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Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, Stang AS, Rowe BH, Johnson DW, Allain D, Klassen TP, Hartling L. Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis. BMJ Open 2019; 9:e028511. [PMID: 31375615 PMCID: PMC6688746 DOI: 10.1136/bmjopen-2018-028511] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children. DESIGN Systematic review of primary studies. DATA SOURCES Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017. ELIGIBILITY CRITERIA Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days. DATA EXTRACTION AND SYNTHESIS One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose. RESULTS Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events. CONCLUSIONS Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.
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Affiliation(s)
- Ricardo M Fernandes
- Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
- Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Laboratory of Clinical Pharmacology and Therapeutics, Lisbon, Portugal
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Samina Ali
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children's Health Research Institute, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonia S Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - David W Johnson
- Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dominic Allain
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Terry P Klassen
- Manitoba Institute of Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Corticosteroids, delivered systemically and by inhalation, are widely used for the treatment of multiple acute respiratory illnesses in children. However, the level of evidence to support the utility of this therapy varies between these different acute respiratory illnesses. OBJECTIVE To summarize the evidence regarding the utility of corticosteroids in the management of common acute pediatric respiratory conditions and to highlights the controversies regarding their use. METHODS Literature search of manuscripts describing the evidence regarding the efficacy of corticosteroids (systemic and inhaled) in the management of: acute asthma exacerbation among school age children, acute episodic wheeze among preschool children, viral croup, and acute viral bronchiolitis. RESULTS Current evidence indicates that systemic corticosteroids provide benefits for the treatment of acute asthma exacerbations in school age children, mainly in the acute care setting. In addition, high dose inhaled corticosteroid therapy administered in the Emergency Department appears to have comparable effect for the prevention of asthma-related hospital admission as systemic corticosteroids in this age group. In contrast, most available studies have not shown benefit for systemic corticosteroids during acute wheezing episodes in preschool children. Systemic corticosteroids decrease symptoms and the rate of hospital admissions in patients with severe croup; however, corticosteroids have no role in the treatment of acute bronchiolitis and their use in this condition should be discouraged. CONCLUSION Corticosteroids treatment response varies between the acute respiratory illnesses presented in this review. Future research should aim to fill the current gaps-of-knowledge regarding the utility this intervention such as the identification of specific wheezing phenotypes among preschool children which might benefit from systemic corticosteroids as a treatment for acute viral wheeze.
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Affiliation(s)
- Avraham Beigelman
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri, USA
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Ducharme FM, Ochs HD, Resendes S, Zhang X, Mazer BD. A Short Burst of Oral Corticosteroid for Children with Acute Asthma: Is There an Impact on Immunity? Pediatric Allergy, Immunology, and Pulmonology 2010. [DOI: 10.1089/ped.2010.0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Francine M. Ducharme
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
- Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Hans D. Ochs
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Sandy Resendes
- Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Xun Zhang
- Research Institute, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Bruce D. Mazer
- Service of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
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Abstract
A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.
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Affiliation(s)
- Peggy B Hasley
- University of Pittsburgh School of Medicine, PA 15213, USA.
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Rigourd V, Leclainche L, Timsit S, De Blic J, Scheinmann P, Paupe J. [An unusual foreign body. Report of a case of subcutaneous emphysema during an asthma attack]. ACTA ACUST UNITED AC 2005; 38:709-712. [PMID: 32287955 PMCID: PMC7143691 DOI: 10.1016/s0335-7457(98)80140-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/1998] [Accepted: 07/07/1998] [Indexed: 10/28/2022]
Abstract
Pneumomediastinum is an uncommon complication after an asthma attack. The essential clinical sign is the presence of subcutaneous emphysema. In the great majority of cases, the treatment of pneumomediastinum corresponds to that of asthma, with resorption over several days. The situation is very different when the development of pneumomediastinum and subcutaneous emphysema is secondary to an aspiration syndrome.
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Affiliation(s)
- V Rigourd
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
| | - L Leclainche
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
| | - S Timsit
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
| | - J De Blic
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
| | - P Scheinmann
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
| | - J Paupe
- Service de Pneumologie-Allergologie, Hôpital Necker - Enfants Malades, 149, rue de Sèvres, 75743 PARIS Cedex 15, France
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Abstract
BACKGROUND Lack of information about medication effects and use in children is a long-standing and troublesome policy issue. Documenting patterns of use for medications with potential for suboptimal use and adverse effects, such as oral corticosteroids, would be useful. OBJECTIVE To describe the use of oral corticosteroids among children enrolled in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured individuals. DESIGN A retrospective cohort study. DRUG EXPOSURE: Children enrolled in TennCare who had prescriptions filled in their name for oral corticosteroids during 1998 were identified. Descriptive information included age, race, sex, and county of residence. We identified possible indications for corticosteroid use for new users by searching encounter files for encounters temporally related to the index prescription. Subsequent use of corticosteroids was measured in the 365 days after the index prescription. RESULTS Of 400 724 children continuously enrolled in TennCare during the study period, 29 362 (7327 per 100 000) children had a prescription filled for an oral corticosteroid. Steroid prescription filling was more common among young children and male children and less common among black children. Children in rural counties had oral corticosteroid prescriptions filled at a higher rate than children residing in urban counties. Nearly 75% of corticosteroid users filled only 1 prescription during the study period; 1319 children filled 4 or more prescriptions. Asthma was the most common indication for oral corticosteroid use (16%), whereas 1 in 5 users (22%) had an unknown indication for oral corticosteroid use. CONCLUSIONS A large number of children enrolled in TennCare had a prescription for oral corticosteroids filled in 1998. Further population-based studies describing the development of adverse effects in users of corticosteroids would be important.
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Affiliation(s)
- William O Cooper
- Division of General Pediatrics/Department of Pediatrics, Vanderbilt University School of Medicine, Suite 5028 MCE, Nashville, TN 37232-8555, USA.
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Abstract
Inhaled corticosteroids remain the primary long-term treatment for controlling childhood asthma. Sodium cromoglycate (cromolyn sodium) and nedocromil sodium are both well tolerated, but usually less effective, alternatives to corticosteroids. Long-acting beta(2)-agonists (beta(2)-adrenoceptor agonists) may be useful adjuncts in patients already receiving inhaled corticosteroids who require frequent use of short-acting bronchodilators or experience nocturnal exacerbations (i.e. overall asthma control suboptimal). Theophylline has bronchodilator and anti-inflammatory effects and may also be used as an adjunct to inhaled corticosteroids. Leukotriene receptor antagonists are now an alternative as monotherapy in young children with mild persistent asthma, or as adjunctive therapy with inhaled corticosteroids as well. Short-acting inhaled beta(2)-agonists or other short-acting bronchodilators should be used as needed for acute episodes. For inhaled delivery, metered-dose inhalers with spacer devices (holding chambers) may be used as the delivery system in many patients, but the choice of inhalation method must be individualised, based largely on patient acceptance and compliance. Systemic corticosteroids may be used to gain prompt control when initiating long-term therapy in patients with severe, persistent asthma that does not respond to inhaled medication or in patients who are unable to take inhaled medication. The anti-immunoglobulin E antibody, omalizumab, is a novel therapy that attacks a fundamental immunopathological process of asthma and has shown promising results in several clinical trials.
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Affiliation(s)
- R F Lemanske
- University of Wisconsin Children's Hospital, H4/432, 600 Highland Avenue, Madison, WI 53792, USA.
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Becker JM, Arora A, Scarfone RJ, Spector ND, Fontana-Penn ME, Gracely E, Joffe MD, Goldsmith DP, Malatack JJ. Oral versus intravenous corticosteroids in children hospitalized with asthma. J Allergy Clin Immunol 1999; 103:586-90. [PMID: 10200005 DOI: 10.1016/s0091-6749(99)70228-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with beta-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. OBJECTIVE The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. METHODS We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before beta-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. RESULTS Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group (P =.52). Children in the prednisone group were successfully weaned to beta-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group (P =.47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group (P =.04). CONCLUSION There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings.
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Affiliation(s)
- J M Becker
- Department of Pediatrics, MCP Hahnemann School of Medicine, Pennsylvania, Philadelphia, USA
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Davis H, Gergen PJ, Graham DJ. The risk for outpatient antibiotic-treated infections following a course of oral corticosteroids among children with asthma. J Asthma 1998; 35:419-25. [PMID: 9734349 DOI: 10.3109/02770909809048950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Short courses of oral corticosteroids are widely used to treat asthma. The objective of this study was to assess if one course of oral corticosteroids increases asthmatic children's risk for infections treated with outpatient antibiotics. Using New York State Medicaid claims data on asthmatic children 2-15 years old, we made cohorts of oral corticosteroid users and nonusers. We determined the percentage of children who filled antibiotic prescriptions in the 30 days after index dates. Index dates were dates oral steroids were started (for steroid users) or matched dates (for nonusers). Odds ratios were adjusted for age, month of index date, and prior antibiotic use. Among children not receiving antibiotics on index dates, antibiotic prescriptions were filled in the next 30 days for 438 (20%) of 2145 steroid nonusers and 130 (19%) of 698 steroid users (p=0.30); compared to nonusers, steroid users had an adjusted odds ratio of subsequent antibiotic use of 0.92 (95% confidence interval [CI] 0.73-1.15). Among children receiving antibiotics on index dates, antibiotic prescriptions were filled in the next 30 days for 116 (26%) of 451 steroid nonusers and 50 (19%) of 260 steroid users (p=0.05); compared to nonusers, steroid users had an adjusted odds ratio of subsequent antibiotic use of 0.65 (95% CI 0.53-0.97). We conclude that one course of oral corticosteroids does not increase asthmatic children's risk for infections treated with outpatient antibiotics.
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Affiliation(s)
- H Davis
- Office of Epidemiology and Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Rockville, Maryland 20857, USA.
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Winker MA. A global theme issue: bibliography of references. Emerg Infect Dis 1996; 2:365-72. [PMID: 9011382 PMCID: PMC2639924 DOI: 10.3201/eid0204.960422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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