Inhaled corticosteroids and HPA axis suppression: how important is it and how should it be managed?

Local and systemic adverse effects of inhaled corticosteroids - Does ciclesonide differ from other inhaled corticosteroids?

BACKGROUND AND AIM

The pharmacological profile of ciclesonide suggests that it may be associated with fewer local and systemic adverse effects compared to other inhaled corticosteroids. The aim of this systematic review is to provide an update on the current evidence of the local and systemic adverse effects of ciclesonide for the treatment of asthma compared to other inhaled corticosteroids.

METHODS

Systematic review performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guidelines. The search was last updated in September 2024. The search algorithm consisted of the following Medical Subject Headings (MeSH) terms: (ciclesonide) AND (asthma).

RESULTS

Of the 296 hits, 28 studies fulfilled the predefined criteria and were included in the present review. A total of 15 out of 25 studies addressing local adverse effects showed insignificant differences between ciclesonide and the comparative inhaled corticosteroid. Of these 15 studies, 13 were randomized controlled trials (RCTs). Seven RCTs reported a reduced risk of local adverse effects associated with ciclesonide-treatment. One observational study found ciclesonide treated patients more likely to have been treated for oropharyngeal candidiasis compared to patients treated with another inhaled corticosteroid. Twelve studies investigated systemic adverse effects of CIC vs. other inhaled corticosteroid. Of the nine trials measuring urine cortisol suppression compared to baseline, seven found no suppression in the ciclesonide treated groups in contrast to a significant suppression in the comparative inhaled corticosteroid treated groups. On the contrary, two trials found no suppression in either treatment group. Two of three studies assessing HPA-axis function by plasma cortisol response to corticotropin-releasing factor reported no difference between ciclesonide and fluticasone propionate, whereas one found significantly reduced response with fluticasone treatment, but not with ciclesonide. One study assessed the risk of developing signs of cataract and found no significant difference between ciclesonide and other inhaled corticosteroids, and another investigated patient reported adverse effects and found superiority in CIC to FP in terms of reducing "vision deterioration".

CONCLUSION

The current evidence of possible differences in adverse effects between ciclesonide and other inhaled corticosteroids are conflicting. However, there is some evidence in favor of fewer local adverse effects in ciclesonide treated patients and, additionally, ciclesonide treatment is either more favorable or similar to other inhaled corticosteroids with regard to systemic adverse effects.

Background therapy in severe asthma on monoclonal antibody treatment in real life

BACKGROUND

Global Initiative for Asthma (GINA) recently recommends clinicians to reduce inhaled corticosteroid doses in patients with severe asthma who respond positively to monoclonal antibodies (MAbs).

OBJECTIVE

As we operated this reduction even before the document, we analysed our cohort of subjects on treatment with a MAbs for at least 24 months.

METHODS

Data stored in our electronic archive and at the 6-month follow-up (FU) were registered and patients' adherence to asthma therapy was derived by electronic pharmacy claim database.

RESULTS

Sixty-three subjects were enrolled. A complete asthma remission and reduction to GINA Step 3 was obtained in 41 % and 61 % of them, respectively. Non-adherent subjects to inhaled and oral asthma therapy were 45 % of them, with a higher percentage among those in complete remission (59 % vs 33 %).

CONCLUSION

In our cohort, stepping down asthma therapy from 5 to 3 level in severe asthmatic patients on Mabs is without any negative consequences on asthma control, even in the case of non-adherence.

Glucocorticoid treatment and adrenal suppression in children: current view and open issues

PURPOSE

Glucocorticoids (GCs) are commonly used for several acute and chronic pediatric diseases. However, chronic treatment may result in hypothalamic-pituitary-adrenal axis (HPA) dysfunction. Glucocorticoid-induced adrenal insufficiency (GI-AI) is indeed the most frequent cause of adrenal insufficiency (AI) in children, possibly resulting in a life-threatening event such as adrenal crisis (AC). It is generally underestimated, especially when using non-systemic glucocorticoid formulations. This review aims at summarizing current evidence on the effects of long-term GC treatment on the HPA axis, management of GC tapering and assessment of the HPA recovery.

METHODS

We conducted a narrative review of the relevant literature focusing on pathogenic mechanisms, predictive factors, diagnosis and treatment of GI-AI.

RESULTS

All types of GCs, whatever the route of administration, may have suppressive effects on the HPA axis, especially when compounds with higher potency and long half-life are used. Moreover, chronic GC administration is the most common cause of Cushing syndrome in children. In order to overcome the risk of GI-AI, slow withdrawal of GCs is necessary. When approaching the replacement dose, it is recommended to switch to shorter half-life formulations such as hydrocortisone. Assessment of HPA axis recovery with basal and stimulated cortisol levels may help detecting children at risk of AC that may require hydrocortisone supplementation.

CONCLUSION

The management of GI-AI in children is challenging and many areas of uncertainty remain. Improving the knowledge on long-term GC effects on HPA in children, the management of steroid discontinuation and emergency dosing may help preventing GI-AI symptoms and acute hospital admission for AC.

Effect of Long-term Inhaled Corticosteroids on the Hypothalamic-Pituitary-Adrenal Axis in Children with Asthma

OBJECTIVES

To assess the effect of the long-term use of inhaled corticosteroids (ICS) on the hypothalamic-pituitary-adrenal (HPA) axis.

METHODS

Children (5-18 y) diagnosed with asthma and on ICS therapy for ≥6 mo were included. In the first step, screening with fasting at 8 AM, cortisol level was measured; a value <15 mcg/dl was considered low. Children with low fasting cortisol levels were subjected to adreno-corticotropic hormone (ACTH) stimulation test in the second step. Post-ACTH stimulation, cortisol level <18 mcg/dl was considered to have HPA axis suppression.

RESULTS

A total of 78 children (males 55, 70.5%) diagnosed with asthma, with a median age of 11.5 (8, 14) y, were enrolled. The median duration of ICS use was 12 (12-24) mo. The median value of post-ACTH stimulation cortisol level was 22.5 (20.6, 25.5) mcg/dl, and a value <18 mcg/dl was observed in 4 (5.1%; 95% CI 0.2-10%) children. There was statistically no significant correlation between low post-ACTH stimulation cortisol level with ICS dose (p = 0.23) and asthma control (p = 0.67). None of the children had clinical features of adrenal insufficiency.

CONCLUSIONS

In this study, a few children had low post-ACTH stimulation cortisol values; however, none had clinical evidence of HPA axis suppression. Therefore, ICS is a safe drug in children for treating asthma, even for long-term use.

Incidence and Risk Factors of Systemic Adverse Effects and Complications of Ultrasound- and Fluoroscopy-Guided Glucocorticoid Injections: A Retrospective Cohort Study

OBJECTIVES

The aims of the study are to assess the incidence of systemic adverse effects and complications of ultrasound-guided and fluoroscopy-guided glucocorticoid injections and to identify associated risk factors.

DESIGN

This retrospective cohort study compared participants who received a glucocorticoid injection at the outpatient clinic and participants who had an appointment but did not receive a glucocorticoid injection. Participants were called to verify whether they had experienced any of the predetermined systemic adverse effects and complications. Multiple binary logistic regression was used to identify systemic adverse effect and complication risk factors.

RESULTS

There were 1010 participants in the glucocorticoid injection group and 328 in the nonglucocorticoid injection group. There was no statistically significant difference in the occurrence of systemic infection and decompensated heart failure between the two groups. More participants in the glucocorticoid injection group developed abnormal uterine bleeding and erectile dysfunction, but the differences did not reach statistical significance. Female participants were 1.9 times more likely to develop systemic adverse effects ( P < 0.001). Younger age ( P < 0.001), diabetes ( P = 0.012), and higher glucocorticoid injection doses ( P = 0.024) were also associated with an increased risk of developing systemic adverse effects.

CONCLUSIONS

Identified risk factors for developing glucocorticoid injection systemic adverse effects were younger age, female sex, diabetes, tobacco use, and high glucocorticoid injection doses.

Lung-brain axis

The appreciation of human microbiome is gaining strong grounds in biomedical research. In addition to gut-brain axis, is the lung-brain axis, which is hypothesised to link pulmonary microbes to neurodegenerative disorders and behavioural changes. There is a need for analysis based on emerging studies to map out the prospects for lung-brain axis. In this review, relevant English literature and researches in the field of 'lung-brain axis' is reported. We recommend all the highlighted prospective studies to be integrated with an interdisciplinary approach. This might require conceptual research approaches based on physiology and pathophysiology. Multimodal aspects should include experimental animal units, while exploring the research gaps and making reference to the already existing human data. The overall microbiome medicine is gaining more ground. Aetiological paths and experimental recommendations as per prospective studies in this review will be an important guideline to develop effective treatments for any lung induced neurodegenerative diseases. An in-depth knowledge of the bi-directional communication between host and microbiome in the lung could help treatment to respiratory infections, alleviate stress, anxiety and enhanced neurological effects. The timely prevention and treatment of neurodegenerative diseases requires paradigm shift of the aetiology and more innovative experimentation.Impact statementThe overall microbiome medicine is gaining more ground. An in-depth knowledge of the bi-directional communication between host and microbiome in the lung could confer treatment to respiratory infections, alleviate stress, anxiety and enhanced neurological effects. Based on this review, we recommend all the highlighted prospective studies to be integrated and be given an interdisciplinary approach. This might require conceptual research approaches based on physiology and pathophysiology. Multimodal aspects should include experimental animal units; while exploring the research gaps and making reference to the already existing human data.

Nebulized dexamethasone sodium phosphate in the treatment of horses with severe asthma

Background

A study reported low systemic availability of injectable dexamethasone nebulized to healthy horses using the Flexineb mask. When used in horses with severe asthma and a different nebulizer, lack of efficacy and cortisol suppression were observed.

Hypothesis

Nebulized dexamethasone is as effective as PO administration for the treatment of severe asthma in horses.

Animals

Twelve horses with severe asthma from a research herd.

Methods

Randomized clinical trial. Horses were divided into 2 groups and received 5 mg of dexamethasone sodium phosphate by nebulization using a Flexineb mask (NE, n = 6) or PO (OR, n = 6) q24h for 7 days. Lung function and serum cortisol concentrations were evaluated at baseline, after 4 days of treatment (D4) and 1 day after the last treatment (D8). Data were analyzed using linear mixed models with Benjamini‐Hochberg adjustments.

Results

Lung resistance significantly improved at D4 (mean decrease ± SD, −1.5 ± 0.45 cm H₂O/L/s; 95% confidence interval [CI], −2; −0.6) and D8 (−1.4 ± 0.45 cm H₂O/L/s; 95% CI, −2.4; −0.5) compared to baseline in the OR group only (P = .004 and .01, respectively). Serum cortisol concentration was significantly decreased at D4 and D8 for both groups (maximum decrease, −1.2 ± 0.3 μg/dL; 95% CI, −1.9; −0.6 at D4 for NE group and −2.2 ± 0.3 μg/dL; 95% CI, −2.8; −1.6 at D8 for OR group; P < .001).

Conclusions and Clinical Importance

Oral, but not nebulized dexamethasone is an effective therapy for horses with severe asthma and both treatment modalities inhibit the hypothalamic‐pituitary‐adrenal axis.

Adrenal Insufficiency Caused by Chronic Corticosteroid Use, Identified through Medication Therapy Management

OBJECTIVE: To report a case of adrenal insufficiency caused by chronic corticosteroid treatment.Summary: This case study describes a 71-year-old Caucasian woman diagnosed with secondary adrenal insufficiency (SAI). She had a long history of multiple medical problems that affected her quality of life. The pharmacist reviewed 18 years (2001-2018) of medical records, including her corticosteroid usage history. The patient had been receiving chronic medium-high dose inhaled corticosteroids for asthma, with intermittent oral prednisone for exacerbations. The pharmacist suspected a possible SAI or tertiary adrenal insufficiency (TAI) caused by hypothalamic pituitary adrenal axis suppression induced by chronic corticosteroid use. After discussions with the patient's primary care physician and a screening adrenal function test, the patient was referred to an endocrinologist, and the diagnosis was confirmed. Low-dose hydrocortisone (<30 mg daily) was prescribed; the patient had improvements in mood, skin hyperpigmentation, and asthma symptoms, which eliminated the routine visits to the emergency room/clinic during the winter season.CONCLUSION: The case illustrated the benefits of utilizing a pharmacist's expertise. A consultant pharmacist can identify an underdiagnosed and rare condition, corticosteroid-induced adrenal insufficiency, through comprehensive medication review in a community medication therapy management service setting.

A randomized, double-blind, placebo-controlled, parallel-group study of once-daily inhaled fluticasone furoate on the hypothalamic-pituitary-adrenocortical axis of children with asthma

Background

To evaluate the effects of fluticasone furoate on the hypothalamic–pituitary–adrenocortical axis, and the safety and tolerability of fluticasone furoate treatment in children with asthma.

Methods

This was a randomized, double-blind, placebo-controlled, multicenter, stratified, parallel-group, non-inferiority study of fluticasone furoate 50 µg inhalation powder administered once daily. The study enrolled children (aged 5–11 years inclusive) with a documented diagnosis of asthma for ≥ 6 months and a Childhood Asthma Control Test score of > 19. After a 7–14-day run-in period, eligible subjects were stratified by age and randomized to fluticasone furoate 50 µg once daily or placebo once daily via ELLIPTA for 6 weeks. The primary endpoint was the change from baseline (expressed as a ratio) in 0–24-h weighted mean serum cortisol at the end of the treatment period.

Results

Fifty-six randomized subjects received fluticasone furoate 50 µg once daily and 55 received placebo. The primary analysis was performed in the serum cortisol population (n = 104) and demonstrated that fluticasone furoate 50 µg once daily was non-inferior to placebo (ratio = 0.93; 95% confidence interval 0.8096, 1.0620), as the lower limit of the 95% confidence interval for the geometric mean treatment ratio of fluticasone furoate 50 µg once daily versus placebo was greater than 0.80. Findings from the intent-to-treat population (n = 111) were similar.

Conclusions

Six weeks of treatment with inhaled fluticasone furoate 50 µg once daily had no clinically relevant effect on the hypothalamic–pituitary–adrenocortical axis function of children, as measured by 24-h serum cortisol profiles. The primary analysis showed that fluticasone furoate 50 µg once daily was non-inferior to placebo. Fluticasone furoate 50 µg once daily was well tolerated and no new safety concerns emerged during the study.

Trial registration

This study is registered in ClinicalTrials.gov (NCT02483975). Date of submission: 25 June 2015.

Air pollution and resistance to inhaled glucocorticoids: Evidence, mechanisms and gaps to fill

Substantial evidence indicates that cigarette smoke exposure induces resistance to glucocorticoids, the primary maintenance medication in asthma treatment. Modest evidence also suggests that air pollution may reduce the effectiveness of these critical medications. Cigarette smoke, which has clear parallels with air pollution, has been shown to induce glucocorticoid resistance in asthma and it has been speculated that air pollution may have similar effects. However, the literature on an association of air pollution with glucocorticoid resistance is modest to date. In this review, we detail the evidence for, and against, the effects of air pollution on glucocorticoid effectiveness, focusing on results from epidemiology and controlled human exposure studies. Epidemiological studies indicate a correlation between increased air pollution exposure and worse asthma symptoms. But these studies also show a mix of beneficial and harmful effects of glucocorticoids on spirometry and asthma symptoms, perhaps due to confounding influences, or the induction of glucocorticoid resistance. We describe mechanisms that may contribute to reductions in glucocorticoid responsiveness following air pollution exposure, including changes to phosphorylation or oxidation of the glucocorticoid receptor, repression by cytokines, or inflammatory pathways, and epigenetic effects. Possible interactions between air pollution and respiratory infections are also briefly discussed. Finally, we detail a number of therapies that may boost glucocorticoid effectiveness or reverse resistance in the presence of air pollution, and comment on the beneficial effects of engineering controls, such as air filtration and asthma action plans. We also call attention to the benefits of improved clean air policy on asthma. This review highlights numerous gaps in our knowledge of the interactions between air pollution and glucocorticoids to encourage further research in this area with a view to reducing the harm caused to those with airways disease.