CFDB - Cystic Fibrosis DataBase

Anti-inflammatory therapy

Inhaled corticosteroids

Background

 

 

Neutrophil-dominated airway inflammation leads to lung damage in CF patients and finding a suitable anti-inflammatory strategy is a relevant issue. Oral prednisolone on alternate days demonstrated to have a good impact on lung condition, but showed severe side effects. Besides their effectiveness in the management of recurrent wheezing or asthmatic symptoms, Inhaled Corticosteroids (ICS) could also be effective in treating lung inflammation. In lung diseases other than CF, ICS risk-benefit profile as anti-inflammatory therapy remains unclear (Park HY,2012), both in children (Fuhlbrigge AL, 2014) and in older patients (Mattishent K,2014). Specifically, it has been affirmed ( KellY HW, 2012) that, even at moderate doses, ICS , if given consistently and daily, can suppress growth.

In CF, one retrospective analysis of data from 2978 patients collected in a period of 10 years showed that ICS therapy is associated with a significant reduction in the rate of FEV1 decline, a decreased linear growth and an increased hypoglycemic use (Ren CL. 2008). These results are confirmed by a more recent study on Belgium CF Registry data (De Boeck K. 2011). However, concerns about ICS adverse effects are present (Erdem E, 2012) and, also recently (Preville-Ratelle S, 2018), it has been affirmed that because of the adrenal insufficiency possibly associated with corticosteroids use, also with the inhaled ones, ICS therapy has to be limited to patients who demonstrate real benefit from it. Moreover, a study (Noni M,, 2014) has shown that the duration of inhaled corticosteroid treatment is associated with A. fumigatus first isolation and its chronic colonization.

So, up to now, even if they are commonly prescribed also without reversible obstruction (Levine H, 2016), a eminent part of the international literature affirms that it cannot be concluded that inhaled steroids, as anti-inflammatory therapy, are beneficial and that the daily dose of ICS should be adapted to control symptoms, in order to prescribe the smallest possible dose (Fayon M,  2014). Recent clinical practice guidelines from the Cystic Fibrosis Foundation for CF children 2-5 years old ( Lahiri T, 2016), agree upon that ICS are not recommended for management of lung disease, as no clear benefit has been identified.

Issues

Effectiveness of ICS on lung disease progression.

Effectiveness of ICS on quality of life and long-term prognosis.

Impact on bronchial hyperreactivity.

Impact on nutritional indices.

Occurrence of any adverse event.

Impact of ICS withdrawal on lung condition.

What is known

One Cochrane review (Balfour-Lynn IM, 2016) is available. Thirteen RCTs on 506 people aged between 6 and 55 years were included. One trial was a withdrawal study in individuals who were already taking ICS. Significant benefits have not been conclusively demonstrated, because it has not been established whether long-term use is beneficial in reducing lung inflammation and so improving survival. Withdrawal in individuals already taking ICS was shown to be safe. There is some concerns about adverse events associated with long-term therapy, above all those affecting growth.

Unresolved questions

Evidences about ICS efficacy and safety in CF patients.

Up to now, no registered RCT on ICS is ongoing.

Keywords: Anti-Inflammatory Agents; Steroids;