Meta-Analysis Finds Use of Inhaled Corticosteroids During Pregnancy Safe: A Systematic Meta-Analysis Review

Complex interplays: Asthma management and maternal‑fetal outcomes in pregnancy (Review)

Asthma, a common chronic respiratory condition, poses unique challenges in pregnancy, impacting both maternal and fetal health. Of note, 8-13% of pregnant women suffer from asthma, a condition that can worsen, stabilize, or improve during pregnancy. These fluctuations necessitate a nuanced management strategy to ensure the health of both the mother and fetus. Adverse outcomes, such as preeclampsia, gestational diabetes and increased cesarean delivery rates are associated with poorly controlled asthma. From a fetal perspective, the risks include preterm birth and a low birth weight. Physiological changes in pregnancy, such as an increased tidal volume and altered drug metabolism due to increased blood volume, complicate the management of asthma. The safety of asthma medications during pregnancy remains a significant concern, with ongoing research into their teratogenic effects. Recent advancements in treatment include the development of biologics and the increased use of personalized medicine, integrating pharmacogenomics and immunological profiling to tailor treatments to individual needs. Digital health tools have also emerged, enabling improved patient monitoring and management. The present review highlights the complex interplay between asthma management and pregnancy outcomes, advocating for comprehensive care approaches that consider the dynamic physiological changes during pregnancy. It underscores the need for ongoing research into the safety of medication and innovative therapeutic strategies to improve health outcomes for pregnant women with asthma and their babies.

Summary of the Dutch Multidisciplinary Practice Guideline on Asthma and Pregnancy

Asthma is the most common chronic respiratory disease in women of childbearing age and during pregnancy. This paper presents a summary of the Dutch multidisciplinary guideline on asthma and pregnancy. The aim of this guideline is to provide structured, where possible, evidence-based recommendations to optimize the management of asthma during pregnancy. The main topics covered in this guideline are preconception counseling, the safety of asthma medications during pregnancy and breastfeeding and risk assessment and monitoring of asthma during pregnancy. Because many caregivers are involved and a uniform approach is desirable, this guideline has been developed in collaboration with all relevant health care providers and patient representatives.

Asthma in pregnancy: a review of recent literature

PURPOSE OF REVIEW

Asthma remains the most common respiratory disease in pregnancy. Identifying risk factors for asthma exacerbations during pregnancy is critical, as uncontrolled asthma can have detrimental effects for both mother and baby. In this review, we discuss recent literature exploring risk factors, fetal and maternal effects, and treatment options for asthma during pregnancy.

RECENT FINDINGS

Recent literature suggests that optimizing asthma during pregnancy improves outcomes for both mother and baby, as well as later in childhood. Current research affirms that the benefit of asthma medication use outweighs any potential risks related to the medications themselves. Limited information is available regarding the use of newer therapies such as biologics during pregnancy.

SUMMARY

Identifying risk factors for asthma exacerbations during pregnancy is critical to prevent adverse outcomes for both mother and baby. Recent evidence continues to affirm the safety of asthma medication use; more studies are needed regarding the use of new therapies during pregnancy.

Treatable Traits in Pregnant Women with Asthma

BACKGROUND

Asthma is the most common chronic respiratory disease in pregnancy, affecting approximately 8-10% of pregnant women. Uncontrolled asthma is associated with adverse perinatal outcomes, including low birth weight, preterm birth, and maternal complications such as pre-eclampsia.

SUMMARY

A current approach to the management of chronic airway diseases is based on targeting treatable traits. The aim of this review was to define treatable traits in pregnant women with asthma based on recent literature and to determine personalized treatment options according to these traits. Traits addressed in this review that may improve asthma control and pregnancy outcomes are fractional exhaled nitric oxide-based asthma monitoring and treatment, medication adherence and inhalation technique, impaired lung function, smoking cessation and comorbidity including psychological conditions (depression and anxiety), obesity, rhinitis, gastroesophageal reflux disease, chronic rhinosinusitis with or without nasal polyps, and sleep apnea.

KEY MESSAGES

All the treatable traits discussed have the potential to improve asthma control and pregnancy outcomes in pregnant women with asthma. Further research is needed to determine which management approaches are best to improve asthma control during pregnancy, to identify other relevant treatable traits, and to determine whether the treatable trait approach is feasible and beneficial in pregnant women with asthma.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Chronic Management of Asthma During Pregnancy

Asthma is one of the most common potentially serious medical problems to complicate pregnancy. Optimal management of asthma during pregnancy is thus important for both mother and baby. Treating asthmatic women requires understanding the effects of pregnancy on the course of asthma, and, conversely, the effects of asthma on pregnancy outcomes. Successful management also requires an understanding the barriers to asthma control in this population of patients. Evidence has shown that it is essential that the allergist-immunologist, obstetrician, and patient work as a team during pregnancy to achieve optimal maternal and neonatal outcomes.

Personalized Treatment of Asthma: The Importance of Sex and Gender Differences

An individual's sex (nominally male or female, based on biological attributes) and gender (a complex term referring to socially constructed roles, behaviors, and expressions of identity) influence the clinical course of asthma in several ways. The physiologic development of the lungs and effects of sex hormones may explain why more boys than girls have asthma, and after puberty, more women than men have asthma. Female sex hormones have an impact throughout the life span and are associated with poor asthma control. Gender may influence exposure to asthma triggers, and sex and gender can influence the prevalence of comorbidities and interactions with health care professionals. Despite widely reported sex- and gender-based differences in asthma and asthma management, these issues frequently are not considered by health care professionals. There is also inconsistency regarding the use of "sex" and "gender" in scientific discourse; research is needed to define sex- and gender-based differences better and how they might interact to influence asthma outcomes. This review outlines the impact an individual's sex and gender can have on the pathogenesis, clinical course, diagnosis, treatment, and management of asthma.

Contemporary management and treatment strategies for asthma during pregnancy

Introduction: Asthma is one of the most common conditions that afflict pregnant women. Because uncontrolled asthma in pregnancy affects both maternal and offspring outcomes, careful attention to maintaining control of asthma symptoms throughout pregnancy is of critical importance.Areas Covered: Using a search of PUBMED/MEDLINE for 'asthma and pregnancy,' this article will review the current literature regarding epidemiology and course of asthma in pregnancy, the effects of uncontrolled asthma on both the mother and offspring, and provide an overview of the management, both non-pharmacologic and pharmacologic, of asthma in pregnancy.Expert Opinion: There is a lack of adequate safety information for most medications taken during pregnancy. Future research might allow better methods to predict which women will experience worsening during pregnancy. For now, surveillance systems like pregnancy registries or observational cohort studies can provide safety information for medications used during pregnancy.

[Management of asthma during pregnancy]

Asthma is the most common chronic condition in pregnant women. The risks of complications associated with asthma for the mother, the foetus and the pregnancy are mainly due to uncontrolled asthma and the occurrence of exacerbations. These events are promoted by the patient's difficulty in complying with treatment or by prescription insufficiency for an unjustified fear of teratogenicity. The challenge of the management of asthma during pregnancy is to ensure optimal maternal asthma control in order to prevent foetal hypoxia and thus, reduce the risk of complications. Preventing the occurrence of asthma symptoms and exacerbations, ensuring optimal lung function and managing the risk factors of poor asthma outcomes and comorbidities are the principles necessary to achieve this goal. Because of the low or non-existent risks of the main treatments of asthma for the foetus and the mother, it is widely recommended that all therapies initiated before conception are continued, in particular inhaled corticosteroids, and to adjust the dosage to the minimum effective dose. During the preconception period and throughout pregnancy, coordination of the different healthcare professionals (general practitioner, respiratory specialist and gynecologist) is essential, with the mother-to-be playing a central role in the management of her asthma.

A hierarchical procedure to select intrauterine and extrauterine factors for methodological validation of preterm birth risk estimation

BACKGROUND

Etiopathogenesis of preterm birth (PTB) is multifactorial, with a universe of risk factors interplaying between the mother and the environment. It is of utmost importance to identify the most informative factors in order to estimate the degree of PTB risk and trace an individualized profile. The aims of the present study were: 1) to identify all acknowledged risk factors for PTB and to select the most informative ones for defining an accurate model of risk prediction; 2) to verify predictive accuracy of the model and 3) to identify group profiles according to the degree of PTB risk based on the most informative factors.

METHODS

The Maternal Frailty Inventory (MaFra) was created based on a systematic review of the literature including 174 identified intrauterine (IU) and extrauterine (EU) factors. A sample of 111 pregnant women previously categorized in low or high risk for PTB below 37 weeks, according to ACOG guidelines, underwent the MaFra Inventory. First, univariate logistic regression enabled p-value ordering and the Akaike Information Criterion (AIC) selected the model including the most informative MaFra factors. Second, random forest classifier verified the overall predictive accuracy of the model. Third, fuzzy c-means clustering assigned group membership based on the most informative MaFra factors.

RESULTS

The most informative and parsimonious model selected through AIC included Placenta Previa, Pregnancy Induced Hypertension, Antibiotics, Cervix Length, Physical Exercise, Fetal Growth, Maternal Anxiety, Preeclampsia, Antihypertensives. The random forest classifier including only the most informative IU and EU factors achieved an overall accuracy of 81.08% and an AUC of 0.8122. The cluster analysis identified three groups of typical pregnant women, profiled on the basis of the most informative IU and EU risk factors from a lower to a higher degree of PTB risk, which paralleled time of birth delivery.

CONCLUSIONS

This study establishes a generalized methodology for building-up an evidence-based holistic risk assessment for PTB to be used in clinical practice. Relevant and essential factors were selected and were able to provide an accurate estimation of degree of PTB risk based on the most informative constellation of IU and EU factors.

The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities

Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.

Association between the timing of asthma diagnosis and medication use during pregnancy

STUDY OBJECTIVE

To assess whether asthma medication use during pregnancy differs in women newly diagnosed with asthma early in pregnancy (first 19 weeks of pregnancy) compared to those newly diagnosed up to 2 years pre-pregnancy.

DESIGN

A retrospective population-based cohort study.

DATA SOURCE

To conduct this study, we used the Quebec Asthma and Pregnancy Database (QAPD) constructed by linking two administrative health databases from the province of Quebec (Canada): the Régie de l'Assurance Maladie du Québec and Maintenance et Exploitation des Données pour l'Étude de la Clientèle Hospitalière databases.

PATIENTS

A cohort comprising pregnant women newly diagnosed with asthma at any time in the 2 years prior to pregnancy or during the first 19 weeks of pregnancy was selected from the QAPD.

MEASUREMENTS AND MAIN RESULTS

We assessed the number of filled prescriptions of inhaled corticosteroids (ICS), ICS/long-acting β2 agonists (LABA), and short-acting β2 agonists (SABA), as well as the number of days' supply of oral corticosteroid (OCS) from the 20^th week of pregnancy until delivery. Poisson regression was used to compare the rates of asthma medication use in women diagnosed pre-pregnancy versus early in pregnancy. The cohort included 1731 women newly diagnosed with asthma pre-pregnancy and 359 women newly diagnosed with asthma early in pregnancy. Women diagnosed early in pregnancy were more likely to use ICS (adjusted rate ratio: 1.9, 95% confidence interval (CI): 1.6-2.3) and SABA (adjusted rate ratio: 2.0, 95% CI: 1.7-2.4) from the 20th week of pregnancy until delivery than those newly diagnosed pre-pregnancy. No significant differences were observed in the use of ICS/LABA [adjusted rate ratio: 0.9, 95% CI: 0.7-1.3] and OCS [adjusted rate ratio: 0.8, 95% CI: 0.6-1.2].

CONCLUSION

The higher use of ICS and SABA observed in women newly diagnosed with asthma early in pregnancy may suggest a more persistent asthma phenotype caused by pregnancy-triggered hormonal changes.

A Multi-Objective Approach for Drug Repurposing in Preeclampsia

Preeclampsia is a hypertensive disorder that occurs during pregnancy. It is a complex disease with unknown pathogenesis and the leading cause of fetal and maternal mortality during pregnancy. Using all drugs currently under clinical trial for preeclampsia, we extracted all their possible targets from the DrugBank and ChEMBL databases and labeled them as "targets". The proteins labeled as "off-targets" were extracted in the same way but while taking all antihypertensive drugs which are inhibitors of ACE and/or angiotensin receptor antagonist as query molecules. Classification models were obtained for each of the 55 total proteins (45 targets and 10 off-targets) using the TPOT pipeline optimization tool. The average accuracy of the models in predicting the external dataset for targets and off-targets was 0.830 and 0.850, respectively. The combinations of models maximizing their virtual screening performance were explored by combining the desirability function and genetic algorithms. The virtual screening performance metrics for the best model were: the Boltzmann-Enhanced Discrimination of ROC (BEDROC)α=160.9 = 0.258, the Enrichment Factor (EF)1% = 31.55 and the Area Under the Accumulation Curve (AUAC) = 0.831. The most relevant targets for preeclampsia were: AR, VDR, SLC6A2, NOS3 and CHRM4, while ABCG2, ERBB2, CES1 and REN led to the most relevant off-targets. A virtual screening of the DrugBank database identified estradiol, estriol, vitamins E and D, lynestrenol, mifrepristone, simvastatin, ambroxol, and some antibiotics and antiparasitics as drugs with potential application in the treatment of preeclampsia.

ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases

This European Respiratory Society/Thoracic Society of Australia and New Zealand statement outlines a review of the literature and expert opinion concerning the management of reproduction and pregnancy in women with airways diseases: asthma, cystic fibrosis (CF) and non-CF bronchiectasis. Many women with these diseases are now living into reproductive age, with some developing moderate-to-severe impairment of lung function in early adulthood. The statement covers aspects of fertility, management during pregnancy, effects of drugs, issues during delivery and the post-partum period, and patients' views about family planning, pregnancy and parenthood. The statement summarises current knowledge and proposes topics for future research, but does not make specific clinical recommendations.

Medications that Cause Fetal Anomalies and Possible Prevention Strategies

Many conditions that require frequent medication use are common during pregnancy. The purpose of this article is to list some of the most common of these disorders and to discuss the risk to the developing fetus of the medications used most frequently to treat them. Included are drugs used for the treatment of asthma, nausea and vomiting, hyperthyroidism, pain and fever, and depression during pregnancy.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Asthma knowledge, care, and outcome during pregnancy: The QAKCOP study

Asthma is the most common chronic medical condition affecting pregnancy. Optimizing asthma management in pregnancy is paramount for the well-being of both the mother and the baby. The primary objectives of this study were to assess patient’s knowledge about asthma, the level of asthma care, and fetal and maternal outcomes among pregnant asthmatic women in this wealthy country with tremendous improvement in maternal and fetal health care. The secondary objective was to identify barriers to asthma control. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. About 56% of patients reported worsening of their asthma control during pregnancy, of which 52.3% felt this worsening in the third trimester. About 65% of patients had uncontrolled asthma during their pregnancy, and inhaler technique was incorrect in 64.4%. Only 38% of patients knew the difference between controller and reliever asthma medications, 12.7% of patients had received written asthma action plan, 17% had a spirometry done in the previous 5 years, and 3.8% had peak expiratory flow meter at home. The main reasons for uncontrolled asthma were lack of knowledge about right asthma medications in 30% and fear of side effects of inhaled corticosteroids in 19% of patients. No financial reason was reported. Significant associations between total number of pregnancies, poor perception of asthma medications, asthma exacerbation during delivery and poor asthma control were observed. Preeclampsia and congenital anomalies occurred at higher rates than previously reported among general population in this country. The tremendous improvements in maternal health care and socioeconomic status do not seem to be a barrier to the globally recognized poor asthma care in pregnancy. Important strategies are much needed.

A simplified acute physiology score in the prediction of acute organophosphate poisoning outcome in an intensive care unit

Organophosphate poisoning (OPP) occurs frequently and accounts for a large number of intoxication cases treated in intensive care units (ICU). Poisoning by these agents is a serious public health problem. Among pesticides, OPs are the main cause of poisoning and death in Loghman-Hakim Poison Center of Tehran, Iran. The aim of this study was to determine the impact of the Simplified Acute Physiology Score (SAPS II) in the prediction of mortality in patients with acute OPP requiring admission to the ICU of Loghman-Hakim Hospital Poison Center over a period of 12 months. This study was a prospective, case-control of records of patients with acute OPP admitted to the ICU between January 2006 and December 2006. The Demographic data were collected and SAPS II score was recorded. During the study period, 24 subjects were admitted to the ICU with acute OPP. All 24 patients (15 male) required endotracheal intubation and mechanical ventilation in addition to gastric decontamination and standard therapy with atropine and oximes and adequate hydration. Of these, 24 patients, eight (five male) died. SAPS II score was significantly higher in the non-survival group than the survival group. Mortality following acute OPP remains high despite adequate intensive care and specific therapy with atropine and oximes. One-third of the subjects needing intensive care die within the hospitalization period. SAPS II scores calculated within the first 24 hours were recognized as good prognostic indicator among patients with acute OPP that required ICU admission. It is concluded that SAPS II score above 11 within the first 24 hours is a predictor of poor outcome in patients with acute OPP requiring ICU admission. Human & Experimental Toxicology (2007) 26, 623—627

Maternal inhaled fluticasone propionate intake during pregnancy is detected in neonatal cord blood

BACKGROUND

Despite recommendations to use inhaled corticosteroids as treatment to control asthma during pregnancy, it is unknown whether inhaled fluticasone propionate (FP) reaches the fetus. Results & methodology: We collected maternal blood on the morning following delivery. FP was detected by ultra-performance LC-MS/MS (UPLC-MS/MS) in 9/17 asthmatic women using FP. Delay between last FP inhalation and maternal blood sampling ranged between 3 and 33 h and FP was detected in a range of 1.572-46.440 pg/ml. Among the nine offspring of these FP users, FP was detected in five cord blood samples. Delay between last predelivery FP inhalation and cord blood sampling ranged from 4 to 20 h and FP was detected in a range of 0.423-4.510 pg/ml.

CONCLUSION

Our findings demonstrate placental passage of inhaled FP.

Inhaled Corticosteroids Use Is Not Associated With an Increased Risk of Pregnancy-Induced Hypertension and Gestational Diabetes Mellitus: Two Nested Case-Control Studies

There have been concerns that systemic corticosteroid use is associated with pregnancy-induced hypertension (PIH) and diabetes mellitus. However, the relationship between inhaled corticosteroids (ICSs) and the risk of PIH has not been fully examined, and there was no study investigating the association between ICS use and the development of gestational diabetes mellitus (GDM). The aims of the study are to determine whether the use of ICSs during pregnancy increases the risk of PIH and GDM in women.We conducted 2 nested case-control studies utilizing the nationwide insurance claims database of the Health Insurance Review and Assessment Service (Seoul, Republic of Korea), in which 1,306,281 pregnant women who delivered between January 1, 2009 and December 31, 2011 were included. Among them, PIH cases and GDM cases were identified and matched controls were included. Conditional logistic regression analyses adjusted by other concomitant drugs use during and before pregnancy and confounding covariates including comorbidities were performed.Total 43,908 PIH cases and 219,534 controls, and 34,190 GDM cases and 170,934 control subjects were identified. When other concomitant drugs use during pregnancy was adjusted, ICS use was associated with an increased rate of PIH (adjusted odds ratio, 1.40 [95% CI, 1.05-1.87]). ICS medication possession ratios and cumulative doses were associated with an increased risk of PIH. However, the statistical significance was not found in other models. In both unadjusted and adjusted multivariable models, ICSs use was not associated with increase in the risk of GDM.ICSs use is not associated with an increased risk of PIH and GDM.

Safety of Drugs during Pregnancy and Breastfeeding in Cystic Fibrosis Patients

Health management of cystic fibrosis (CF) patients should be maximized during pregnancy and breastfeeding because of its significant impact on the maternal and newborn outcomes. Thus, numerous drugs will have to be continued during pregnancy and lactation. Most of the drugs representing CF treatment lines cross the placenta or are excreted into human milk. Research addressing the risks and benefits of drugs used in CF patients during pregnancy and lactation is often incomplete or challenged by limited methodology, which often leads to conflicting or inconclusive results. Yet, potential treatment benefits for CF pregnant patients most often outbalance potential risks for the unborn child.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Safety of Fluticasone Propionate Prescribed for Asthma During Pregnancy: A UK Population-Based Cohort Study

BACKGROUND

Asthma is commonly treated during pregnancy, yet data on the safety of asthma medicines used during pregnancy are sparse.

OBJECTIVE

The objective of this study was to evaluate the safety of the inhaled corticosteroid (ICS) fluticasone propionate (FP), alone and in fixed-dose combination with salmeterol (FSC) in terms of the risk of all major congenital malformations (MCMs), compared with all other non-FP ICS.

METHODS

Women with asthma who had a pregnancy between January 1, 2000, and December 31, 2010, were identified in the United Kingdom's Clinical Practice Research Datalink. Exposure to asthma medicines during the first trimester of pregnancy was based on issued prescriptions. The mothers' and infants' medical records were linked where possible, and pregnancy outcomes with an MCM diagnosed by age 1 year were identified based on medical codes in the mother's and infant's medical records, including those MCMs prenatally diagnosed that ended in an induced pregnancy termination. The absolute and relative risks of an MCM after different ICS exposures, stratified by the asthma treatment intensity level, were calculated.

RESULTS

A total of 14,654 mother-infant pairs were identified, of which 6,174 received an ICS prescription during the first trimester, in addition to 13 first trimester ICS exposed pregnancies that ended in an induced termination after a prenatal MCM diagnosis. In total, 5,362 pregnancies were eligible for the primary analysis at age 1 year. The absolute risk of an MCM after any first trimester FP exposure was 2.4% (CI95 0.8-4.1) and 2.7% (CI95 1.8-3.6) for the "moderate" and "considerable/severe" asthma treatment intensity levels, respectively. The adjusted odds ratios when compared with non-FP ICS were 1.1 (CI95 0.5-2.3) and 1.2 (CI95 0.7-2.0) for the "moderate" and "considerable/severe" intensity levels; risks for any FP and for FSC did not differ substantially.

CONCLUSION

No increase in the overall risk of MCMs was identified after first trimester FP exposure compared with non-FP ICS.

The Xolair Pregnancy Registry (EXPECT): the safety of omalizumab use during pregnancy

BACKGROUND

For many asthma medications, pregnancy safety data remains insufficient.

OBJECTIVE

The omalizumab pregnancy registry, EXPECT, evaluates maternal, pregnancy, and infant outcomes after exposure to omalizumab, including incidence of congenital anomalies.

METHODS

EXPECT is a prospective, observational study of pregnant women exposed to ≥1 dose of omalizumab within 8 weeks prior to conception or at any time during pregnancy. Primary outcome measures include rates of live births, elective terminations, stillbirths, and congenital anomalies. Data were collected at enrollment, each trimester, birth, and every 6 months up to 18 months post-delivery.

RESULTS

As of November 2012, 188 of 191 pregnant women were exposed to omalizumab during their first trimester. Of 169 pregnancies with known outcomes (median exposure during pregnancy, 8.8 months), there were 156 live births of 160 infants (4 twin pairs), 1 fetal death/stillbirth, 11 spontaneous abortions, and 1 elective termination. Among 152 singleton infants, 22 (14.5%) were born prematurely. Of 147 singleton infants with weight data, 16 (10.9%) were small for gestational age. Among 125 singleton full-term infants, 4 (3.2%) had low birth weights. Overall, 20 infants had congenital anomalies confirmed, 7 (4.4%) of whom had 1 major defect. No pattern of anomalies was observed.

CONCLUSIONS

To date, proportions of major congenital anomalies, prematurity, low birth weight, and small size for gestational age observed in the EXPECT registry are not inconsistent with findings from other studies in this asthma population. Recognizing the small sample size available, no apparent increased birth prevalence of major anomalies or patterns of major anomalies has been observed.

Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better

Asthma is a common medical condition complicating pregnancy with potentially serious effects on pregnancy outcome. The aim of this review is to provide an update on efficacy and safety of asthma medications, primarily bronchodilators and corticosteroids, used during pregnancy with focus on pregnancy outcome, and, furthermore, to discuss limitations of available studies and point to possible improvements in future studies. A planned series of systematic searches was conducted using the PubMed database. Use of short-acting β2-agonists has generally been established as safe, and the few studies stating otherwise appear to have, perhaps critical, methodological limitations. The safety of long-acting β2-agonists remains to be further investigated, and the few available studies have methodological limitations and, therefore, provide no definite answers, although a very recent study supports the safety of add-on long-acting β2-agonists to inhaled corticosteroids. Inhaled corticosteroids are generally found to be safe, although further research is needed to investigate both the efficacy and safety of high dose therapy with inhaled corticosteroids. Studies have reported associations between the use of systemic corticosteroids and adverse perinatal outcomes, such as preterm birth, low birth weight, and pre-eclampsia. This must, however, be weighed against the potential serious impact of severe, uncontrolled asthma itself on pregnancy outcome. The main obstacle to a valid interpretation of several of the available studies is the inadequate stratification for asthma severity and control. Overall, asthma in itself and not just poor asthma control poses a greater risk to pregnancy outcomes than asthma medication. Nonetheless, more studies focusing on disentangling the effects of asthma alone and asthma medications are needed. Increased use of stratified risk assessments, taking the concept of asthma severity into greater consideration, is much warranted in future studies.

Multidisciplinary approach to management of maternal asthma (MAMMA [copyright]): the PROTOCOL for a randomized controlled trial

Background

Uncontrolled asthma during pregnancy is associated with the maternal hazards of disease exacerbation, and perinatal hazards including intrauterine growth restriction and preterm birth. Interventions directed at achieving better asthma control during pregnancy should be considered a high priority in order to optimise both maternal and perinatal outcomes. Poor compliance with prescribed asthma medications during pregnancy and suboptimal prescribing patterns to pregnant women have both been shown to be contributing factors that jeopardise asthma control. The aim is to design and evaluate an intervention involving multidisciplinary care for women experiencing asthma in pregnancy.

Methods/design

A pilot single-blinded parallel-group randomized controlled trial testing a Multidisciplinary Approach to Management of Maternal Asthma (MAMMA©) which involves education and regular monitoring. Pregnant women with asthma will be recruited from antenatal clinics in Victoria, Australia. Recruited participants, stratified by disease severity, will be allocated to the intervention or the usual care group in a 1:1 ratio. Both groups will be followed prospectively throughout pregnancy and outcomes will be compared between groups at three and six months after recruitment to evaluate the effectiveness of this intervention. Outcome measures include Asthma Control Questionnaire (ACQ) scores, oral corticosteroid use, asthma exacerbations and asthma related hospital admissions, and days off work, preventer to reliever ratio, along with pregnancy and neonatal adverse events at delivery. The use of FEV₁/FEV₆ will be also investigated during this trial as a marker for asthma control.

Discussion

If successful, this model of care could be widely implemented in clinical practice and justify more funding for support services and resources for these women. This intervention will also promote awareness of the risks of poorly controlled asthma and the need for a collaborative, multidisciplinary approach to asthma management during pregnancy. This is also the first study to investigate the use of FEV₁/FEV₆ as a marker for asthma control during pregnancy.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12612000681853)

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

Single course of high dose dexamethasone is more effective than conventional prednisolone therapy in the treatment of primary newly diagnosed immune thrombocytopenia

INTRODUCTION

Immune thrombocytopenia (ITP) is an immune disorder commonly presents as isolated thrombocytopenia. Generally corticosteroids are the main treatment of ITP. This study was designed to evaluate effectiveness of high dose dexamethasone comparing conventional corticosteroid therapy in the treatment of ITP.

MATERIALS AND METHODS

In a randomized prospective study, sixty adult patients with newly diagnosed primary symptomatic ITP (Platelet count < 20,000) were evaluated. Patients divided into two groups. In group A, thirty patients (mean age of 24.9 years) received Dexamethasone 40 mg/IV/daily for four days (10 mg/q6h); and then Prednisolone 1 mg/kg/day/PO with rapid tapering of prednisolone (10 mg/week). From the other hand, in group B, thirty patients (mean age of 27.2 years) were treated with Prednisolone 1 mg/kg/day/PO for four weeks, then the drug tapered weekly.

RESULTS

All the patients in group A showed favorable response within the first seven days, 27 cases presented complete response (CR) and three cases revealed response (R). In group B, 11 cases had CR, 13 cases showed R and six cases had No response (NR). After three months, rates of CR were 80% and 23.3% in group A and B; respectively. Responses were 16.7% and 33.3%, NRs were 6.6% and 43.3% in group A and B; respectively (P < 0.0001). After 6 months, CR was 73.3% vs.16.7%, and R was 16.7% vs.36.7% and NR was 10% vs. 46.7% in group A and B; respectively (P < 0.0001). After 12 months, there was no change in response rate in group A, but in group B 53% were non responsive, 40% showed R (chronic ITP) and complete response was observed only in 6.7% (P < 0.0001). Three cases in group A and 12 cases in group B had needed splenectomy (P < 0.00002).

CONCLUSION

We showed that high dose dexamethasone is more effective than conventional steroid therapy in newly diagnosed ITP as initial treatment with less relapses and toxicities.

Inhaled glucocorticoids during pregnancy and offspring pediatric diseases: a national cohort study

RATIONALE

Glucocorticoid inhalation is the preferred asthma treatment during pregnancy. Previous studies on its safety focused on obstetric outcomes and offspring malformations.

OBJECTIVES

To determine whether glucocorticoid inhalation during pregnancy is a risk factor for offspring pediatric diseases.

METHODS

We studied offspring (live singletons) of pregnant women suffering from asthma during pregnancy (prevalence = 6.3%; n = 4,083 mother-child pairs) from the Danish National Birth Cohort (births, 1996-2002; prospective data). We estimated the associations between use of inhaled glucocorticoids for asthma treatment during pregnancy (n = 1231; 79.9% budesonide, 17.6% fluticasone, 5.4% beclomethasone, and 0.9% other or unspecified glucocorticoids) and offspring diseases (International Classification of Diseases-10th Revision, diagnoses) during childhood. We conducted Cox or logistic regression analyses for each International Classification of Diseases-10th Revision category, controlling for use of non-glucocorticoid-containing inhalants, and confirmed results by addressing confounding by treatment indication using propensity score.

MEASUREMENTS AND MAIN RESULTS

Offspring median age at end of follow-up was 6.1 (range, 3.6-8.9) years. Glucocorticoid inhalation was not associated with offspring disease risk in most categories, except for offspring endocrine, metabolic, and nutritional disorders (hazard ratio, 1.84; 95% confidence interval, 1.13-2.99). When repeating analyses with the major subgroup that used budesonide only, association estimates were of similar magnitude.

CONCLUSIONS

Regarding most disease categories, data are reassuring, supporting the use of inhaled glucocorticoids during pregnancy. In line with animal data, glucocorticoid inhalation during pregnancy may be a risk factor for offspring endocrine and metabolic disturbances, which should be considered further.

[Exacerbations of asthma in pregnant women]

Prevention of exacerbations and effective treatment is essential in pregnant asthmatic women. The management is well documented. Misunderstanding of the recommendations leads to unsuitable, insufficient treatment and is responsible for more frequent recurrences in the pregnant woman compared with the non pregnant. Above all, good control of the disease and the prevention of exacerbations, based on inhaled corticosteroid therapy and smoking cessation, reduces complications, in particular prematurity and low birth weight.

Asthma in pregnancy

Worldwide the prevalence of asthma among pregnant women is on the rise, and pregnancy leads to a worsening of asthma for many women. This article examines the changes in asthma that may occur during pregnancy, with particular reference to asthma exacerbations. Asthma affects not only the mother but the baby as well, with potential complications including low birth weight, preterm delivery, perinatal mortality, and preeclampsia. Barriers to effective asthma management and opportunities for optimized care and treatment are discussed, and a summary of the clinical guidelines for the management of asthma during pregnancy is presented.

Asthma and pregnancy: a review of two decades

The prevalence of asthma among pregnant women varies among studies from 4 to 8%, making it by far the most common respiratory disorder complicating pregnancy. Controversy exists among the numerous retrospective and prospective studies regarding pregnancy outcomes of asthmatic patients. Overall, the literature indicates that women with severe asthma are at an increased risk for preterm delivery, low birth weight, preeclampsia and Caesarean delivery, especially in the absence of inhaled corticosteroid therapy. Asthmatic women carrying a female fetus may particularly be at increased risk of these adverse outcomes. On the other hand, mild or moderate, well-controlled asthma is associated with favorable pregnancy and perinatal outcomes. Pregnancy also influences the course of asthma. Recently published data indicate that the real risk for an exacerbation during pregnancy may be underestimated. There is no question, however, that the risk of having an exacerbation correlates closely with the severity of asthma. The mechanisms responsible for these changes are not fully understood. Maternal hypoxia or inflammatory processes have been suggested and could explain reduced fetal growth through alterations in placental function. The goal of asthma therapy is to maintain adequate oxygenation of the fetus by prevention of exacerbations. Optimal management of asthma during pregnancy should include scheduled monitoring of objective lung function tests, avoiding triggers, patient education and tailored pharmacologic therapy. Inhaled corticosteroids are the treatment of choice for all levels of persistent asthma, yet other drug classes, such as beta(2)-agonists and theophylline, are effective and safe for use during pregnancy.

Inhaled fluticasone propionate reduces postoperative sore throat, cough, and hoarseness

BACKGROUND

Sore throat is a common complication after surgery. Postoperative cough and hoarseness can also be distressing to patients. We sought to determine the effect of an inhaler steroid on sore throat, cough, and hoarseness during the first 24 hours of the postoperative period.

METHODS

We enrolled 120 women with ASA physical status I or II and term singleton pregnancy who were scheduled for elective cesarean delivery under general anesthesia. Patients were randomized into 2 groups: in the sitting position, group F patients received 500 μg inhaled fluticasone propionate via a spacer device during 2 deep inspirations, after arrival in the operating room, and group C had no treatment. The patients were interviewed by a blinded investigator for postoperative sore throat, cough, and hoarseness at 1 and 24 hours after surgery.

RESULTS

There were no significant differences in age, height, weight, body mass index, duration of surgery, intubation, and grade of laryngeal exposure between the 2 groups. The incidence of sore throat, cough, and hoarseness was significantly lower in group F (3.33%, 3.33%, and 3.33%) compared with the control group (36.67%, 18.33%, and 35%) (P < 0.05 for all comparisons), not only in the first postoperative hour but also 24 hours after surgery (13.33%, 13.33%, and 25% in group F vs 40%, 41.67%, and 50% in the control group). The incidence of moderate and severe hoarseness in group F at the first hour was significantly less than the control group (P < 0.05).

CONCLUSIONS

Inhaled fluticasone propionate decreases the incidence and severity of postoperative sore throat, cough, and hoarseness in patients undergoing cesarean delivery under general anesthesia.

The Saudi Initiative for Asthma

The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.

[Asthma and pregnancy. Review of the current literature and management according to the GINA 2006-2007 guidelines]

INTRODUCTION

Many pregnant women are asthmatics and maternal asthma is a source of questions and complications concerning both the progress of the pregnancy itself and the impact on the foetus. In this situation good asthma control is essential as the disease can deteriorate with acute exacerbations, possibly precipitated by reduction or even withdrawal of treatment on account of fear of teratogenicity.

BACKGROUND

Even though asthma treatments are not totally harmless during pregnancy, their use has been validated by several studies and guidelines. To help clinicians, we undertake here a review of the complications induced by maternal asthma and its medications, and then suggest management guidelines according to the most recent publications.

CONCLUSIONS

The risks and benefits of asthma treatments should be explained in a real partnership between the patient and her general practitioner and specialists (obstetrician, chest physician or allergist). In order to reduce complications to both mother and child, perfect control of asthma is required and inhaled steroids remain the treatment of choice for partially or uncontrolled asthma in the pregnant woman.

Advances in therapy for adult asthma

There are >22 million Americans with asthma. Chronic asthma is a worldwide problem with an increasing socioeconomic burden on individuals and on society. Recent advances have been made in diagnostic lung imaging, defining control of asthma, as well as in the education of patients with asthma. Accurate diagnosis of the cause of chronic cough in adults and of asthma in elderly individuals will help affected individuals receive appropriate treatment. Inhaled corticosteroids are the recommended first-line therapy for persistent asthma and can help prevent exacerbations in patients with asthma that are not well controlled. Early intervention and improved management can significantly reduce the socioeconomic burden of asthma. Patient education is an essential part of asthma management.

Gender-medicine aspects in allergology

Despite the identical immunological mechanisms activating the release of mediators and consecutive symptoms in immediate-type allergy, there is still a clear clinical difference between female and male allergic patients. Even though the risk of being allergic is greater for boys in childhood, almost from adolescence onwards it seems to be a clear disadvantage to be a woman as far as atopic disorders are concerned. Asthma, food allergies and anaphylaxis are more frequently diagnosed in females. In turn, asthma and hay fever are associated with irregular menstruation. Pointing towards a role of sex hormones, an association of asthma and intake of contraceptives, and a risk for asthma exacerbations during pregnancy have been observed. Moreover, peri- and postmenopausal women were reported to increasingly suffer from asthma, wheeze and hay fever, being even enhanced by hormone replacement therapy. This may be on account of the recently identified oestradiol-receptor-dependent mast-cell activation. As a paradox of nature, women may even become hypersensitive against their own sex hormones, resulting in positive reactivity upon intradermal injection of oestrogen or progesterone. More importantly, this specific hypersensitivity is associated with recurrent miscarriages. Even though there is a striking gender-specific bias in IgE-mediated allergic diseases, public awareness of this fact still remains minimal today.

Inhaled corticosteroids during pregnancy: a review of methodologic issues

BACKGROUND

There is evidence in the literature that inhaled corticosteroids (ICSs) are safe for pregnant women with asthma and their infants. Although this is useful information about ICS use during pregnancy, some articles must be viewed cautiously because of lack of power and adjustment for potentially important confounding variables.

OBJECTIVE

To summarize evidence on the potential effects of ICSs to treat asthma in pregnant mothers and their children with particular focus on study power.

METHODS

Studies published before September 1, 2007, and focusing mainly on ICS use for asthma treatment during pregnancy were researched in Pubmed and the Cochrane Library. Post hoc power calculations were completed using data reported in the published articles.

RESULTS

Twenty-three studies that evaluated the associations between ICS use during pregnancy and maternal and/or perinatal outcomes were retained. Only six studies on the association between ICS use and maternal outcomes reported significant results; five studies found significant associations between ICS use and perinatal outcomes. Regarding non-significant results, two studies on maternal outcomes and seven studies on perinatal outcomes had a power higher than 80% to detect a relative risk of 1.5 or a mean birth weight difference of 500 g.

CONCLUSION

While there currently is some degree of evidence to support the safety of ICS use during pregnancy, this review highlights the limited statistical power of several studies published in this area.

Pregnancy outcomes in women using inhaled fluticasone during pregnancy: a case series

BACKGROUND

The aim of the study was to report the maternal and fetal outcomes of women with respiratory illnesses who were treated with inhaled fluticasone during pregnancy.

MATERIAL AND METHODS

We identified 12 cases treated with inhaled fluticasone during pregnancy out of women who received obstetric and teratogen-risk evaluation at the Korean Motherisk Program. A detailed medical and obstetric history was obtained and cases were followed-up until either spontaneous or voluntary pregnancy termination or delivery occurred.

RESULTS

None of the participants had any obstetric complication. However, in addition to fluticasone, most of the 12 cases were simultaneously exposed to a variety of medications. There were 3 abortions (one spontaneous and 2 requested by the patients arguing personal reasons). Live born babies without any evidence of major congenital malformations included 8 singleton babies and 2 twins. Of them, 3 babies were born prematurely.

CONCLUSIONS

Our results are in agreement with previous large studies where no increased rate of adverse outcomes was reported with the use of inhaled corticosteroids during pregnancy.

Review article: Reproduction in the patient with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) affects mainly the young population. The effect of IBD and its treatment on fertility and pregnancy is therefore an important clinical consideration.

AIM

To review the best management of IBD in the reproductive and pregnant population.

METHODS

A MEDLINE and an EMBASE search were performed using mainly the search phrases 'pregnancy AND IBD,''sulphasalazine AND male fertility,''abdominal surgery AND female fertility,''AZA AND placenta' and 'infliximab AND pregnancy.' No language or date restrictions were placed. References of review articles were examined.

RESULTS

Overall male and female fertility are not affected by IBD. Sulphasalzine reduces male fertility. No other drugs used in IBD affect significantly fertility in humans. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. Proactive treatment for maintenance of disease remission during gestation is recommended. Except for methotrexate, drugs used in IBD appear safe in pregnancy. Breast feeding should be encouraged.

CONCLUSION

The management of IBD in the young and pregnant population remains controversial because the literature comes mostly from retrospective studies. Further studies particularly large prospective trials are needed to guide clinicians in decision making.