Medical Journal Article Reviews

Juan Carlos Ivancevich, MD, WAO Web Editor-in-Chief, in collaboration with Phil Lieberman, MD, Web Editor of Medical Literature Reviews, conducted these reviews of premier medical journal articles for practicing allergists. Read their top three picks here, and link to the remaining reviews from the menu. Medical Journal Review section of the WAO Web site.

To read translations of past Medical Journal Reviews, click here.

1. The use of beclomethasone dipropionate plus salbutamol as rescue treatment for exacerbations in children.
The TREXA study examined the use of beclomethasone dipropionate (BDP) in children with mild, persistent asthma. The two goals of the study were to establish (1) whether discontinuation of daily inhaled corticosteroids (ICSs) in children with well-controlled, mild, persistent asthma would increase the risk of exacerbations, and (2) whether the use of BDP plus salbutamol for relief, with or without concomitant use of daily BDP, protects against exacerbations better than a rescue strategy of salbutamol alone. The study enrolled 843 children and adolescents (ages 6-18 years) who had mild persistent asthma during the previous 2 years. Those who were using daily ICSs prior to inclusion had to qualify for interruption or discontinuation due to well-controlled disease. Following a 4-week run-in period, those whose asthma remained well controlled with no exacerbations (n = 288) were randomized to one of four treatment groups: 1) BDP (40 mcg puff) twice daily with BDP plus salbutamol as rescue (combined group); 2) BDP twice daily with placebo plus salbutamol as rescue (daily BDP group); 3) placebo twice daily with BDP plus salbutamol as rescue (rescue BDP group); 4) placebo twice daily with placebo plus salbutamol rescue (placebo group). In the rescue groups, two puffs of BDP (80 mcg) or placebo were given for each two puffs of salbutamol (180 mcg) required for symptom relief. The primary outcome was time to first exacerbation requiring oral corticosteroids. The probability of a first exacerbation by the end of the study was 31% (21%-43%) in the combined group (P = 0.07 vs. placebo), 28% (18%-40%) in the daily group (P = 0.03), and 35% (24%-47%) in the rescue group (P = 0.07), compared to 49% (37%-61%) in the placebo group. The hazard ratios for asthma exacerbations were lower in the daily BDP and combined groups compared to placebo, but the difference was not statistically significant for the rescue BDP group. More treatment failures occurred in the placebo group than in the other three groups. ICSs can impair growth, and children in the combined and daily arms grew 1.1 cm (SD 0.3) less than children in the placebo group (P < 0.0001), but growth did not differ between the rescue and placebo groups (P = 0.26). The authors concluded that daily ICSs are the most effective treatment to prevent exacerbations and reduce treatment failure in children with mild persistent asthma, and that salbutamol rescue therapy alone is not suitable. Rescue BDP decreases the risk of an exacerbation and treatment failure compared to rescue salbutamol alone and may be useful as a step-down strategy for children with well-controlled, mild asthma.
Editor's comment: Rescue BDP is not as effective as daily corticosteroids at preventing exacerbations, but is more effective than salbutamol alone and avoids the growth impairment associated with corticosteroids in children.
Martinez FD, Chinchilli VM, Morgan WJ, et al. Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial. The Lancet 2011; 377: 650-657.
Abstract

2. No association of obesity and adiposity with eosinophilic airway inflammation in people without asthma.
Obesity and adiposity are closely associated with the development and severity of asthma, but data on their effects on airway inflammation have been inconsistent. To resolve the issue, the authors assessed whether fractional exhaled nitric oxide (FeNO) was associated with obesity/adiposity in 117 healthy, nonsmoking, Korean adults without a previous diagnosis of asthma or current asthma symptoms. Associations between FeNO and measures of obesity/adiposity (body mass index [BMI], body fat mass, and body fat percentage) and serum levels of adipose-derived hormones and adipokines were examined by correlation analyses and uni- and multi-variate linear regression analyses. In the multivariate linear regression model, after adjusting for age, gender, chronic rhinitis, atopy, and lung function, FeNO was not significantly associated with BMI, body fat mass, or body fat percentage, although it was associated with age and male sex. FeNO was also not significantly associated with serum levels of leptin, adiponectin, tumor necrosis factor (TNF)-α, or interleukin (IL)-6. These findings suggest that in healthy subjects without asthma, neither obesity/adiposity nor hormones and systemic inflammation derived from adipose tissue significantly affect eosinophilic airway inflammation.
Editor's comment: In patients without asthma, the association between obesity and airway inflammation seems quite different from that in asthmatics.
Kim SH, Kim TH, Lee JS, et al. Adiposity, Adipokines, and Exhaled Nitric Oxide in Healthy Adults Without Asthma. Journal of Asthma 2011; 48(2): 177-182.
Abstract

3. No negative effect of long-term treatment with intranasal budesonide on bone mineral density in children.
Intranasal corticosteroids (INS) are an effective treatment for allergic rhinitis (AR) and, unlike glucocorticoids, have not been associated with loss of bone density. However, this risk to bone metabolism has not been sufficiently studied in children. This retrospective case-control study evaluated the effects of long-term treatment with intranasal budesonide spray on bone mineral status in pediatric patients with AR. The 230 children with perennial AR (145 boys, ages 7 to 11) had used nasal budesonide intermittently for at least 3 years at a mean daily dose of 100 mcg (range, 89-132 mcg). The mean (± SEM) steroid dosage used was 73.5 ± 7.0 mcg daily, with 65.2 ± 5.2 g total steroid use during treatment. Bone mineral density of the lumbar spine was measured by dual-energy X-ray absorptiometry. Levels of serum calcium, phosphorus, alkaline phosphatase (ALP), parathyroid hormone, and osteocalcin were also assessed. The results were compared to sex- and age-matched controls that were newly diagnosed with AR and had not previously received any corticosteroid treatment. The 140 control patients (90 boys) were aged from 6 to 11 years. No significant differences were observed in bone mineral density, mean serum ALP, cortisol, phosphorus and osteocalcin levels between the study and the control groups. The findings suggest that long-term intermittent treatment with intranasal budesonide spray has no negative effects on BMD and associated bone health parameters.
Editor's comment: The use of intranasal budesonide appears to be safe in children.
Ozkaya E, Mete F, Dibek E, et al. Lack of bone metabolism side effects after 3 years of nasal topical steroids in children with allergic rhinitis. Journal of Bone and Mineral Metabolism 2011 [Published online before print. doi: 10.1007/s00774-010-0255-3].
Abstract

All 13 journal article reviews are posted in the literature review section of the WAO website.

Reviews of medical books can be accessed on the Reviews and News section of the website.

This Month in the Journal

World Allergy Organization Journal
April 2011
Volume 4, Issue 4
ISSN: 1939-4551

Editor-in-Chief: Lanny J. Rosenwasser, M.D.

INVITED REVIEW ARTICLE

Asthma Care in Resource Poor Settings
Mario Sánchez-Borges, MD; Arnaldo Capriles-Hulett, MD; and Fernan Caballero-Fonseca, MD
Venezuela

NOTES OF ALLERGY WATCHERS

Bradykinin and the Pathogenesis of Hereditary Angioedema
Allen P. Kaplan, MD
United States

Additional Journal Reviews

4. Association between acetaminophen (paracetamol) use and an increased risk for asthma symptoms.
5. Link between early acetaminophen (paracetamol) use and childhood asthma and atopy.
6. The potential role of heparin in allergic and inflammatory reactions.
7. Association of low vitamin D levels and allergy in children.
8. Additive effect of mometasone and desloratadine on allergic rhinitis and chronic rhinosinusitis.
9. Biomass fuel linked to respiratory disease.
10. Downregulation of lipid biosynthesis protects the host against viral infection.
11. Long-term safety of bronchial thermoplasty.
12. Risk for asthma and allergies with regular swimming pool use.
13. Safety of inhaled corticosteroid use for asthma during pregnancy.

To read translations of past Medical Journal Reviews, click here.

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