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Melani AS, Croce S, Cassai L, Montuori G, Fabbri G, Messina M, Viani M, Bargagli E. Systemic Corticosteroids for Treating Respiratory Diseases: Less Is Better, but… When and How Is It Possible in Real Life? Pulm Ther 2023; 9:329-344. [PMID: 37356085 PMCID: PMC10447722 DOI: 10.1007/s41030-023-00227-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/28/2023] [Indexed: 06/27/2023] Open
Abstract
Systemic corticosteroids (CSs), a keystone in pulmonology, are drugs with strong antiinflammatory activity. They are cheap, easily available, and accessible, but with common and serious side effects. Moreover, the use of exogenous CSs may suppress the hypothalamic-pituitary-adrenal (HPA) axis, predisposing to adrenal insufficiency. Safe CS treatment is a challenge of pharmacological research. This narrative review examined the indications of CSs in some respiratory diseases, analyzing what types, dosages, and length of treatment are required as the dosage and duration of CS treatments need to be minimized. Chronic maintenance treatments with CSs are associated with poor prognosis, but they are still prescribed in patients with severe asthma, Chronic obstructive pulmonary disease (COPD), and interstitial lung diseases. When CS discontinuation is not possible, all efforts should be made to achieve clinically meaningful reductions. Guidelines suggest the use of methylprednisolone at a dose of 20-40 mg/day or equivalent for up to 10 days in subjects with COVID-19 pneumonia (but not other respiratory viral diseases) and respiratory failure, exacerbations of asthma, and COPD. Some guidelines suggest that CS treatment shorter than 10-14 days can be abruptly stopped, strictly monitoring subjects with unexplained symptoms after CS withdrawal, who should promptly be tested for adrenal insufficiency (AI) and eventually treated. CSs are often used in severe community-acquired pneumonia associated with markedly increased serum inflammation markers, in acute respiratory distress syndrome (ARDS), in septic shock unresponsive to hydro-saline replenishment and vasopressors, and acute exacerbations of interstitial lung diseases. As these cases often require higher doses and longer duration of CS treatment, CS tapering should be gradual and, when useful, supported by an evaluation of HPA axis function.
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Affiliation(s)
- Andrea S. Melani
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Sara Croce
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Lucia Cassai
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Giusy Montuori
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Gaia Fabbri
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Maddalena Messina
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Magda Viani
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
| | - Elena Bargagli
- Clinica di Malattie Apparato Respiratorio, Dipartimento Scienze Mediche, Chirurgiche e Neuroscienze, Università degli Studi di Siena, Azienda Ospedaliero-Universitaria Senese, Policlinico S.Maria alle Scotte, Viale Bracci, 53100 Siena, Italy
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Park SY, Kang SY, Song WJ, Kim JH. Evolving Concept of Severe Asthma: Transition From Diagnosis to Treatable Traits. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:447-464. [PMID: 36174989 PMCID: PMC9523415 DOI: 10.4168/aair.2022.14.5.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
In recent decades, the concept of severe asthma has evolved from an umbrella term encompassing patients with high-intensity treatment needs to a clinical syndrome with heterogeneous, albeit distinct, pathophysiological processes. Biased and unbiased cluster approaches have been used to identify several clinical phenotypes. In parallel, cellular and molecular approaches allow for the development of biological therapies, especially targeting type 2 (T2) cytokine pathways. Although T2-biologics have significantly improved clinical outcomes for patients with severe asthma in real-world practice, questions on the proper use of biologics remain open. Furthermore, a subset of severe asthma patients remains poorly controlled. The unmet needs require a new approach. The “treatable traits” concept has been suggested to address a diversity of pathophysiological factors in severe asthma and overcome the limitations of existing treatment strategies. With a tailored therapy that targets the treatable traits in individual patients, better personalized medical care and outcomes should be achieved.
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Affiliation(s)
- So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University Gwangmyeong Medical Center, Gwangmyeong, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
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