Long-term corticosteroid use, adrenal insufficiency and the need for steroid-sparing treatment in adult severe asthma.
Long-term corticosteroid use, adrenal insufficiency and the need for steroid-sparing treatment in adult severe asthma.
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DOI：
10.1111/joim.13273
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发表时间：
2021-08
影响因子：
11.1
通讯作者：
Menzies-Gow A
中科院分区：
文献类型：
--
作者：
Gurnell M;Heaney LG;Price D;Menzies-Gow A
继发性肾上腺功能不全（AI）是由于任何破坏正常下丘脑和/或垂体前叶功能并导致肾上腺皮质类固醇激素分泌减少的过程而发生的。继发性AI的最常见原因是以超生理剂量给予外源性皮质类固醇治疗≥ 1个月。口服皮质类固醇（OCS）引起的AI尚未得到很好的认识或诊断，但通常与健康状况下降有关，并且在肾上腺危象的情况下可能危及生命。皮质类固醇的使用在呼吸系统疾病中很常见，哮喘是一种代表性疾病，说明了与皮质类固醇保留治疗相关的潜在挑战和机会。对于患有严重哮喘的个体（约占所有病例的5%-10%），现在可以通过靶向炎症介质的生物疗法来减少或消除维持性OCS而不失去控制。然而，在常规临床实践中，确保早期识别和治疗AI以及安全退出OCS的最佳策略仍有待确定。许多生物制剂研究的评价期较短，样本量较小;此外，安慰剂组研究中OCS逐渐减少的谨慎方法，加上AI监测不一致，导致缺乏明确性。如果目标是通过越来越多地采用生物治疗来大大减少并在可能的情况下消除严重哮喘中的长期OCS使用，那么迫切需要进行临床试验，以解决OCS停药的速度以及如何监测AI。
Secondary adrenal insufficiency (AI) occurs as the result of any process that disrupts normal hypothalamic and/or anterior pituitary function and causes a decrease in the secretion of steroid hormones from the adrenal cortex. The most common cause of secondary AI is exogenous corticosteroid therapy administered at supraphysiologic dosages for ≥ 1 month. AI caused by oral corticosteroids (OCS) is not well‐recognized or commonly diagnosed but is often associated with reduced well‐being and can be life‐threatening in the event of an adrenal crisis. Corticosteroid use is common in respiratory diseases, and asthma is a representative condition that illustrates the potential challenges and opportunities related to corticosteroid‐sparing therapies. For individuals with severe asthma (approximately 5%–10% of all cases), reduction or elimination of maintenance OCS without loss of control can now be accomplished with biologic therapies targeting inflammatory mediators. However, the optimal strategy to ensure early identification and treatment of AI and safe OCS withdrawal in routine clinical practice remains to be defined. Many studies with biologics have involved short evaluation periods and small sample sizes; in addition, cautious approaches to OCS tapering in studies with a placebo arm, coupled with inconsistent monitoring for AI, have contributed to the lack of clarity. If the goal is to greatly reduce and, where possible, eliminate long‐term OCS use in severe asthma through the increasing adoption of biologic treatments, there is an urgent need for clinical trials that address both the speed of OCS withdrawal and how to monitor for AI.
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