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Elzayat S, Elgendy A, Lasheen H, El-Deeb ME, Aouf MM, Gehad I. The role of budesonide intrapolyp injection in the management of type 2 chronic rhinosinusitis with nasal polyps: a randomised clinical trial. J Laryngol Otol 2024; 138:416-424. [PMID: 37781760 DOI: 10.1017/s0022215123001688] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
PROBLEM To assess the efficacy of budesonide intrapolyp injection in chronic rhinosinusitis with nasal polyps. METHOD Ninety patients were divided into three groups; group A was given oral prednisolone, group B was given budesonide intrapolyp injection weekly for five consecutive weeks and group C was given budesonide as nasal irrigation for one month. Patients were assessed using Sino-Nasal Outcome Test 22 score, total nasal polyp score, serum immunoglobulin E, absolute eosinophilic count, and morning cortisol level before treatment, one week and three months after completing their treatment. RESULTS Total nasal polyp score decreased significantly in all groups compared to those at baseline. Reduction in the oral and injection groups was greater than the wash group (p2 = 0.004), (p3 < 0.001), and the same trend concerning Sino-Nasal Outcome Test 22 score (p2 < 0.001), (p3 < 0.001). CONCLUSION Budesonide is an effective agent used in intrapolyp injection with no documented systemic or visual side effects that has comparable results with oral steroids.
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Affiliation(s)
- Saad Elzayat
- Otorhinolaryngology Department, Faculty of Medicine - Kafrelsheikh University, Kafr ElSheikh, Egypt
| | - Ahmed Elgendy
- Otorhinolaryngology Department, Faculty of Medicine - Kafrelsheikh University, Kafr ElSheikh, Egypt
| | - Hesham Lasheen
- Otorhinolaryngology Department, Faculty of Medicine - Cairo University, Cairo, Egypt
| | - Mohamed E El-Deeb
- Otorhinolaryngology Department, Faculty of Medicine - Kafrelsheikh University, Kafr ElSheikh, Egypt
| | - Mohammad Mahmoud Aouf
- Otorhinolaryngology Department, Faculty of Medicine - Kafrelsheikh University, Kafr ElSheikh, Egypt
| | - Ibrahim Gehad
- Otorhinolaryngology Department, Faculty of Medicine - Kafrelsheikh University, Kafr ElSheikh, Egypt
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D'Amico F, Fasulo E, Jairath V, Paridaens K, Peyrin-Biroulet L, Danese S. Management and treatment optimization of patients with mild to moderate ulcerative colitis. Expert Rev Clin Immunol 2024; 20:277-290. [PMID: 38059454 DOI: 10.1080/1744666x.2023.2292768] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/05/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Ulcerative colitis (UC) is a chronic inflammatory bowel disease with a significant health-care burden worldwide. While medical therapy aims to induce and maintain remission, optimal management of mild to moderate UC remains challenging due to heterogeneity in severity classifications and non-standardized approaches. This comprehensive review summarizes current evidence and knowledge gaps to optimize clinical decision-making in patients with mild to moderate UC. AREAS COVERED After an extensive literature search of PubMed, Medline, and Embase through August 2023, we provide an overview of definitions utilized to characterize mild to moderate UC severity and established therapeutic targets. Current medical treatments including mesalazine formulations, corticosteroids, and their combinations are surveyed. The role of emerging intestinal ultrasound, telemedicine, and home testing is explored. Individualized, patient-centered paradigms aiming to streamline care delivery through proactive identification of relapses are also examined. EXPERT OPINION Addressing inconsistencies in disease activity stratification will better align tailored regimens with each patient's profile. Advancing noninvasive technologies like ultrasound criteria and home testing could improve UC management by enabling personalized models. Realizing individualized plans through informed shared-decision making between health-care providers and fully engaged patients holds promise to maximize quality of life outcomes. Continuous improvement relies on innovation bridging different domains to overcome current limitations and push the field toward more predictive and tailored care.
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Affiliation(s)
- Ferdinando D'Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ernesto Fasulo
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Nancy, France
- INSERM, NGERE, University of Lorraine, Nancy, France
- INFINY Institute, Nancy University Hospital, Nancy, France
- FHU-CURE, Nancy University Hospital, Nancy, France
- Groupe Hospitalier privé Ambroise Paré - Hartmann, Paris IBD center, Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
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Wimbury D, Muto M, Bhachu JS, Scionti K, Brown J, Molyneux K, Seikrit C, Maixnerová D, Pérez-Alós L, Garred P, Floege J, Tesař V, Fellstrom B, Coppo R, Barratt J. Targeted-release budesonide modifies key pathogenic biomarkers in immunoglobulin A nephropathy: insights from the NEFIGAN trial. Kidney Int 2024; 105:381-388. [PMID: 38008160 DOI: 10.1016/j.kint.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/28/2023]
Affiliation(s)
- David Wimbury
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Masahiro Muto
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Jasraj S Bhachu
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Katrin Scionti
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jeremy Brown
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Karen Molyneux
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Claudia Seikrit
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Dita Maixnerová
- Department of Nephrology, 1st Faculty of Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Laura Pérez-Alós
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet, Copenhagen, Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet, Copenhagen, Denmark
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Vladimír Tesař
- Department of Nephrology, 1st Faculty of Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Bengt Fellstrom
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Jonathan Barratt
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Silva BRC, Tyler MA, Ma Y, Wang J, Nayak JV, Patel ZM, Hwang PH. Incidence of hypocortisolism with long-term budesonide irrigation for chronic rhinosinusitis. Int Forum Allergy Rhinol 2024; 14:78-85. [PMID: 37389470 DOI: 10.1002/alr.23227] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/05/2023] [Accepted: 06/28/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Budesonide irrigations (BIs) are commonly used to control inflammation in chronic rhinosinusitis (CRS). In 2016 we reported an analysis of long-term BI with regard to hypothalamic-pituitary-adrenal axis function. We present a follow-up analysis in a larger cohort of patients with longer follow-up. METHODS Patients were candidates for stimulated cortisol testing after regularly performing BI for CRS at least daily for ≥6 months. We retrospectively evaluated all patients who received stimulated cortisol testing at our center between 2012 and 2022. We correlated cortisol levels with the use of BI and other forms of corticosteroids. RESULTS We analyzed 401 cortisol test results in 285 patients. The mean duration of use was 34 months. Overall, 21.8% of patients were hypocortisolemic (<18 ug/dL) at first test. In patients who used only BI, the rate of hypocortisolemia was 7.5%, whereas in patients who also used concurrent oral and inhaled corticosteroids, the rate was 40% to 50%. Lower cortisol levels were associated with male sex (p < 0.0001) and concomitant use of oral and inhaled steroids (p < 0.0001). Duration of BI use was not significantly associated with lower cortisol levels (p = 0.701), nor was greater dosing frequency (p = 0.289). CONCLUSION Prolonged use of BI alone is not likely to cause hypocortisolemia in the majority of patients. However, concomitant use of inhaled and oral steroids and male sex may be associated with hypocortisolemia. Surveillance of cortisol levels may be considered in vulnerable populations who use BI regularly, particularly in patients using other forms of corticosteroids with known systemic absorption.
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Affiliation(s)
- Bruna R C Silva
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yifei Ma
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jane Wang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jayakar V Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zara M Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter H Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Rathi VK, Sawicki NW, Schlosser RJ, Soler ZM, Scangas GA, Workman AD, Gray ST. Adverse events associated with budesonide nasal irrigation reported to the US Food and Drug Administration: 2007 to 2022. Int Forum Allergy Rhinol 2024; 14:123-126. [PMID: 37394843 DOI: 10.1002/alr.23232] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/04/2023]
Abstract
KEYPOINTS Between 2007 and 2022, the FDA received 119 US-based reports mentioning budesonide nasal irrigation. Most reports were submitted by patients and alerted FDA to off-label usage of budesonide. Notable adverse events reported to the FDA included headache, dyspnea, and blurred vision.
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Affiliation(s)
- Vinay K Rathi
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - George A Scangas
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
| | - Alan D Workman
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
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Abstract
IgA nephropathy (IgAN) is the most frequent primary form of glomerulonephritis. The origin of IgAN is only partially understood and appears to involve the occurrence of IgA1, which is normally secreted by mucous membranes, in the circulation followed by its glomerular deposition and inflammatory changes. Clinically, IgAN mostly follows an inapparent course and the disease is often only first diagnosed by kidney biopsy when kidney function disorders are already manifested. Key prognostic indicators include the extent of proteinuria and the already manifested evidence of irreversible kidney damage. Treatment includes supportive measures. The effectiveness of high-dose systemic corticosteroid treatment in European patients is uncertain and controversial due to the adverse side effects. Nefecon (encapsulated budesonide) is the first specific drug licensed for treatment of high risk IgAN patients. A number of further approaches are currently in clinical trials.
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Affiliation(s)
- Jürgen Floege
- Medizinische Klinik II, Uniklinik der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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Mukkada VA, Gupta SK, Gold BD, Dellon ES, Collins MH, Katzka DA, Falk GW, Williams J, Zhang W, Boules M, Hirano I, Desai NK. Pooled Phase 2 and 3 Efficacy and Safety Data on Budesonide Oral Suspension in Adolescents with Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 77:760-768. [PMID: 37718471 PMCID: PMC10642696 DOI: 10.1097/mpg.0000000000003948] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/07/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the efficacy and safety of budesonide oral suspension (BOS) in adolescents with eosinophilic esophagitis (EoE). METHODS This post hoc analysis pooled data from two 12-week, randomized, double-blind, placebo-controlled studies of BOS 2.0 mg twice daily (b.i.d.) (phase 2, NCT01642212; phase 3, NCT02605837) in patients aged 11-17 years with EoE and dysphagia. Efficacy endpoints included histologic (≤6, ≤1, and <15 eosinophils per high-power field [eos/hpf]), dysphagia symptom (≥30% reduction in Dysphagia Symptom Questionnaire [DSQ] scores from baseline), and clinicopathologic (≤6 eos/hpf and ≥30% reduction in DSQ scores from baseline) responses at week 12. Change from baseline to week 12 in peak eosinophil counts, DSQ scores, EoE Histology Scoring System (EoEHSS) grade (severity) and stage (extent) total score ratios (TSRs), and total EoE Endoscopic Reference Scores (EREFS) were assessed. Safety outcomes were also examined. RESULTS Overall, 76 adolescents were included (BOS, n = 45; placebo, n = 31). Significantly more patients who received BOS than placebo achieved histologic responses (≤6 eos/hpf: 46.7% vs 6.5%; ≤1 eos/hpf: 42.2% vs 0.0%; <15 eos/hpf: 53.3% vs 9.7%; P < 0.001) and a clinicopathologic response (31.1% vs 3.2%; P = 0.003) at week 12. More BOS-treated than placebo-treated patients achieved a dysphagia symptom response at week 12 (68.9% vs 58.1%; not statistically significant P = 0.314). BOS-treated patients had significantly greater reductions in EoEHSS grade and stage TSRs ( P < 0.001) and total EREFS ( P = 0.021) from baseline to week 12 than placebo-treated patients. BOS was well tolerated, with no clinically meaningful differences in adverse events versus placebo. CONCLUSIONS BOS 2.0 mg b.i.d. significantly improved most efficacy outcomes in adolescents with EoE versus placebo.
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Affiliation(s)
- Vincent A Mukkada
- From the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sandeep K Gupta
- the Section of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
- the Community Health Network, Indianapolis, IN
| | - Benjamin D Gold
- the GI Care for Kids, LLC, Children's Center for Digestive Healthcare, Atlanta, GA
| | - Evan S Dellon
- the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Margaret H Collins
- the Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David A Katzka
- the Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Gary W Falk
- the Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - James Williams
- the Takeda Development Center Americas, Inc., Cambridge, MA
| | - Wenwen Zhang
- the Takeda Development Center Americas, Inc., Cambridge, MA
| | - Mena Boules
- the Takeda Pharmaceuticals USA, Inc., Lexington, MA
| | - Ikuo Hirano
- the Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nirav K Desai
- the Takeda Development Center Americas, Inc., Cambridge, MA
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Zhang L, Yuan S, Pan C, Zhang J, Wu J, Yin Y. Outcomes of Holmium Laser, Cryoablation, and Budesonide Inhalation for Treating Severe Central Airway Stenosis in Infants. J INVEST SURG 2023; 36:2257792. [PMID: 37733404 DOI: 10.1080/08941939.2023.2257792] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Central airway stenosis (CAS) in infants is characterized by dysphonia, dyspnea, cyanosis, repeated apnea, and infection. This case series study aimed to evaluate the safety and efficacy of holmium laser, cryoablation and budesonide inhalation in treating infants with severe CAS. METHODS This retrospective study reviewed medical records data of 28 infants with severe CAS who underwent holmium laser treatment with cryoablation and/or balloon dilatation and budesonide inhalation therapy at Shanghai Children's Medical Center between June 2014 and May 2020. Outcomes were defined as treatment success when the stenotic area was <25% for the normal age group with stable reopening diameter at one-year follow-up. RESULTS Patients' mean age was 12.8 ± 8.8 months and 17 (60%) were male. Sixteen cases had web-like stenosis and 12 had scar contracture stenosis. Among 16 patients with web-like stenosis, 8 (50%) underwent balloon dilation with cryotherapy and 8 (50%) underwent balloon dilation only; treatment success was achieved in 10 (62.5%) cases and after revised treatments in 5 (31.25%) cases. Among 12 patients with scar contracture stenosis, 6 (50%) underwent balloon dilation with cryotherapy, 4 (33.3%) underwent cryotherapy and 2 (16.7%) underwent balloon dilation only; treatment success was achieved in 3 (23.1%) cases and after 1-4 revised treatments in 8 (61.5%) cases. Symptoms of the 2 unsuccessful (7.1%) cases were relieved after tracheal stent insertion. Neither severe adverse events nor complications were observed during follow-up. CONCLUSION Holmium laser with cryoablation followed by budesonide inhalation therapy safely and effectively cleans stenotic tissues and maintains airway reopening. Balloon dilation after holmium laser is recommended for treating web-like stenosis.
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Affiliation(s)
- Lei Zhang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuhua Yuan
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chunhong Pan
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Zhang
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jinhong Wu
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yong Yin
- Department of Respiratory Medicine, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Obrișcă B, Vornicu A, Mocanu V, Dimofte G, Andronesi A, Bobeică R, Jurubiță R, Sorohan B, Caceaune N, Ismail G. An open-label study evaluating the safety and efficacy of budesonide in patients with IgA nephropathy at high risk of progression. Sci Rep 2023; 13:20119. [PMID: 37978255 PMCID: PMC10656480 DOI: 10.1038/s41598-023-47393-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
We sought to evaluate the efficacy and safety of budesonide (Budenofalk) in the treatment of patients with IgA Nephropathy. We conducted a prospective, interventional, open-label, single-arm, non-randomized study that enrolled 32 patients with IgAN at high risk of progression (BUDIGAN study, ISRCTN47722295, date of registration 14/02/2020). Patients were treated with Budesonide at a dose of 9 mg/day for 12 months, subsequently tapered to 3 mg/day for another 12 months. The primary endpoints were change of eGFR and proteinuria at 12, 24 and 36 months. The study cohort had a mean eGFR and 24-h proteinuria of 59 ± 24 ml/min/1.73m2 and 1.89 ± 1.5 g/day, respectively. Treatment with budesonide determined a reduction in proteinuria at 12-, 24- and 36-months by -32.9% (95% CI - 53.6 to - 12.2), - 49.7% (95% CI - 70.1 to - 29.4) and - 68.1% (95% CI - 80.6 to - 55.7). Budesonide determined an eGFR preservation corresponding to a 12-, 24- and 36-months change of + 7.68% (95% CI - 4.7 to 20.1), + 7.42% (95% CI - 7.23 to 22.1) and + 4.74% (95%CI - 13.5 to 23), respectively. The overall eGFR change/year was + 0.83 ml/min/y (95% CI - 0.54 to 4.46). Budesonide was well-tolerated, and treatment emergent adverse events were mostly mild in severity and reversible. Budesonide was effective in the treatment of patients with IgAN at high-risk of progression in terms of reducing proteinuria and preserving renal function over 36 months of therapy.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Valentin Mocanu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - George Dimofte
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
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Strange C, Tkacz J, Schinkel J, Lewing B, Agatep B, Swisher S, Patel S, Edwards D, Touchette DR, Portillo E, Feigler N, Pollack M. Exacerbations and Real-World Outcomes After Single-Inhaler Triple Therapy of Budesonide/Glycopyrrolate/Formoterol Fumarate, Among Patients with COPD: Results from the EROS (US) Study. Int J Chron Obstruct Pulmon Dis 2023; 18:2245-2256. [PMID: 37849918 PMCID: PMC10577086 DOI: 10.2147/copd.s432963] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/01/2023] [Indexed: 10/19/2023] Open
Abstract
Purpose Triple therapy to prevent exacerbations from chronic obstructive pulmonary disease (COPD) is associated with improved health compared to single and dual-agent therapy in some populations. This study assessed the benefits of prompt administration of budesonide/glycopyrrolate/formoterol fumarate (BGF) following a COPD exacerbation. Patients and methods EROS was a retrospective analysis of people with COPD using the MORE2 Registry®. Inclusion required ≥1 severe, ≥2 moderate, or ≥1 moderate exacerbation while on other maintenance treatment. Within 12 months following the index exacerbation, ≥1 pharmacy claim for BGF was required. Primary outcomes were the rate of COPD exacerbations and healthcare costs for those that received BGF promptly (within 30 days of index exacerbation) versus delayed (31-180 days) and very delayed (181-365 days). The effect of each 30-day delay in initiation of BGF was estimated using a multivariable negative binomial regression model. Results 2409 patients were identified: 434 prompt, 1187 delayed, and 788 very delayed. The rate (95% CI) of total exacerbations post-index increased as time to BGF initiation increased: prompt 1.52 (1.39-1.66); delayed 2.00 (1.92-2.09); and very delayed 2.30 (2.20-2.40). Adjusting for patient characteristics, each 30-day delay in receiving BGF was associated with a 5% increase in the average number of subsequent exacerbations (rate ratio, 95% CI: 1.05, 1.01-1.08; p<0.05). Prompt initiation of BGF was also associated with lower post-index annualized COPD-related costs ($5002 for prompt vs $7639 and $8724 for the delayed and very delayed groups, respectively). Conclusion Following a COPD exacerbation, promptly initiating BGF was associated with a reduction in subsequent exacerbations and reduced healthcare utilization and costs.
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Affiliation(s)
- Charlie Strange
- College of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | - Sean Swisher
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Sushma Patel
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | | | - Daniel R Touchette
- College of Pharmacy - Pharmacy Systems Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
| | - Edward Portillo
- Pharmacy Practice & Translational Research Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Norbert Feigler
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Michael Pollack
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
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11
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Svendsen SV, Bindslev-Jensen C, Mortz CG. Contact allergy to corticosteroids: Is the European baseline series sufficient? Contact Dermatitis 2023; 89:277-283. [PMID: 37321366 DOI: 10.1111/cod.14358] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/27/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Patients are consecutively screened for contact allergy to corticosteroids with budesonide and tixocortol-21-pivalate in the European baseline series. Centres using TRUE Test also include hydrocortisone-17-butyrate. A supplementary corticosteroid patch test series is used in case of suspicion of corticosteroid contact allergy or when a marker of corticosteroid contact allergy is positive. OBJECTIVE The aims were to evaluate (1) the efficacy of corticosteroids in the TRUE Test and (2) co-sensitization patterns. METHODS This retrospective study analysed patients patch tested with TRUE Test corticosteroids plus supplementary corticosteroid series in the period 2006-2020 at the Department of Dermatology and Allergy Centre, Odense University Hospital. RESULTS Of 1852 patients tested, 119 were sensitised to TRUE Test corticosteroids and supplementary testing found additional reactions to other corticosteroids in 19 of 119 patients. TRUE Test corticosteroids gave more positive and stronger reactions compared to allergens in petrolatum/ethanol. Fourteen percent of sensitised patients were co-sensitised to multiple corticosteroid groups. Baeck group 3 corticosteroids accounted for 9 of 16 patients not identified by TRUE Test. CONCLUSIONS Budesonide, hydrocortisone-17-butyrate, and tixocortol-21-pivalate in combination are sensitive corticosteroid markers. In case of clinical suspicion of corticosteroid contact allergy, patch testing with supplementary corticosteroids is highly recommended.
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Affiliation(s)
- Sebastian Vigand Svendsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
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12
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Lafayette R, Kristensen J, Stone A, Floege J, Tesař V, Trimarchi H, Zhang H, Eren N, Paliege A, Reich HN, Rovin BH, Barratt J. Efficacy and safety of a targeted-release formulation of budesonide in patients with primary IgA nephropathy (NefIgArd): 2-year results from a randomised phase 3 trial. Lancet 2023; 402:859-870. [PMID: 37591292 DOI: 10.1016/s0140-6736(23)01554-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND IgA nephropathy is a chronic immune-mediated kidney disease and a major cause of kidney failure worldwide. The gut mucosal immune system is implicated in its pathogenesis, and Nefecon is a novel, oral, targeted-release formulation of budesonide designed to act at the gut mucosal level. We present findings from the 2-year, phase 3 NefIgArd trial of Nefecon in patients with IgA nephropathy. METHODS In this phase 3, multicentre, randomised, double-blind, placebo-controlled trial, adult patients (aged ≥18 years) with primary IgA nephropathy, estimated glomerular filtration rate (eGFR) 35-90 mL/min per 1·73 m2, and persistent proteinuria (urine protein-creatinine ratio ≥0·8 g/g or proteinuria ≥1 g/24 h) despite optimised renin-angiotensin system blockade were enrolled at 132 hospital-based clinical sites in 20 countries worldwide. Patients were randomly assigned (1:1) to receive 16 mg/day oral capsules of Nefecon or matching placebo for 9 months, followed by a 15-month observational follow-up period off study drug. Randomisation via an interactive response technology system was stratified according to baseline proteinuria (<2 or ≥2 g/24 h), baseline eGFR (<60 or ≥60 mL/min per 1·73 m2), and region (Asia-Pacific, Europe, North America, or South America). Patients, investigators, and site staff were masked to treatment assignment throughout the 2-year trial. Optimised supportive care was also continued throughout the trial. The primary efficacy endpoint was time-weighted average of eGFR over 2 years. Efficacy and safety analyses were done in the full analysis set (ie, all randomly assigned patients). The trial was registered on ClinicalTrials.gov, NCT03643965, and is completed. FINDINGS Patients were recruited to the NefIgArd trial between Sept 5, 2018, and Jan 20, 2021, with 364 patients (182 per treatment group) randomly assigned in the full analysis set. 240 (66%) patients were men and 124 (34%) were women, and 275 (76%) identified as White. The time-weighted average of eGFR over 2 years showed a statistically significant treatment benefit with Nefecon versus placebo (difference 5·05 mL/min per 1·73 m2 [95% CI 3·24 to 7·38], p<0·0001), with a time-weighted average change of -2·47 mL/min per 1·73 m2 (95% CI -3·88 to -1·02) reported with Nefecon and -7·52 mL/min per 1·73 m2 (-8·83 to -6·18) reported with placebo. The most commonly reported treatment-emergent adverse events during treatment with Nefecon were peripheral oedema (31 [17%] patients, vs placebo, seven [4%] patients), hypertension (22 [12%] vs six [3%]), muscle spasms (22 [12%] vs seven [4%]), acne (20 [11%] vs two [1%]), and headache (19 [10%] vs 14 [8%]). No treatment-related deaths were reported. INTERPRETATION A 9-month treatment period with Nefecon provided a clinically relevant reduction in eGFR decline and a durable reduction in proteinuria versus placebo, providing support for a disease-modifying effect in patients with IgA nephropathy. Nefecon was also well tolerated, with a safety profile as expected for a locally acting oral budesonide product. FUNDING Calliditas Therapeutics.
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Affiliation(s)
- Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA.
| | | | | | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen University Hospital, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Necmi Eren
- Department of Nephrology, Kocaeli University, Kocaeli, Turkey
| | - Alexander Paliege
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Heather N Reich
- Division of Nephrology, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jonathan Barratt
- College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK
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13
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Peng S, Tan C, Du L, Niu Y, Liu X, Wang R. Effect of fracture risk in inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2023; 23:304. [PMID: 37592316 PMCID: PMC10436625 DOI: 10.1186/s12890-023-02602-5] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The fracture risk of patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids is controversial. And some large-scale randomized controlled trials have not solved this problem. The purpose of our systematic review and meta-analysis including 44 RCTs is to reveal the effect of inhaled corticosteroids on the fracture risk of COPD patients. METHODS Two reviewers independently retrieved randomized controlled trials of inhaled corticosteroids or combinations of inhaled corticosteroids in the treatment of COPD from PubMed, Embase, Medline, Cochrane Library, and Web of Science. The primary outcome was a fracture event. This study was registered at PROSPERO (CRD42022366778). RESULTS Forty-four RCTs were performed in 87,594 patients. Inhaled therapy containing ICSs (RR, 1.19; 95%CI, 1.04-1.37; P = 0.010), especially ICS/LABA (RR, 1.30; 95%CI, 1.10-1.53; P = 0.002) and triple therapy (RR, 1.49; 95%CI, 1.03-2.17; P = 0.04) were significantly associated with the increased risk of fracture in COPD patients when compared with inhaled therapy without ICSs. Subgroup analyses showed that treatment duration ≥ 12 months (RR, 1.19; 95%CI, 1.04-1.38; P = 0.01), budesonide therapy (RR, 1.64; 95%CI., 1.07-2.51; P = 0.02), fluticasone furoate therapy (RR, 1.37; 95%CI, 1.05-1.78; P = 0.02), mean age of study participants ≥ 65 (RR, 1.27; 95%CI, 1.01-1.61; P = 0.04), and GOLD stage III(RR, 1.18; 95%CI, 1.00-1.38; P = 0.04) were significantly associated with an increased risk of fracture. In addition, budesonide ≥ 320 ug bid via MDI (RR, 1.75; 95%CI, 1.07-2.87; P = 0.03) was significantly associated with the increased risk of fracture. CONCLUSION Inhalation therapy with ICSs, especially ICS/LABA or triple therapy, increased the risk of fracture in patients with COPD compared with inhaled therapy without ICS. Treatment duration, mean age of participants, GOLD stage, drug dosage form, and drug dose participated in this association. Moreover, different inhalation devices of the same drug also had differences in risk of fracture.
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Affiliation(s)
- Shisheng Peng
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Cong Tan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Lirong Du
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yanan Niu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xiansheng Liu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ruiying Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
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14
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Rajizadeh MA, Nematollahi MH, Jafari E, Bejeshk MA, Mehrabani M, Rostamzadeh F, Samareh Fekri M, Najafipour H. Formulation and Evaluation of the Anti-inflammatory, Anti-oxidative, and Anti-remodelling Effects of the Niosomal Myrtenol on the Lungs of Asthmatic Rats. Iran J Allergy Asthma Immunol 2023; 22:265-280. [PMID: 37524663 DOI: 10.18502/ijaai.v22i3.13054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/24/2023] [Indexed: 08/02/2023]
Abstract
Asthma is a common chronic allergic disease that affects a significant percentage of the world's population. Niosomes are nanoparticles consisting of non-ionic surfactants that can be used for drug delivery. This research was designed to investigate the impacts of inhalation of simple and niosomal forms of myrtenol against adverse consequences of asthma in rats. Asthma induction was performed via injection of ovalbumin, followed by its inhalation. Niosomes were created by a heating protocol, and their physicochemical features were evaluated. Forty-nine male Wistar rats were allotted into 7 groups (n=7 each): Control (CTL), vacant niosome (VN), Asthma, Asthma+VN, Asthma+SM (simple myrtenol), Asthma+NM (niosomal myrtenol), and Asthma+B (budesonide). Lung remodeling, serum immunoglobulin E (IgE), inflammatory and cytokines, and antioxidant factors in the lung tissue and bronchoalveolar fluid (BALF), as well as), were evaluated. The results showed that myrtenol-loaded niosomes had appropriate encapsulation efficiency, kinetic release, size, and zeta potential. The thickness of the epithelial cell layer in the lungs, as well as cell infiltration, fibrosis, IgE, reactive oxygen species, interleukin (IL)-6, and tumor nuclear factor alpha (TNF-α) levels, decreased significantly. In contrast, superoxide dismutase and glutathione peroxide activity increased significantly in the serum and BALF of the treated groups. The niosomal form of myrtenol revealed a higher efficacy than simple myrtenol and was similar to budesonide in ameliorating asthma indices. Inhalation of simple and niosomal forms of myrtenol improved the detrimental changes in the asthmatic lung. The niosomal form induced more prominent anti-asthmatic effects comparable to those of budesonide.
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Affiliation(s)
- Mohammad Amin Rajizadeh
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran AND Department of Physiology and Pharmacology, Afzalipour Medical Faculty, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammad Hadi Nematollahi
- Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran.
| | - Elham Jafari
- Department of Pathology, Pathology and Stem Cells Research Center, School of Medicine, Kerman University of Medical Science, Kerman, Iran.
| | - Mohammad Abbas Bejeshk
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran AND Department of Physiology and Pharmacology, Afzalipour Medical Faculty, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mehrnaz Mehrabani
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.
| | - Farzaneh Rostamzadeh
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mitra Samareh Fekri
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran.
| | - Hamid Najafipour
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran.
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Díaz-González Á, Hernández-Guerra M, Pérez-Medrano I, Sapena V, Riveiro-Barciela M, Barreira-Díaz A, Gómez E, Morillas RM, Del Barrio M, Escudé L, Mateos B, Horta D, Gómez J, Conde I, Ferre-Aracil C, El Hajra I, Arencibía A, Zamora J, Fernández A, Salcedo M, Molina E, Soria A, Estévez P, López C, Álvarez-Navascúes C, García-Retortillo M, Crespo J, Londoño MC. Budesonide as first-line treatment in patients with autoimmune hepatitis seems inferior to standard predniso(lo)ne administration. Hepatology 2023; 77:1095-1105. [PMID: 36626622 DOI: 10.1097/hep.0000000000000018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/06/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS In patients with non-severe acute or chronic autoimmune hepatitis (AIH) without cirrhosis, clinical practice guidelines recommend indistinct use of prednisone or budesonide. However, budesonide is infrequently used in clinical practice. We aimed to describe its use and compare its efficacy and safety with prednisone as first-line options. APPROACH AND RESULTS This was a retrospective, multicenter study of 105 naive AIH patients treated with budesonide as the first-line drug. The control group included 276 patients treated with prednisone. Efficacy was assessed using logistic regression and validated using inverse probability of treatment weighting propensity score. The median time to biochemical response (BR) was 3.1 months in patients treated with budesonide and 4.9 months in those with prednisone. The BR rate was significantly higher in patients treated with prednisone (87% vs. 49% of patients with budesonide, p < 0.001). The probability of achieving BR, assessed using the inverse probability of treatment weighting propensity score, was significantly lower in the budesonide group (OR = 0.20; 95% CI: 0.11-0.38) at any time during follow-up, and at 6 (OR = 0.51; 95% CI: 0.29-0.89) and 12 months after starting treatment (0.41; 95% CI: 0.23-0.73). In patients with transaminases <2 × upper limit of normal, BR was similar in both treatment groups. Prednisone treatment was significantly associated with a higher risk of adverse events (24.2% vs. 15.9%, p = 0.047). CONCLUSIONS In the real-life setting, the use of budesonide as first-line treatment is low, and it is generally prescribed to patients with perceived less disease activity. Budesonide was inferior to prednisone as a first-line drug but was associated with fewer side effects.
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Affiliation(s)
- Álvaro Díaz-González
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases Group, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | | | - Indhira Pérez-Medrano
- Servicio de Aparato Digestivo, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, España
| | - Víctor Sapena
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spainand CIBERehd
| | - Ana Barreira-Díaz
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spainand CIBERehd
| | - Elena Gómez
- Servicio de Aparato Digestivo, Hospital Universitario 12 de Octubre, Madrid, España
| | - Rosa M Morillas
- Hepatology Department, Hospital Germans Trias i Pujol and Germans Trias i Pujol Research Institute, IGTP, Badalona, Department of Medicine, Universitat Autònoma de Barcelona; Centro de investigación biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd
| | - María Del Barrio
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases Group, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Laia Escudé
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de investigación biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, University of Barcelona, Barcelona, España
| | - Beatriz Mateos
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, CIBERehd, IRYCIS, Madrid, Spain
| | - Diana Horta
- Servicio de Aparato Digestivo, Hospital Universitari Mutua de Terrassa, Terrassa, España
| | - Judith Gómez
- Servicio de Aparato Digestivo, Hospital Universitario de Burgos, Burgos, España
| | - Isabel Conde
- Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Instituto de Investigación Sanitaria La Fe, Valencia, España
| | - Carlos Ferre-Aracil
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Ismael El Hajra
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Ana Arencibía
- Servicio de Aparato Digestivo, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - Javier Zamora
- Servicio de Aparato Digestivo, Hospital Universitario Reina Sofía, Córdoba, España
| | - Ainhoa Fernández
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Magdalena Salcedo
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Esther Molina
- Servicio de Aparato Digestivo, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, España
| | - Anna Soria
- Unidad de Hepatología, Servicio de Aparato Digestivo, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, España
| | - Pamela Estévez
- Servicio de Aparato Digestivo, Hospital Universitario Álvaro Cunqueiro, Vigo, España
| | - Carmen López
- Servicio de Aparato Digestivo, Hospital Universitari Josep Trueta, Girona, España
| | | | | | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases Group, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - María-Carlota Londoño
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de investigación biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, University of Barcelona, Barcelona, España
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Hobbs R, Gbinigie O, Ogburn E, Yu LM, van Hecke O, Dorward J, Butler C, Saville B. Inhaled Budesonide for COVID-19 in People at Higher Risk of Complications in the Community: The UK National Community Randomi. Ann Fam Med 2023; 21:3859. [PMID: 36944089 PMCID: PMC10549521 DOI: 10.1370/afm.21.s1.3859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background The effectiveness of repurposed treatments with supportive evidence for higher risk individuals with COVID-19 in the community is unknown. In the UK PRINCIPLE national platform trial we aimed to determine whether 're-purposed medicines' (hydroxychloroquine, azithromycin, doxycycline, colchicine, inhaled budesonide, and other interventions) reduced time to recovery and COVID-19 related hospitalisations/deaths among people at higher risk of COVID-19 complications in the community. We mainly report the findings for budesonide arm here. Methods Participants in this multicentre, open-label, multi-arm, adaptive platform randomised controlled trial were aged ≥65, or ≥50 years with comorbidities, and unwell ≤14 days with suspected COVID-19 in the community, and were randomised to usual care, usual care plus inhaled budesonide (800μg twice daily for 14 days), or usual care plus other interventions. The co-primary endpoints are time to first self-reported recovery, and hospitalisation/death related to COVID-19, within 28 days, analysed using Bayesian models. Trial registration: ISRCTN86534580. Funded by United Kingdom Research Innovation (MC_PC_19079). Findings The trial opened on April 2, 2020, with the first 4 intervention arms stopped on futility grounds. Randomisation to the budesonide arm occurred from November 27, 2020 until March 31, 2021, when the pre-specified time to recovery superiority criterion was met. The primary analysis model includes 2530 SARS-CoV-2 positive participants, randomised to budesonide (n=787), usual care (n=1069), and other treatments (n=674). Time to first self-reported recovery was shorter in the budesonide group versus usual care (hazard ratio 1·21 [95% credible interval 1·08 to 1·36], probability of superiority >O·999, estimated benefit 2·94 [95% credible interval 1·19 to 5·12] days). An estimated 6·8% COVID-19 related hospitalisations/deaths occurred in the budesonide group versus 8·8% in usual care (estimated absolute difference, 2·0% [95% credible interval -0.2% to 4.5%], probability of superiority 0.963). In the main secondary analysis of admissions using only concurrent controls, admissions occurred in 6.6% (3.8 to 10.1%) in the budesonide group versus 8.8% (95% CI 5.2 to 13.1%), with an absolute difference of 2.2% (0.0 to 4.9%) and a hazard ratio of 0.73 (0.53 to 1.00), meeting the pre-specified superiority probability of 0.975. Three serious adverse events occurred in the budesonide group and three in usual care.
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17
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Resál T, Mangó K, Bacsur P, Szántó K, Pigniczki D, Keresztes C, Rutka M, Bálint A, Milassin Á, Bor R, Fábián A, Szepes Z, Farkas K, Monostory K, Molnár T. Possible genetical predictors of efficacy and safety of budesonide-MMX in patients with mild-to-moderate ulcerative colitis, and safety comparison with methylprednisolone. Expert Opin Drug Saf 2023; 22:517-524. [PMID: 36811412 DOI: 10.1080/14740338.2023.2181336] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Budesonide-MMX is a topically active corticosteroid degraded by cytochrome-P450 enzymes, resulting in favorable side-effect profile. We aimed to assess the effect of CYP genotypes on safety and efficacy, and make a direct comparison with systemic corticosteroids. RESEARCH DESIGN AND METHODS We enrolled UC patients receiving budesonide-MMX and IBD patients on methylprednisolone in our prospective, observational-cohort study. Before and after treatment regimen clinical activity indexes, laboratory parameters (electrolytes, CRP, cholesterol, triglyceride, dehydroepiandrosterone, cortisol, beta-crosslaps, osteocalcin), and body composition measurements were assessed. CYP3A4 and CYP3A5 genotypes were determined in the budesonide-MMX group. RESULTS 71 participants were enrolled (budesonide-MMX: 52; methylprednisolone: 19). CAI decreased (p<0.05) in both groups. Cortisol decreased (p<0.001), and the level of cholesterol was elevated in both groups (p<0.001). Body composition altered only following methylprednisolone. Bone homeostasis (osteocalcin; p<0.05) and DHEA (p<0.001) changed more prominently after methylprednisolone. Glucocorticoid-related adverse events were more common following methylprednisolone treatment (47.4% compared to 1.9%). CYP3A5(*1/*3) genotype positively influenced efficacy, but not safety. Only one patient's CYP3A4 genotype differed. CONCLUSIONS CYP genotypes can affect the efficacy of budesonide-MMX; however, further studies would be needed with analyses of gene expression. Although budesonide-MMX is safer than methylprednisolone, due to glucocorticoid-related side effects, admission should require greater precaution.
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Affiliation(s)
- Tamás Resál
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Katalin Mangó
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Péter Bacsur
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Kata Szántó
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Daniella Pigniczki
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Department of Surgery, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Csilla Keresztes
- Department for Medical Communication and Translation Studies, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Mariann Rutka
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Ágnes Milassin
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Renáta Bor
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Anna Fábián
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Tamás Molnár
- Gastroenterology, Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Rumi G, Canonica GW, Foster JM, Chavannes NH, Valenti G, Contiguglia R, Rapsomaniki E, Kocks JWH, De Brasi D, Braido F. Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study. JMIR Mhealth Uhealth 2022; 10:e25879. [PMID: 36322120 PMCID: PMC9669888 DOI: 10.2196/25879] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/01/2021] [Accepted: 05/20/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Reliance on short-acting β-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined. OBJECTIVE The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life. METHODS Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose. RESULTS In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1‑BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01). CONCLUSIONS Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.
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Affiliation(s)
- Gabriele Rumi
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore - Medicina Interna, Rome, Italy
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic-Humanitas University & Research Hospital, IRCCS, Milan, Italy
| | - Juliet M Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | | | | | | | | | | | - Fulvio Braido
- Department of Internal Medicine, University of Genova, Genova, Italy
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19
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Lingaraj U, Mallapur S, Viswanathan A, Vankalakunti M. Clinical Response to Intestine-targeted Steroid Therapy in Biopsy-proven Immunoglobulin A Nephropathy. Saudi J Kidney Dis Transpl 2022; 33:755-760. [PMID: 38018717 DOI: 10.4103/1319-2442.390255] [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: 11/30/2023] Open
Abstract
Primary immunoglobulin A (IgA) nephropathy is associated with a dysfunctional mucosal immune system, leading to renal deposition of IgA and injury. Fifty patients with biopsy-proven IgA nephropathy were included. All patients were initiated on renin-angiotensin-aldosterone system (RAAS) inhibitors, polyunsaturated fatty acids, and a controlled release formulation (CRF) of budesonide. All drugs were started together, as isolated RAAS inhibitors will not prevent the immunological damage caused by the ongoing deposition of IgA. Depending on the histology (mesangial hypercellularity, endocapillary proliferation, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, and crescents score), the patients received 9 mg or 12 mg of budesonide. All patients were followed up every 4 weeks to monitor renal function, 24-h urinary protein, and adverse effects. Our primary outcome was a mean change in the estimated glomerular filtration rate (eGFR) and 24-h urinary protein from the baseline to the end of 6 months. The percentage of decline in mean 24-h protein at 6 months from the baseline was 33%. The mean decrease in serum creatinine from the baseline was 0.73 mg/dL. The mean gain in eGFR from the baseline was an increase of 9 mL/min/1.73 m2. Of 50 patients, 11 (22%) achieved complete remission, 20 (40%) achieved partial remission, and 16 (32%) were non-responders. Three patients (6%) were lost to follow-up. The early initiation of CRF budesonide with optimized supportive care led to reductions in proteinuria and improvements in eGFR at 6 months in patients with IgA nephropathy. Early lesions with minimal chronicity showed an excellent response to budesonide.
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Affiliation(s)
- Umesh Lingaraj
- Department of Nephrology, Institute of Nephro Urology, Victoria Campus, Bengaluru, Karnataka, India
| | - Sashikanth Mallapur
- Department of Nephrology, Institute of Nephro Urology, Victoria Campus, Bengaluru, Karnataka, India
| | - Akila Viswanathan
- Department of Nephrology, Institute of Nephro Urology, Victoria Campus, Bengaluru, Karnataka, India
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20
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Eleftheriotis G, Skopelitis E. Immune-checkpoint inhibitor-associated grade 3 hepatotoxicity managed with enteric-coated budesonide monotherapy: A case report. Medicine (Baltimore) 2022; 101:e29473. [PMID: 35945730 PMCID: PMC9351916 DOI: 10.1097/md.0000000000029473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
RATIONALE The introduction of immune-checkpoint inhibitors (ICPI) in recent years has changed the natural course of many neoplasms. However, patients receiving these medications may present immune-mediated adverse events; management includes temporary or permanent cessation of treatment and corticosteroids, occasionally combined with other immunomodulators. Such immunosuppression, however, also has numerous adverse events and even if it is effective in controlling toxicity, it delays immunotherapy reinitiation, as current evidence requires dose tapering to ≤10 mg prednisolone equivalent before rechallenge. Enteric-coated budesonide is a corticosteroid formulation acting primarily to the intestine and liver, as a result of its extensive first-pass hepatic metabolism. PATIENT CONCERNS A 76-year-old woman treated with ipilimumab for metastatic melanoma presented with abdominal pain, vomiting, and diarrhea for at least the previous 4 days. Laboratory tests, among others, revealed elevated aminotransferases and C-reactive protein. During hospitalization, the patient also developed fever. DIAGNOSIS The patient, after excluding alternative causes of aminotransferase elevation, was diagnosed with grade 3 ipilimumab-associated hepatotoxicity. INTERVENTIONS Budesonide monotherapy was administered; initial daily dose was 12 mg. OUTCOMES Fever subsided after the first dose of budesonide. Aminotransferases returned to normal-near normal approximately 1 month after the first dose of budesonide. After this point, daily dose was reduced by 3 mg every 2 weeks, with no clinical or biochemical relapse. CONCLUSIONS This case of ICPI hepatitis is, to our knowledge, the first in the literature managed with budesonide monotherapy. Therefore, budesonide may be a potentially attractive option for the management of ICPI-associated liver injury in cases where corticosteroid treatment is necessary due to its safety profile and the potential advantage of faster immunotherapy rechallenge in selected patients without requiring dose tapering, in contrast to systemically acting corticosteroids. Clinical trials should be conducted in the future in order to validate or refute these findings.
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Affiliation(s)
- Gerasimos Eleftheriotis
- 2nd Department of Internal Medicine, General Hospital of Nikaia-Piraeus “Agios Panteleimon,” Athens, Greece
| | - Elias Skopelitis
- 2nd Department of Internal Medicine, General Hospital of Nikaia-Piraeus “Agios Panteleimon,” Athens, Greece
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Cerón-Pisa N, Shafiek H, Martín-Medina A, Verdú J, Jordana-Lluch E, Escobar-Salom M, Barceló IM, López-Causapé C, Oliver A, Juan C, Iglesias A, Cosío BG. Effects of Inhaled Corticosteroids on the Innate Immunological Response to Pseudomonas aeruginosa Infection in Patients with COPD. Int J Mol Sci 2022; 23:ijms23158127. [PMID: 35897707 PMCID: PMC9332726 DOI: 10.3390/ijms23158127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/16/2022] Open
Abstract
Inhaled corticosteroids (ICS) use is associated with an increased risk of Pseudomonas aeruginosa (PA) infection in patients with COPD. We aimed to evaluate the effects of ICS on alveolar macrophages in response to PA in COPD patients with and without baseline ICS treatment (COPD and COPD + ICS, respectively) as well as smoker and nonsmoker controls. To do so, cells were infected with PA and cotreated with budesonide (BUD) or fluticasone propionate (FLU). The analysis of NF-κB and c-jun activity revealed a significant increase in both factors in response to PA cotreated with BUD/FLU in smokers but not in COPD or COPD + ICS patients when compared with PA infection alone. The expression of Toll-like receptor 2 (TLR2) and the transcription factor c-jun were induced upon PA infection in nonsmokers only. Moreover, in the smoker and COPD groups, there was a significant increase in TLR2 and a decrease in c-jun expression when treated with BUD/FLU after PA infection, which were not observed in COPD + ICS patients. Therefore, the chronic use of ICS seemingly makes the macrophages tolerant to BUD/FLU stimulation compared with those from patients not treated with ICS, promoting an impaired recognition of PA and activity of alveolar macrophages in terms of altered expression of TLR2 and cytokine production, which could explain the increased risk of PA infection in COPD patients under ICS treatment.
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Affiliation(s)
- Noemi Cerón-Pisa
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
| | - Hanaa Shafiek
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt;
| | - Aina Martín-Medina
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
| | - Javier Verdú
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Department of Respiratory Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Elena Jordana-Lluch
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Maria Escobar-Salom
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Isabel M. Barceló
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Carla López-Causapé
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Antonio Oliver
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Carlos Juan
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC), 28029 Madrid, Spain
- Department of Microbiology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Amanda Iglesias
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), 28029 Madrid, Spain
- Correspondence: (A.I.); (B.G.C.); Tel.: +34-871-205-050 (ext. 64521) (A.I. & B.G.C.)
| | - Borja G. Cosío
- Instituto de Investigación Sanitaria de Les Illes Balears (IdISBa), Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain; (N.C.-P.); (A.M.-M.); (J.V.); (E.J.-L.); (M.E.-S.); (I.M.B.); (C.L.-C.); (A.O.); (C.J.)
- Department of Respiratory Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), 28029 Madrid, Spain
- Correspondence: (A.I.); (B.G.C.); Tel.: +34-871-205-050 (ext. 64521) (A.I. & B.G.C.)
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Wiest I, Roig A, Antoni C, Ebert M, Teufel A. Safety and efficacy of budesonide during pregnancy in women with autoimmune hepatitis. J Gastrointestin Liver Dis 2022; 31:256-257. [PMID: 35694989 DOI: 10.15403/jgld-4315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Isabella Wiest
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .
| | - Ana Roig
- Division of Hepatology, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Christoph Antoni
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Matthias Ebert
- Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim; Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Andreas Teufel
- Division of Hepatology, Department of Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim; Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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23
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Papi A, Chipps BE, Beasley R, Panettieri RA, Israel E, Cooper M, Dunsire L, Jeynes-Ellis A, Johnsson E, Rees R, Cappelletti C, Albers FC. Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma. N Engl J Med 2022; 386:2071-2083. [PMID: 35569035 DOI: 10.1056/nejmoa2203163] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND As asthma symptoms worsen, patients typically rely on short-acting β2-agonist (SABA) rescue therapy, but SABAs do not address worsening inflammation, which leaves patients at risk for severe asthma exacerbations. The use of a fixed-dose combination of albuterol and budesonide, as compared with albuterol alone, as rescue medication might reduce the risk of severe asthma exacerbation. METHODS We conducted a multinational, phase 3, double-blind, randomized, event-driven trial to evaluate the efficacy and safety of albuterol-budesonide, as compared with albuterol alone, as rescue medication in patients with uncontrolled moderate-to-severe asthma who were receiving inhaled glucocorticoid-containing maintenance therapies, which were continued throughout the trial. Adults and adolescents (≥12 years of age) were randomly assigned in a 1:1:1 ratio to one of three trial groups: a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide (with each dose consisting of two actuations of 90 μg and 80 μg, respectively [the higher-dose combination group]), a fixed-dose combination of 180 μg of albuterol and 80 μg of budesonide (with each dose consisting of two actuations of 90 μg and 40 μg, respectively [the lower-dose combination group]), or 180 μg of albuterol (with each dose consisting of two actuations of 90 μg [the albuterol-alone group]). Children 4 to 11 years of age were randomly assigned to only the lower-dose combination group or the albuterol-alone group. The primary efficacy end point was the first event of severe asthma exacerbation in a time-to-event analysis, which was performed in the intention-to-treat population. RESULTS A total of 3132 patients underwent randomization, among whom 97% were 12 years of age or older. The risk of severe asthma exacerbation was significantly lower, by 26%, in the higher-dose combination group than in the albuterol-alone group (hazard ratio, 0.74; 95% confidence interval [CI], 0.62 to 0.89; P = 0.001). The hazard ratio in the lower-dose combination group, as compared with the albuterol-alone group, was 0.84 (95% CI, 0.71 to 1.00; P = 0.052). The incidence of adverse events was similar in the three trial groups. CONCLUSIONS The risk of severe asthma exacerbation was significantly lower with as-needed use of a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide than with as-needed use of albuterol alone among patients with uncontrolled moderate-to-severe asthma who were receiving a wide range of inhaled glucocorticoid-containing maintenance therapies. (Funded by Avillion; MANDALA ClinicalTrials.gov number, NCT03769090.).
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Affiliation(s)
- Alberto Papi
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Bradley E Chipps
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Richard Beasley
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Reynold A Panettieri
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Elliot Israel
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Mark Cooper
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Lynn Dunsire
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Allison Jeynes-Ellis
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Eva Johnsson
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Robert Rees
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Christy Cappelletti
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
| | - Frank C Albers
- From the Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara, Italy (A.P.); the Capital Allergy and Respiratory Disease Center, Sacramento, CA (B.E.C.); the Medical Research Institute of New Zealand, Capital and Coast District Health Board, and Victoria University Wellington - all in Wellington, New Zealand (R.B.); Rutgers Institute for Translational Medicine and Science, Child Health Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick (R.A.P.); Brigham and Women's Hospital, Harvard Medical School, Boston (E.I.); BioPharmaceuticals Research and Development, AstraZeneca, Cambridge (M.C., L.D.), and Avillion, London (A.J.-E., R.R.) - both in the United Kingdom; BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (E.J.); BioPharmaceuticals Research and Development, AstraZeneca, Durham, NC (C.C.); and Avillion, Northbrook, IL (F.C.A.)
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Delayed-release budesonide (Tarpeyo) for primary immunoglobulin A nephropathy. Med Lett Drugs Ther 2022; 64:76-7. [PMID: 35536122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Zhang J, Kan D. Evaluation of efficiency and safety of combined loratadine and budesonide in patients with anaphylactic rhinitis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28851. [PMID: 35512063 PMCID: PMC9276336 DOI: 10.1097/md.0000000000028851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Among the most prevalent allergic conditions that affect children is anaphylactic rhinitis (AR). It is capable of leading to physical as well as mental health issues. Concomitant use of loratadine and budesonide may improve symptoms of AR more than treatment with either drug alone. To assess the efficacy and safety of combined loratadine and budesonide for patients experiencing AR is the aim of this study. METHODS We will apply 2 independent authors in six databases, including EMBASE, Pub Med, Web of Science, China National Knowledge Infrastructure, WanFang Database, Chinese Scientific Journal Database (VIP database). Studies evaluating the efficacy and safety of combined loratadine and budesonide in patients with AR will include studies published between inception and Dec 2021. Accordingly, the data will have to be in English and Chinese. For the selection of data extraction, the studies and risk of bias assessment will be completed by 2 independent authors. Accordingly, data synthesis will be conducted through RevMan 5.3 software. The study will establish heterogeneity using the I2 test. Without correct data or information, there is a need for Publication bias, which is assessed by performing the Begg and Egger test and generating a funnel plot. RESULTS The study provides a trustable clinical foundation for loratadine and budesonide for AR treatment.OSF registration number: DOI 10.17605/OSF.IO/M2RFGEthics and dissemination: Because the present study is founded on existing studies, it does not require ethics approval.
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Affiliation(s)
- Jing Zhang
- Department of Otorhinolaryngology, WuHan Puren Hospital, Wuhan, Hubei, China
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Faryabi R, Vaghasloo MA, Athari SS, Boskabady MH, Zangii BM, Kaveh S, Kabiri M. Immunomodulatory Effect of SINA 1.2 Therapy Protocol in Asthmatic Mice Model: A Combination of Oxymel and Sauna. Iran J Allergy Asthma Immunol 2022; 21:128-140. [PMID: 35490267 DOI: 10.18502/ijaai.v21i2.9221] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/01/2021] [Indexed: 06/14/2023]
Abstract
Alternative medicine, has become popular in asthmatic patients. We evaluated the immunomodulatory effects of SINA 1.2 therapy protocol derived from Persian medicine in an asthmatic mice model. Forty-two male BALB/c mice divided into six groups: one control (sham) and five sensitized groups (by parenteral injection of 20 μg ovalbumin in 100 μL normal saline plus 50 μL alum on days 1 and 14). Sensitized groups were as: untreated, budesonide (1 mg nebulized budesonide: 200 μg/puff every 5 min for 25 min), dry sauna (30 min, 37°C), oral oxymel (gavaged: 0.2 mL of the syrup plus 0.8 mL of water), and SINA protocol No.1.2 (oxymel followed by sauna) groups. Treatments were given for 10 days from day 23 to 33 then sacrificed. Significant gene expression reduction of interleukin(IL)-4, IL-5, and MUC5AC and increase of interferon(IFN)-γ and IFN-γ/IL-4 ratio and decreased perivascular and peribronchial inflammation, goblet cell hyperplasia, and subsequent mucus hypersecretion in SINA group were seen compared to untreated group. SINA lowered IL-5 and MUC5AC gene expression levels similar to the budesonide and acted better than budesonide in increasing IFN-γ gene expression up to normal level. Compared with the asthma group, sauna alone only affected MUC5AC and IFN-γ gene expressions and oxymel alone, only reduced IL-4 gene expression, perivascular and peribronchial inflammation, and mucus hypersecretion. It seems that SINA therapy alleviates asthma via immune modulation of pro-inflammatory cytokines and improvement of pathological changes in ovalbumin-induced asthma in mice, supporting the notion of innate healing power mentioned in Persian medicine literature.
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Affiliation(s)
- Roghayeh Faryabi
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahdi Alizadeh Vaghasloo
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyyed Shamsadin Athari
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.
| | - Mohammad Hossein Boskabady
- Applied Biomedical Research Center, Department of Physiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Bagher Minaii Zangii
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran AND Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, IranDepartment of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Shahpar Kaveh
- Department of Traditional Medicine, School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahdi Kabiri
- Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Deglurkar R, Mathew JL, Singh M. Efficacy and Safety of Pidotimod in Persistent Asthma: A Randomized Triple-Blinded Placebo-Controlled Trial. Indian Pediatr 2022; 59:201-205. [PMID: 35014615] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To study whether addition of pidotimod to inhaled corticosteroid (ICS) therapy enhances control in children with persistent asthma, as compared to ICS therapy alone. DESIGN Triple-blinded, randomized controlled trial. SETTING Allergy and Asthma Clinic, Department of Pediatrics, at a tertiary care hospital between May, 2018 and June, 2019. PATIENTS 79 children (5-12 years) with newly diagnosed persistent asthma as per Global Initiative for Asthma guidelines. INTERVENTIONS Children received 7 mL twice-a-day for 15 day, followed by 7 mL once-a-day for 45 days of either pidotimod (n=39) or placebo (n=40). In addition, both groups received inhaled budesonide via metered dose inhaler and spacer, throughout the study. Children were followed up every 4 weeks for a total of 12 weeks. At each follow-up visit, peak expiratory flow (PEF) and asthma symptom score and medicine adverse effects were recorded. MAIN OUTCOME MEASURES Change in PEF at 12 weeks compared to baseline. Secondary outcomes were PEF at each follow-up visit, asthma symptom score at each visit, change in asthma symptom score at 12 weeks, and adverse event profile. RESULTS The median (IQR) change in PEF (from baseline to 12 weeks) was 13.0% (0.8%, 28.3%) in pidotimod group (n=35) vs 17.7% (4.3%, 35.2%) in placebo group (n=35) (P=0.69). All the secondary outcomes were also comparable between the two groups. There were no significant adverse effects observed. CONCLUSIONS Addition of pidotimod for 8 weeks to standard ICS therapy did not enhance asthma control compared to placebo.
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Affiliation(s)
- Revati Deglurkar
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
| | - Joseph L Mathew
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh. Correspondence to: Prof Joseph L Mathew, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh.
| | - Meenu Singh
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh. Correspondence to: Prof Joseph L Mathew, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh.
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Abstract
GOALS There is an unmet need in investigating corticosteroid-sparing treatments for induction and maintenance of remission in microscopic colitis (MC). The authors' aim was to evaluate the outcomes of patients with MC treated with bile acid sequestrants (BAS). BACKGROUND MC is a common chronic diarrheal illness. Budesonide is effective induction therapy, but relapses are high after cessation of treatment. STUDY Our cohort consisted of patients enrolled in our institutional MC registry, a biorepository of histology-confirmed diagnoses of MC. Patients receiving BAS for the treatment of MC were reviewed at each clinical visit for efficacy or ability to decrease budesonide maintenance dosing. RESULTS The authors included 79 patients (29 collagenous colitis and 50 lymphocytic colitis) with a median follow-up period of 35 months (range, 1 to 120). Most patients were female individuals (78%) and the median age was 69 years (range, 29 to 87). BAS therapy was used in 21 patients who were budesonide-naive, with a response rate of 76% (16/21). In patients treated previously with budesonide, 46 patients were budesonide-dependent and given BAS as maintenance therapy. Of these patients, 23 (50%) were able to decrease their budesonide dosing and 9 (20%) were able to stop budesonide completely. Seven of 46 patients (15%) stopped BAS because of intolerance, perceived lack of benefit, or treatment of concomitant diarrhea illness. CONCLUSIONS BAS may be an effective corticosteroid-sparing option in the treatment of MC and should be considered after budesonide induction. Larger controlled studies are needed to confirm the efficacy for long-term maintenance and tolerability of BAS in patients with MC.
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Affiliation(s)
- Michael J Northcutt
- Division of Gastroenterology, University of Chicago Medicine, NorthShore University Health System, Evanston, IL
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Münch A, Mihaly E, Nagy F, Madisch A, Kupčinskas J, Miehlke S, Bohr J, Bouma G, Guardiola J, Belloc B, Shi C, Aust D, Mohrbacher R, Greinwald R, Munck LK. Budesonide as induction therapy for incomplete microscopic colitis: A randomised, placebo-controlled multicentre trial. United European Gastroenterol J 2021; 9:837-847. [PMID: 34414678 PMCID: PMC8435258 DOI: 10.1002/ueg2.12131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Incomplete microscopic colitis (MCi) is a subtype of microscopic colitis (MC). Budesonide is recommended as a first-line treatment for MC. However, randomised trials on efficacy of treatment in MCi are missing. We therefore performed a randomised, placebo-controlled trial to evaluate budesonide as induction therapy for MCi. METHODS Patients with active MCi were randomly assigned to either budesonide 9 mg once daily or placebo for 8 weeks in a double-blind, double-dummy design. The primary endpoint was clinical remission, defined as a mean of <3 stools/day and a mean of <1 watery stool/day in the 7 days before week 8. RESULTS Due to insufficient patient recruitment, the trial was discontinued prematurely. The intention-to-treat analysis included 44 patients (21 budesonide and 23 placebo). The primary endpoint of clinical remission at week 8 was obtained by 71.4% on budesonide and 43.5% on placebo (p = 0.0582). All clinical secondary endpoints were in favour of budesonide. Budesonide decreased the number of soft or watery stools (16.3 vs. 7.7, p = 0.0186) and improved health-related quality of life for all four dimensions of the short health scale. Adverse events with a suspected relation to study drug were reported in one patient in the budesonide group and two patients in the placebo group. Neither serious nor severe adverse events occurred during the double-blind phase. CONCLUSIONS Budesonide decreased the frequency of soft or watery stools and improved the patients' quality of life significantly in MCi, but the primary endpoint was not met due to the low sample size (type 2 error). Budesonide was safe and well tolerated during the 8-weeks treatment course.
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Affiliation(s)
- Andreas Münch
- Department of Gastroenterology and HepatologyLinköping University Hospital School of MedicineLinköpingSweden
| | - Emese Mihaly
- Department of Internal MedicineSemmelweis EgyetemBudapestHungary
| | - Ferenc Nagy
- First Department of MedicineSzegedi Egyetem ÁOK I sz.SzegedHungary
| | - Ahmed Madisch
- Medical Department IKRH Klinikum SiloahHannoverGermany
| | - Juozas Kupčinskas
- Department of GastroenterologyInstitute for Digestive ResearchLithuanian University of Health SciencesKaunasLithuania
| | - Stephan Miehlke
- Center for Digestive DiseasesInternal Medicine Center EppendorfHamburgGermany
- Centre for Interdisciplinary EndoscopyUniversity Hospital EppendorfHamburgGermany
| | - Johan Bohr
- Division of GastroenterologyDepartment of MedicineÖrebro University HospitalÖrebroSweden
| | - Gerd Bouma
- Department of GastroenterologyVrije Universiteit Medical CentreAmsterdamNetherlands
| | - Jordi Guardiola
- Department of Digestive DiseasesHospital Universitario de BellvitgeBarcelonaSpain
| | - Blanca Belloc
- Department of GastroenterologyHospital San Jorge – University of ZaragozaHuescaSpain
| | - Chunliang Shi
- Department of GastroenterologyNorrlands UniversitetssjukhusUmeåSweden
| | - Daniela Aust
- Institute for PathologyUniversity Hospital Carl Gustav CarusDresdenGermany
| | - Ralf Mohrbacher
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Roland Greinwald
- Clinical Research and Development DepartmentDr Falk Pharma GmbHFreiburgGermany
| | - Lars Kristian Munck
- Department of GastroenterologyZealand University HospitalKøgeDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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Tang Q, Lei H, You J, Wang J, Cao J. Evaluation of efficiency and safety of combined montelukast sodium and budesonide in children with cough variant asthma: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26416. [PMID: 34160429 PMCID: PMC8238328 DOI: 10.1097/md.0000000000026416] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cough variant asthma (CVA) is classified as a distinct form of asthma. As the primary or only symptom, cough is the leading cause for the most prevalent chronic cough among kids. The American College of Clinical Pharmacy, British Thoracic Society, and Chinese guidelines established for diagnosing and treating chronic cough in kids recommend inhaled corticosteroids, combined with leukotriene receptor antagonists when necessary. METHODS We will conduct a comprehensive search in major databases using keywords to find studies related to the analysis of montelukast sodium and budesonide for treating CVA in kids. Two reviewers will independently assess the quality of the selected research articles and perform data extraction. Next, we will use the RevMan software (version: 5.3) to conduct the statistical analysis of the present study. RESULTS This study will assess the efficacy and safeness of using montelukast sodium and budesonide to treat kids with CVA by pooling the results of individual studies. CONCLUSION Our findings will provide vigorous evidence to judge whether montelukast sodium and budesonide therapy is an efficient form of therapy for CVA patients. ETHICS AND DISSEMINATION Ethics approval is not needed for the present meta-analysis. OSF REGISTRATION NUMBER May 17, 2021.osf.io/cuvjz (https://osf.io/cuvjz/).
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Affiliation(s)
- Qiongyao Tang
- Department of Pediatrics, the First People's Hospital of Jiangxia District
| | - Huizhen Lei
- Department of Pediatrics, the First People's Hospital of Jiangxia District
| | - Jinbing You
- Department of Pediatrics, Hubei Maternal and Child Health Care Hospital, Wuhan 430200, Hubei, PR China
| | - Jiangjiang Wang
- Department of Pediatrics, the First People's Hospital of Jiangxia District
| | - Junyi Cao
- Department of Pediatrics, the First People's Hospital of Jiangxia District
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Bourdin A, Molinari N, Ferguson GT, Singh B, Siddiqui MK, Holmgren U, Ouwens M, Jenkins M, De Nigris E. Efficacy and Safety of Budesonide/Glycopyrronium/Formoterol Fumarate versus Other Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2021; 38:3089-3112. [PMID: 33929661 PMCID: PMC8189959 DOI: 10.1007/s12325-021-01703-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/10/2021] [Indexed: 11/30/2022]
Abstract
In patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations or symptoms, despite being prescribed dual long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) or inhaled corticosteroid (ICS)/LABA therapies, triple ICS/LAMA/LABA therapy is recommended. A previous network meta-analysis showed comparable efficacy of the ICS/LAMA/LABA, budesonide/glycopyrronium bromide/formoterol fumarate (BUD/GLY/FOR) 320/18/9.6 µg, to other fixed-dose and open combination triple therapies at 24 weeks in COPD. Subsequently, the ETHOS study was published, including data for 8509 patients, assessing the efficacy and safety of BUD/GLY/FOR over 52 weeks. This network meta-analysis (NMA) was conducted to compare the relative efficacy, safety, and tolerability of BUD/GLY/FOR 320/18/9.6 µg with other fixed-dose and open combination triple therapies in COPD over 52 weeks, including data from ETHOS. A systematic literature review was conducted to identify ≥ 10-week randomized controlled trials, including ≥ 1 fixed-dose or open combination triple-therapy arm, in patients with moderate-to-very severe COPD. The methodologic quality and risk of bias of included studies were assessed. Study results were combined using a three-level hierarchical Bayesian NMA model to assess efficacy and safety outcomes at or over 24 and 52 weeks. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. Nineteen studies (n = 37,741 patients) met the inclusion criteria of the review; 15 contributed to the base case network. LAMA/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes for exacerbations, lung function, symptoms, health-related quality of life, safety, and tolerability, the efficacy and safety of BUD/GLY/FOR were comparable to those of other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium bromide/formoterol fumarate) and open combinations at or over 24 and 52 weeks. Sensitivity analyses and meta-regression results for exacerbation outcomes were broadly in line with the base case NMA. In this NMA, BUD/GLY/FOR 320/18/9.6 μg showed comparable efficacy versus other ICS/LAMA/LABA fixed-dose or open combination therapies in terms of reducing exacerbation rates and improving lung function, symptoms and health-related quality of life in patients with moderate-to-very-severe COPD, in line with previously published meta-analysis results of triple combinations in COPD. The safety and tolerability profile of BUD/GLY/FOR was also found to be comparable to other triple combination therapies.
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Affiliation(s)
- Arnaud Bourdin
- Department of Respiratory Diseases, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France.
- Département Pneumologie et Addictologie, CHU de Montpellier-Hôpital Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
| | - Nicolas Molinari
- IMAG, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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O'Shea O, Stovold E, Cates CJ. Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2021; 4:CD007694. [PMID: 33852162 PMCID: PMC8095067 DOI: 10.1002/14651858.cd007694.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness, and cough. Treatment with inhaled steroids and bronchodilators can result in good control of symptoms, prevention of further morbidity, and improved quality of life. However, an increase in serious adverse events with the use of both regular formoterol and regular salmeterol (long-acting beta₂-agonists) compared with placebo for chronic asthma has been demonstrated in previous Cochrane Reviews. This increase was statistically significant in trials that did not randomise participants to an inhaled corticosteroid, but not when formoterol or salmeterol was combined with an inhaled corticosteroid. The confidence intervals were found to be too wide to ensure that the addition of an inhaled corticosteroid renders regular long-acting beta₂-agonists completely safe; few participants and insufficient serious adverse events in these trials precluded a definitive decision about the safety of combination treatments. OBJECTIVES To assess risks of mortality and non-fatal serious adverse events in trials that have randomised patients with chronic asthma to regular formoterol and an inhaled corticosteroid versus regular salmeterol and an inhaled corticosteroid. SEARCH METHODS We searched the Cochrane Airways Register of Trials, CENTRAL, MEDLINE, Embase, and two trial registries to identify reports of randomised trials for inclusion. We checked manufacturers' websites and clinical trial registers for unpublished trial data, as well as Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol. The date of the most recent search was 24 February 2021. SELECTION CRITERIA We included controlled clinical trials with a parallel design, recruiting patients of any age and severity of asthma, if they randomised patients to treatment with regular formoterol versus regular salmeterol (each with a randomised inhaled corticosteroid) and were of at least 12 weeks' duration. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion in the review, extracted outcome data from published papers and trial registries, and applied GRADE rating for the results. We sought unpublished data on mortality and serious adverse events from study sponsors and authors. The primary outcomes were all cause mortality and non-fatal serious adverse events. We chose not to calculate an average result from all the formulations of formoterol and inhaled steroid, as the doses and delivery devices are too diverse to assume a single class effect. MAIN RESULTS Twenty-one studies in 11,572 adults and adolescents and two studies in 723 children met the eligibility criteria of the review. No data were available for two studies; therefore these were not included in the analysis. Among adult and adolescent studies, seven compared formoterol and budesonide to salmeterol and fluticasone (N = 7764), six compared formoterol and beclomethasone to salmeterol and fluticasone (N = 1923), two compared formoterol and mometasone to salmeterol and fluticasone (N = 1126), two compared formoterol and fluticasone to salmeterol and fluticasone (N = 790), and one compared formoterol and budesonide to salmeterol and budesonide (N = 229). In total, five deaths were reported among adults, none of which was thought to be related to asthma. The certainty of evidence for all-cause mortality was low, as there were not enough deaths to permit any precise conclusions regarding the risk of mortality on combination formoterol versus combination salmeterol. In all, 201 adults reported non-fatal serious adverse events. In studies comparing formoterol and budesonide to salmeterol and fluticasone, there were 77 in the formoterol arm and 68 in the salmeterol arm (Peto odds ratio (OR) 1.14, 95% confidence interval (CI) 0.82 to 1.59; 5935 participants, 7 studies; moderate-certainty evidence). In the formoterol and beclomethasone studies, there were 12 adults in the formoterol arm and 13 in the salmeterol arm with events (Peto OR 0.94, 95% CI 0.43 to 2.08; 1941 participants, 6 studies; moderate-certainty evidence). In the formoterol and mometasone studies, there were 18 in the formoterol arm and 11 in the salmeterol arm (Peto OR 1.02, 95% CI 0.47 to 2.20; 1126 participants, 2 studies; moderate-certainty evidence). One adult in the formoterol and fluticasone studies in the salmeterol arm experienced an event (Peto OR 0.05, 95% CI 0.00 to 3.10; 293 participants, 2 studies; low-certainty evidence). Another adult in the formoterol and budesonide compared to salmeterol and budesonide study in the formoterol arm had an event (Peto OR 7.45, 95% CI 0.15 to 375.68; 229 participants, 1 study; low-certainty evidence). Only 46 adults were reported to have experienced asthma-related serious adverse events. The certainty of the evidence was low to very low due to the small number of events and the absence of independent assessment of causation. The two studies in children compared formoterol and fluticasone to salmeterol and fluticasone. No deaths and no asthma-related serious adverse events were reported in these studies. Four all-cause serious adverse events were reported: three in the formoterol arm, and one in the salmeterol arm (Peto OR 2.72, 95% CI 0.38 to 19.46; 548 participants, 2 studies; low-certainty evidence). AUTHORS' CONCLUSIONS Overall, for both adults and children, evidence is insufficient to show whether regular formoterol in combination with budesonide, beclomethasone, fluticasone, or mometasone has a different safety profile from salmeterol in combination with fluticasone or budesonide. Five deaths of any cause were reported across all studies and no deaths from asthma; this information is insufficient to permit any firm conclusions about the relative risks of mortality on combination formoterol in comparison to combination salmeterol inhalers. Evidence on all-cause non-fatal serious adverse events indicates that there is probably little to no difference between formoterol/budesonide and salmeterol/fluticasone inhalers. However events for the other formoterol combination inhalers were too few to allow conclusions. Only 46 non-fatal serious adverse events were thought to be asthma related; this small number in addition to the absence of independent outcome assessment means that we have very low confidence for this outcome. We found no evidence of safety issues that would affect the choice between salmeterol and formoterol combination inhalers used for regular maintenance therapy by adults and children with asthma.
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Affiliation(s)
- Orlagh O'Shea
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Christopher J Cates
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
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Abstract
Corticosteroids are a nonspecific immune modulator used in the treatment of ulcerative colitis. Topical and systemic forms of corticosteroids have been shown to be effective in induction of clinical remission and remain first-line therapy for acute severe ulcerative colitis. A large proportion of patients experience adverse effects, however, including some serious adverse effects, including infection and increased mortality. Newer formulations of gut selective corticosteroids have reduced adverse effects associated with steroids.
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Affiliation(s)
- Lauren A George
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 685 West Baltimore Street, Suite 8-00, Baltimore, MD 21201, USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 685 West Baltimore Street, Suite 8-00, Baltimore, MD 21201, USA.
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Ferguson GT, Skärby T, Nordenmark LH, Lamarca R, Aksomaityte A, Lythgoe D, Gilbert I, Trudo F. Unreported and Overlooked: A Post Hoc Analysis of COPD Symptom-Related Attacks from the RISE Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3123-3134. [PMID: 33273814 PMCID: PMC7708268 DOI: 10.2147/copd.s277147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/06/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Moderate and severe COPD exacerbations are a significant health-care burden, but patients also experience "mild" exacerbations, or COPD symptom-related attacks, which often go unreported. We aimed to define and then determine the incidence of COPD symptom-related attacks and their impact on future risk of moderate/severe exacerbations, health-related quality of life (HRQoL), and lung function. The effect of COPD maintenance therapy on the attack definition was then evaluated by comparing budesonide/formoterol with formoterol alone. Patients and Methods This post hoc analysis of the RISE study defined COPD symptom-related attacks as ≥2 consecutive days of both worsening symptoms and increased daily rescue medication use based upon thresholds of >2 and >4 short-acting β2-agonist (SABA) inhalations/day above baseline. The impact of these events on subsequent moderate/severe exacerbation risk was estimated using a time-varying Cox proportional hazards model. The effects of COPD symptom-related attacks on St George's Respiratory Questionnaire (SGRQ) total score and pre-bronchodilator forced expiratory volume in 1 second (FEV1) were evaluated as average changes from baseline to first post-attack measurement. Rates of attacks were compared between treatment groups using negative binomial regression models. Results COPD symptom-related attacks elevated the risk of subsequent moderate/severe exacerbations at both >2 and >4 inhalations/day above baseline (HR 1.86 and 2.21, respectively; p<0.0001), with a cumulative increase in risk with increasing attacks. HRQoL and lung function were reduced for patients with ≥1 versus no COPD symptom-related attacks at both rescue medication thresholds. There were fewer COPD symptom-related attacks with budesonide/formoterol versus formoterol alone, with no increased risk of pneumonia and lower respiratory tract infections. Conclusion COPD symptom-related attacks are common and typically unreported. Importantly, these attacks can account for considerable morbidity and should not be regarded as "mild". Detection of such exacerbations may be valuable in identifying patients at greater risk and guiding preventive therapeutic interventions.
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Affiliation(s)
- Gary T Ferguson
- Department of Medicine, Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Tor Skärby
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Rosa Lamarca
- BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| | | | | | - Ileen Gilbert
- BioPharmaceuticals Medical – US, AstraZeneca LP, Wilmington, DE, USA
| | - Frank Trudo
- BioPharmaceuticals Medical – US, AstraZeneca LP, Wilmington, DE, USA
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35
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Pastorelli L, Bezzio C, Saibeni S. Hold the Foam: Why Topical Budesonide Remains Relevant for IBD Therapy. Dig Dis Sci 2020; 65:3066-3068. [PMID: 32189103 DOI: 10.1007/s10620-020-06199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Luca Pastorelli
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese, MI, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, MI, Italy
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Corso Europa 250, 20017, Rho, MI, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Corso Europa 250, 20017, Rho, MI, Italy.
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Saito Z, Yoshida M, Kojima A, Tamura K, Hasegawa T, Kuwano K. Benefits and Risks of Inhaled Corticosteroid Treatment in Patients with Chronic Obstructive Pulmonary Disease Classified by Blood Eosinophil Counts. Lung 2020; 198:925-931. [PMID: 33068153 DOI: 10.1007/s00408-020-00397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) typically includes neutrophilic airway inflammation and eosinophilic inflammation in some cases. Inhaled corticosteroid (ICS) suppresses eosinophilic inflammation of the airway and reduces acute exacerbation (AE). The present study investigated the relationship between ICS and AE in patients with COPD classified by blood eosinophil counts. METHODS Overall, 244 patients with COPD were retrospectively evaluated between 2014 and 2017 and classified into two groups based on blood eosinophil counts (≥ 300/μL and < 300/μL). These patients were then reclassified into subgroups of those with and without ICS. Differences in the characteristics and incidence of AE and pneumonia with AE in each subgroup were evaluated retrospectively. RESULTS All patients with ICS used 320 μg budesonide twice daily. In the group with blood eosinophil counts ≥ 300/μL, patients with ICS had a significantly lower incidence of AE than those without ICS (P = 0.023). Meanwhile, no significant differences were observed in incidence of AE in the group with blood eosinophil counts < 300/μL. In the group with blood eosinophil counts < 300/μL, patients with ICS had a higher incidence of pneumonia with AE (P = 0.009). Conversely, no significant differences were observed in the group with blood eosinophil counts ≥ 300/μL. CONCLUSIONS ICS significantly reduced AE in COPD patients with blood eosinophil counts ≥ 300/μL. Meanwhile, ICS significantly increased pneumonia rate in patients with blood eosinophil count < 300/μL. Blood eosinophil count may be a useful indicator to identify the benefits and risks of ICS in COPD.
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Affiliation(s)
- Zenya Saito
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan.
| | - Masahiro Yoshida
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Ayako Kojima
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kentaro Tamura
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Tsukasa Hasegawa
- Division of Respiratory Diseases, Department of Internal Medicine, Atsugi City Hospital, 1-16-36 Mizuhiki, Atsugi-shi, Kanagawa, 243-8588, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Nennstiel S, Schlag C. Treatment of eosinophlic esophagitis with swallowed topical corticosteroids. World J Gastroenterol 2020; 26:5395-5407. [PMID: 33024392 PMCID: PMC7520613 DOI: 10.3748/wjg.v26.i36.5395] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/09/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic local immune-mediated disease of the esophagus. Beside proton pump inhibitors and food-restriction-diets swallowed topical corticosteroids (STC) can be offered as a first line therapy according to current guidelines. This review describes the background and practical management of STCs in EoE. So far, mainly asthma inhalers containing either budesonide or fluticasone have been administered to the esophagus by swallowing these medications “off label”. Recently esophagus-targeted formulations of topical steroids have been developed showing clinicopathological response rates up to 85% - an orodispersible tablet of budesonide has been approved as the first “in label” medication for EoE in Europe in June 2018. Whereas it was shown that disease remission induction of EoE by STCs is highly effective, there is still a lack of data regarding long-term and maintenance therapy. However, current studies on STC maintenance therapy add some movement into the game.
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Affiliation(s)
- Simon Nennstiel
- Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für Innere Medizin II, Munich 81675, Germany
| | - Christoph Schlag
- Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für Innere Medizin II, Munich 81675, Germany
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Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, Wedzicha JA, Trivedi R, St Rose E, Ballal S, McLaren J, Darken P, Aurivillius M, Reisner C, Dorinsky P. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med 2020; 383:35-48. [PMID: 32579807 DOI: 10.1056/nejmoa1916046] [Citation(s) in RCA: 277] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Triple fixed-dose regimens of an inhaled glucocorticoid, a long-acting muscarinic antagonist (LAMA), and a long-acting β2-agonist (LABA) for chronic obstructive pulmonary disease (COPD) have been studied at single dose levels of inhaled glucocorticoid, but studies at two dose levels are lacking. METHODS In a 52-week, phase 3, randomized trial to evaluate the efficacy and safety of triple therapy at two dose levels of inhaled glucocorticoid in patients with moderate-to-very-severe COPD and at least one exacerbation in the past year, we assigned patients in a 1:1:1:1 ratio to receive twice-daily inhaled doses of triple therapy (inhaled glucocorticoid [320 μg or 160 μg of budesonide], a LAMA [18 μg of glycopyrrolate], and a LABA [9.6 μg of formoterol]) or one of two dual therapies (18 μg of glycopyrrolate plus 9.6 μg of formoterol or 320 μg of budesonide plus 9.6 μg of formoterol). The primary end point was the annual rate (the estimated mean number per patient per year) of moderate or severe COPD exacerbations, as analyzed in the modified intention-to-treat population with the use of on-treatment data only. RESULTS The modified intention-to-treat population comprised 8509 patients. The annual rates of moderate or severe exacerbations were 1.08 in the 320-μg-budesonide triple-therapy group (2137 patients), 1.07 in the 160-μg-budesonide triple-therapy group (2121 patients), 1.42 in the glycopyrrolate-formoterol group (2120 patients), and 1.24 in the budesonide-formoterol group (2131 patients). The rate was significantly lower with 320-μg-budesonide triple therapy than with glycopyrrolate-formoterol (24% lower: rate ratio, 0.76; 95% confidence interval [CI], 0.69 to 0.83; P<0.001) or budesonide-formoterol (13% lower: rate ratio, 0.87; 95% CI, 0.79 to 0.95; P = 0.003). Similarly, the rate was significantly lower with 160-μg-budesonide triple therapy than with glycopyrrolate-formoterol (25% lower: rate ratio, 0.75; 95% CI, 0.69 to 0.83; P<0.001) or budesonide-formoterol (14% lower: rate ratio, 0.86; 95% CI, 0.79 to 0.95; P = 0.002). The incidence of any adverse event was similar across the treatment groups (range, 61.7 to 64.5%); the incidence of confirmed pneumonia ranged from 3.5 to 4.5% in the groups that included inhaled glucocorticoid use and was 2.3% in the glycopyrrolate-formoterol group. CONCLUSIONS Triple therapy with twice-daily budesonide (at either the 160-μg or 320-μg dose), glycopyrrolate, and formoterol resulted in a lower rate of moderate or severe COPD exacerbations than glycopyrrolate-formoterol or budesonide-formoterol. (Funded by AstraZeneca, ETHOS ClinicalTrials.gov number, NCT02465567.).
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Affiliation(s)
- Klaus F Rabe
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Fernando J Martinez
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Gary T Ferguson
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Chen Wang
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Dave Singh
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Jadwiga A Wedzicha
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Roopa Trivedi
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Earl St Rose
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Shaila Ballal
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Julie McLaren
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Patrick Darken
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Magnus Aurivillius
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Colin Reisner
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
| | - Paul Dorinsky
- From LungenClinic Grosshansdorf and Christian-Albrechts University Kiel, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany (K.F.R.); the Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York (F.J.M.); the Pulmonary Research Institute of Southeast Michigan, Farmington Hills (G.T.F.); the National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing (C.W.); the Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester (D.S.), and the National Heart and Lung Institute, Imperial College London, London (J.A.W.) - both in the United Kingdom; AstraZeneca, Durham, NC (R.T., P. Dorinsky); AstraZeneca, Morristown, NJ (E.S.R., S.B., P. Darken, C.R.); AstraZeneca, Gaithersburg, MD (J.M.); and AstraZeneca, Gothenburg, Sweden (M.A.)
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Graham JA, Sato M, Moore AR, McGrew AK, Ballweber LR, Byas AD, Dowers KL. Disseminated Strongyloides stercoralis infection in a dog following long-term treatment with budesonide. J Am Vet Med Assoc 2020; 254:974-978. [PMID: 30938621 DOI: 10.2460/javma.254.8.974] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 1.5-year-old 1.5-kg (3.3-lb) castrated male Pomeranian was examined because of a 10-month history of diarrhea characterized by hematochezia and weight loss and an acute onset of respiratory distress (ie, tachypnea and dyspnea). A presumptive diagnosis of inflammatory bowel disease had been made previously, and the dog had been treated with budesonide and tylosin but continued to have diarrhea and weight loss. CLINICAL FINDINGS On initial examination, the dog was weak and slightly obtunded. Thoracic radiography revealed a moderate to severe, diffuse, unstructured interstitial pattern. Serum biochemical abnormalities consisted of mild hypoalbuminemia, hypoglycemia, hypocalcemia, hypomagnesemia, and hypocholesterolemia that were likely secondary to chronic gastrointestinal disease and malnutrition. Pyuria and moderate bacteriuria with a single live larva were found on microscopic evaluation of the urine sediment. Fecal examination revealed numerous nematode larvae; the morphology was consistent with first-stage, rhabditiform larvae of Strongyloides stercoralis. TREATMENT AND OUTCOME A diagnosis of disseminated S stercoralis infection was made. The dog was treated with fenbendazole and ivermectin but developed respiratory collapse approximately 12 hours later and was euthanized because of the poor prognosis. Postmortem examination revealed S stercoralis in the lungs, small intestine, and kidney. CLINICAL RELEVANCE Findings illustrated the importance of performing diagnostic testing, including routine fecal examination, to rule out infectious causes of diarrhea before beginning empirical treatment with glucocorticoids such as budesonide. Further, repeated fecal examinations, including Baermann tests, should be considered if a positive response to glucocorticoids is not observed.
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Ismail G, Obrişcă B, Jurubiţă R, Andronesi A, Sorohan B, Vornicu A, Sinescu I, Hârza M. Budesonide versus systemic corticosteroids in IgA Nephropathy: A retrospective, propensity-matched comparison. Medicine (Baltimore) 2020; 99:e21000. [PMID: 32590815 PMCID: PMC7329020 DOI: 10.1097/md.0000000000021000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IgA Nephropathy (IgAN) is characterized by mesangial deposition of dominant, polymeric, galactose-deficient IgA1 molecules of gut-associated lymphoid tissue origin. We sought to evaluate the efficacy of targeting the mucosal immune system dysregulation underlying IgAN pathogenesis with a pH-modified formulation of budesonide with a maximum release of active compound in the distal ileum and proximal colon.We did a retrospective study evaluating the efficacy of budesonide (Budenofalk) in the treatment of IgAN. From a retrospective cohort of 143 patients with IgAN followed in our department we identified 21 patients that received treatment with budesonide. These patients received budesonide at a dose of 9 mg/d in the first 12 months, followed by a dose reduction to 3 mg/d for the subsequent period. Only patients that received a 24-month treatment with budesonide were included in the analysis (n = 18). We matched the budesonide-treated cohort to 18 patients with IgAN treated with systemic steroids from the same retrospective cohort. Efficacy was measured as change in proteinuria, hematuria and estimated glomerular filtration rate over a 24-month period.Treatment with budesonide was associated with a 24-month renal function decline of -0.22 (95%CI, -8.2 to 7.8) ml/min/1.73m, compared to -5.89 (95%CI, -12.2 to 0.4) ml/min/1.73m in the corticosteroid treatment group (p = 0.44, for between group difference). The median reduction in proteinuria at 24-month was 45% (interquartile range [IQR]: -79%; -22%) in the budesonide group and 11% (IQR: -39%; 43%) in the corticosteroid group, respectively (P = .009, for between group difference). The median reduction in hematuria at 24-month was 72% (IQR: -90%; -45%) in the budesonide group and 73% (IQR: -85%; 18%) in the corticosteroid group, respectively (P = .22, for between group difference). Treatment with budesonide was well tolerated with minimal side effects.Budesonide (Budenofalk) was effective in the treatment of patients with IgAN at high-risk of progression in terms of reducing proteinuria, hematuria and preserving renal function over 24 months of therapy.
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Affiliation(s)
- Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
| | - Bogdan Obrişcă
- Department of Nephrology, Fundeni Clinical Institute
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
| | - Roxana Jurubiţă
- Department of Nephrology, Fundeni Clinical Institute
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
| | - Andreea Andronesi
- Department of Nephrology, Fundeni Clinical Institute
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
| | | | - Ioanel Sinescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Mihai Hârza
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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Abstract
BACKGROUND Pouchitis occurs in approximately 50% of patients following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (UC). OBJECTIVES The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. SELECTION CRITERIA Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. MAIN RESULTS Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear. Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty-three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty-seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty-five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty-eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy-five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence). Chronic pouchitis: Eighty-five per cent (34/40) of De Simone Formulation (a probiotic formulation) participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty-five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty-five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. PREVENTION At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty-six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty-six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty-one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). AUTHORS' CONCLUSIONS The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis.
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Affiliation(s)
- Nghia Nguyen
- University of California San DiegoDivision of GastroenterologyLa JollaCaliforniaUSA
| | - Bing Zhang
- University of California San FranciscoDivision of GastroenterologySan FranciscoCaliforniaUSA
| | - Stefan D Holubar
- Cleveland ClinicDepartment of Colon and Rectal SurgeryClevelandOHUSA
| | - Darrell S Pardi
- Mayo ClinicDivision of Gastroenterology and Hepatology200 First Street SWRochesterMNUSA55905
| | - Siddharth Singh
- University of California San DiegoDivision of GastroenterologyLa JollaCaliforniaUSA
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Hughes MS, Molina GE, Chen ST, Zheng H, Deshpande V, Fadden R, Sullivan RJ, Dougan M. Budesonide treatment for microscopic colitis from immune checkpoint inhibitors. J Immunother Cancer 2019; 7:292. [PMID: 31699151 PMCID: PMC6839080 DOI: 10.1186/s40425-019-0756-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) are effective against a variety of malignancies but can be limited by inflammatory toxicities such as enterocolitis. Enterocolitis is typically treated with systemically active glucocorticoids. Endoscopy can stratify patients by the severity of mucosal inflammation, including identifying patients with colitis in the absence of visible mucosal changes: microscopic colitis. Whether patients with CPI microscopic colitis could be managed differently from colitis with more severe mucosal involvement is unclear. The objective of this study was to describe outcomes in CPI microscopic colitis focusing on the response to first line treatment with budesonide. METHODS We evaluated data from a retrospective cohort from a single-center large academic hospital. The participants were all adult patients evaluated by endoscopy for suspected CPI enterocolitis between 3/2017 and 3/2019. The exposures were: Mayo Endoscopic Score (range 0-3). The subset was: oral budesonide, maximum dose 12 mg daily, administered minimum of 5 weeks. The main outcomes and measures were: Primary: time from first CPI exposure to first glucocorticoid use; use of systemic glucocorticoids; time from symptom onset to resolution; continuation of CPI therapy; number of additional CPI infusions received. Secondary: admissions for symptom control; novel irAE development; need for second-line immunosuppression; oncologic outcomes. RESULTS We identified 38 patients with biopsy confirmed CPI enterocolitis, 13 in the microscopic colitis cohort, and 25 in the non-microscopic colitis cohort. Budesonide use was higher in the microscopic colitis cohort (12/13 vs 3/25, p < 0.001), and systemic glucocorticoid use was higher in non-microscopic colitis (22/25 vs. 3/13, p < 0.001). Time from symptom onset to resolution did not differ. Microscopic colitis patients more frequently remained on CPI after developing (entero)colitis (76.9% vs 16.0%, p < 0.001). Microscopic colitis patients tolerating further CPI received, on average, 4.2 CPI infusions more than non-microscopic colitis patients tolerating CPI (5.8 vs 1.6, p = 0.03). Microscopic colitis was associated with increased time-to-treatment-failure (HR 0.30, 95% CI 0.14-0.66) and progression-free survival (HR 0.22, 95% CI 0.07-0.70). CONCLUSIONS Gastrointestinal mucosal inflammation without visible mucosal injury is a distinct, prevalent CPI enterocolitis subset that can be diagnosed by endoscopy. First-line budesonide appears effective in controlling "microscopic colitis" symptoms and prolonging immunotherapy duration. These findings present a compelling rationale for routine endoscopic evaluation of suspected CPI enterocolitis and suggest an alternative glucocorticoid-sparing treatment strategy for a subset of such patients.
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Affiliation(s)
- Michael S Hughes
- Harvard Medical School, Boston, MA, USA
- Present address: Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Steven T Chen
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Riley Fadden
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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Allen G, Mitchell A, Ramirez M, Holsten S, Shah N. A Case of a Post-Operative Addisonian Crisis from HPA Axis Suppression from Inhaled Corticosteroids. Am Surg 2019; 85:e483-e484. [PMID: 31638547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Abstract
BACKGROUND Pouchitis occurs in approximately 50% of patients following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (UC). OBJECTIVES The primary objective was to determine the efficacy and safety of medical therapies for prevention or treatment of acute or chronic pouchitis. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 25 July 2018. We also searched references, trials registers, and conference proceedings. SELECTION CRITERIA Randomized controlled trials of prevention or treatment of acute or chronic pouchitis in adults who underwent IPAA for UC were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was evaluated using GRADE. The primary outcome was clinical improvement or remission in participants with acute or chronic pouchitis, or the proportion of participants with no episodes of pouchitis after IPAA. Adverse events (AEs) was a secondary outcome. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for each dichotomous outcome. MAIN RESULTS Fifteen studies (547 participants) were included. Four studies assessed treatment of acute pouchitis. Five studies assessed treatment of chronic pouchitis. Six studies assessed prevention of pouchitis. Three studies were low risk of bias. Three studies were high risk of bias and the other studies were unclear.Acute pouchitis: All ciprofloxacin participants (7/7) achieved remission at two weeks compared to 33% (3/9) of metronidazole participants (RR 2.68, 95% CI 1.13 to 6.35, very low certainty evidence). No ciprofloxacin participants (0/7) had an AE compared to 33% (3/9) of metronidazole participants (RR 0.18, 95% CI 0.01 to 2.98; very low certainty evidence). AEs included vomiting, dysgeusia or transient peripheral neuropathy. Forty-three per cent (6/14) of metronidazole participants achieved remission at 6 weeks compared to 50% (6/12) of budesonide enema participants (RR 0.86, 95% CI 0.37 to 1.96, very low certainty evidence). Fifty per cent (7/14) of metronidazole participants improved clinically at 6 weeks compared to 58% (7/12) of budesonide enema participants (RR 0.86, 95% CI 0.42 to 1.74, very low certainty evidence). Fifty-seven per cent (8/14) of metronidazole participants had an AE compared to 25% (3/12) of budesonide enema participants (RR 2.29, 95% CI 0.78 to 6.73, very low certainty evidence). AEs included anorexia, nausea, headache, asthenia, metallic taste, vomiting, paraesthesia, and depression. Twenty-five per cent (2/8) of rifaximin participants achieved remission at 4 weeks compared to 0% (0/10) of placebo participants (RR 6.11, 95% CI 0.33 to 111.71, very low certainty evidence). Thirty-eight per cent (3/8) of rifaximin participants improved clinically at 4 weeks compared to 30% (3/10) of placebo participants (RR 1.25, 95% CI 0.34 to 4.60, very low certainty evidence). Seventy-five per cent (6/8) of rifaximin participants had an AE compared to 50% (5/10) of placebo participants (RR 1.50, 95% CI 0.72 to 3.14, very low certainty evidence). AEs included diarrhea, flatulence, nausea, proctalgia, vomiting, thirst, candida, upper respiratory tract infection, increased hepatic enzyme, and cluster headache. Ten per cent (1/10) of Lactobacillus GG participants improved clinically at 12 weeks compared to 0% (0/10) of placebo participants (RR 3.00, 95% CI 0.14 to 65.90, very low certainty evidence).Chronic pouchitis: Eighty-five per cent (34/40) of De Simone Formulation participants maintained remission at 9 to 12 months compared to 3% (1/36) of placebo participants (RR 20.24, 95% CI 4.28 to 95.81, 2 studies; low certainty evidence). Two per cent (1/40) of De Simone Formulation participants had an AE compared to 0% (0/36) of placebo participants (RR 2.43, 95% CI 0.11 to 55.89; low certainty evidence). AEs included abdominal cramps, vomiting and diarrhea. Fifty per cent (3/6) of adalimumab patients achieved clinical improvement at 4 weeks compared to 43% (3/7) of placebo participants (RR, 1.17, 95% CI 0.36 to 3.76, low certainty evidence). Sixty per cent (6/10) of glutamine participants maintained remission at 3 weeks compared to 33% (3/9) of butyrate participants (RR 1.80, 95% CI 0.63 to 5.16, very low certainty evidence). Forty-five per cent (9/20) of patients treated with bismuth carbomer foam enema improved clinically at 3 weeks compared to 45% (9/20) of placebo participants (RR 1.00, 95% CI 0.50 to 1.98, very low certainty evidence). Twenty-five per cent (5/20) of participants in the bismuth carbomer foam enema group had an AE compared to 35% (7/20) of placebo participants (RR 0.71, 95% CI 0.27 to 1.88, very low certainty evidence). Adverse events included diarrhea, worsening symptoms, cramping, sinusitis, and abdominal pain. PREVENTION At 12 months, 90% (18/20) of De Simone Formulation participants had no episodes of acute pouchitis compared to 60% (12/20) of placebo participants (RR 1.50, 95% CI 1.02 to 2.21, low certainty evidence). Another study found 100% (16/16) of De Simone Formulation participants had no episodes of acute pouchitis at 12 months compared to 92% (11/12) of the no treatment control group (RR 1.10, 95% 0.89 to 1.36, very low certainty evidence). Eighty-six per cent (6/7) of Bifidobacterium longum participants had no episodes of acute pouchitis at 6 months compared to 60% (3/5) of placebo participants (RR 1.43, 95% CI 0.66 to 3.11, very low certainty evidence). Eleven per cent (1/9) of Clostridium butyricum MIYAIRI participants had no episodes of acute pouchitis at 24 months compared to 50% (4/8) of placebo participants (RR 0.22, 95% CI 0.03 to 1.60, very low certainty evidence). Forty-six per cent (43/94) of allopurinol participants had no episodes of pouchitis at 24 months compared to 43% (39/90) of placebo participants (RR 1.06, 95% CI 0.76 to 1.46; low certainty evidence). Eighty-one per cent (21/26) of tinidazole participants had no episodes of pouchitis over 12 months compared to 58% (7/12) of placebo participants (RR 1.38, 95% CI 0.83 to 2.31, very low certainty evidence). AUTHORS' CONCLUSIONS The effects of antibiotics, probiotics and other interventions for treating and preventing pouchitis are uncertain. Well designed, adequately powered studies are needed to determine the optimal therapy for the treatment and prevention of pouchitis.
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Affiliation(s)
- Nghia Nguyen
- University of California San DiegoDivision of GastroenterologyLa JollaUSA
| | - Bing Zhang
- University of California San FranciscoDivision of GastroenterologySan FranciscoUSA
| | - Stefan D Holubar
- Cleveland ClinicDepartment of Colon and Rectal SurgeryClevelandUSA
| | - Darrell S Pardi
- Mayo ClinicDivision of Gastroenterology and Hepatology200 First Street SWRochesterUSA55905
| | - Siddharth Singh
- University of California San DiegoDivision of GastroenterologyLa JollaUSA
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Beasley R, Holliday M, Reddel HK, Braithwaite I, Ebmeier S, Hancox RJ, Harrison T, Houghton C, Oldfield K, Papi A, Pavord ID, Williams M, Weatherall M. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med 2019; 380:2020-2030. [PMID: 31112386 DOI: 10.1056/nejmoa1901963] [Citation(s) in RCA: 247] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In double-blind, placebo-controlled trials, budesonide-formoterol used on an as-needed basis resulted in a lower risk of severe exacerbation of asthma than as-needed use of a short-acting β2-agonist (SABA); the risk was similar to that of budesonide maintenance therapy plus as-needed SABA. The availability of data from clinical trials designed to better reflect clinical practice would be beneficial. METHODS We conducted a 52-week, randomized, open-label, parallel-group, controlled trial involving adults with mild asthma. Patients were randomly assigned to one of three treatment groups: albuterol (100 μg, two inhalations from a pressurized metered-dose inhaler as needed for asthma symptoms) (albuterol group); budesonide (200 μg, one inhalation through a Turbuhaler twice daily) plus as-needed albuterol (budesonide maintenance group); or budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol, one inhalation through a Turbuhaler as needed) (budesonide-formoterol group). Electronic monitoring of inhalers was used to measure medication use. The primary outcome was the annualized rate of asthma exacerbations. RESULTS The analysis included 668 of 675 patients who underwent randomization. The annualized exacerbation rate in the budesonide-formoterol group was lower than that in the albuterol group (absolute rate, 0.195 vs. 0.400; relative rate, 0.49; 95% confidence interval [CI], 0.33 to 0.72; P<0.001) and did not differ significantly from the rate in the budesonide maintenance group (absolute rate, 0.195 in the budesonide-formoterol group vs. 0.175 in the budesonide maintenance group; relative rate, 1.12; 95% CI, 0.70 to 1.79; P = 0.65). The number of severe exacerbations was lower in the budesonide-formoterol group than in both the albuterol group (9 vs. 23; relative risk, 0.40; 95% CI, 0.18 to 0.86) and the budesonide maintenance group (9 vs. 21; relative risk, 0.44; 95% CI, 0.20 to 0.96). The mean (±SD) dose of inhaled budesonide was 107±109 μg per day in the budesonide-formoterol group and 222±113 μg per day in the budesonide maintenance group. The incidence and type of adverse events reported were consistent with those in previous trials and with reports in clinical use. CONCLUSIONS In an open-label trial involving adults with mild asthma, budesonide-formoterol used as needed was superior to albuterol used as needed for the prevention of asthma exacerbations. (Funded by AstraZeneca and the Health Research Council of New Zealand; Novel START Australian New Zealand Clinical Trials Registry number, ACTRN12615000999538.).
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Affiliation(s)
- Richard Beasley
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Mark Holliday
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Helen K Reddel
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Irene Braithwaite
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Stefan Ebmeier
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Robert J Hancox
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Tim Harrison
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Claire Houghton
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Karen Oldfield
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Alberto Papi
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Ian D Pavord
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Mathew Williams
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
| | - Mark Weatherall
- From the Medical Research Institute of New Zealand (R.B., M.H., I.B., S.E., C.H., K.O., M. Williams), the Capital and Coast District Health Board (R.B.), and the University of Otago Wellington (M. Weatherall), Wellington, the Department of Respiratory Medicine, Waikato Hospital, Hamilton (R.J.H.), and the Department of Preventive and Social Medicine, University of Otago, Dunedin (R.J.H.) - all in New Zealand; Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); the Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham (T.H.), and the Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford (I.D.P.) - both in the United Kingdom; and the Respiratory Medicine Unit, Department of Medical Sciences, Università di Ferrara, Ferrara, Italy (A.P.)
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Rawla P, Sunkara T, Thandra KC, Gaduputi V. Efficacy and Safety of Budesonide in the Treatment of Eosinophilic Esophagitis: Updated Systematic Review and Meta-Analysis of Randomized and Non-Randomized Studies. Drugs R D 2019; 18:259-269. [PMID: 30387081 PMCID: PMC6277325 DOI: 10.1007/s40268-018-0253-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objective Eosinophilic esophagitis (EE) is an immune/antigen-driven inflammation that causes esophageal dysfunction. Budesonide has shown promising effect in the management of EE in multiple studies, and we therefore conducted this systematic review/meta-analysis to assess budesonide efficacy and safety in order to provide more updated and robust evidence. Methods In April 2018, we conducted a systematic electronic search through four databases: PubMed, Scopus, Web of Science (ISI), and Cochrane Central. All original studies reporting the efficacy of budesonide in the treatment of EE were included in our meta-analysis. The Cochrane Collaboration tool was employed to assess the risk of bias among included randomized controlled trials, while the Newcastle–Ottawa Scale was used for non-randomized studies. Results A total of 12 studies including 555 participants were included in our review. Budesonide showed marked efficacy at the level of histological response compared to placebo [risk ratio (RR) (95% confidence interval (CI)) 11.93 (4.82–29.50); p > 0.001]. Analysis of randomized and non-randomized studies revealed considerable reduction in eosinophil count, with a mean difference (MD) (95% CI) of − 69.41 (− 105.31 to − 33.51; p < 0.001) and 46.85 (33.93–59.77; p < 0.001), respectively. Similarly, there was a marked improvement in the clinical symptoms via the analysis of randomized and non-randomized studies, with an RR (95% CI) of 1.72 (1.22–2.41; p = 0.002) and MD (95% CI) of 2.45 (0.76–4.15; p = 0.005), respectively. Conclusion Budesonide showed significant effect at all treatment endpoints. However, since budesonide carries a risk of candidiasis and our inferences are based only on a small number of included studies, more research is warranted to clarify these results. Electronic supplementary material The online version of this article (10.1007/s40268-018-0253-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Prashanth Rawla
- Department of Internal Medicine, SOVAH Health, 320 Hospital Dr, Martinsville, VA 24112 USA
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201 USA
| | | | - Vinaya Gaduputi
- Division of Gastroenterology, SBH Health System, 4422 Third Ave, Bronx, NY 19457 USA
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47
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Toskala E. Editorial. Int Forum Allergy Rhinol 2018; 7:439-440. [PMID: 28493305 DOI: 10.1002/alr.21947] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
This study investigated the effectiveness and safety of montelukast combined budesonide (MCB) treatment for children with chronic cough-variant asthma (CCVA).In total, 82 cases of children with CCVA, aged 4 to 11 years were included in this study. All cases received either MCB or budesonide alone between May 2015 and April 2017. The primary outcome was lung function, measured by the peak expiratory flow rates (PEFRs) and forced expiratory volume in 1 second (FEV1). The secondary outcome was measured by the clinical assessment score. Furthermore, adverse events (AEs) were also recorded in this study. All outcomes were measured after 8-week treatment.After 8-week treatment, MCB showed greater effectiveness than did budesonide alone in improving the lung function, measured by PEFR V1 (P = .02), and FEV1 (P < .01). Similarly, the clinical assessment score also demonstrated significant difference between the 2 groups (P < .05). In addition, no serious AEs occurred in both groups.The results of this study demonstrate that the effectiveness of MCB is superior to budesonide alone in the treatment of children with CCVA.
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49
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Bateman ED, Reddel HK, O'Byrne PM, Barnes PJ, Zhong N, Keen C, Jorup C, Lamarca R, Siwek-Posluszna A, FitzGerald JM. As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma. N Engl J Med 2018; 378:1877-1887. [PMID: 29768147 DOI: 10.1056/nejmoa1715275] [Citation(s) in RCA: 279] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with mild asthma often rely on inhaled short-acting β2-agonists for symptom relief and have poor adherence to maintenance therapy. Another approach might be for patients to receive a fast-acting reliever plus an inhaled glucocorticoid component on an as-needed basis to address symptoms and exacerbation risk. METHODS We conducted a 52-week, double-blind, multicenter trial involving patients 12 years of age or older who had mild asthma and were eligible for treatment with regular inhaled glucocorticoids. Patients were randomly assigned to receive twice-daily placebo plus budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol) used as needed or budesonide maintenance therapy with twice-daily budesonide (200 μg) plus terbutaline (0.5 mg) used as needed. The primary analysis compared budesonide-formoterol used as needed with budesonide maintenance therapy with regard to the annualized rate of severe exacerbations, with a prespecified noninferiority limit of 1.2. Symptoms were assessed according to scores on the Asthma Control Questionnaire-5 (ACQ-5) on a scale from 0 (no impairment) to 6 (maximum impairment). RESULTS A total of 4215 patients underwent randomization, and 4176 (2089 in the budesonide-formoterol group and 2087 in the budesonide maintenance group) were included in the full analysis set. Budesonide-formoterol used as needed was noninferior to budesonide maintenance therapy for severe exacerbations; the annualized rate of severe exacerbations was 0.11 (95% confidence interval [CI], 0.10 to 0.13) and 0.12 (95% CI, 0.10 to 0.14), respectively (rate ratio, 0.97; upper one-sided 95% confidence limit, 1.16). The median daily metered dose of inhaled glucocorticoid was lower in the budesonide-formoterol group (66 μg) than in the budesonide maintenance group (267 μg). The time to the first exacerbation was similar in the two groups (hazard ratio, 0.96; 95% CI, 0.78 to 1.17). The change in ACQ-5 score showed a difference of 0.11 units (95% CI, 0.07 to 0.15) in favor of budesonide maintenance therapy. CONCLUSIONS In patients with mild asthma, budesonide-formoterol used as needed was noninferior to twice-daily budesonide with respect to the rate of severe asthma exacerbations during 52 weeks of treatment but was inferior in controlling symptoms. Patients in the budesonide-formoterol group had approximately one quarter of the inhaled glucocorticoid exposure of those in the budesonide maintenance group. (Funded by AstraZeneca; SYGMA 2 ClinicalTrials.gov number, NCT02224157 .).
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Affiliation(s)
- Eric D Bateman
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Helen K Reddel
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Paul M O'Byrne
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Peter J Barnes
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Nanshan Zhong
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Christina Keen
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Carin Jorup
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Rosa Lamarca
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - Agnieszka Siwek-Posluszna
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
| | - J Mark FitzGerald
- From the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.); Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J.); AstraZeneca Research and Development, Barcelona (R.L.); and AstraZeneca Research and Development, Warsaw, Poland (A.S.-P.)
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O'Byrne PM, FitzGerald JM, Bateman ED, Barnes PJ, Zhong N, Keen C, Jorup C, Lamarca R, Ivanov S, Reddel HK. Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma. N Engl J Med 2018; 378:1865-1876. [PMID: 29768149 DOI: 10.1056/nejmoa1715274] [Citation(s) in RCA: 357] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with mild asthma, as-needed use of an inhaled glucocorticoid plus a fast-acting β2-agonist may be an alternative to conventional treatment strategies. METHODS We conducted a 52-week, double-blind trial involving patients 12 years of age or older with mild asthma. Patients were randomly assigned to one of three regimens: twice-daily placebo plus terbutaline (0.5 mg) used as needed (terbutaline group), twice-daily placebo plus budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol) used as needed (budesonide-formoterol group), or twice-daily budesonide (200 μg) plus terbutaline used as needed (budesonide maintenance group). The primary objective was to investigate the superiority of as-needed budesonide-formoterol to as-needed terbutaline with regard to electronically recorded weeks with well-controlled asthma. RESULTS A total of 3849 patients underwent randomization, and 3836 (1277 in the terbutaline group, 1277 in the budesonide-formoterol group, and 1282 in the budesonide maintenance group) were included in the full analysis and safety data sets. With respect to the mean percentage of weeks with well-controlled asthma per patient, budesonide-formoterol was superior to terbutaline (34.4% vs. 31.1% of weeks; odds ratio, 1.14; 95% confidence interval [CI], 1.00 to 1.30; P=0.046) but inferior to budesonide maintenance therapy (34.4% and 44.4%, respectively; odds ratio, 0.64; 95% CI, 0.57 to 0.73). The annual rate of severe exacerbations was 0.20 with terbutaline, 0.07 with budesonide-formoterol, and 0.09 with budesonide maintenance therapy; the rate ratio was 0.36 (95% CI, 0.27 to 0.49) for budesonide-formoterol versus terbutaline and 0.83 (95% CI, 0.59 to 1.16) for budesonide-formoterol versus budesonide maintenance therapy. The rate of adherence in the budesonide maintenance group was 78.9%. The median metered daily dose of inhaled glucocorticoid in the budesonide-formoterol group (57 μg) was 17% of the dose in the budesonide maintenance group (340 μg). CONCLUSIONS In patients with mild asthma, as-needed budesonide-formoterol provided superior asthma-symptom control to as-needed terbutaline, assessed according to electronically recorded weeks with well-controlled asthma, but was inferior to budesonide maintenance therapy. Exacerbation rates with the two budesonide-containing regimens were similar and were lower than the rate with terbutaline. Budesonide-formoterol used as needed resulted in substantially lower glucocorticoid exposure than budesonide maintenance therapy. (Funded by AstraZeneca; SYGMA 1 ClinicalTrials.gov number, NCT02149199 .).
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Affiliation(s)
- Paul M O'Byrne
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - J Mark FitzGerald
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Eric D Bateman
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Peter J Barnes
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Nanshan Zhong
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Christina Keen
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Carin Jorup
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Rosa Lamarca
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Stefan Ivanov
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Helen K Reddel
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
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