Asthma steroids

Corticosteroids Glucocorticoid agonists Steroids Asthma controllers... 

Aerosolized steroids clearly play an important role in the present-day management of asthma (87). They are reasonably safe and work best when taken prophylacticaHy. Patient compliance, however, remains a significant problem. In part this problem is typical of any aerosolized agent. But in the case of steroids, the problem is exacerbated because a patient needs to take the steroids (especially prednisone) are the antiasthmatic agents of last resort and are widely used to treat status asthmaticus. An agent that could mimic the actions of steroids but which would work faster and/or without side effects might be the ideal antiasthmatic agent. 

Asthma is a chronic inflammatory disease. Therefore steroids represent the most important and most frequently used medication. Already after the fust treatment, steroids reduce cellular infiltration, inflammation, and the LAR, whereas changes in the EAR require prolonged treatment to lower the existent IgE levels. The mechanisms of steroid actions are complex and only incompletely understood. Besides their general antiinflammatory properties (see chapter glucocorticoids), the reduction of IL-4 and IL-5 production from T-lymphocytes is particularly important for asthma therapy. The introduction of inhaled steroids, which have dramatically limited side effects of steroids, is considered one of the most important advancements in asthma therapy. Inhaled steroids (beclomethasone, budesonide, fluticasone, triamcinolone, momethasone) are used in mild, moderate, and partially also in severe asthma oral steroids are used only in severe asthma and the treatment of status asthmaticus. Minor side effects of most inhaled steroids are hoarseness and candidasis, which are avoided by the prodrug steroid ciclesonide. 

Inhaled steroids (commonly used are beclomethasone, budesonide, triamcinolone, fluticasone, flunisolide) appear to attenuate the inflammatory response, to reduce bronchial hyperreactivity, to decrease exacerbations and to improve health status they may also reduce the risk of myocar dial infar ction, but they do not modify the longterm decline in lung function. Whether- steroids affect mortality remains unclear. Many patients appear to be resistant to steroids and large, long-term trials have shown only limited effectiveness of inhaled corticosteroid ther apy. Certainly, the benefit from steroids is smaller in COPD than in asthma. Topical side-effects of inhaled steroids are oropharyngeal candidiasis and hoarse voice. At the normal doses systemic side-effects of inhaled steroids have not been firmly established. The current recommendation is that the addition of inhaled gluco-coiticosteroids to bronchodilator treatment is appropriate for patients with severe to veiy sever e COPD. 

Acute and chronic sinusitis can also aggravate asthma, and antibiotic therapy of sinusitis may improve asthma symptoms.3 Nasal polyps are associated with aspirin-sensitive asthma, and adult patients with nasal polyps should be counseled against using non-steroidal anti-inflammatory medications.1,3... 

Patients who may benefit from allergen immunotherapy include those who do not tolerate traditional drug therapy (e.g., nosebleeds with intranasal steroids or sedation with antihistamines), suffer from severe symptoms, have comorbid conditions (e.g., asthma or sinusitis), fail drug therapy, or prefer not to take long-term medication. 

A 39-year-old male with chronic steroid-dependent asthma who recently relocated to Phoenix, Arizona presents with a 4-week history of increasing fever, dry cough, and pain upon deep inspiration. He also reports arthralgias and night sweats over the last 3 weeks. A chest radiograph reveals a small area of consolidation in the left lower lobe and some hilar adenopathy. Otherwise, all other routine tests and cultures appear negative. 

Kurashima K, Fujimura M, Myou S, et al. Effects of oral steroids on blood CXCR3+ and CCR4+ T cells in patients with bronchial asthma. Am J Respir Crit Care Med 2001 164(5) 754-758. 

Patterson suffered the first of many severe asthmatic attacks after collecting acidic gas samples from a Hawaiian volcano in 1983. The steroids he took for the asthma exacerbated his inherited osteoporosis, and his frame shrank nine inches to five foot seven. He applied twice for funds to create a line of lead-free rats to study biological processes in uncontaminated mammals. After both applications were rejected, he frequently became depressed. 

A 22-year-oId male with a five-year history of bronchial asthma has developed increased frequency and severity of acute asthmatic attacks. A low dose of which inhaled steroid could be added to his treatment regimen ... 

Inhaled corticosteroids are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness they are also the only therapy shown to reduce the risk of death from asthma. Comparative doses are included in Table 80-3. Most patients with moderate disease can be controlled with twice-daily dosing some products have once-daily dosing indications. Patients with more severe disease require multiple daily dosing. Because the inflammatory response of asthma inhibits steroid receptor binding, patients should be started on higher and more frequent doses and then tapered down once control has been achieved. The response to inhaled corticosteroids is delayed symptoms improve in most patients within the first 1 to 2 weeks and reach maximum improvement in 4 to 8 weeks. Maximum improvement in FEVj and PEF rates may require 3 to 6 weeks. 

Systemic corticosteroids (Table 80-4) are indicated in all patients with acute severe asthma not responding completely to initial inhaled /J2-agonist administration (every 20 minutes for three to four doses). Prednisone, 1 to 2 mg/kg/day (up to 40 to 60 mg/day), is administered orally in two divided doses for 3 to 10 days. Because short-term (1 to 2 weeks), high-dose systemic steroids do not produce serious toxicities, the ideal method is to use a short burst and then maintain the patient on appropriate long-term control therapy with inhaled corticosteroids. 

Adverse reactions to sulfites appear to occur mainly among a small percentage of asthmatics, but it is possible for individuals without asthma to be sulfite sensitive. It is typically more of a problem in individuals with severe asthma who are also taking corticosteroid drugs to control their disease. Among these individuals, the prevalence of sulfite sensitivity is about 8%, while it is about 1% in asthmatics who are not dependent on steroids (Taylor and Bush, 1986). 

Aerosolised medicines have been used for centuries to treat respiratory diseases, with inhalation therapy for the airways focused primarily on the treatment of asthma and chronic obstructive pulmonary disease (COPD). The development of new products for delivery to the lungs for these respiratory diseases includes new steroids and beta agonists plus combination products featuring both agents. New classes of anti-asthma medication are also being developed for inhalation with the aim of delivering them directly to the inflamed airways. 

Inhaled corticosteroids mediate a variety of immunological actions and are commonly used in the treatment of allergic asthma [28]. However, not all patients respond well to this treatment and some are steroid-resistant. In a recent study, Tantisira et al. [29] described a new genetic non-synonymous variation in TBX21 that encodes for the transcription factor T-bet (T-box expressed in T cells) associated with significant improvement of the airway hyperresponsiveness in children affected by allergic asthma [30]. Noteworthy, the... 

Goleva E, Li LB, Eves PT, Strand MJ, Martin RJ, Leung DY. (2006) Increased glucocorticoid receptor beta alters steroid response in glucocorticoid-insensitive asthma. Am J Respir Crit Care Med. 173,607-616. 

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