The jury is still out on whether patients with acute lung injury and adult respiratory distress syndrome derive any benefit from the use of corticosteroids, according to Dr. Stephen M. Pastores.

“This is probably the most controversial topic in acute lung injury and ARDS,” Dr. Pastores of the department of anesthesiology and critical care medicine at Memorial Sloan-Kettering Cancer Center, New York, said at the annual meeting of the American College of Chest Physicians.

From Familypracticenews.com:

He went on to note that physicians should give steroids in conjunction with infection surveillance, “avoiding neuromuscular blockers if you can, and being concerned about the phenomenon of rebound inflammation if you stop steroids abruptly.”

Inhaled nitric oxide has also been studied as a nonventilatory strategy in ALI/ARDS. A Cochrane review of 13 randomized, controlled trials involving 1,303 patients found no significant effect with this approach in overall mortality, but did show a transient improvement in oxygenation in the first 24 hours. The review also found that inhaled nitric oxide had no significant effect on duration of ventilation, ventilator-free days, and ICU and hospital length of stay. An increased risk of renal impairment among adults was also noted (Cochrane Database Syst. Rev. 2010 Oct. 23 [doi:10.1002/14651858.CD002787.pub2]).

“An important piece of this study was that [the researchers] did regular infection surveillance with regular bronchoscopies, and they avoided the use of neuromuscular blockers,” said Dr. Pastores, who is also professor of medicine and anesthesiology at Cornell University in New York.

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Inhaling corticosteroids can elevate chances of being diagnosed with type 2 diabetes, according to investigators from the Jewish General Hospital’s Lady Davis Institute for Medical Research (LDI) in Montreal.

The investigators’ findings suggested that asthmatics and those suffering from chronic obstructive pulmonary disorder (COPD) taking corticosteroids may be at a considerable risk.

From Healthjockey.com:

Dr. Samy Suissa, Director of the Centre for Clinical Epidemiology at the LDI, and lead investigator, highlighted, “These are not insubstantial numbers. Over a large population the absolute numbers of affected people are significant. We recommend that physicians reserve the use of inhaled steroids for the patients who truly benefit from these medications, namely asthmatics, and curb their use in COPD to the few patients for whom they are indicated. In all cases, patients using high doses should be assessed for possible hyperglycemia and the lowest effective dose targeted.”

The study was published in the American Journal of Medicine.

Tags: COPD, corticosteroids, Inhaled steroids

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Corticosteroids showed a neutral response to eye ulcers when considered cumulatively, according to a team from the University of California.

The steroids are believed to aid patients who were infected with more severe kinds of bacterial corneal ulcers.

From Healthjockey.com:

The team observed that steroid therapy apparently showed some enhancement of vision in persons afflicted with serious form of ulcers. There is a controversy surrounding the use of topical corticosteroids in the ophthalmology front. Some of the areas of concern include corneal perforation and deterioration of vision.

“We consider this finding very significant; it’s a clinically meaningful difference. Although secondary to the study’s original purpose, the results in severe cases were identified early on, so we didn’t start doing all of these analyses after the fact. It was of interest. So I think there is something there,” commented the paper’s co-author NishaAcharya, MD, MS, associate professor and director of the Uveitis Service in the UCSF Department of Ophthalmology.

The findings are published in the journal, Archives of Ophthalmology.

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According to the results of a randomized trial, bacterial corneal ulcers responded no better to adjunctive topical steroids than to placebo.

“A larger study examining only severe corneal ulcers is needed to confirm this supposition,” Nisha R. Acharya, MD, of the University of California San Francisco, and co-authors wrote. “To our knowledge, this is the first large randomized controlled trial to provide evidence regarding the safety and efficacy of the use of corticosteroids in the treatment of bacterial corneal ulcers.”

From Medpagetoday.com:

Use of topical steroids to treat corneal ulcers has remained controversial for decades, owing to a lack of data to provide a definitive answer. The clinical rationale lies in steroids‘ potential to reduce immune-mediated damage and in evidence of efficacy in some systemic bacterial infections.

In an effort to resolve the uncertainty, investigators in theU.S.andIndiaconducted the Steroids for Corneal Ulcers Trial (SCUT). They enrolled 500 patients, primarily fromIndia, with culture-positive bacterial corneal ulcers, who had been using topical moxifloxacin for 48 hours.

Patients were randomized to 1% prednisolone phosphate or placebo in addition to moxifloxacin. They were followed for three months.

The primary endpoint was best spectacle-corrected visual acuity at the end of the study. Secondary outcomes included adverse events; infiltrate/scar size; rigid contact lens-corrected visual acuity at three weeks, three months, and 12 months; time to resolution of epithelial defect; and best spectacle-corrected visual acuity at three weeks and 12 months.

The study was supported by the National Eye Institute and Alcon/Novartis provided the moxifloxacin used in the study.

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A UCSF study has given hope to those suffering from severe cases of bacterial corneal ulcers that can result in blindness, if left untreated.

During the study, the use of topical corticosteroids in a randomized controlled trial was found to be neither beneficial nor harmful in the overall patient population.

From Ucsf.edu:

In a paper published this month in the Archives of Ophthalmology, one of the JAMA/Archives journals, researchers found significant vision improvement — one and a half to two lines of improvement on an eye chart — by using steroid therapy on patients with severe ulcers.

“We consider this finding very significant; it’s a clinically meaningful difference,” said the paper’s co-author Nisha Acharya, MD, MS, associate professor and director of the Uveitis Service in the UCSF Department of Ophthalmology. Although secondary to the study’s original purpose, Acharyasaid the results in severe cases were identified early on, so “we didn’t start doing all of these analyses after the fact. It was of interest. So I think there is something there.”

The use of topical corticosteroids is somewhat controversial within the ophthalmology community, with no specific evidence pointing one way or the other. Concerns include corneal perforation and worsening vision.

“It’s important to note that in the worst ulcer group, not only do we not find a safety problem, we actually found that steroids resulted in a benefit in vision,” Acharya said.

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Patients who receive kidney transplants who are withdrawn from corticosteroid-based immunosuppression (CSBI) as early as possible after transplantation have significantly lower fracture rates compared with patients who continue receiving corticosteroids.

This finding was presented by a research presented at the American Society for Bone and Mineral Research (ASBMR) 2011 Annual Meeting.

From Medscape.com:

Corticosteroids are known to be toxic to osteoblasts, and the drugs are typically given in exceptionally high doses after kidney transplants, potentially causing substantial bone loss, said coauthor Thomas L. Nickolas, MD, from Columbia University Medical School in New York City.

“Kidney transplant patients typically initially get very high intravenous doses of corticosteroids that are tapered down to a high oral dose, then to a small oral dose, by 6 months, but it is in that first 6 months after transplantation when the majority of bone loss occurs,” he explained.

Studies show that the bone loss at the lumbar spine and the hip during that initial 6 months posttransplantation can range from 2% to as much as 10%, he said.

The study was supported by the Doris Duke Charitable Foundation.

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Young boys with Duchenne muscular dystrophy are able to walk on their own for longer period of time when they receive daily steroid treatments for several years.

Daily steroid treatment also helps them reduce the risk of scoliosis, according to a study published in an issue of Neurology®, the scientific journal of the American Academy of Neurology.

From Sciencedaily.com:

Duchenne muscular dystrophy occurs in one in 3,500 boys. Symptoms start in early childhood and rapidly progress with most boys losing the ability to walk between ages nine and 11. There is no cure for the disorder.

For the study, researchers reviewed records of 143 boys seen at the Ohio State University Muscular Dystrophy Clinic in Columbus. Of the group, 75 had been treated with corticosteroids for an average of eight years and the rest of the boys had never been treated or had received a brief dose of steroids.

The study found boys who were treated with daily steroids walked by themselves 3.3 years longer than the untreated boys and had a lower rate of scoliosis, 31 percent compared to 91 percent.

“Previous studies have shown steroids improve strength and function in Duchenne muscular dystrophy, but this is the first study to show the long-term impact and how treated boys are able to walk longer on their own,” said study author Wendy King, PT, with the Department of Neurology at Ohio State University Medical Center, and member of the American Academy of Neurology.

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The use of corticosteroids is effective for reducing the morbidity and mortality of severe bacterial pneumonia, Dr. Antoni Torres said at the 12th International Congress on Infectious Diseases.

The finding was supported by results from two positive randomized trials, multiple observational studies, and animal models.

From Internalmedicinenews.com:

A prospective observational study by Dr. Torres and his coworkers involving 1,424 CAP patients hospitalized at 15 medical centers was among the work that fanned interest in the use of steroids in pneumonia. In that study, 15% of the patients experienced empirical treatment failure, which was associated with an adjusted 11-fold increase in hospital mortality.

The independent risk factors for treatment failure included multilobar CAP, radiologic cavitation, pleural effusion, liver disease, leukopenia, and pneumonia risk class (Thorax 2004;59:960–5).

However, it was the factors identified as protective against treatment failure, such as influenza vaccination, initial treatment with a fluoroquino-lone, and especially chronic obstructive pulmonary disease (COPD), that caught the researchers’ attention. Dr. Torres and his coworkers hypothesized that COPD‘s protective effect might involve the use of steroids in affected patients.

The first randomized trial was a multicenter, double-blind, Italian study involving 46 patients with severe CAP on placebo or 200 mg of hydrocortisone as an IV bolus, followed by 7 days of therapy at 10 mg/hour.

Tags: COPD, corticosteroids, steroids, use of steroids

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In a large 12-month randomized trial, Roflumilast was found effective for improving lung function and prevent exacerbations in patients with COPD with chronic bronchitis and severe airflow obstruction.

Dr. Andrew McIvor said at the annual meeting of the American College of Chest Physicians that results of the 1,568-patient, double-blind, placebo-controlled study known as the M2-125 trial indicate that roflumilast is an important potential advance in the treatment of a subset of patients with COPD.

From Internalmedicinenews.com:

Participants in the eight-nation M2-125 trial had to have at least one documented moderate or severe COPD exacerbation during the year prior to enrollment. They were randomized to roflumilast 500 mcg once daily or placebo for 1 year, on top of background long-acting beta2-agonist or short-acting anticholinergic therapy at stable doses, along with short-acting beta2-agonists as needed. Long-acting anticholinergics and inhaled corticosteroids were not permitted.

The rate of moderate to severe COPD exacerbations requiring systemic steroids and/or treatment in a hospital—one of two co-primary study end points—was 1.21 cases per patient per year in the roflumilast group and 1.49 in controls, for a highly significant 18.5% relative risk reduction.

The other primary end point was improvement in lung function as reflected in mean change from baseline in forced expiratory volume in 1 second (FEV1) prior to administration of a bronchodilator.

Again, roflumilast showed a highly significant advantage, with a 33-mL increase in FEV1 as compared to a 25-mL decrease with placebo over the course of 12 months.

Dr. McIvor of St. Joseph’s Healthcare Hamilton (Ont.) explained that Roflumilast (Daxas) is an investigational selective phosphodiesterase 4 inhibitor that can target the inflammation that is a hallmark of the disease when taken daily in an oral form.

Tags: COPD, corticosteroids, Roflumilast, steroids

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Thomas A. Luger, M.D., said at a satellite symposium held in conjunction with the annual meeting of the European Society for Dermatological Research that the topical calcineurin inhibitors constitute the most important advance in topical therapy of inflammatory dermatoses in half a century.

Dr. Luger, professor and chair of dermatology at the University of Münster (Germany) added, “I think that this is the first new and effective development in topical therapy since Marion Sulzberger introduced the corticosteroids for treatment of inflammatory skin diseases 50 years ago.”

From Internalmedicinenews.com:

A recent 11-patient series reported by investigators at Ruhr University in Bochum, Germany, concluded that 3 weeks of twice-daily 1% pimecrolimus cream, with the second application followed by overnight occlusion, resulted in excellent results in all patients, with the benefits being sustained in most patients during 8 weeks of follow-up off treatment (J. Am. Acad. Dermatol. 2004;51:407–10). The investigators found that the skin lesions of systemic lupus erythematosus (SLE) and subacute cutaneous lupus erythematosus (LE) responded better than those of long-standing discoid LE, which tend to be more hyperkeratotic and therefore resistant to transdermal drug penetration.

Topical tacrolimus appears to be effective as well. Investigators at St. Thomas’ Hospital, London, have reported that 6 of 11 LE patients with resistant cutaneous lesions showed clear improvement in their skin lesions in response to a minimum of 6 weeks of 0.1% tacrolimus ointment. Among the responders were patients with discoid LE, subacute cutaneous LE, and SLE (Rheumatology 2004;43:1383–5).

Dr. Luger said at the satellite symposium sponsored by Novartis that there are some skin diseases where the early off-label clinical experience with the topical calcineurin inhibitors appears to be favorable but randomized controlled trials will be required to establish which patients are best treated with these agents.

Tags: calcineurin inhibitors, corticosteroids, pimecrolimus

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