Magnesium sulfate for acute asthma in adults: a systematic literature review

Safety and Effectiveness of Prolonged Magnesium Sulfate (MgSO 4 ) Infusion for Asthma Exacerbation in Children

The objective of this study was to assess the safety and describe treatment details of prolonged magnesium sulfate (MgSO 4 ) infusion for children with asthma exacerbation. A retrospective cross-sectional study included children under 13 years of age who were admitted with asthma exacerbation and received at least 24 hours of MgSO 4 infusion. One hundred children were included. No patients developed serious adverse events. The mean infusion duration was 74.2 hours. Eighty-nine percent recovered with no other bronchodilator infusions, and 94% did not require respiratory support escalation. Prolonged MgSO 4 infusion is safe at a maximum dose of 30 mg/kg/h and may be beneficial for children with asthma exacerbation.

Role of nebulised magnesium sulfate in treating acute asthma in children: a systematic review and meta-analysis

OBJECTIVES

To review the efficacy of nebulised magnesium sulfate (MgSO4) in acute asthma in children.

METHODS

The authors searched Medline, Embase, Web of Science and Cochrane Library for randomised controlled trials (RCTs) published until 15 December 2023. RCTs were included if they compared the efficacy and safety of nebulised MgSO4 as a second-line agent in children presenting with acute asthma exacerbation. A random-effects meta-analysis was performed, and the Risk of Bias V.2 tool was used to assess the biases among them.

RESULTS

10 RCTs enrolling 2301 children with acute asthma were included. All trials were placebo controlled and administered nebulised MgSO4/placebo and salbutamol (±ipratropium bromide). There was no significant difference in Composite Asthma Severity Score between the two groups (6 RCTs, 1953 participants; standardised mean difference: -0.09; 95% CI: -0.2 to +0.02, I2=21%). Children in the MgSO4 group have significantly better peak expiratory flow rate (% predicted) than the control group (2 RCTs, 145 participants; mean difference: 19.3; 95% CI: 8.9 to 29.8; I2=0%). There was no difference in the need for hospitalisation, intensive care unit admission or duration of hospital stay. Adverse events were minor, infrequent (7.3%) and similar among the two groups.

CONCLUSIONS

There is low-certainty evidence that nebulised MgSO4 as an add-on second-line therapy for acute asthma in children does not reduce asthma severity or a need for hospitalisation. However, it was associated with slightly better lung functions. The current evidence does not support the routine use of nebulised MgSO4 in paediatric acute asthma management.

PROSPERO REGISTRATION NUMBER

CRD42022373692.

A case-control study on asthma and obese patients: Influence of lifestyle patterns, serum trace elements, heavy metals, and total antioxidants

Background and aim

Asthma is a chronic airway hyperresponsiveness disorder and Obese people have greater rates of asthma incidence and prevalence. Obesity, a complex condition, can cause nutritional metabolic problems that change trace elements and minerals. Trace element and antioxidant levels affect asthma aetiology. In this study, we aim to determine the serum levels of trace elements Zn, Fe, Cu, Mg, Co, Ni, Pb, Cd, and Cr, total antioxidants (TAS), and lifestyle that determine specific clinical conditions in asthma and obesity patients from Vellore City (Tamil Nadu, India).

Methods

A case-control study to determine the level of the serum trace elements with 838 subjects (n = 242 asthma patients, n = 140 asthmatic obese, n = 185 obese patients, and n = 271 controls) between the ages of 20 and 60 years was carried out. Asthma was diagnosed based on the clinical examination and pulmonary function tests. Trace element levels were determined by atomic absorption spectrophotometry (AAS) in serum, and a DPPH-free radical scavenging assay was used to determine the total antioxidant capacity level in serum.

Result

In asthma male patients, serum levels of Zn, Fe, Cu, Mg, and TAS were significantly lower and Pb, Cd, and Cr significantly higher, whereas in female asthma patients, serum levels of Zn, Fe, Mg, and TAS were significantly lower and Pb significantly higher. In asthmatic obese male patients, Fe, Cu, and TAS were significantly lower, and Pb, Cd, and Co were significantly higher; in asthmatic obese female patients, Zn, Fe, Cu, Mg, and TAS were significantly lower, and Ni was significantly higher. In obese male patients, Zn, Fe, Cu, and TAS were significantly lower and Cd was significantly higher, and in obese female patients, Zn, Fe, Cu, Mg, and TAS were significantly lower.

Conclusion

The influence of the level of trace elements, heavy metal, total antioxidant, and the lifestyle patterns, may increase the risk of asthma and obesity.

A randomized clinical trial investigating the impact of magnesium supplementation on clinical and biochemical measures in COVID-19 patients

BACKGROUND

This study sought to examine the impact of magnesium supplementation on clinical outcomes and biochemical factors among hospitalized patients with COVID-19.

METHODS

This double-blind, randomized clinical trial was conducted at Razi Hospital, Ahvaz, Iran, between September 2021 and March 2022. Participants aged 18-70 years with moderate disease severity were enrolled. Magnesium supplementation (300 mg daily) was administered to the intervention group, while the control group received a placebo. Clinical outcomes, including the need for oxygen therapy, oxygen saturation, respiratory rate, fever, hs-CRP and TNF-α levels, as well as quality of life and mental health, were assessed. Blood samples were collected to measure biochemical variables.

RESULTS

The main result was the count of individuals requiring oxygen therapy. Additional outcomes comprised of oxygen saturation, respiratory rate, fever, hs-CRP and TNF-α levels, as well as quality of life and mental health. Out of 64 participants, 60 completed the study. The results showed that magnesium supplementation significantly reduced the number of patients requiring oxygen therapy (9 vs. 14; P < 0.001). Moreover, the magnesium group demonstrated improved oxygen saturation compared to the control group (4.55 ± 2.35 vs. 1.8 ± 1.67; P < 0.001). Furthermore, we observed a noteworthy enhancement in the quality of life and depression score in the magnesium group. No significant differences were observed in respiratory rate, fever, hs-CRP, and TNF-α levels (P > 0.05).

CONCLUSION

The findings suggest that magnesium supplementation may have beneficial effects on clinical outcomes and arterial oxygen saturation in COVID-19 patients. More investigation is necessary to delve into its potential mechanisms and long-term effects on patient outcomes.

TRIAL REGISTRATION

This study is registered on Iranian Registry of Clinical Trials (IRCT) under identifier IRCT20210413050957N1. (The registration date: May 1, 2021).

Hypertonic Aerosols Hydrate Airways Longer and Reduce Acidification Risk with Nonpermeating Cation and Permeating Anion Salts

Background: Hyperosmolar aerosols appear to promote or suppress upper airway dysfunction caused by dehydration in a composition-dependent manner. We sought to explore this composition dependence experimentally, in an interventional human clinical study, and theoretically, by numerical analysis of upper airway ion and water transport. Methods: In a double-blinded, placebo-controlled clinical study, phonation threshold pressure (PTP) was measured prenasal and postnasal inhalation of hypertonic aerosols of NaCl, KCl, CaCl2, and MgCl2 in seven human subjects. Numerical analysis of water and solute exchanges in the upper airways following deposition of these same aerosols was performed using a mathematical model previously described in the literature. Results: PTP decreased by 9%-22% relative to baseline (p < 0.05) for all salts within the first 30 minutes postadministration, indicating effective laryngeal hydration. Only MgCl2 reduced PTP beyond 90 minutes (21% below baseline at 2 hours postadministration). By numerical analysis, we determined that, while airway water volume up to 15 minutes postdeposition is dictated by osmolarity, after 30 minutes, divalent cation salts, such as MgCl2, better retain airway surface liquid (ASL) volume by slow paracellular clearance of the divalent cation. Fall of CFTR chloride flux with rise in ASL height, a promoter of airway acidification, appears to be a signature of permeating cation (NaCl) and nonpermeating anion (mannitol) aerosol deposition. For hypertonic aerosols that lack permeating cation and include permeating anion (CaCl2 and MgCl2), this acid-trigger signature does not exist. Conclusions: Nonpermeating cation and permeating anion hypertonic aerosols appear to hydrate upper airways longer and, rather than provoke, may reduce laryngeal dysfunction such as cough and bronchoconstriction.

Critical Care Management of Severe Asthma Exacerbations

Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients.

Clinical outcomes of children with acute asthma managed with intravenous magnesium sulfate outside intensive care setting

Asthma in children constitutes a well-known respiratory condition with significant mortality. In poorly controlled asthma, multiple adjunct therapies, including magnesium sulfate (MS), are recommended to decrease the likelihood of intubation; however, limited evidence exists to support their routine usage in day-to-day situations. The aim of this study is to determine the outcomes of pediatric patients treated with MS during exacerbations of asthma admitted at a tertiary care unit. A retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan, from January 2019 to December 2021. Patients aged 6 years to 15 years who presented with acute asthma through the emergency room, having a clinical respiratory score of more than 5, and were admitted to the high-dependency unit (HDU) were included in the study. Patients who were started on MS within 24 hours of admission were categorized in the MS group. Patients receiving all standard acute asthma treatment but were not started on magnesium therapy within 24 hours of admission were categorized in the non-MS group. Different outcome variables were compared between the groups. A total of 110 patients with asthma were enrolled. A total of 54 patients were categorized into the MS group, while 56 were included in the non-MS group. Fewer patients were transferred from HDU to the pediatric intensive care unit (PICU) (24.07%) in the MS group compared to the non-MS group (42.85%), (p=0.02). In the MS group, the mean number of days spent on oxygen in HDU was 2.38±0.81, while the non-MS group spent more days (3.10±0.84) (p<0.01). This study demonstrates that for pediatric patients with severe asthma exacerbations, administration of intravenous MS (within 24 hours) is beneficial, results in fewer admissions to PICU, and reduces the mean number of days spent on oxygen therapy.

Importance of Magnesium Status in COVID-19

A large amount of published research points to the interesting concept (hypothesis) that magnesium (Mg) status may have relevance for the outcome of COVID-19 and that Mg could be protective during the COVID disease course. As an essential element, Mg plays basic biochemical, cellular, and physiological roles required for cardiovascular, immunological, respiratory, and neurological functions. Both low serum and dietary Mg have been associated with the severity of COVID-19 outcomes, including mortality; both are also associated with COVID-19 risk factors such as older age, obesity, type 2 diabetes, kidney disease, cardiovascular disease, hypertension, and asthma. In addition, populations with high rates of COVID-19 mortality and hospitalization tend to consume diets high in modern processed foods, which are generally low in Mg. In this review, we review the research to describe and consider the possible impact of Mg and Mg status on COVID-19 showing that (1) serum Mg between 2.19 and 2.26 mg/dL and dietary Mg intakes > 329 mg/day could be protective during the disease course and (2) inhaled Mg may improve oxygenation of hypoxic COVID-19 patients. In spite of such promise, oral Mg for COVID-19 has thus far been studied only in combination with other nutrients. Mg deficiency is involved in the occurrence and aggravation of neuropsychiatric complications of COVID-19, including memory loss, cognition, loss of taste and smell, ataxia, confusion, dizziness, and headache. Potential of zinc and/or Mg as useful for increasing drug therapy effectiveness or reducing adverse effect of anti-COVID-19 drugs is reviewed. Oral Mg trials of patients with COVID-19 are warranted.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Correlation Between Serum Magnesium Level and Acute Exacerbation in Patients With Chronic Obstructive Pulmonary Disease (COPD)

Introduction

Although chronic obstructive pulmonary disease (COPD) is preventable and treatable, it is a major public health problem. The mortality risks are higher in patients with exacerbations. Magnesium (Mg) is crucial in numerous physiological processes, including membrane stabilization. However, incomplete information is available regarding the effect of magnesium on the frequency of acute exacerbation of COPD.

Objectives

To determine the serum magnesium level in COPD patients and its correlation with acute exacerbation of COPD.

Materials and methods

This cross-sectional study included 100 patients diagnosed with acute exacerbation of COPD. The serum magnesium level was measured in all patients with acute exacerbation of COPD at admission. Serum Mg level <1.7 mg/dl was considered hypomagnesemia. The correlation between serum magnesium level and duration of hospital stay and patient outcome was studied. 

Results

In the present study, hypomagnesemia was reported in 57% of patients with acute exacerbation of COPD. The duration of hospital stay (more than seven days) among hypomagnesemia (80.7%) patients was significantly higher than that of the normomagnesemia patients (55.8%). Mortality in patients with hypomagnesemia was higher than in patients with normomagnesemia, although not statistically significant.

Conclusion

Hypomagnesaemia is a common finding in acute exacerbation of COPD. The level of magnesium found is related to the length of hospital stay, but it is not related to mortality among patients with acute exacerbation of COPD. Further studies with larger sample sizes and extended follow-up periods are required to validate the results.

The effects of nebulized ketamine and intravenous magnesium sulfate on corticosteroid resistant asthma exacerbation; a randomized clinical trial

BACKGROUND AND AIMS

Asthma exacerbation is defined as an acute attack of shortness of breath with more than 25% decrease in morning peak flow compared to the baseline on 2 consecutive days, which requires immediate standard therapy. The majority of asthmatic patients are considered to be steroid-sensitive; however, corticosteroid-resistant asthma is a subset of asthma with poor response to corticosteroids and is responsible for frequent hospital admissions. In this study we aimed to compare the effects of two enhancing strategies, the nebulized ketamine and IV magnesium sulfate, in treatment of severe steroid resistant asthma.

MATERIALS AND METHODS

This double-blind randomized clinical trial was conducted on patients who presented to a referral clinic in Alborz, Iran. Using random allocation, patients were divided into two groups. The first group was treated with nebulized ketamine and the second group was treated with intravenous magnesium sulfate. Peak expiratory flow rates were assessed before the intervention, 30 and 60 min after the intervention and compared with the aid of SPSS software.

RESULTS

The Peak expiratory flow rates before the intervention, 30 min and 60 min after the intervention was statistically significantly different in both ketamine and magnesium sulfate groups. Peak expiratory flow rates change between 0 and 60 min were 29.4 and 15.2% in the ketamine and magnesium sulfate group respectively. Although the ketamine group showed much higher increase in mean PEFR compared to the MgSO4 groups, there was no statistically significant difference across both groups.

CONCLUSION

Our study concluded that combined with standard therapy, both ketamine and IV magnesium sulfate are effective agents in the improvement of PEFR in patients with acute severe asthma that failed to respond to traditional therapies. However, there were no statistically significant difference between the two groups.

Pyroptosis: mechanisms and diseases

Currently, pyroptosis has received more and more attention because of its association with innate immunity and disease. The research scope of pyroptosis has expanded with the discovery of the gasdermin family. A great deal of evidence shows that pyroptosis can affect the development of tumors. The relationship between pyroptosis and tumors is diverse in different tissues and genetic backgrounds. In this review, we provide basic knowledge of pyroptosis, explain the relationship between pyroptosis and tumors, and focus on the significance of pyroptosis in tumor treatment. In addition, we further summarize the possibility of pyroptosis as a potential tumor treatment strategy and describe the side effects of radiotherapy and chemotherapy caused by pyroptosis. In brief, pyroptosis is a double-edged sword for tumors. The rational use of this dual effect will help us further explore the formation and development of tumors, and provide ideas for patients to develop new drugs based on pyroptosis.

Diet Modifications in Primary Prevention of Asthma. Where Do We Stand?

The steep increase in asthma prevalence, observed worldwide in recent decades, has created an urgent need to search for effective methods of its prevention. Among other environmental factors, changes in diet habits and the potential influence of individual food components on immunological processes have been extensively studied as a potential method of intervention in primary prevention of asthma. The preventive role of some nutrients has been confirmed: unpasteurized milk reduced the risk of asthma in epidemiological studies, vitamin D supplementation was effective in preventing the transient forms of wheezing in small children and high maternal intake of fish oil reduced the risk of persistent wheeze and asthma in children. However, not all studies provided consistent results, and many food ingredients are still pending for defining their role in asthma development. Moreover, a novel approach looking not only at single food ingredients, but the whole dietary patterns and diversity has recently been proposed. In this paper, we discuss the current role of nutrients in asthma primary prevention and the reasons for inconsistencies in the study results. We look at single diet components, but also the whole dietary patterns. We describe the proposed mechanisms of action at different stages of life, identify the role of modifiers and delineate future perspectives on the application of nutrients in targeting strategies for asthma primary prevention.

'Magnesium'-the master cation-as a drug-possibilities and evidences

Magnesium (Mg²⁺) is the 2nd most abundant intracellular cation, which participates in various enzymatic reactions; there by regulating vital biological functions. Magnesium (Mg²⁺) can regulate several cations, including sodium, potassium, and calcium; it consequently maintains physiological functions like impulse conduction, blood pressure, heart rhythm, and muscle contraction. But, it doesn't get much attention in account with its functions, making it a "Forgotten cation". Like other cations, maintenance of the normal physiological level of Mg²⁺ is important. Its deficiency is associated with various diseases, which point out to the importance of Mg²⁺ as a drug. The roles of Mg²⁺ such as natural calcium antagonist, glutamate NMDA receptor blocker, vasodilator, antioxidant and anti-inflammatory agent are responsible for its therapeutic benefits. Various salts of Mg²⁺ are currently in clinical use, but their application is limited. This review collates all the possible mechanisms behind the behavior of magnesium as a drug at different disease conditions with clinical shreds of evidence.

The role of oral magnesium supplements for the management of stable bronchial asthma: a systematic review and meta-analysis

Asthma is a chronic lung disease characterized by airway inflammation and hyper-responsiveness of airway smooth muscles. There is growing evidence that magnesium may have a role in managing asthma through its dual effect as an anti-inflammatory and bronchodilating agent. To assess the efficacy of oral magnesium supplements in chronic asthmatic patients. In addition to searching through Clinicaltrials.gov/ and references for oral magnesium supplement studies, we performed a database search in Medline, CINAHL, CENTRAL, and Embase. We contacted the authors of the included trials to ask for additional information. We included randomized controlled trials that compared oral magnesium supplements versus placebo, in addition to standard asthma treatment in mild-moderate asthmatic adults and children (older than 6 years). Two reviewers independently performed the study selection, data abstraction, and the assessment of the risk of bias. Eight trials at moderate risk of bias enrolling a total of 917 patients were included. Oral magnesium improved FEV1 at week 8 (5.69 (L/min); 95% CI: 1.92, 9.46; I2: 45%). There was no significant improvement in FEV1 at other follow up periods. There was no significant change in FVC, Methacholine challenge test, the frequency of bronchodilator use, or symptoms score. There were no data on mortality or quality of life. Oral magnesium supplements may lead to improvement in FEV1 that was only demonstrated at eight weeks; but no effect on any other outcome. Until future evidence emerges, oral magnesium cannot be recommended as adjuvants to standard treatment for mild to moderate asthmatic individuals.

Efficacy of Treatment of Non-hereditary Angioedema

Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be presumably bradykinin- or mast cell-mediated, or of unknown cause. In this systematic review, we searched PubMed, EMBASE, and Scopus to provide an overview of the efficacy of different treatment options for the abovementioned subtypes of refractory non-hereditary AE with or without wheals and with normal C1INH. After study selection and risk of bias assessment, 61 articles were included for data extraction and analysis. Therapies were described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Described treatments consisted of ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab. Additionally, individual studies for anti-vitamin K, progestin, and methotrexate were found. Safety information was available in 26 articles. Most therapies were used off-label and in few patients. There is a need for additional studies with a high level of evidence. In conclusion, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.

Serum magnesium levels and its correlation with level of control in patients with asthma: A hospital-based, cross-sectional, prospective study

Context

Magnesium (Mg) is an intracellular cation which takes part in various functions including smooth muscle contractility. Studies have shown that serum Mg level has no significant effect on asthma severity. There are only sparse data on the effect of serum Mg level on asthma control.

Aims

The aim of this study was to evaluate the effect of serum Mg level on asthma control.

Settings and Design

This hospital-based cross-sectional study was conducted at the Department of Respiratory Medicine, Kasturba Medical College, Manipal.

Subjects and Methods

Our participants were adult asthma patients over 18 years of age. Asthma control was assessed using a questionnaire. Serum Mg level was estimated. The study was approved by the Institutional Ethics Committee, and informed consent was obtained from the participants.

Statistical Analysis Used

Welch's ANOVA test was used to analyze the correlation between serum Mg level and level of control of asthma.

Results

We screened 256 patients who met the inclusion criteria. After 96 patients were removed based on exclusion criteria, 160 patients were grouped into three based on the level of symptom control. Forty-eight patients belonged to the "well controlled" group, 59 in "partly controlled" group, and the remaining 53 in "uncontrolled" group. The mean serum Mg level (mg/dl) was 2.08 ± 0.37, 2.07 ± 0.28, and 1.83 ± 0.34 in well, partly, and uncontrolled groups, respectively. As the level of control of asthma decreased from well controlled to uncontrolled, the level of mean serum Mg also decreased.

Conclusions

Serum Mg levels have a positive correlation with the level of symptom control in asthma. In uncontrolled asthma, serum Mg is significantly low. Hence, it might be useful as a biomarker in assessing control or severity of asthma.

Effects of MgSO4 on inhibiting Nod-like receptor protein 3 inflammasome involve decreasing intracellular calcium

BACKGROUND

Nod-like receptor protein 3 (NLRP3) inflammasome is a multiprotein complex composed of NLRP3, caspase-1, and apoptosis-associated speck-like protein containing a caspase recruitment domain. Activation of NLRP3 inflammasome leads to interleukin-1β (IL-1β) upregulation and pyroptosis, a proinflammatory cell death characterized by increased cell size. Of note, calcium signaling is crucial for NLRP3 inflammasome activation. This study elucidated the effects of magnesium sulfate (MgSO4), a potent calcium antagonist, on modulating NLRP3 inflammasome.

MATERIALS AND METHODS

THP-1 cells, the human monocytic leukemia cell line, were treated with lipopolysaccharide (LPS, 1 μg/ml) plus nigericin (5 μM) (the LPS + Nig group) and LPS plus nigericin plus MgSO4 (20 mM) [the LPS + Nig + M(20)] to facilitate investigations. Levels of IL-1β, pyroptosis, and NLRP3 inflammasome induction as well as intracellular calcium were assayed.

RESULTS

IL-1β concentration of the LPS + Nig + M(20) group was significantly lower than the LPS + Nig group (P = 0.001). Cell size of the LPS + Nig + M(20) group was significantly smaller than the LPS + Nig group (P < 0.001). Level of pyroptotic cell death of the LPS + Nig + M(20) group was significantly lower than the LPS + Nig group (P = 0.004). NLRP3 mRNA and protein concentrations of the LPS + Nig + M(20) group were also significantly lower than the LPS + Nig group (P = 0.021 and P < 0.001). Similarly, apoptosis-associated speck-like protein containing a caspase recruitment domain speck formation ratio and caspase-1 concentration of the LPS + Nig + M(20) group were significantly lower than the LPS + Nig group (both P < 0.001). The change in intracellular calcium level of the LPS + Nig + M(20) group was significantly smaller than the LPS + Nig group (P = 0.001).

CONCLUSIONS

MgSO4 inhibits NLRP3 inflammasome, IL-1β upregulation, and pyroptosis. The mechanism is consistent with decreased intracellular calcium levels.

Inhaled magnesium sulfate in the treatment of acute asthma

BACKGROUND

Asthma exacerbations can be frequent and range in severity from mild to life-threatening. The use of magnesium sulfate (MgSO₄) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO₄ has been demonstrated, the role of inhaled MgSO₄ is less clear.

OBJECTIVES

To determine the efficacy and safety of inhaled MgSO₄ administered in acute asthma.

SPECIFIC AIMS

to quantify the effects of inhaled MgSO₄ I) in addition to combination treatment with inhaled β₂-agonist and ipratropium bromide; ii) in addition to inhaled β₂-agonist; and iii) in comparison to inhaled β₂-agonist.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Group register of trials and online trials registries in September 2017. We supplemented these with searches of the reference lists of published studies and by contact with trialists.

SELECTION CRITERIA

RCTs including adults or children with acute asthma were eligible for inclusion in the review. We included studies if patients were treated with nebulised MgSO₄ alone or in combination with β₂-agonist or ipratropium bromide or both, and were compared with the same co-intervention alone or inactive control.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial selection, data extraction and risk of bias. We made efforts to collect missing data from authors. We present results, with their 95% confidence intervals (CIs), as mean differences (MDs) or standardised mean differences (SMDs) for pulmonary function, clinical severity scores and vital signs; and risk ratios (RRs) for hospital admission. We used risk differences (RDs) to analyse adverse events because events were rare.

MAIN RESULTS

Twenty-five trials (43 references) of varying methodological quality were eligible; they included 2907 randomised patients (2777 patients completed). Nine of the 25 included studies involved adults; four included adult and paediatric patients; eight studies enrolled paediatric patients; and in the remaining four studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 25 studies; this heterogeneity made direct comparisons difficult. The quality of the evidence presented ranged from high to very low, with most outcomes graded as low or very low. This was largely due to concerns about the methodological quality of the included studies and imprecision in the pooled effect estimates. Inhaled magnesium sulfate in addition to inhaled β₂-agonist and ipratropiumWe included seven studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, results were inconsistent overall and the largest study reporting this outcome found no between-group difference at 60 minutes (MD -0.3 % predicted peak expiratory flow rate (PEFR), 95% CI -2.71% to 2.11%). Admissions to hospital at initial presentation may be reduced by the addition of inhaled magnesium sulfate (RR 0.95, 95% CI 0.91 to 1.00; participants = 1308; studies = 4; I² = 52%) but no difference was detected for re-admissions or escalation of care to ITU/HDU. Serious adverse events during admission were rare. There was no difference between groups for all adverse events during admission (RD 0.01, 95% CI -0.03 to 0.05; participants = 1197; studies = 2). Inhaled magnesium sulfate in addition to inhaled β₂-agonistWe included 13 studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, none of the pooled results showed a conclusive benefit as measured by FEV1 or PEFR. Pooled results for hospital admission showed a point estimate that favoured the combination of MgSO₄ and β₂-agonist, but the confidence interval includes the possibility of admissions increasing in the intervention group (RR 0.78, 95% CI 0.52 to 1.15; participants = 375; studies = 6; I² = 0%). There were no serious adverse events reported by any of the included studies and no between-group difference for all adverse events (RD -0.01, 95% CI -0.05 to 0.03; participants = 694; studies = 5). Inhaled magnesium sulfate versus inhaled β₂-agonistWe included four studies in this comparison. The evidence for the efficacy of β₂-agonists in acute asthma is well-established and therefore this could be considered a historical comparison. Two studies reported a benefit of β₂-agonist over MgSO₄ alone for PEFR and two studies reported no difference; we did not pool these results. Admissions to hospital were only reported by one small study and events were rare, leading to an uncertain result. No serious adverse events were reported in any of the studies in this comparison; one small study reported mild to moderate adverse events but the result is imprecise.

AUTHORS' CONCLUSIONS

Treatment with nebulised MgSO₄ may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled β₂-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO₄ has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.

The Importance of Magnesium in Clinical Healthcare

The scientific literature provides extensive evidence of widespread magnesium deficiency and the potential need for magnesium repletion in diverse medical conditions. Magnesium is an essential element required as a cofactor for over 300 enzymatic reactions and is thus necessary for the biochemical functioning of numerous metabolic pathways. Inadequate magnesium status may impair biochemical processes dependent on sufficiency of this element. Emerging evidence confirms that nearly two-thirds of the population in the western world is not achieving the recommended daily allowance for magnesium, a deficiency problem contributing to various health conditions. This review assesses available medical and scientific literature on health issues related to magnesium. A traditional integrated review format was utilized for this study. Level I evidence supports the use of magnesium in the prevention and treatment of many common health conditions including migraine headache, metabolic syndrome, diabetes, hyperlipidemia, asthma, premenstrual syndrome, preeclampsia, and various cardiac arrhythmias. Magnesium may also be considered for prevention of renal calculi and cataract formation, as an adjunct or treatment for depression, and as a therapeutic intervention for many other health-related disorders. In clinical practice, optimizing magnesium status through diet and supplementation appears to be a safe, useful, and well-documented therapy for several medical conditions.

Survey of physicians' attitudes toward the use of magnesium sulfate for acute asthma exacerbations in Turkey

BACKGROUND

Magnesium sulfate (MgSO4) is considered to be a well-tolerated, inexpensive, and effective medication for severe asthma exacerbations. We surveyed physicians who treat patients with asthma to evaluate the current knowledge and usage of MgSO4.

METHODS

A self-administered questionnaire was e-mailed to members of the Turkish National Society of Allergy and Clinical Immunology and was distributed to participants of its annual congress.

RESULTS

Of the 456 respondents (mean age: 36.53 ± 9.11 years), 42.3% reported to use MgSO4 in asthma exacerbations in their practice, and 48.7% agreed that MgSO4 was included in asthma guidelines. The best known indication was that it was useful only in patients refractory to bronchodilators and systemic corticosteroids (67.7%). The two most common reasons to use MgSO4 were to shorten hospital stay (94.7%), and prevent admission to intensive care unit (80.3%). The respondents mostly used MgSO4 in the treatment of severe or life-threatening exacerbations. Thirty-nine percent believed that MgSO4 had no effect on discharge period, and 29% of them marked minor side effects. The most common reason for not using MgSO4 was inexperience (36.5%). Having an academic affiliation (OR = 3.20, p < 0.001), the number of asthmatic outpatients seen per month (OR = 1.82, p = 0.007), and more recent graduation from medical school (≤1991) (OR = 0.23, p < 0.001) were associated with the use of MgSO4 in the multivariate analysis.

CONCLUSION

Even though the effect of MgSO4 in acute severe asthma is well known, only half of the physicians dealing with asthma patients have used it in their practice. Education and encouragement in this regard are necessary.

Bioeffects of micron-size magnesium particles on inflammatory cells and bone turnover in vivo and in vitro

Magnesium (Mg) is a promising biodegradable metal offering many potential advantages over current scaffold technologies. Many studies have reported on the corrosion characteristics the Mg and its bioeffects in vitro and in vivo, but there are few studies on the biological effects of the corrosive products of Mg - the micron-size Mg particles (MgMPs). In this study, the effects of size-selected commercial MgMPs on bone turnover and macrophages were investigated in vivo and in vitro. We found that MgMPs were susceptible to engulfment by macrophages, leading to cell lysis, likely resulting from H2 gas production. We also found that the inflammatory cytokines IL-1, IL-6, and TNF-α were induced more strongly by titanium particles (TiMPs) group than by either MgMPs or control. Examination of the expression of bone remodeling markers revealed that MgMPs are beneficial for bone regeneration. Micro-CT scanning indicated that, 30 days postimplantation, unlike TiMPs, MgMPs had no adverse effect on either bone quality or quantity. We have investigated the bioeffects of micron-size MgMPs in vivo and in vitro, and our results indicate that MgMPs may promote bone regeneration without inducing inflammation. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 923-931, 2016.

Pharmacotherapy of critical asthma syndrome: current and emerging therapies

The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.

The acute management of asthma

Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.

Role of Cellular Magnesium in Human Diseases

Magnesium is required for many of the major organs to function and plays a crucial role in human and mammalian physiology. Magnesium is essential for the structure of bones and teeth, acts as a cofactor for more than 300 enzymes in the body, including binding to ATP for kinase reactions, and affects permeability of excitable membranes and neuromuscular transmission. Despite these essential roles, much is still unknown about magnesium physiology and homeostasis. Currently, nutritionists believe that the general population intakes insufficient magnesium daily through the diet. The effects of magnesium deficiency are, for the most part undetected, and simple, widespread assessments of magnesium intake remain unavailable for humans. Many of the patients admitted to hospitals or medical care facilities are unaware of their low magnesium levels. Moreover, because magnesium is predominantly an intracellular cation (>99%), serum magnesium levels remain a poor predictor of tissue magnesium content and availability. This review will discuss the effects of magnesium deficiency in various pathologies affecting the human population. The underlying causes for magnesium depletion in major physiological systems will be examined along with the involved signaling pathways and the main roles of magnesium homeostasis. Where possible (e.g. alcoholism), the implications of administering supplemental magnesium will be discussed. Ultimately, this review will advocate for the necessity of identifying easy and reproducible methods to assess serum and cellular magnesium levels and to identify magnesium deficiency in order to alleviate related pathological conditions.

Medical emergencies: pulmonary embolism and acute severe asthma

In this, the second of two articles covering specific medical emergencies, we discuss the definitions, epidemiology, pathophysiology, acute and chronic management of pulmonary embolus and acute severe asthma.