Tapering inhaled corticosteroids

There have been no randomized trials examining the effect of hydrocortisone given after the first week of life or used to treat infants with prolonged ventilator dependence. One retrospective cohort study compared infants who required assisted ventilation and oxygen after the first one to two weeks of age and received hydrocortisone with a group of healthier infants who did not receive hydrocortisone. [27] Infants treated with hydrocortisone experienced decreasing oxygen requirements and were successfully weaned from assisted ventilation. After seven days of treatment, there were no differences in oxygen requirements between the two groups. On follow-up, there were no differences in head circumference, neurological outcome, psychomotor development or school performance. Magnetic resonance imaging performed at eight years of age on a similar cohort of infants treated with hydrocortisone showed that although, overall, children born preterm had significantly reduced grey matter volumes compared to term children, there were no differences in the intracranial volumes, grey matter volumes or white matter volumes between children who did and did not receive hydrocortisone for treatment of CLD. [28] There were also no differences in neurocognitive outcomes, assessed using the Wechsler Intelligence Scales for Children.

PULMICORT RESPULES (budesonide inhalation suspension) , will often help control asthma symptoms with less suppression of HPA function than therapeutically equivalent oral doses of prednisone. Since individual sensitivity to effects on cortisol production exists, physicians should consider this information when prescribing PULMICORT RESPULES (budesonide inhalation suspension) . Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with PULMICORT RESPULES (budesonide inhalation suspension) should be observed carefully for any evidence of systemic corticosteroid effects. Particular care should be taken in observing patients post-operatively or during periods of stress for evidence of inadequate adrenal response. It is possible that systemic corticosteroid effects such as hypercorticism, and adrenal suppression (including adrenal crisis) may appear in a small number of patients, particularly when budesonide is administered at higher than recommended doses over prolonged periods of time. If such effects occur, the dosage of PULMICORT RESPULES (budesonide inhalation suspension) should be reduced slowly, consistent with accepted procedures for tapering of systemic corticosteroids and for management of asthma.

Short courses of systemic corticosteroids may provide important benefits in patients with exacerbations of COPD. A recent clinical trial 32 involving 271 patients in Veterans Affairs hospitals showed that steroid therapy resulted in moderate improvement of clinical outcomes, with shorter hospital stays and increases in FEV 1 . The fact that there were no significant differences between patients treated for two weeks and those treated for eight weeks justifies the use of a shorter course of corticosteroids to reduce the occurrence of adverse effects. Adverse effects can include hyperglycemia, secondary infection and behavioral changes. 33

This confusing situation happens often, even when the rescue and maintenance inhalers are of different color. The root problem is lack of standardization among inhalers, with unclear labeling to distinguish between rescue and maintenance inhalers. A contributing cause is lack of proper education for both the caregivers and their patients . All too often proper instructions were not given when the drug was first prescribed. And even when they are provided, patients sometimes don't really understand, or they forget. Either way, having similar inhalers for different purposes is an invitation to error. (This was less likely to be a problem when the drug was studied by the drug companies; see YELLOW BOX above, under 'DPI Type 2'.) The problem is compounded when patients are on multiple inhalers, eg, Proventil for rescue, Advair and Spiriva for maintenance. That's 3 separate devices with two different purposes -- easy for the patient to get confused. (Pills and capsules come in many colors and sizes, but they are all swallowed the same way.) What's needed is a universal delivery device for all inhalers, with perhaps just two colors: red for rescue drugs and green for maintenance drugs. Anyone with clinical interest in the inhaler problems discussed above (Errors 1 & 2) should definitely read Problems With Inhaler Use: A Call for Improved Clinician and Patient Education , by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10, pages 1360-75). 3. Not checking some objective measurement of the patient's air flow obstruction. Every patient should have a breathing test to ascertain the degree of impairment caused by the asthma. The most frequently performed test is 'spirometry', which takes just a few minutes and requires the patient to exhale forcefully thru a testing device (shown below).
A patient performing the spirometry test


Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.

Tapering inhaled corticosteroids

tapering inhaled corticosteroids

This confusing situation happens often, even when the rescue and maintenance inhalers are of different color. The root problem is lack of standardization among inhalers, with unclear labeling to distinguish between rescue and maintenance inhalers. A contributing cause is lack of proper education for both the caregivers and their patients . All too often proper instructions were not given when the drug was first prescribed. And even when they are provided, patients sometimes don't really understand, or they forget. Either way, having similar inhalers for different purposes is an invitation to error. (This was less likely to be a problem when the drug was studied by the drug companies; see YELLOW BOX above, under 'DPI Type 2'.) The problem is compounded when patients are on multiple inhalers, eg, Proventil for rescue, Advair and Spiriva for maintenance. That's 3 separate devices with two different purposes -- easy for the patient to get confused. (Pills and capsules come in many colors and sizes, but they are all swallowed the same way.) What's needed is a universal delivery device for all inhalers, with perhaps just two colors: red for rescue drugs and green for maintenance drugs. Anyone with clinical interest in the inhaler problems discussed above (Errors 1 & 2) should definitely read Problems With Inhaler Use: A Call for Improved Clinician and Patient Education , by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10, pages 1360-75). 3. Not checking some objective measurement of the patient's air flow obstruction. Every patient should have a breathing test to ascertain the degree of impairment caused by the asthma. The most frequently performed test is 'spirometry', which takes just a few minutes and requires the patient to exhale forcefully thru a testing device (shown below).
A patient performing the spirometry test


Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.

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