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Chindris A, Rao SN, Chirila RM, Dumitrascu AG. A case of celiac plexus block causing iatrogenic Cushing's syndrome. Clin Case Rep 2024; 12:e8777. [PMID: 38623358 PMCID: PMC11017460 DOI: 10.1002/ccr3.8777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
Treatment with corticosteroids can lead to iatrogenic Cushing's syndrome when used for longer intervals and in high doses. Less common administration routes may conceal the exposure, raising the possibility of misdiagnosis and mismanagement.
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Affiliation(s)
- Ana‐Maria Chindris
- Division of Endocrinology, Department of Internal MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Sarika N. Rao
- Division of Endocrinology, Department of Internal MedicineMayo ClinicJacksonvilleFloridaUSA
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Matsuoka T, Araki M, Lin Y, Okamoto T, Gold R, Chihara N, Sato W, Kimura A, Tachimori H, Miyamoto K, Kusunoki S, Yamamura T. Long-term Effects of IL-6 Receptor Blockade Therapy on Regulatory Lymphocytes and Neutrophils in Neuromyelitis Optica Spectrum Disorder. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200173. [PMID: 37863660 PMCID: PMC10691226 DOI: 10.1212/nxi.0000000000200173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/29/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Neuromyelitis optica spectrum disorder (NMOSD) is a disabling autoimmune neurologic disease. Anti-IL-6 receptor (IL-6R) therapy prevents relapses in patients with anti-aquaporin 4 (AQP4)-IgG-positive NMOSD; however, it remains unclear how cellular immune components are altered by anti-IL-6R therapy. In this study, we examined the long-term effects of the anti-IL-6R monoclonal antibody tocilizumab (TCZ) on immune cell profiles in patients with NMOSD. METHODS Monthly IV injections of TCZ (8 mg/kg) were administered as an add-on therapy to 19 anti-AQP4-IgG-positive patients, who had been refractory to corticosteroids and immunosuppressive drugs. Peripheral blood was collected before infusion of TCZ for flow cytometry analysis of lymphocyte subsets. Seven patients provided whole blood samples for gene expression profiles. RESULTS Patients with NMOSD had reduced numbers of lymphocyte subsets with regulatory functions, including transitional B cells, CD56high NK cells, and CD45RA-FoxP3high regulatory T cells. However, after initiating TCZ therapy, the numbers increased to normal levels within 1 year. Gene expression analysis revealed that neutrophil granule-related genes, predominated by those related to azurophil granules, were significantly upregulated in patients with NMOSD. Such alterations suggestive of accelerated myeloid turnover were not observed 1 year after TCZ therapy, and the effects of TCZ on some neutrophil genes were observed as early as 5 days after starting TCZ. In vitro analysis demonstrated that naïve T-cell division was impaired in the enrolled patients, which was fully recovered after 18 months of therapy. DISCUSSION In patients with active NMOSD not treated with molecular targeting drugs, we observed reduction or deficiency in lymphocytes with regulatory potentials and activation of neutrophils. However, introduction of anti-IL-6R therapy accompanied by tapering concomitant drugs corrected such abnormalities, which might contribute to persistent relapse prevention. The recovery in the naïve T-cell division after starting TCZ may underlie the relatively low risk of infection in patients under anti-IL-6R therapy. TRIAL REGISTRATION INFORMATION University Hospital Medical Information Network Clinical Trials Registry: UMIN000005889 (July 8, 2011) and UMIN000007866 (May 1, 2012) (umin.ac.jp/ctr/index.htm). The first participant was enrolled on November 2, 2011.
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Affiliation(s)
- Takako Matsuoka
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Manabu Araki
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Youwei Lin
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Tomoko Okamoto
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Ralf Gold
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Norio Chihara
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Wakiro Sato
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Atsuko Kimura
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Hisateru Tachimori
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Katsuichi Miyamoto
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Susumu Kusunoki
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan
| | - Takashi Yamamura
- From the Department of Immunology (T.M., W.S., A.K., T.Y.), National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira; Department of Pediatrics (T.M.), Graduate School of Medicine, The University of Tokyo, Bunkyo; Multiple Sclerosis Center (M.A., Y.L., T.O., W.S., T.Y.), National Center of Neurology and Psychiatry, Kodaira; Department of Neurology (M.A.), Kawakita General Hospital, Suginami; Department of Neurology (Y.L., T.O.), National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology (R.G.), Ruhr University, Bochum, Germany; Division of Neurology (N.C.), Kobe University Graduate School of Medicine; Department of Clinical Epidemiology (H.T.), Translational Medical Center, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira; Bureau of International Health Cooperation (H.T.), National Center for Global Health and Medicine, Shinjuku, Tokyo; Department of Neurology (K.M., S.K.), Kindai University Faculty of Medicine, Osakasayama, Osaka; and Department of Neurology (K.M.), Wakayama Medical University, Japan.
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Koenig NI, McGuire JA, Shackleford VP, Bauer K. Reactivation of Herpes Simplex Virus Following Sphenopalatine Ganglion Nerve Block: Case Report and Review of the Literature. A A Pract 2023; 17:e01719. [PMID: 37870295 PMCID: PMC10609693 DOI: 10.1213/xaa.0000000000001719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 10/24/2023]
Abstract
A 36-year-old woman with no significant past medical history underwent a sphenopalatine ganglion block for treatment of a month-long migraine headache refractory to conservative treatment protocols. The headache resolved initially, but 1 day following the procedure, the headache recurred. The patient also developed an erythematous and edematous rash which cultures confirmed to be herpes simplex virus (HSV). Following several unsuccessful treatment modalities, the patient received valacyclovir, which resulted in resolution of her headache. Underlying HSV-1 infection may cause intractable migraine headache and nerve blocks may potentiate reactivation of latent HSV infection that caused the skin lesion in this case.
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Affiliation(s)
- Nicholas I. Koenig
- From the West Virginia University School of Medicine, Morgantown, West Virginia
| | - Joseph A. McGuire
- Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Violet P. Shackleford
- Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Kelsey Bauer
- Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, West Virginia
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Zhong H, Huan X, Zhao R, Su M, Yan C, Song J, Xi J, Zhao C, Luo F, Luo S. Peripheral immune landscape for hypercytokinemia in myasthenic crisis utilizing single-cell transcriptomics. J Transl Med 2023; 21:564. [PMID: 37620910 PMCID: PMC10464341 DOI: 10.1186/s12967-023-04421-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is the most prevalent autoimmune disorder affecting the neuromuscular junction. A rapid deterioration in respiratory muscle can lead to a myasthenic crisis (MC), which represents a life-threatening condition with high mortality in MG. Multiple CD4+ T subsets and hypercytokinemia have been identified in the peripheral pro-inflammatory milieu during the crisis. However, the pathogenesis is complicated due to the many types of cells involved, leaving the underlying mechanism largely unexplored. METHODS We conducted single-cell transcriptomic and immune repertoire sequencing on 33,577 peripheral blood mononuclear cells (PBMCs) from two acetylcholine receptor antibody-positive (AChR +) MG patients during MC and again three months post-MC. We followed the Scanpy workflow for quality control, dimension reduction, and clustering of the single-cell data. Subsequently, we annotated high-resolution cell types utilizing transfer-learning models derived from publicly available single-cell immune datasets. RNA velocity calculations from unspliced and spliced mRNAs were applied to infer cellular state progression. We analyzed cell communication and MG-relevant cytokines and chemokines to identify potential inflammation initiators. RESULTS We identified a unique subset of monocytes, termed monocytes 3 (FCGR3B+ monocytes), which exhibited significant differential expression of pro-inflammatory signaling pathways during and after the crisis. In line with the activated innate immune state indicated by MC, a high neutrophil-lymphocyte ratio (NLR) was confirmed in an additional 22 AChR + MC patients in subsequent hemogram analysis and was associated with MG-relevant clinical scores. Furthermore, oligoclonal expansions were identified in age-associated B cells exhibiting high autoimmune activity, and in CD4+ and CD8+ T cells demonstrating persistent T exhaustion. CONCLUSIONS In summary, our integrated analysis of single-cell transcriptomics and TCR/BCR sequencing has underscored the role of innate immune activation which is associated with hypercytokinemia in MC. The identification of a specific monocyte cluster that dominates the peripheral immune profile may provide some hints into the etiology and pathology of MC. However, future functional studies are required to explore causality.
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Affiliation(s)
- Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Rui Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Manqiqige Su
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Feifei Luo
- Department of Digestive Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China.
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5
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Saha AK, Das S, Biswas D, Sain B, Mitra M, Chakraborty R, Basu S, Shamim S, Mukherjee A, Ghosh D, Biswas S, Kumar S, Gowsami DN, Todi SK. Treatment Outcome with High versus low-to-moderate Dosing of Corticosteroids in Early vis-a-vis Late-onset Hypoxic Cases of COVID-19: A Multicentric Retrospective Cohort Study. IJID REGIONS 2023; 7:31-42. [PMID: 36164344 PMCID: PMC9492392 DOI: 10.1016/j.ijregi.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 12/15/2022]
Abstract
Background Corticosteroid dosing in COVID-19 cases associated with early-onset and late-onset hypoxia have not been separately explored. Methods In this retrospective cohort study, we divided hypoxic COVID-19 cases into groups based on timing of initiation of corticosteroids relative to onset of symptoms; Group A (≤6th day), Group B (7th-9th day) and Group C (≥10th day), each group being sub-grouped into high and low-to-moderate dose corticosteroid recipients. Cox regression with propensity scoring was used to compare 28-day mortality between high and low-to-moderate dose recipients separately in Group A, Group B, Group C. Results Among 505 patients included, propensity score matched Cox regression showed greater risk of all-cause mortality among high dose recipients in Group A [HR= 7.35, 95%CI 3.36-16.11, p-value<0·01, N=114] and Group B [HR=3.17, 95%CI 1.65-6.07, p-value<0·01, N=251]. In Group C, mortality was lowest [12.8% (18/140)] with no significant difference between sub-groups [HR=2.52, 95%CI 0.22-29.15, p-value=0.459, N=140]. Kruskal-Wallis Test between Group A, Group B and Group C for six pre-defined exposure variables showed significant differences for Neutrophil:Lymphocyte Ratio (NLR). Conclusion When steroids were initiated early (owing to an earlier onset of hypoxic symptoms), a high dose of corticosteroid was associated with greater overall 28-day mortality compared to a low-to-moderate dose. NLR, a marker for individual immune response, varied between treatment groups.
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Affiliation(s)
- Arpit Kumar Saha
- Assistant Professor, Department of Microbiology, Santiniketan Medical College (under West Bengal University of Health Sciences), Bolpur, West Bengal, India
| | - Suvajit Das
- Assistant Professor, Department of Pharmacology, Rampurhat Government Medical College and Hospital (under West Bengal University of Health Sciences), Rampurhat, West Bengal, India
| | - Daliya Biswas
- Assistant Professor, Department of Community Medicine, North Bengal Medical College and Hospital (under West Bengal University of Health Sciences), Darjeeling, West Bengal India
| | - Baijaeek Sain
- Junior Clinical Fellow - Surgery Aneurin Bevan University Health Board, NHS Wales, the UK
| | - Mrinmoy Mitra
- Consultant, Pulmonary Medicine and Critical Care Medicine, AMRI Hospitals Mukundapur, Kolkata, West Bengal, India
| | - Ritam Chakraborty
- Consultant, Pulmonary Medicine and Critical Care Medicine, AMRI Hospitals Mukundapur, Kolkata, West Bengal, India
| | - Sushmita Basu
- Consultant, Critical Care Medicine, AMRI Hospitals Mukundapur, Kolkata, West Bengal, India
| | - Shelley Shamim
- Associate Professor, Department of Pulmonary Medicine, Calcutta National Medical College (under West Bengal University of Health Sciences), Kolkata, West Bengal, India
| | - Avik Mukherjee
- Medical Faculty, Department of Neuro-Medicine, Calcutta Medical College and Hospital (under West Bengal University of Health Sciences), Kolkata, West Bengal, India
| | - Debajyoti Ghosh
- Medical Faculty, Department of PMR, R G Kar Medical College and Hospitals (under West Bengal University of Health Sciences), Kolkata, West Bengal, India
| | - Sujash Biswas
- Associate Professor, Department of Forensic Medicine and Toxicology, Rampurhat Government Medical College and Hospital (under West Bengal University of Health Sciences), Rampurhat, West Bengal, India
| | - Simit Kumar
- Professor and Head, Department of Microbiology, Rampurhat Government Medical College and Hospital (under West Bengal University of Health Sciences), Rampurhat, West Bengal, India
| | - D N Gowsami
- Professor and Head, Department of Community Medicine, Rampurhat Government Medical College (under West Bengal University of Health Sciences), Rampurhat, West Bengal, India
| | - S K Todi
- Director, Critical Care Unit, AMRI Hospitals Mukundapur, Kolkata, West Bengal, India
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Guidry BS, Chotai S, Tang AR, Le CH, Grisham CJ, McDermott JR, Kelly PD, Morone PJ, Thompson RC, Chambless LB. Association between preoperative hematologic markers and aggressive behavior in meningiomas. Clin Neurol Neurosurg 2023; 226:107629. [PMID: 36822137 DOI: 10.1016/j.clineuro.2023.107629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/03/2023] [Accepted: 02/12/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Meningiomas have varying degrees of aggressive behavior. Some systemic hematologic makers are associated with malignancy, but their value in predicting aggressive meningioma behavior is not fully understood. OBJECTIVE To evaluate the association between preoperative markers such as neutrophil-lymphocyte ratio (NLR), neutrophil-monocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and prognostic nutritional index (PNI), and diagnostic and prognostic factors including WHO grade, proliferation index, presence of edema on preoperative MRI, and tumor recurrence. METHODS A retrospective review of patients treated between 2000 and 2019 with a preoperative complete blood count (CBC) differential lab draw before intracranial meningioma resection was conducted. All preoperative steroid dosages were converted to dexamethasone equivalents. Primary outcomes included presence/absence of perilesional edema, WHO grade, Ki-67/MIB-index, and recurrence. Univariate and multivariable regression analyses were conducted. RESULTS A total of 209 meningioma patients were included. Of these, 143 (68 %) were WHO grade I, 61 (29 %) grade II and 5 (2 %) were grade III. Recurrence was reported in 19 (9.1 %) tumors. No hematologic markers were associated with recurrence. In separate multivariable logistic analyses, no biomarkers were associated with perilesional edema or WHO grade. MLR was associated with higher MIB-index (p = 0.018, OR 6.57, 95 % CI 1.37-30.91). CONCLUSION Most hematologic markers were not associated with meningioma invasiveness, grade, proliferative index, or aggressiveness. Preoperative MLR was associated with high proliferation index in patients undergoing surgery for intracranial meningioma. Higher MLR could be a surrogate for meningioma proliferation and has potential to be used as an adjunct for risk-stratifying meningiomas.
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Affiliation(s)
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Chi H Le
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Reid C Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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7
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Muacevic A, Adler JR, Sidhu SM, Ahmad S, Sikander T, Chaudhry AR, Iftikhar I, Shaik TA. Comparison of Efficacy and Safety of Low-Dose Versus High-Dose Dexamethasone in Hospitalized COVID-19 Patients: A Meta-Analysis. Cureus 2023; 15:e33884. [PMID: 36819444 PMCID: PMC9934008 DOI: 10.7759/cureus.33884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
The aim of this study is to compare the efficacy and safety of low-dose and high-dose dexamethasone in hospitalized coronavirus disease 2019 (COVID-19) patients. The current meta-analysis was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was carried out using PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. Outcomes assessed in the current meta-analysis included 28-day mortality, intensive care unit (ICU) admission, mechanical ventilation, length of ICU admission (days), and length of hospital stay (days). For safety, we compared hypoglycemia and the incidence of infection between the high-dose dexamethasone group and the low-dose dexamethasone group. A total of four studies fulfilled the inclusion criteria and were included in this meta-analysis. No significant difference was found between the two groups in terms of ICU admission (risk ratio (RR): 0.72, 95% confidence interval (CI): 0.41-1.28, p-value: 0.27), length of stay in ICU in days (mean difference (MD): -0.05, 95%CI: -3.96-3.87, p-value: 0.98, I-square: 94%), length of hospital stay in days (MD: -0.94, 95%CI: -1.94-0.06, p-value: 0.07), need of mechanical ventilation (RR: 0.72, 95%CI: 0.36-1.48, p-value: 0.38), and 28-day mortality (RR: 0.90, 95% CI: 0.50-1.64, p-value: 0.74). The current study showed that higher doses of dexamethasone failed to enhance efficacy compared to low-dose dexamethasone. Thus, based on the findings of this meta-analysis, low-dose dexamethasone can be recommended for these patients.
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8
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Wu H, Daouk S, Kebbe J, Chaudry F, Harper J, Brown B. Low-dose versus high-dose dexamethasone for hospitalized patients with COVID-19 pneumonia: A randomized clinical trial. PLoS One 2022; 17:e0275217. [PMID: 36190994 PMCID: PMC9529091 DOI: 10.1371/journal.pone.0275217] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background Dexamethasone 6 mg daily for 10 days is the recommended treatment for patients with severe or critical coronavirus disease 2019 (COVID-19). The evidence on the benefit of high-dose dexamethasone is limited. The goal of this study was to assess the effects of 6 mg daily vs. 20 mg daily of dexamethasone in hospitalized patients with COVID-19 pneumonia. Methods We conducted a single-center, randomized, clinical trial involving hospitalized patients with COVID-19 pneumonia. Participants were randomized 1:1 to dexamethasone 6 mg daily or dexamethasone 20 mg daily, and were stratified by the WHO-Ordinal Scale for Clinical Improvement (OSCI). The primary outcome was clinical improvement equal to or greater than 2 points by OSCI on day 28. Secondary outcomes were 28-day mortality, intensive care unit-free days, and ventilator-free days on day 28. Results Of the 107 patients who enrolled and completed the follow up, 55 patients enrolled in the low-dose group and 52 patients enrolled in the high-dose group. Treatment with dexamethasone 20 mg daily compared with dexamethasone 6 mg daily did not result in better clinical improvement based on OSCI on day 28 (71.2% vs. 78.2%; odds ratio, 1.45 [0.55–3.86]; p = 0.403). For participants who required high-flow oxygen or noninvasive ventilation at randomization, the 6-mg group had better survival than the 20-mg group on day 28 (100% vs. 57.1%; p = 0.025). Although more participants in the 6-mg group received immune modulators (40% vs. 21.2%; p = 0.035), 50% of death cases in the 20-mg group who required high-flow oxygen or noninvasive ventilation at randomization received immune modulators. Conclusions Dexamethasone 20 mg daily did not result in better clinical outcome improvement, and was probably associated with higher 28-day mortality in patients on high-flow oxygen or noninvasive ventilation, compared with dexamethasone 6 mg daily. Trial registration Clinialtrials.gov number, NCT04707534, registered January 13, 2021
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Affiliation(s)
- Huimin Wu
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
- * E-mail:
| | - Salim Daouk
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Jad Kebbe
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Fawad Chaudry
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Jarrod Harper
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Brent Brown
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
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9
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D'Souza RS, Langford B, Wilson RE, Her YF, Schappell J, Eller JS, Evans TC, Hagedorn JM. The State-of-the-art Pharmacotherapeutic Options for the Treatment of Chronic Non-Cancer Pain. Expert Opin Pharmacother 2022; 23:775-789. [PMID: 35354341 DOI: 10.1080/14656566.2022.2060741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pharmacotherapeutic options continue to expand for the treatment of chronic non-cancer pain. There has been an increasing emphasis on multimodal analgesia. This strategy employs use of multiple analgesic medications each with a distinct mechanism of action, which when administered concomitantly may provide profound analgesia. AREAS COVERED The authors describe evidence from randomized controlled trials and systematic reviews on a variety of established medications including anti-inflammatory agents, opioids, anti-convulsants, anti-depressants, N-methyl-D-aspartate receptor antagonists, sodium channel blockers, cannabinoids, and alpha-2-receptor blockers. Furthermore, they provide developing evidence on more novel pharmacotherapeutics including alpha lipoic acid, acetyl-L-carnitine, low dose naltrexone, calcitonin gene-related peptide antagonists, targeted toxin therapy, Nav1.7 inhibitors, neurotensin agonists, purinoceptor antagonists, and sigma-1 receptor antagonists. Furthermore, the authors review the safety and adverse effect profile for these agents. EXPERT OPINION In this era of the opioid epidemic, clinicians should first offer non-opioid analgesics and employ a multimodal analgesic strategy. Current guidelines recommend a personalized approach to the chronic pain treatment, in each case accounting for type, location, severity, and chronicity of pain. Clinicians should also carefully consider the risk-to-benefit ratio to the patient based on the drug side effect profile, patient age, and comorbidities.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rachel E Wilson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Justin Schappell
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, USA
| | - Jennifer S Eller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Timothy C Evans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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10
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Laurent MR, Goemaere S, Verroken C, Bergmann P, Body JJ, Bruyère O, Cavalier E, Rozenberg S, Lapauw B, Gielen E. Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club. Front Endocrinol (Lausanne) 2022; 13:908727. [PMID: 35757436 PMCID: PMC9219603 DOI: 10.3389/fendo.2022.908727] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 01/13/2023] Open
Abstract
Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatrics, Imelda Hospital, Bonheiden, Belgium
- *Correspondence: Michaël R. Laurent,
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Pierre Bergmann
- Department of Nuclear Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Bruyère
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Serge Rozenberg
- Department of Gynaecology and Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Evelien Gielen
- Centre for Metabolic Bone Diseases, Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
- Gerontology and Geriatrics section, Department of Public Health and Primary Care, University Hospitals Leuven and KU Leuven, Leuven, Belgium
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11
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Munch MW, Myatra SN, Vijayaraghavan BKT, Saseedharan S, Benfield T, Wahlin RR, Rasmussen BS, Andreasen AS, Poulsen LM, Cioccari L, Khan MS, Kapadia F, Divatia JV, Brøchner AC, Bestle MH, Helleberg M, Michelsen J, Padmanaban A, Bose N, Møller A, Borawake K, Kristiansen KT, Shukla U, Chew MS, Dixit S, Ulrik CS, Amin PR, Chawla R, Wamberg CA, Shah MS, Darfelt IS, Jørgensen VL, Smitt M, Granholm A, Kjær MBN, Møller MH, Meyhoff TS, Vesterlund GK, Hammond NE, Micallef S, Bassi A, John O, Jha A, Cronhjort M, Jakob SM, Gluud C, Lange T, Kadam V, Marcussen KV, Hollenberg J, Hedman A, Nielsen H, Schjørring OL, Jensen MQ, Leistner JW, Jonassen TB, Kristensen CM, Clapp EC, Hjortsø CJS, Jensen TS, Halstad LS, Bak ERB, Zaabalawi R, Metcalf-Clausen M, Abdi S, Hatley EV, Aksnes TS, Gleipner-Andersen E, Alarcón AF, Yamin G, Heymowski A, Berggren A, La Cour K, Weihe S, Pind AH, Engstrøm J, Jha V, Venkatesh B, Perner A. Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia: The COVID STEROID 2 Randomized Trial. JAMA 2021; 326:1807-1817. [PMID: 34673895 PMCID: PMC8532039 DOI: 10.1001/jama.2021.18295] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease. OBJECTIVE To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021. INTERVENTIONS Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days). RESULTS Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]). CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.
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Affiliation(s)
| | - Marie W Munch
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sheila N Myatra
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Rebecka R Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Lone M Poulsen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Luca Cioccari
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohd S Khan
- Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hilleroed, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Michelsen
- Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Anders Møller
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | | | - Klaus T Kristiansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Urvi Shukla
- Symbiosis University Hospital and Research Centre, Lavale, India
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Charlotte S Ulrik
- Department of Respiratory Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Pravin R Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Christian A Wamberg
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Mehul S Shah
- Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Iben S Darfelt
- Department of Anaesthesia and Intensive Care, Herning Hospital, Herning, Denmark
| | - Vibeke L Jørgensen
- Department of Thoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Margit Smitt
- Department of Neurointensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maj-Brit N Kjær
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tine S Meyhoff
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gitte K Vesterlund
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abhinav Bassi
- The George Institute for Global Health, New Delhi, India
| | - Oommen John
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
| | - Anubhuti Jha
- The George Institute for Global Health, New Delhi, India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M Jakob
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Klaus V Marcussen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Nielsen
- Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | | | - Marie Q Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens W Leistner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine B Jonassen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Camilla M Kristensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Esben C Clapp
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carl J S Hjortsø
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas S Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Liv S Halstad
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emilie R B Bak
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Reem Zaabalawi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matias Metcalf-Clausen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Suhayb Abdi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma V Hatley
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tobias S Aksnes
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Gleipner-Andersen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arif F Alarcón
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Yamin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Adam Heymowski
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anton Berggren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Kirstine La Cour
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Sarah Weihe
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Alison H Pind
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Janus Engstrøm
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
- School of Public Health, Imperial College, London, England
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Intensive Care, Wesley Hospital, Brisbane, Australia
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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12
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Kumar G, Patel D, Hererra M, Jefferies D, Sakhuja A, Meersman M, Dalton D, Nanchal R, Guddati AK. Do high-dose corticosteroids improve outcomes in hospitalized COVID-19 patients? J Med Virol 2021; 94:372-379. [PMID: 34559436 PMCID: PMC8661573 DOI: 10.1002/jmv.27357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is characterized by dysregulated hyperimmune response and steroids have been shown to decrease mortality. However, whether higher dosing of steroids results in better outcomes has been debated. This was a retrospective observation of COVID-19 admissions between March 1, 2020, and March 10, 2021. Adult patients (≥18 years) who received more than 10 mg daily methylprednisolone equivalent dosing (MED) within the first 14 days were included. We excluded patients who were discharged or died within 7 days of admission. We compared the standard dose of steroids (<40 mg MED) versus the high dose of steroids (>40 mg MED). Inverse probability weighted regression adjustment (IPWRA) was used to examine whether higher dose steroids resulted in improved outcomes. The outcomes studied were in-hospital mortality, rate of acute kidney injury (AKI) requiring hemodialysis, invasive mechanical ventilation (IMV), hospital-associated infections (HAI), and readmissions. Of the 1379 patients meeting study criteria, 506 received less than 40 mg of MED (median dose 30 mg MED) and 873 received more than or equal to 40 mg of MED (median dose 78 mg MED). Unadjusted in-hospital mortality was higher in patients who received high-dose corticosteroids (40.7% vs. 18.6%, p < 0.001). On IPWRA, the use of high-dose corticosteroids was associated with higher odds of death (odds ratio [OR] 2.14; 95% confidence interval [CI] 1.45-3.14, p < 0.001) but not with the development of HAI, readmissions, or requirement of IMV. High-dose corticosteroids were associated with lower rates of AKI requiring hemodialysis (OR 0.33; 95% CI 0.18-0.63). In COVID-19, corticosteroids more than or equal to 40 mg MED were associated with higher in-hospital mortality.
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Affiliation(s)
- Gagan Kumar
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, Georgia, USA
| | - Dhaval Patel
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, Georgia, USA
| | - Martin Hererra
- Department of Internal Medicine, Northeast Georgia Health System, Gainesville, Georgia, USA
| | - David Jefferies
- Department of Pulmonary and Critical Care, Northeast Georgia Health System, Gainesville, Georgia, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic surgery, West Virginia University, West Virginia, USA
| | | | | | - Rahul Nanchal
- Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Achuta Kumar Guddati
- Division of Hematology/Oncology, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
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13
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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14
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Munch MW, Granholm A, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Kjær MN, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond N, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Gluud C, Lange T, Perner A. Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan. Acta Anaesthesiol Scand 2021; 65:834-845. [PMID: 33583034 PMCID: PMC8014264 DOI: 10.1111/aas.13795] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/29/2022]
Abstract
Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low‐dose corticosteroids have proven clinical benefit in patients with severe COVID‐19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID‐19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID‐19 is unclear. Methods The COVID STEROID 2 trial is an investigator‐initiated, international, parallel‐grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID‐19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all‐cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health‐related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol. Discussion The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID‐19 patients with severe hypoxia with important implications for patients, their relatives and society.
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Affiliation(s)
- MW Munch
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - SN Myatra
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai India
| | - BKT Vijayaraghavan
- Department of Critical Care Apollo Hospitals Chennai India
- Chennai Critical Care Consultants Chennai India
- The George Institute for Global Health, University of New South Wales New Delhi India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - RR Wahlin
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - MN Kjær
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - GK Vesterlund
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - TS Meyhoff
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - MH Møller
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Center of Research & Disruption of Infectious Diseases Copenhagen University Hospital – Amager and Hvidovre Copenhagen Denmark
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Naomi Hammond
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Abhinav Bassi
- The George Institute for Global Health, University of New South Wales New Delhi India
| | - Oommen John
- The George Institute for Global Health, University of New South Wales New Delhi India
- Prasanna School of Public Health Manipal Academy of Higher Education Manipal India
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales New Delhi India
- Prasanna School of Public Health Manipal Academy of Higher Education Manipal India
- School of Public Health Imperial College London London UK
| | - KT Kristiansen
- Department of Anaesthesia and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - CS Ulrik
- Department of Respiratory Medicine Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - VL Jørgensen
- Department of Thoracic Anaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Morten H. Bestle
- Department of Anaesthesiology and Intensive Care Copenhagen University Hospital Nordsjælland Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - AS Andreasen
- Department of Anaesthesia and Intensive Care Herlev Hospital, University of Copenhagen Copenhagen Denmark
| | - LM Poulsen
- Department of Anaesthesiology Zealand University Hospital Copenhagen Denmark
| | - BS Rasmussen
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - AC Brøchner
- Department of Anaesthesia and Intensive Care Kolding Hospital Kolding Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense C Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Anders Møller
- Department of Anaesthesia and Intensive Care Næstved‐Slagelse‐Ringsted Hospital Slagelse Denmark
| | - MS Khan
- Department of Critical Care Medicine Rajendra Institute of Medical Sciences Ranchi India
| | - Ajay Padmanaban
- Department of Critical Care Apollo Hospitals Chennai India
- Chennai Critical Care Consultants Chennai India
| | - JV Divatia
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai India
| | | | - Kapil Borawake
- Department of Intensive Care Vishwaraj Hospital Pune India
| | - Farhad Kapadia
- Section of Critical Care, Department of Medicine Hinduja Hospital Mahim, Mumbai India
| | - Subhal Dixit
- Department of Critical Care Medicine Sanjeevan Hospital Pune Maharashtra India
| | - Rajesh Chawla
- Department of Respiratory and Critical Care Medicine Indraprastha Apollo Hospital New Delhi India
| | - Urvi Shukla
- Intensive Care Unit and Emergency Services Symbiosis University Hospital and Research Centre Lavale, Pune India
| | - Pravin Amin
- Department of Critical Care Medicine Bombay Hospital Institute of Medical Sciences Mumbai India
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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15
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Kim SJ, Lee HY. Hematological Findings in Patients with Acute Peripheral Facial Palsy. J Int Adv Otol 2020; 16:382-386. [PMID: 33136021 DOI: 10.5152/iao.2020.8748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES This study aimed at evaluating the clinical significance of hematological findings in patients with acute peripheral facial palsy. MATERIALS AND METHODS For this retrospective case series review, 84 patients who visited our university hospital and were diagnosed with Bell's palsy (BP) or Ramsay Hunt syndrome (RHS) between March 2017 and March 2019 were enrolled. We documented their epidemiological details, final diagnoses, House-Brackmann (HB) palsy grades, and pretreatment and day 7 post-hospitalization complete blood counts. The outcome was considered favorable if the HB grade at weeks 10-16 was I or II. We analyzed the hematological findings in terms of diagnosis and the final treatment outcomes. RESULTS A higher pretreatment neutrophil-to-lymphocyte ratio (NLR) and neutrophil count and a lower day-7 lymphocyte count were observed in patients with RHS with unfavorable outcomes. In such patients, moderate positive correlations were observed between the pretreatment white blood cell, neutrophil, and basophil counts; the NLR and basophil-to-lymphocyte ratio; and the initial HB grade. Only the latter was a significant risk factor for a poor treatment outcome. In patients with BP, both the initial HB grade and the pretreatment eosinophil count were included in a regression model predicting prognosis. CONCLUSION Inflammation plays an important role in RHS pathogenesis. Initial RHS severity and the response to corticosteroids may determine the final treatment outcome. However, inflammatory markers do not predict all BP outcomes; BP may be etiologically heterogeneous.
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Affiliation(s)
- Su Jin Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Ho Yun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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16
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Gonçalves C, Monteiro C, Santos JL. Suspected Adverse Drug Reactions From Corticosteroids: Analysis of Reported Notifications to the Portuguese Pharmacovigilance System. J Clin Pharmacol 2020; 60:1367-1375. [DOI: 10.1002/jcph.1630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Cristel Gonçalves
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
| | - Cristina Monteiro
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
- UFBI‐ Pharmacovigilance Unit of Beira Interior University of Beira Interior Covilhã Portugal
| | - Jorge Luiz Santos
- Faculty of Health Sciences University of Beira Interior Covilhã Portugal
- UFBI‐ Pharmacovigilance Unit of Beira Interior University of Beira Interior Covilhã Portugal
- CICS‐UBI‐Health Sciences Research Centre University of Beira Interior Covilhã Portugal
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17
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Manda A, Walker RB, Khamanga SMM. An Artificial Neural Network Approach to Predict the Effects of Formulation and Process Variables on Prednisone Release from a Multipartite System. Pharmaceutics 2019; 11:E109. [PMID: 30866418 PMCID: PMC6470535 DOI: 10.3390/pharmaceutics11030109] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
The impact of formulation and process variables on the in-vitro release of prednisone from a multiple-unit pellet system was investigated. Box-Behnken Response Surface Methodology (RSM) was used to generate multivariate experiments. The extrusion-spheronization method was used to produce pellets and dissolution studies were performed using United States Pharmacopoeia (USP) Apparatus 2 as described in USP XXIV. Analysis of dissolution test samples was performed using a reversed-phase high-performance liquid chromatography (RP-HPLC) method. Four formulation and process variables viz., microcrystalline cellulose concentration, sodium starch glycolate concentration, spheronization time and extrusion speed were investigated and drug release, aspect ratio and yield were monitored for the trained artificial neural networks (ANN). To achieve accurate prediction, data generated from experimentation were used to train a multi-layer perceptron (MLP) using back propagation (BP) and the Broyden-Fletcher-Goldfarb-Shanno (BFGS) 57 training algorithm until a satisfactory value of root mean square error (RMSE) was observed. The study revealed that the in-vitro release profile of prednisone was significantly impacted by microcrystalline cellulose concentration and sodium starch glycolate concentration. Increasing microcrystalline cellulose concentration retarded dissolution rate whereas increasing sodium starch glycolate concentration improved dissolution rate. Spheronization time and extrusion speed had minimal impact on prednisone release but had a significant impact on extrudate and pellet quality. This work demonstrated that RSM can be successfully used concurrently with ANN for dosage form manufacture to permit the exploration of experimental regions that are omitted when using RSM alone.
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Affiliation(s)
- Arthur Manda
- Division of Pharmaceutics, Faculty of Pharmacy, Rhodes University, Grahamstown 6140, South Africa.
| | - Roderick B Walker
- Division of Pharmaceutics, Faculty of Pharmacy, Rhodes University, Grahamstown 6140, South Africa.
| | - Sandile M M Khamanga
- Division of Pharmaceutics, Faculty of Pharmacy, Rhodes University, Grahamstown 6140, South Africa.
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18
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Parker L, Lin X, Garnham A, McConell G, Stepto NK, Hare DL, Byrnes E, Ebeling PR, Seeman E, Brennan-Speranza TC, Levinger I. Glucocorticoid-Induced Insulin Resistance in Men Is Associated With Suppressed Undercarboxylated Osteocalcin. J Bone Miner Res 2019; 34:49-58. [PMID: 30138543 DOI: 10.1002/jbmr.3574] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/05/2018] [Accepted: 08/08/2018] [Indexed: 12/15/2022]
Abstract
In mice, glucocorticoid-induced insulin resistance occurs largely through impaired osteoblast function and decreased circulating undercarboxylated osteocalcin (ucOC). Whether these mechanisms contribute to glucocorticoid-induced insulin resistance in humans has yet to be established. In addition, the effects of glucocorticoids on the exercise-induced increase in circulating ucOC and insulin sensitivity are also unknown. We hypothesized that acute glucocorticoid treatment would lead to basal and postexercise insulin resistance in part through decreased circulating ucOC and ucOC-mediated skeletal muscle protein signaling. Nine healthy men completed two separate cycling sessions 12 hours after ingesting either glucocorticoid (20 mg prednisolone) or placebo (20 mg Avicel). The homeostatic model assessment was used to assess basal insulin sensitivity and a 2-hour euglycemic-hyperinsulinemic clamp was commenced 3 hours after exercise to assess postexercise insulin sensitivity. Serum ucOC and skeletal muscle protein signaling were measured. Single-dose glucocorticoid ingestion increased fasting glucose (27%, p < 0.01) and insulin (83%, p < 0.01), and decreased basal insulin sensitivity (-47%, p < 0.01). Glucocorticoids reduced insulin sensitivity after cycling exercise (-34%, p < 0.01), reduced muscle GPRC6A protein content (16%, p < 0.05), and attenuated protein phosphorylation of mTORSer2481 , AktSer374 , and AS160Thr642 (59%, 61%, and 50%, respectively; all ps < 0.05). Serum ucOC decreased (-24%, p < 0.01) which correlated with lower basal insulin sensitivity (r = 0.54, p = 0.02), lower insulin sensitivity after exercise (r = 0.72, p < 0.05), and attenuated muscle protein signaling (r = 0.48-0.71, p < 0.05). Glucocorticoid-induced basal and postexercise insulin resistance in humans is associated with the suppression of circulating ucOC and ucOC-linked protein signaling in skeletal muscle. Whether ucOC treatment can offset glucocorticoid-induced insulin resistance in human subjects requires further investigation. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Lewan Parker
- Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, VIC, Australia.,Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia
| | - Xuzhu Lin
- Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia
| | - Andrew Garnham
- Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, VIC, Australia.,Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia
| | - Glenn McConell
- Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia
| | - Nigel K Stepto
- Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia.,Monash Centre of Health Research and Implementation (MCHRI), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - David L Hare
- University of Melbourne and the Department of Cardiology, Austin Health, Melbourne, VIC, Australia
| | | | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Ego Seeman
- Department of Endocrinology, Austin Health, University of Melbourne, Melbourne, VIC, Australia.,Mary Mackillop Institute of Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | | | - Itamar Levinger
- Institute of Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia.,University of Melbourne and the Department of Cardiology, Austin Health, Melbourne, VIC, Australia
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19
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Sterl K, Thompson B, Goss CW, Dacey RG, Rich KM, Zipfel GJ, Chicoine MR, Kim AH, Silverstein JM. Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety. Neurosurgery 2018; 85:E226-E232. [DOI: 10.1093/neuros/nyy479] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Perioperative steroid protocols for patients undergoing transsphenoidal surgery (TSS) for pituitary pathology vary by institution.
OBJECTIVE
To assess the safety of withholding glucocorticoids in patients undergoing TSS.
METHODS
Patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing TSS for a pituitary tumor at the same academic institution between 2012 and 2015 were randomized to either receive 100 mg of intravenous hydrocortisone followed by 0.5 mg of intravenous dexamethasone every 6 h for 4 doses (STER, n = 23) or to undergo surgery without steroids (NOSTER, n = 20). Postoperative cortisol levels were then used to determine the need for glucocorticoids after surgery. Data regarding postoperative cortisol levels, hospital stay length, and complications were collected.
RESULTS
Mean postoperative 8 am cortisol levels were higher in the NOSTER group compared to the STER group (745 ± 359 nmol/L and 386 ± 193 nmol/L, respectively, P = .001) and more patients were discharged on glucocorticoids in the STER group (42% vs 12%, P = .07). There was no difference in the incidence of postoperative complications, including hyperglycemia, diabetes insipidus, or permanent adrenal insufficiency. Permanent adrenal insufficiency occurred in 8% of patients.
CONCLUSION
Perioperative steroids can be safely withheld in patients with an intact HPA axis undergoing TSS. Although administration of perioperative glucocorticoids does not appear to increase the risk of complications, it may interfere with assessment of the HPA axis after surgery.
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Affiliation(s)
- Karin Sterl
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julie M Silverstein
- Divsion of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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20
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Conklin LS, Damsker JM, Hoffman EP, Jusko WJ, Mavroudis PD, Schwartz BD, Mengle-Gaw LJ, Smith EC, Mah JK, Guglieri M, Nevo Y, Kuntz N, McDonald CM, Tulinius M, Ryan MM, Webster R, Castro D, Finkel RS, Smith AL, Morgenroth LP, Arrieta A, Shimony M, Jaros M, Shale P, McCall JM, Hathout Y, Nagaraju K, van den Anker J, Ward LM, Ahmet A, Cornish MR, Clemens PR. Phase IIa trial in Duchenne muscular dystrophy shows vamorolone is a first-in-class dissociative steroidal anti-inflammatory drug. Pharmacol Res 2018; 136:140-150. [PMID: 30219580 PMCID: PMC6218284 DOI: 10.1016/j.phrs.2018.09.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/24/2022]
Abstract
We report a first-in-patient study of vamorolone, a first-in-class dissociative steroidal anti-inflammatory drug, in Duchenne muscular dystrophy. This 2-week, open-label Phase IIa multiple ascending dose study (0.25, 0.75, 2.0, and 6.0 mg/kg/day) enrolled 48 boys with Duchenne muscular dystrophy (4 to <7 years), with outcomes including clinical safety, pharmacokinetics and pharmacodynamic biomarkers. The study design included pharmacodynamic biomarkers in three contexts of use: 1. Secondary outcomes for pharmacodynamic safety (insulin resistance, adrenal suppression, bone turnover); 2. Exploratory outcomes for drug mechanism of action; 3. Exploratory outcomes for expanded pharmacodynamic safety. Vamorolone was safe and well-tolerated through the highest dose tested (6.0 mg/kg/day) and pharmacokinetics of vamorolone were similar to prednisolone. Using pharmacodynamic biomarkers, the study demonstrated improved safety of vamorolone versus glucocorticoids as shown by reduction of insulin resistance, beneficial changes in bone turnover (loss of increased bone resorption and decreased bone formation only at the highest dose level), and a reduction in adrenal suppression. Exploratory biomarkers of pharmacodynamic efficacy showed an anti-inflammatory mechanism of action and a beneficial effect on plasma membrane stability, as demonstrated by a dose-responsive decrease in serum creatine kinase activity. With an array of pre-selected biomarkers in multiple contexts of use, we demonstrate the development of the first dissociative steroid that preserves anti-inflammatory efficacy and decreases steroid-associated safety concerns. Ongoing extension studies offer the potential to bridge exploratory efficacy biomarkers to clinical outcomes.
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Affiliation(s)
- Laurie S. Conklin
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | | | - Eric P. Hoffman
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | | | | | | | | | | | - Jean K. Mah
- University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | | | - Yoram Nevo
- Schneider Children’s Medical Center of Israel, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Kuntz
- Ann & Robert H. Lurie Children’s Hospital Chicago, IL, USA
| | | | - Mar Tulinius
- Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Monique M. Ryan
- Royal Children’s Hospital, University of Melbourne, Melbourne, Australia
| | | | - Diana Castro
- University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | | | | | | | | | | | | | - Kanneboyina Nagaraju
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | - John van den Anker
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | | | - Paula R. Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
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Price DB, Trudo F, Voorham J, Xu X, Kerkhof M, Ling Zhi Jie J, Tran TN. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy 2018; 11:193-204. [PMID: 30214247 PMCID: PMC6121746 DOI: 10.2147/jaa.s176026] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Prior work suggests a threshold of four courses/year of systemic corticosteroid (SCS) therapy is associated with adverse consequences. The objective of this study was to investigate the onset of adverse outcomes beginning at SCS initiation in a broad asthma population. Patients and methods This historical matched cohort study utilized anonymized, longitudinal medical record data (1984–2017) of patients (≥18 years) with active asthma. Matched patients with first SCS prescription (SCS arm) and no SCS exposure (non-SCS arm) were followed until first outcome event. Associations between time-varying exposure measures and onset of 17 SCS-associated adverse outcomes were estimated using Cox proportional hazard regression, adjusting for confounders, in separate models. Results We matched 24,117 pairs of patients with median record availability before SCS initiation of 9.9 and 8.7 years and median follow-up 7.4 and 6.4 years in SCS and non-SCS arms, respectively. Compared with patients in the non-SCS arm, patients prescribed SCS had significantly increased risk of osteoporosis/osteoporotic fracture (adjusted hazard ratio 3.11; 95% CI 1.87–5.19), pneumonia (2.68; 2.30–3.11), cardio-/cerebrovascular diseases (1.53; 1.36–1.72), cataract (1.50; 1.31–1.73), sleep apnea (1.40; 1.04–1.86), renal impairment (1.36; 1.26–1.47), depression/anxiety (1.31; 1.21–1.41), type 2 diabetes (1.26; 1.15–1.37), and weight gain (1.14; 1.10–1.18). A dose-response relationship for cumulative SCS exposure with most adverse outcomes began at cumulative exposures of 1.0–<2.5 g and for some outcomes at cumulative exposures of only 0.5–<1 g (vs >0–<0.5 g reference), equivalent to four lifetime SCS courses. Conclusion Our findings suggest urgent need for reappraisal of when patients need specialist care and consideration of nonsteroid therapy.
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Affiliation(s)
- David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore, .,Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK,
| | - Frank Trudo
- Medical Affairs, AstraZeneca, Wilmington, DE, USA
| | - Jaco Voorham
- Observational and Pragmatic Research Institute, Singapore, Singapore,
| | - Xiao Xu
- Global Payer Evidence and Pricing, AstraZeneca, Gaithersburg, MD, USA
| | - Marjan Kerkhof
- Observational and Pragmatic Research Institute, Singapore, Singapore,
| | | | - Trung N Tran
- Medical Evidence and Observational Research, AstraZeneca, Gaithersburg, MD, USA
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22
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Kerkhof M, Tran TN, van den Berge M, Brusselle GG, Gopalan G, Jones RCM, Kocks JWH, Menzies-Gow A, Nuevo J, Pavord ID, Rastogi S, Price DB. Association between blood eosinophil count and risk of readmission for patients with asthma: Historical cohort study. PLoS One 2018; 13:e0201143. [PMID: 30044863 PMCID: PMC6059485 DOI: 10.1371/journal.pone.0201143] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/08/2018] [Indexed: 11/18/2022] Open
Abstract
Background Recent studies have demonstrated an association between high blood eosinophil counts and greater risk of asthma exacerbations. We sought to determine whether patients hospitalized for an asthma exacerbation were at greater risk of readmission if they had a high blood eosinophil count documented before the first hospitalization. Methods This historical cohort study drew on 2 years of medical record data (Clinical Practice Research Datalink with Hospital Episode Statistics linkage) of patients (aged ≥5 years) admitted to hospital in England for asthma, with recorded blood eosinophil count within 1 baseline year before admission. We analyzed the association between high blood eosinophil count (≥0.35x109 cells/L) and readmission risk during 1 year of follow-up after hospital discharge, with adjustment for predefined, relevant confounders using forward selection. Results We identified 2,613 eligible patients with asthma-related admission, of median age 51 years (interquartile range, 36–69) and 76% women (1,997/2,613). Overall, 835/2,613 (32.0%) had a preadmission high blood eosinophil count. During the follow-up year, 130/2,613 patients (5.0%) were readmitted for asthma, including 55/835 (6.6%) with vs. 75/1,778 (4.2%) without high blood eosinophil count at baseline (adjusted hazard ratio [HR] 1.49; 95% CI 1.04–2.13, p = 0.029). The association was strongest in never-smokers (n = 1,296; HR 2.16, 95% CI 1.27–3.68, p = 0.005) and absent in current smokers (n = 547; HR 1.00, 95% CI 0.49–2.04, p = 0.997). Conclusions A high blood eosinophil count in the year before an asthma-related hospitalization is associated with increased risk of readmission within the following year. These findings suggest that patients with asthma and preadmission high blood eosinophil count require careful follow-up, with treatment optimization, after discharge.
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Affiliation(s)
- Marjan Kerkhof
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Trung N Tran
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Gokul Gopalan
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Rupert C M Jones
- The Peninsula College of Medicine and Dentistry, Plymouth, United Kingdom
| | - Janwillem W H Kocks
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Andrew Menzies-Gow
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - David B Price
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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23
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Hu Y, Carman JA, Holloway D, Kansal S, Fan L, Goldstine C, Lee D, Somerville JE, Latek R, Townsend R, Johnsen A, Connolly S, Bandyopadhyay S, Shadick N, Weinblatt ME, Furie R, Nadler SG. Development of a Molecular Signature to Monitor Pharmacodynamic Responses Mediated by In Vivo Administration of Glucocorticoids. Arthritis Rheumatol 2018. [PMID: 29534336 PMCID: PMC6099349 DOI: 10.1002/art.40476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To develop an objective, readily measurable pharmacodynamic biomarker of glucocorticoid (GC) activity. METHODS Genes modulated by prednisolone were identified from in vitro studies using peripheral blood mononuclear cells from normal healthy volunteers. Using the criteria of a >2-fold change relative to vehicle controls and an adjusted P value cutoff of less than 0.05, 64 up-regulated and 18 down-regulated genes were identified. A composite score of the up-regulated genes was generated using a single-sample gene set enrichment analysis algorithm. RESULTS GC gene signature expression was significantly elevated in peripheral blood leukocytes from normal healthy volunteers following oral administration of prednisolone. Expression of the signature increased in a dose-dependent manner, peaked at 4 hours postadministration, and returned to baseline levels by 48 hours after dosing. Lower expression was detected in normal healthy volunteers who received a partial GC receptor agonist, which is consistent with the reduced transactivation potential of this compound. In cohorts of patients with systemic lupus erythematosus and patients with rheumatoid arthritis, expression of the GC signature was negatively correlated with the percentages of peripheral blood lymphocytes and positively correlated with peripheral blood neutrophil counts, which is consistent with the known biology of the GC receptor. Expression of the signature largely agreed with reported GC use in these populations, although there was significant interpatient variability within the dose cohorts. CONCLUSION The GC gene signature identified in this study represents a pharmacodynamic marker of GC exposure.
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Affiliation(s)
- Yanhua Hu
- Bristol-Myers Squibb, Princeton, New Jersey
| | | | | | | | - Li Fan
- Bristol-Myers Squibb, Princeton, New Jersey
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24
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Hoffman EP, Riddle V, Siegler MA, Dickerson D, Backonja M, Kramer WG, Nagaraju K, Gordish-Dressman H, Damsker JM, McCall JM. Phase 1 trial of vamorolone, a first-in-class steroid, shows improvements in side effects via biomarkers bridged to clinical outcomes. Steroids 2018; 134:43-52. [PMID: 29524454 PMCID: PMC6136660 DOI: 10.1016/j.steroids.2018.02.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Glucocorticoid drugs are highly effective anti-inflammatory agents, but chronic use is associated with extensive pharmacodynamic safety concerns that have a considerable negative impact on patient quality of life. PURPOSE Vamorolone (VBP15) is a first-in-class steroidal multi-functional drug that shows potent inhibition of pro-inflammatory NFkB pathways via high-affinity binding to the glucocorticoid receptor, high affinity antagonism for the mineralocorticoid receptor, and membrane stabilization properties. Pre-clinical data in multiple mouse models of inflammation showed retention of anti-inflammatory efficacy, but loss of most or all side effects. EXPERIMENTAL APPROACH We report first-in-human Phase 1 clinical trials (86 healthy adult males), with single ascending doses (0.1-20.0 mg/kg), and multiple ascending doses (1.0-20 mg/kg/day; 14 days treatment). KEY RESULTS Vamorolone was well-tolerated at all dose levels. Vamorolone showed pharmacokinetic and metabolism profiles similar to prednisone. Biomarker studies showed loss of side effects of traditional glucocorticoid drugs (bone fragility, metabolic disturbance, immune suppression). Suppression of the adrenal axis was 10-fold less than prednisone. The crystallographic structure of vamorolone was solved, and compared to prednisone and dexamethasone. There was overlap in structure, but differences in conformation at the C-ring where glucocorticoids interact with Asn564 of the glucocorticoid receptor. The predicted loss of Asn564 binding to vamorolone may underlie the loss of gene transcriptional activity. CONCLUSIONS AND INTERPRETATIONS Vamorolone is a dissociative steroid that retains high affinity binding and nuclear translocation of both glucocorticoid (agonist) and mineralocorticoid (antagonist) receptors, but does not show pharmacodynamic safety concerns of existing glucocorticoid drugs at up to 20 mg/kg/day.
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Affiliation(s)
- Eric P Hoffman
- ReveraGen BioPharma, Rockville, MD, USA; Department of Pharmaceutical Sciences, School of Pharmacy, Binghamton University - SUNY, Binghamton, NY, USA.
| | | | - Maxime A Siegler
- Department of Chemistry, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218 USA
| | | | | | | | - Kanneboyina Nagaraju
- ReveraGen BioPharma, Rockville, MD, USA; Department of Pharmaceutical Sciences, School of Pharmacy, Binghamton University - SUNY, Binghamton, NY, USA
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25
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Li C, Chen Q, Zhang X, Snyder SA, Gong Z, Lam SH. An integrated approach with the zebrafish model for biomonitoring of municipal wastewater effluent and receiving waters. WATER RESEARCH 2018; 131:33-44. [PMID: 29258003 DOI: 10.1016/j.watres.2017.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/04/2017] [Accepted: 12/09/2017] [Indexed: 06/07/2023]
Abstract
Comprehensive monitoring of water pollution is challenging. With the increasing amount and types of anthropogenic compounds being released into water, there are rising concerns of undetected toxicity. This is especially true for municipal wastewater effluents that are discharged to surface waters. This study was designed to integrate zebrafish toxicogenomics, targeted gene expression, and morphological analyses, for toxicity evaluation of effluent discharged from two previously characterized wastewater treatment plants (WWTPs) in Pima County, Arizona, and their receiving surface water. Zebrafish embryos were exposed to organic extracts from the WWTP1 effluent that were reconstituted to represent 1× and 0.5× of the original concentration. Microarray analyses identified deregulated gene probes that mapped to 1666, 779, and 631 unique human homologs in the 1×, 0.5×, and the intersection of both groups, respectively. These were associated with 18 cellular and molecular functions ranging from cell cycle to metabolism and are involved in the development and function of 10 organ systems including nervous, cardiovascular, haematological, reproductive, and hepatic systems. Superpathway of cholesterol biosynthesis, retinoic acid receptor activation, glucocorticoid receptor and prolactin signaling were among the top 11 perturbed canonical pathways. Real-time quantitative PCR validated the expression changes of 12 selected genes. These genes were then tested on zebrafish embryos exposed to the reconstituted extract of water sampled downstream of WWTP1 and another nearby WWTP2. The expression of several targeted genes were significantly affected by the WWTP effluents and some of the downstream receiving waters. Morphological analyses using four transgenic zebrafish lines revealed potential toxicity associated with nervous, hepatic, endothelial-vascular and myeloid systems. This study demonstrated how information can be obtained using adverse outcome pathway framework to derive biological effect-based monitoring tools. This integrated approach using zebrafish can supplement analytical chemistry to provide more comprehensive monitoring of discharged effluents and their receiving waters.
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Affiliation(s)
- Caixia Li
- NUS Environmental Research Institute, National University of Singapore, 5A Engineering Drive 1, Singapore 117411, Singapore; Department of Biological Science, National University of Singapore, 14 Science Drive 4, Singapore 117543, Singapore
| | - Qiyu Chen
- NUS Environmental Research Institute, National University of Singapore, 5A Engineering Drive 1, Singapore 117411, Singapore
| | - Xiaoyan Zhang
- Department of Biological Science, National University of Singapore, 14 Science Drive 4, Singapore 117543, Singapore
| | - Shane A Snyder
- NUS Environmental Research Institute, National University of Singapore, 5A Engineering Drive 1, Singapore 117411, Singapore; Department of Chemical and Environmental Engineering, University of Arizona, 1133 E. James E. Rogers Way, Harshbarger 108, Tucson, AZ 85721-0011, USA
| | - Zhiyuan Gong
- Department of Biological Science, National University of Singapore, 14 Science Drive 4, Singapore 117543, Singapore
| | - Siew Hong Lam
- NUS Environmental Research Institute, National University of Singapore, 5A Engineering Drive 1, Singapore 117411, Singapore; Department of Biological Science, National University of Singapore, 14 Science Drive 4, Singapore 117543, Singapore.
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Seropian IM, Romeo FJ, Pizarro R, Vulcano NO, Posatini RA, Marenchino RG, Berrocal DH, Belziti CA. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of survival after heart transplantation. ESC Heart Fail 2017; 5:149-156. [PMID: 28758719 PMCID: PMC5793982 DOI: 10.1002/ehf2.12199] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/15/2017] [Accepted: 06/27/2017] [Indexed: 12/13/2022] Open
Abstract
Aims The aim of this study was to evaluate whether neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) predict outcome in heart failure (HF) patients undergoing heart transplantation (HTX). Methods and results Data from 111 HF patients undergoing HTX 2010–2015 were retrospectively reviewed. NLR and PLR were calculated before HTX, immediately after HTX, and at 6 and 24 hours. Primary endpoint was in‐hospital mortality, and secondary endpoints were 1 year mortality and renal replacement therapy (RRT). Prognostic factors were assessed by multivariate analysis, and the predictive values of NLR and PLR for mortality were compared. The discriminatory performance for predicting in‐hospital mortality was better for NLR [area under the receiver operating characteristic curve (AUC) = 0.644, 95% confidence interval 0.492–0.797] than for PLR (AUC = 0.599, 95% confidence interval 0.423–0.776). Best cut‐off value was 2.41 for NLR (sensitivity 86%, specificity 67%) and 92.5 for PLR (sensitivity 86%, specificity 68%). When divided according to best cut‐off value, in‐hospital mortality was significantly higher in the high NLR group (17.5% vs. 3.2%, P < 0.05), but not in the high PLR group (16.5% vs. 6.3%, P = ns). One year mortality was not significantly higher for either group (37.5% vs. 6.5% for NLR; 36.7% vs. 9.4% for PLR, P = ns for both), while RRT was significantly higher in both the NLR and PLR high groups (33.8% vs. 0%; 32.9% vs. 3.1%, respectively, P < 0.001). Multivariate analysis indicated that only high NLR (hazard ratio = 3.403, P < 0.05) and pre‐transplant diabetes (hazard ratio = 3.364, P < 0.05) were independent prognostic factors for 1 year mortality. Conclusions High NLR was a predictor for in‐hospital mortality, and an independent prognostic factor for 1 year mortality. Both high NLR and high PLR were predictors for RRT.
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Affiliation(s)
- Ignacio M Seropian
- Interventional Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Francisco J Romeo
- Interventional Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodolfo Pizarro
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Norberto O Vulcano
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo A Posatini
- Cardiovascular Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo G Marenchino
- Cardiovascular Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel H Berrocal
- Interventional Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Cesar A Belziti
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Shoji S, Suzuki A, Conrado DJ, Peterson MC, Hey-Hadavi J, McCabe D, Rojo R, Tammara BK. Dissociated Agonist of Glucocorticoid Receptor or Prednisone for Active Rheumatoid Arthritis: Effects on P1NP and Osteocalcin Pharmacodynamics. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:439-448. [PMID: 28556506 PMCID: PMC5529777 DOI: 10.1002/psp4.12201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/05/2017] [Accepted: 04/10/2017] [Indexed: 11/29/2022]
Abstract
Fosdagrocorat (PF‐04171327), a dissociated agonist of the glucocorticoid receptor, has potent anti‐inflammatory activity in patients with rheumatoid arthritis with reduced adverse effects on bone health. To identify fosdagrocorat doses with bone formation marker changes similar to prednisone 5 mg, we characterized treatment‐related changes in amino‐terminal propeptide of type I collagen (P1NP) and osteocalcin (OC) with fosdagrocorat (1, 5, 10, or 15 mg) and prednisone (5 or 10 mg) in a phase II randomized trial (N = 323). The time course of markers utilized a mixed‐effects longitudinal kinetic‐pharmacodynamic model. Median predicted changes from baseline at week 8 with fosdagrocorat 5, 10, and 15 mg were −18, −22, and −22% (P1NP), and −7, −13, and −17% (OC), respectively. Changes with prednisone 5 and 10 mg were −15% and −18% (P1NP) and −10% and −17% (OC). The probability of fosdagrocorat doses up to 15 mg being noninferior to prednisone 5 mg for P1NP and OC changes was >90%.
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Affiliation(s)
- S Shoji
- Pfizer Japan Inc, Tokyo, Japan
| | | | | | | | | | - D McCabe
- Pfizer Inc, New York, New York, USA
| | - R Rojo
- Pfizer Inc, Groton, Connecticut, USA
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Zeiger RS, Schatz M, Li Q, Chen W, Khatry DB, Tran TN. Burden of Chronic Oral Corticosteroid Use by Adults with Persistent Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1050-1060.e9. [PMID: 28215604 DOI: 10.1016/j.jaip.2016.12.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/13/2016] [Accepted: 12/28/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic oral corticosteroid (C-OCS) use in asthma is an indicator of disease severity, but its risk factors are largely unknown. OBJECTIVE To describe patient characteristics and disease burden associated with C-OCS use by adults with persistent asthma. METHODS We identified 9546 patients aged 18 to 64 years in a large managed care organization who met the Healthcare Effectiveness Data and Information Set 2-year criteria (2009-2010) for persistent asthma. A subgroup had blood eosinophil counts. We calculated cumulative OCS dispensed per patient in 2010 and examined the distribution of disease characteristics by average daily amounts of OCS dispensed. C-OCS use was defined as 2.5 mg/d or more. Baseline factors (2010) associated with C-OCS use during follow-up (2011) were investigated by multivariable Poisson regression. RESULTS At baseline, 782 (8.2%) patients were C-OCS users. Compared with patients who received no or less than 2.5 mg/d OCS, C-OCS users were older and more often female and ethnic minorities; and had more comorbidities, asthma specialist care, greater step-care level, controllers, asthma exacerbations, and greater blood eosinophil counts (all P < .01). Baseline factors significantly associated with C-OCS use in the follow-up year included (1) demographic characteristics: older age, females, blacks versus whites, and whites versus others/unknown ethnicities; (2) disease burden: more asthma emergency department or hospitalization visits, greater step-care level, excessive short-acting β2-agonist dispensed, theophylline use, asthma specialist care, and nasal polyposis; (3) greater blood eosinophil counts; and (4) most strongly, C-OCS use. CONCLUSIONS C-OCS use was associated with more asthma burden, comorbidities, and greater blood eosinophil counts. Prior C-OCS use was the strongest predictor of future C-OCS use.
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Affiliation(s)
- Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif.
| | - Michael Schatz
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
| | - Qiaowu Li
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
| | - Wansu Chen
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
| | | | - Trung N Tran
- Observational Research Center, AstraZeneca, Gaithersburg, Md
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