95% CI, 1.11-1.97) and at the current high dose exposure level (RR, 1.97; 95% CI, 1.18-3.3).

CONCLUSIONS

Exposure to ICS is not associated with risk of TB in the presence of OCS but is associated with increased TB risk in nonusers of OCS.

COPD and the risk of tuberculosis--a population-based cohort study

Background

Both chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) primarily affect the lungs and are major causes of morbidity and mortality worldwide. COPD and TB have common risk factors such as smoking, low socioeconomic status and dysregulation of host defence functions. COPD is a prevalent co-morbid condition, especially in elderly with TB but in contrast to other diseases known to increase the risk of TB, relatively little is known about the specific relationship and impact from COPD on TB-incidence and mortality.

Methods and Findings

All individuals ≥40 years of age, discharged with a diagnosis of COPD from Swedish hospitals 1987–2003 were identified in the Swedish Inpatient Register (n = 115,867). Records were linked to the Swedish Tuberculosis Register 1989–2007 and the relative risk of active TB in patients with COPD compared to control subjects randomly selected from the general population (matched for sex, year of birth and county of residence) was estimated using Cox regression. The analyses were stratified by year of birth, sex and county of residence and adjusted for immigration status, socioeconomic status (SES) and inpatient co-morbidities previously known to increase the risk of TB. COPD patients had a three-fold increased hazard ratio (HR) of developing active TB (HR 3.0 (95% confidence interval 2.4 to 4.0)) that was mainly dependent on an increased risk of pulmonary TB. In addition, logistic regression estimates showed that COPD patients who developed active TB had a two-fold increased risk of death from all causes within first year after the TB diagnosis compared to the general population control subjects with TB (OR 2.2, 95% confidence interval 1.2 to 4.1).

Conclusions

This population-based study comprised of a large number of COPD patients shows that these patients have an increased risk of developing active TB compared to the general population. The results raise concerns that the increasing global burden of COPD will increase the incidence of active TB. The underlying contributory factors need to be disentangled in further studies.

Pharmacological strategies for improving the efficacy and therapeutic ratio of glucocorticoids in inflammatory lung diseases

Glucocorticoids are widely used to treat various inflammatory lung diseases. Acting via the glucocorticoid receptor (GR), they exert clinical effects predominantly by modulating gene transcription. This may be to either induce (transactivate) or repress (transrepress) gene transcription. However, certain individuals, including those who smoke, have certain asthma phenotypes, chronic obstructive pulmonary disease (COPD) or some interstitial diseases may respond poorly to the beneficial effects of glucocorticoids. In these cases, high dose, often oral or parental, glucocorticoids are typically prescribed. This generally leads to adverse effects that compromise clinical utility. There is, therefore, a need to enhance the clinical efficacy of glucocorticoids while minimizing adverse effects. In this context, a long-acting beta(2)-adrenoceptor agonist (LABA) can enhance the clinical efficacy of an inhaled corticosteroid (ICS) in asthma and COPD. Furthermore, LABAs can augment glucocorticoid-dependent gene expression and this action may account for some of the benefits of LABA/ICS combination therapies when compared to ICS given as a monotherapy. In addition to metabolic genes and other adverse effects that are induced by glucocorticoids, there are many other glucocorticoid-inducible genes that have significant anti-inflammatory potential. We therefore advocate a move away from the search for ligands of GR that dissociate transactivation from transrepression. Instead, we submit that ligands should be functionally screened by virtue of their ability to induce or repress biologically-relevant genes in target tissues. In this review, we discuss pharmacological methods by which selective GR modulators and "add-on" therapies may be exploited to improve the clinical efficacy of glucocorticoids while reducing potential adverse effects.

Hoarseness in asthmatic patients: the side effect of inhaled steroid or not?

Hoarseness is one of the possible side effects of inhaled steroid in asthmatic patients as well as a common presenting feature of laryngeal tuberculosis. We report an asthmatic patient on inhaled corticosteroid treatment who presented with a 3-month history of hoarseness. Laryngeal tuberculosis without pulmonary involvement was diagnosed by laryngeal biopsy and microbiologic studies. Laryngeal tuberculosis should be considered in asthmatic patients who present with hoarseness, at least in regions in which tuberculosis is prevalent.

Safety and efficacy of intravesical bacillus Calmette-Guerin instillations in steroid treated and immunocompromised patients

PURPOSE

We assessed the safety and efficacy of intravesical bacillus Calmette-Guerin instillations in steroid treated and immunocompromised patients.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 697 patients treated with bacillus Calmette-Guerin instillations at our institution from 1991 to 2004. In 24 patients (3.5%) an underlying comorbidity directly affecting the immune system was diagnosed before bacillus Calmette-Guerin administration or steroids were administered at least 6 weeks before and at the time of bacillus Calmette-Guerin instillations. The immunosuppressive effect of steroids was assessed by the percent of lymphocytes. End points were the bacillus Calmette-Guerin response at 6 months, defined as normal cystoscopy, cytology and biopsy when available, and treatment related toxicity.

RESULTS

Four patients (17%) had active lymphoma or chronic lymphocytic leukemia during bacillus Calmette-Guerin administration and 21 (88%) had a concurrent condition for which oral steroids (11), inhaled steroids (14) or oral and inhaled steroids (4) were administered. Patients treated with oral steroids had a lower percent of lymphocytes than patients treated with inhaled steroids and 15 age matched patients with high risk superficial bladder cancer and no steroid treatment (12.3% vs 17.5% and 18.6%, respectively). The overall bacillus Calmette-Guerin response rate at 6 months was 58%. Ten of the 24 patients had disease recurrence and 3 had disease progression at a median followup of 63.5 months (IQR 19.5, 89). One patient treated with oral steroids had self-limited febrile disease and worsening of myalgia 48 hours after his third bacillus Calmette-Guerin cycle. No other systemic adverse event following bacillus Calmette-Guerin therapy was recorded and all patients completed scheduled treatments.

CONCLUSIONS

Intravesical bacillus Calmette-Guerin is a viable therapeutic option in patients with high risk superficial bladder cancer and concomitant lymphoma or chronic lymphocytic leukemia, treatment with low dose oral steroids or treatment with inhaled steroids. The bacillus Calmette-Guerin response rate at 6 months and the side effects profile associated with bacillus Calmette-Guerin therapy in these patients were comparable to those in patients with no evidence of immunosuppression. Further studies are warranted to assess the safety and efficacy of bacillus Calmette-Guerin instillations in critically immunocompromised patients.

Safety and tolerability of inhaled budesonide in children in the Steroid Treatment As Regular Therapy in early asthma (START) trial

The safety and tolerability of asthma medications are still a concern to many asthma patients receiving long-term treatment. Therefore, more safety data from long-term, controlled trials are needed. The aim of this study was to evaluate the safety and tolerability of long-term treatment with once-daily budesonide in children aged 5-10 yrs with mild persistent asthma of recent onset in the inhaled Steroid Treatment As Regular Therapy in early asthma (START) study. Children aged 5-10 yrs with early asthma were randomized to double-blind treatment with budesonide 200 microg or placebo once daily via Turbuhaler in addition to usual asthma therapy, for 3 yrs. Adverse events were recorded from both spontaneous reports and responses to standard questions, and asthma-related events and asthma control were recorded between visits and subsequently graded by the blinded investigators. Of the study population of 1981 children (1004 budesonide and 977 usual care), 81% (812 of 1004) in the budesonide group and 82% (797 of 977) in the usual care group experienced a total of 6414 events listed by preferred term (3209 budesonide plus usual care and 3205 placebo plus usual care). The most commonly reported events included respiratory infection, pharyngitis, rhinitis, viral infection and bronchitis, and there were no clinically relevant differences in incidence between treatments. There were no reports of tuberculosis or aspergillosis, and no evidence of increased risk of systemic or ocular adverse events with budesonide relative to placebo. There were 106 serious adverse events in the budesonide group and 128 with usual care. The most frequent, aggravated asthma, was more common with usual care than with budesonide. There were no deaths among children participating in START. In conclusion, the addition of once-daily inhaled budesonide 200 microg via Turbuhaler to usual care is safe and well tolerated in children with recent-onset mild persistent asthma.

Safety of inhaled corticosteroids: room for improvement

Inhaled corticosteroids (ICS) are the standard of care in asthma and are widely used in the treatment of patients with chronic obstructive pulmonary disease. High-dose regimens and long-term use of ICS in predisposed individuals may be associated with a variety of side effects, similar to those observed with systemic corticosteroid therapy. Side effects associated with long-term ICS use include reduction in growth velocity, cataracts, glaucoma, osteoporosis, and fractures. Fear of unwanted complications may be of concern in all patients using ICS, particularly in age- and gender-specific populations that are more prone to develop side effects or to reduce treatment adherence because of physical, behavioral, or psychological problems. In addition to concerns about ICS safety, dosing regimens that are difficult to follow may further reduce a patient's ability to comply with treatment. Ciclesonide, a new-generation ICS with unique pharmacokinetic properties, was developed to provide effective anti-inflammatory control for asthma with once-daily administration to improve patient adherence and a high safety profile to reduce the occurrence of local and systemic side effects.

Long-term safety of once-daily budesonide in patients with early-onset mild persistent asthma: results of the Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) study

BACKGROUND

The Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) study is a worldwide, randomized, prospective study to investigate early intervention with inhaled corticosteroids in recent-onset mild persistent asthma.

OBJECTIVE

To evaluate the safety and tolerability of long-term treatment with once-daily budesonide therapy in patients with mild persistent asthma.

METHODS

Patients aged 5 to 66 years with mild persistent asthma for fewer than 2 years and no previous regular corticosteroid treatment received budesonide or placebo once daily for 3 years, in addition to their usual asthma therapy. The daily budesonide dose was 200 microg for children younger than 11 years and 400 microg for those 11 years or older.

RESULTS

Overall, 7,221 patients were included in the safety analysis, and a total of 21,520 adverse events were reported (10,850 in the budesonide group and 10,670 in the placebo group). The most commonly reported events included respiratory infections, rhinitis, pharyngitis, bronchitis, viral infections, and sinusitis. The number of deaths and serious adverse events were similar for children and adults in both treatment groups. Fewer asthma-related serious adverse events were reported with budesonide (162) compared with placebo (276). Oral candidiasis was reported more frequently with budesonide (1.2%) than with placebo (0.5%); the frequencies of other adverse effects previously reported to be associated with inhaled corticosteroids (psychiatric disorders, skin disorders, and allergic reactions) were similar.

CONCLUSIONS

Three-year treatment with budesonide once daily (200 or 400 microg) is safe and well tolerated in children and adults with newly detected mild persistent asthma.

Is the mycobacteria-derived purified protein response in atopic asthmatic children different?

BACKGROUND

The response to mycobacteria-derived purified protein (PPD) is mediated primarily by T-helper-1 response and is expected to be inhibited in atopic diseases. The aim of this study was to investigate whether the PPD response is different in atopic asthmatic children.

METHODS

40 atopic asthmatic children (mean age 8.3 +/- 4.9 years) and 40 healthy age- and sex-matched children who had received bacillus Calmette-Guerin (BCG) vaccination were included in the study. Five PPD units were administered intradermally to all children and were interpreted after 48 h.

RESULTS

There was no correlation between serum total IgE level and PPD induration (p=0.054). The PPD induration was not statistically different between the children who used inhaled corticosteroid and those who did not. Although the PPD positivity (induration > or =5 mm) rate was higher in atopic asthmatic children (50%) than in healthy children (32.5%), the difference was not found to be statistically significant. The PPD induration in atopic asthmatic children (7.41 +/- 5.58 mm) was found to be greater than the one in healthy children (5.21 +/- 3.39) (p < 0.039). The induration in atopic asthmatic children (5.21 +/- 3.77) and healthy children (4.43 +/- 2.32) did not show a difference in children who where vaccinated only once with BCG, but it was found to be statistically significantly greater in atopic asthmatic children (12.50 +/- 5.90) than healthy children (7.08 +/- 4.70) who were vaccinated with BCG twice (p <0.012). The proportion of having a PPD induration of > or =10 mm was found to be higher in atopic asthmatic children than in the healthy ones (32.5 vs. 12.5%) (p <0.032).

CONCLUSION

Our data showed that the PPD response was stronger in BCG-vaccinated atopic asthmatic children than in healthy BCG-vaccinated ones.