- Predictors of efficacy for combination oral and topical corticosteroids to treat patients with chronic rhinosinusitis with nasal polyps. [Journal Article]Int Forum Allergy Rhinol 2019IF
- CONCLUSIONS: In treatment of CRSwNP with prednisone and budesonide irrigations, pretreatment endoscopy was not informative of treatment response. Pretreatment SNOT-22 and comorbid asthma may be more predictive.
- Esophageal lichen planus: towards diagnosis of an underdiagnosed disease. [Journal Article]Scand J Gastroenterol 2019; :1-10SJ
- CONCLUSIONS: Esophageal involvement of LP is frequent, but may be asymptomatic. ELP can be diagnosed using the diagnostic criteria proposed here. Dysphagia and combined oral and genital manifestation are associated with ELP. Therapy with topical corticosteroids appears to be a prudent therapeutic approach for ELP.
- Oral steroid sparing effect of high dose inhaled corticosteroids in asthma. [Journal Article]Eur Respir J 2019ER
- CONCLUSIONS: In patients with oral corticosteroid-dependent asthma, the limited available evidence suggests that the majority of the oral corticosteroid sparing effect of high dose ICS is likely to be due to systemic effects.
- Efficacy of treatment with montelukast, fluticasone propionate and budesonide liquid suspension for the prevention of recurrent asthma paroxysms in children with wheezing disorders. [Journal Article]Exp Ther Med 2019; 18(4):3090-3094ET
- One-third of the children who suffer from first-time wheezing are estimated to experience recurrences; however, no standard therapeutic strategy with which to prevent these recurrences currently exists. A few studies have compared the three drugs commonly used for the treatment of persistent asthma in children to identify the most effective one for preventing recurrent wheezing. In this study, in…
One-third of the children who suffer from first-time wheezing are estimated to experience recurrences; however, no standard therapeutic strategy with which to prevent these recurrences currently exists. A few studies have compared the three drugs commonly used for the treatment of persistent asthma in children to identify the most effective one for preventing recurrent wheezing. In this study, in an aim to determine the most effective of these drugs, we recruited patients <5 years of age with recurrent wheezing at our hospital, and assigned them randomly to either the oral montelukast [leukotriene receptor antagonist (LTRA)], the inhaled fluticasone propionate (FP), or the inhaled budesonide suspension (BUD) groups for 12-week treatments. We then determined the treatment efficacy (symptomatic improvement) by recording the number of wheezing episodes and emergency visits, the daily treatment cost, the mean accumulated down time and the patient compliance; we then compared the results among the groups. All treatments were found to be equally effective. The daily cost of inhaled FP was lower than that of oral LTRA and inhaled BUD (P<0.00001). The difference in the mean accumulated down time between these groups was not significant (P=0.132). The adherence (patient compliance) to LTRA was significantly higher than the adherence to inhaled corticosteroids (ICS) (P<0.017). On the whole, the findings of this study indicated that all three treatments prevented recurrent wheezing in our pediatric population. FP was found to be more convenient, to require fewer doses, and that it could be easily adjusted. Patient adherence/compliance to treatment was significantly better with LTRA than with ICS.
- Lymphomatoid Papulosis Type B in a Patient with Crohn's Disease Treated with TNF-Alpha Inhibitors Infliximab and Adalimumab. [Journal Article]Acta Dermatovenerol Croat 2019; 27(3):202-204AD
- Dear Editor, Lymphomatoid papulosis (LP) is a chronic, recurrent, usually self-limited papulonecrotic or papulonodular skin disease, which belongs to the group of primary cutaneous CD30+ lymphoproliferative disorders (1). Three main histological subtypes of LP have been recognized: type A (histiocytic), type B (mycosis fungoides-like), and type C (anaplastic large cell lymphoma-like). Recently, n…
Dear Editor, Lymphomatoid papulosis (LP) is a chronic, recurrent, usually self-limited papulonecrotic or papulonodular skin disease, which belongs to the group of primary cutaneous CD30+ lymphoproliferative disorders (1). Three main histological subtypes of LP have been recognized: type A (histiocytic), type B (mycosis fungoides-like), and type C (anaplastic large cell lymphoma-like). Recently, new histologic LP variants classified as type D (CD8-positive, cytotoxic form) and type E (angioinvasive form) have also been described. The etiology of LP has not been determined to date (2-4). Herein we report a case of LP type B evolving in a patient with Crohn's disease after treatment with infliximab and adalimumab. A 38-year-old man suffering from terminal ileitis form of luminar Crohn's disease for 10 years presented at our department. During the last 10 years, the patient had been treated with a number of conventional disease-modifying anti-inflammatory drugs including non-steroid anti-inflammatory drugs, mesalazine, and immunomodulatory agents such as corticosteroids and azathioprine. As the disease was not sufficiently controlled, TNF-α inhibitor therapy was initiated. Infliximab was administered in standard dosage (5 mg/kg body weight every 8 weeks after the induction period) for one year. Concomitant therapy with azathioprine was established to reduce the risk of adverse immunological reactions. Since the patient showed only partial clinical response, infliximab was switched to adalimumab (40 mg biweekly), resulting in notable improvement. 18 months after the initiation of adalimumab treatment, asymptomatic, small, red to brown papules developed on the extremities. Multiple lesions were observed, initially on the legs, but the symptoms rapidly progressed to the arms and trunk (Figure 1). An acquired ichthyosis further complicated the disease course by extended, extremely xerotic, scaling skin lesions. Neither systemic symptoms nor significant lymphadenopathy was observed. The clinical picture suggested either ichthyosiform mycosis fungoides or a coincidence of LP and acquired ichthyosis. The histology of a typical papule showed perivascular and periadnexal lymphoid infiltration with massive hemorrhage in the dermis. The infiltration was dense, composed of small-to-medium-sized lymphoid cells showing focal significant epidermotropism (Figure 2). Most observed epidermal lymphocytes were CD3+, CD4+, and CD30+, while the dermal infiltration had higher CD4 and lower CD30 expression (10-15%). Polymerase chain reaction (PCR) analysis of skin and peripheral blood samples did not show clonal rearrangement of T-cell receptor gamma (TcRgamma) genes. Normal phenotypes of lymphocyte subsets were detected by flow cytometry of peripheral blood. Ichthyosiform mycosis fungoides was excluded since histology of ichthyosiform skin lesions showed only hyperkeratosis with a reduced granular layer. While the cutaneous CD4+ epidermotropic infiltrate was suspicious of either mycosis fungoides or LP type B, the complexity of clinicopathological data confirmed the diagnosis of LP type B. The peripheral blood counts, serum biochemical tests, and urinalysis were within normal range, while the elevated serum anti-Saccharomyces cerevisiae antibodies (ASCA) of IgG and IgA subclasses indicated the activity of Crohn's disease. Adalimumab and azathioprine were discontinued, and oral budesonide therapy was started in combination with topical corticosteroids and PUVA phototherapy. The skin lesions resolved with hyperpigmentation, and there was no relapse during the twelve-month follow-up. Recent data suggest that LP occurs more commonly in immunocompromised patients, especially in those with solid organ or bone marrow transplants (3). Though TNF-α inhibitors have dramatically advanced the treatment of various diseases, the risk of lymphoma associated with their use remains controversial (5). Several cases of cutaneous lymphoproliferative disorders associated with TNF-α inhibitor treatment have been reported, including two patients with LP (6). One of the two patients with LP received infliximab for Crohn's disease (7), while the other one had juvenile rheumatoid arthritis and received adalimumab (8). Our case is the third report on LP developing under TNF-α inhibitor therapy and the first LP type B in a patient with Crohn's disease treated with infliximab and later with adalimumab. A further interesting aspect of our case is that it also represents an example of the known association of acquired ichthyosis with inflammatory bowel disease (9). Multidisciplinary management was needed to provide optimal care and disease outcome for our patient. Since it is usually difficult to prove causality in most of such cases, it is important to collect similar clinical observations. Acknowledgments: The authors are grateful to Dr. László Bene, Dr. József Szakonyi, and Dr. Fruzsina Kovács for additional medical care of the patient and to Tamás Szaák for the clinical photos. The authors thank Prof. Miklós Sárdy for his critical review of the paper.
- Rapid Recurrence of Eosinophilic Esophagitis Activity After Successful Treatment in the Observation Phase of a Randomized, Double-blind, Double-dummy Trial. [Journal Article]Clin Gastroenterol Hepatol 2019CG
- CONCLUSIONS: EoE disease activity recurred rapidly after initial histologic response to topical steroids (either OVB or MDI). Because most subjects had recurrent endoscopic and histologic signs not reliably detected by symptoms, maintenance therapy should be recommended in EoE patients achieving histologic response to topical steroids. Clinicaltrials.gov no: NCT02019758.
- Comparing a fixed combination of budesonide/formoterol with other inhaled corticosteroid plus long-acting beta-agonist combinations in patients with chronic obstructive pulmonary disease: a review. [Journal Article]Expert Rev Respir Med 2019; 13(11):1087-1094ER
- Introduction: Inhaled corticosteroid (ICS) plus long-acting β2-agonist (LABA) combinations are commonly used in the treatment of patients with chronic obstructive pulmonary disease (COPD). At least four fixed-dose ICS/LABA combinations are available, including budesonide/formoterol, beclomethasone/formoterol, fluticasone/vilanterol and fluticasone/salmeterol, but there is little guidance for clin…
Introduction: Inhaled corticosteroid (ICS) plus long-acting β2-agonist (LABA) combinations are commonly used in the treatment of patients with chronic obstructive pulmonary disease (COPD). At least four fixed-dose ICS/LABA combinations are available, including budesonide/formoterol, beclomethasone/formoterol, fluticasone/vilanterol and fluticasone/salmeterol, but there is little guidance for clinicians on which of these combinations to prescribe. Areas covered: The aim of this in-depth review was to identify studies that compared budesonide/formoterol with the other ICS/LABA combinations and assess the data on exacerbations, safety, and patient quality of life. PubMed and Ovid databases were searched, and 14 studies were identified. Our findings highlight the lack of prospective, randomized, controlled trials comparing LABA/ICS combinations in the treatment of COPD as only two such studies were identified. However, current evidence suggests that the effects of budesonide/formoterol on reducing exacerbations and improving quality of life may be similar to, or more marked than, those of other LABA/ICS combinations in COPD and, compared with the other LABA/ICS combinations, budesonide/formoterol may be associated with a lower incidence of serious pneumonia events and oral candidiasis. Expert opinion: To better guide clinicians in selecting between the available ICS/LABA, robust meta-analyses and well-designed head-to-head clinical trials are urgently needed.
- Budesonide Oral Suspension Significantly Improves Eosinophilic Esophagitis Histology Scoring System Results: Analyses From a 12-Week, Phase 2, Randomized, Placebo-controlled Trial. [Journal Article]Am J Surg Pathol 2019; 43(11):1501-1509AJ
- Budesonide oral suspension (BOS) is a novel topical corticosteroid, which has been shown to improve symptoms and endoscopic appearance, and reduce peak eosinophil counts in patients with eosinophilic esophagitis (EoE). This trial evaluated the effect of BOS or placebo on the severity (grade) and extent (stage) of 8 histopathologic features observed in EoE, using the validated eosinophilic esophag…
Budesonide oral suspension (BOS) is a novel topical corticosteroid, which has been shown to improve symptoms and endoscopic appearance, and reduce peak eosinophil counts in patients with eosinophilic esophagitis (EoE). This trial evaluated the effect of BOS or placebo on the severity (grade) and extent (stage) of 8 histopathologic features observed in EoE, using the validated eosinophilic esophagitis histologic scoring system (EoE HSS). Patients with EoE aged 11 to 40 years with dysphagia were randomized to receive either BOS (2.0 mg twice daily) or placebo for 12 weeks. Mean (SD) EoE HSS grade and stage total scores at baseline for placebo and BOS groups were: grade, 0.42 (0.16) and 0.49 (0.14), respectively; stage: 0.38 (0.14) and 0.46 (0.11), respectively. These scores significantly decreased (improved) from baseline for patients receiving BOS versus placebo (grade: least squares mean change [SE]: placebo vs. BOS, -0.04 [0.03] vs. -0.24 [0.02]; P<0.0001; stage: -0.01 [0.02] vs. -0.19 [0.02]; P<0.0001). EoE HSS total scores improved for 6 of the 8 and 5 of the 8 histopathologic features for grade and stage, respectively, versus placebo. Change in EoE HSS total scores correlated moderately but significantly with change in endoscopic severity (endoscopic reference score; grade: R=0.5349; stage: R=0.5416; both P<0.0001). Change in EoE HSS stage total score correlated weakly with change in Dysphagia Symptom Questionnaire scores (grade: R=0.1925; P=0.0740; stage: R=0.2135; P=0.0471). These data demonstrate that the EoE HSS is a valuable endpoint of treatment response in randomized clinical trials and should be considered for future trials for EoE.
- Is there a relationship between asthma and diabetes? [Journal Article]J Asthma 2019; :1-7JA
- CONCLUSIONS: The effect of asthma on diabetes does not seem to be significant, except for in patients with severe asthma. Inhaled steroids administered in low or mild doses do not affect fasting glycemia.
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- An Exploration of Factors Affecting In Vitro Deposition of Pharmaceutical Aerosols in the Alberta Idealized Throat. [Journal Article]J Aerosol Med Pulm Drug Deliv 2019JA
- CONCLUSIONS: Three of six inhalers showed sensitivity to insertion angle. When directed toward the tongue versus the back of the mouth, the filter dose decreased from 21.9% to 15.6% (percent delivered dose) for Easyhaler Budesonide (p < 0.001), from 46.5% to 26.0% for Ventolin Evohaler (p < 0.001), and from 56.7% to 35.7% for Flovent HFA (p < 0.001) for tests at ambient laboratory humidity. Sensitivity to insertion angle and increases in total lung dose variability may be reduced in future products using larger diameter mouthpieces and smaller particles for DPIs and lower-momentum sprays for pMDIs. Humidity influenced deposition from Ventolin Evohaler and Flovent HFA. When oriented toward the back of the oral cavity, the filter dose decreased from 46.5% to 36.9% for Ventolin Evohaler (p = 0.005) and from 56.7% to 44.2% for Flovent HFA (p < 0.001) at high humidity relative to low. High humidity may cause a reduction in total in vitro lung doses for some pMDI aerosols.