哮喘患者吸入皮质类固醇的全身不良反应：系统评价。
Systemic adverse effects from inhaled corticosteroid use in asthma: a systematic review.
机构信息
Faculty of Medicine, Imperial College London, London, UK.
Centre for Primary Care and Public Health, Queen Mary University of London, London, UK.
出版信息
BMJ Open Respir Res. 2020 Dec;7(1). doi: 10.1136/bmjresp-2020-000756.
BACKGROUND
Oral corticosteroid use increases the risk of systemic adverse effects including osteoporosis, bone fractures, diabetes, ocular disorders and respiratory infections. We sought to understand if inhaled corticosteroid (ICS) use in asthma is also associated with increased risk of systemic effects.
METHODS
MEDLINE and Embase databases were searched to identify studies that were designed to investigate ICS-related systemic adverse effects in people with asthma. Studies were grouped by outcome: bone mineral density (BMD), respiratory infection (pneumonia or mycobacterial infection), diabetes and ocular disorder (glaucoma or cataracts). Study information was extracted using the PICO checklist. Risk of bias was assessed using the Cochrane Risk of Bias tool (randomised controlled trials) and Risk of Bias In Non-randomised Studies of Interventions-I tool (observational studies). A narrative synthesis was carried out due to the low number of studies reporting each outcome.
RESULTS
Thirteen studies met the inclusion criteria, 2 trials and 11 observational studies. Study numbers by outcome were: six BMD, six respiratory infections (four pneumonia, one tuberculosis (TB), one non-TB mycobacteria), one ocular disorder (cataracts) and no diabetes. BMD studies found conflicting results (three found loss of BMD and three found no loss), but were limited by study size, short follow-up and lack of generalisability. Studies addressing infection risk generally found positive associations but suffered from a lack of power, misclassification and selection bias. The one study which assessed ocular disorders found an increased risk of cataracts. Most studies were not able to fully adjust for known confounders, including oral corticosteroids.
CONCLUSION
There is a paucity of studies assessing systemic adverse effects associated with ICS use in asthma. Those studies that have been carried out present conflicting findings and are limited by multiple biases and residual confounding. Further appropriately designed studies are needed to quantify the magnitude of the risk for ICS-related systemic effects in people with asthma.
背景
口服皮质类固醇的使用会增加发生全身性不良反应的风险，包括骨质疏松症、骨折、糖尿病、眼部疾病和呼吸道感染。我们试图了解哮喘患者使用吸入皮质类固醇（ICS）是否也与全身性不良反应风险增加有关。
方法
检索 MEDLINE 和 Embase 数据库，以确定旨在研究哮喘患者 ICS 相关全身性不良反应的研究。研究结果分为以下几类：骨密度（BMD）、呼吸道感染（肺炎或分枝杆菌感染）、糖尿病和眼部疾病（青光眼或白内障）。使用 PICO 清单提取研究信息。使用 Cochrane 偏倚风险工具（随机对照试验）和干预措施非随机研究偏倚风险工具（观察性研究）评估偏倚风险。由于每个结果报告的研究数量较少，因此进行了叙述性综合。
结果
符合纳入标准的研究共有 13 项，其中 2 项为试验，11 项为观察性研究。按结果分类的研究数量如下：6 项 BMD、6 项呼吸道感染（4 项肺炎、1 项肺结核（TB）、1 项非 TB 分枝杆菌）、1 项眼部疾病（白内障）和无糖尿病。BMD 研究结果存在矛盾（3 项研究发现 BMD 丢失，3 项研究发现 BMD 未丢失），但受到研究规模、随访时间短和缺乏普遍性的限制。研究感染风险的研究通常发现存在正相关，但存在缺乏效力、分类错误和选择偏倚的问题。评估眼部疾病的唯一一项研究发现白内障风险增加。大多数研究都无法充分调整已知的混杂因素，包括口服皮质类固醇。
结论
评估哮喘患者使用 ICS 与全身性不良反应相关的研究很少。已开展的研究结果存在矛盾，受到多种偏倚和残余混杂因素的限制。需要进一步开展设计合理的研究，以量化哮喘患者 ICS 相关全身性不良反应的风险程度。
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