Switching between biologics in severe asthma patients. When the first choice is not proven to be the best

During the last decades, new treatments targeting disease mechanisms referred as biologics have been introduced in the therapy of asthma and currently, five monoclonal antibodies have been approved. Although these therapeutic agents have been formulated to target specific asthma endotypes, it is often difficult for the treating physician to identify which patient is the best candidate for each one of these specific treatments especially in the clinical scenario of a patient in whom clinical characteristics overlap between different endotypes, allowing the selection of more than one biologic agent. As no head-to-head comparisons between these biologics have been attempted, there is no evidence on the superiority of one biologic agent over the other. Furthermore, a physician's first therapeutic decision, no matter how carefully has been made, may often result in suboptimal clinical response and drug discontinuation, indicating the need for switching to a different biologic. In this short review, we discuss the available evidence regarding the switching between biologics in patients with severe asthma and we propose a simple algorithm on switching possibilities in case that the physicians’ initial choice is proven not to be the best.     

Screening practices for paediatric asymptomatic adrenal suppression in Canada: Are we addressing this important risk?

BackgroundChildren with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable.ObjectiveTo assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases.MethodsBefore and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013.ResultsResponse rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year.ConclusionFrequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop.     

The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis

BackgroundCorticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.MethodsThe MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids.ResultsCritical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA.ConclusionStrong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.