TL;DR
Corticosteroid bursts were significantly associated with an increase of GI bleeding, sepsis, and pneumonia, but not glaucoma, within the first month after initiation of corticosteroid therapy. However, the study design has severe limitations in regard to glaucoma. The FitEyes opinion is that this study is of limited value re: glaucoma. See "Commentary on Study Design" section below for details. But the take away is that this study does almost nothing to inform us about the risks of developing primary open angle glaucoma from oral corticosteroid bursts in children under 18.
SOURCE: JAMA Pediatr. Published online April 19, 2021. doi:10.1001/jamapediatrics.2021.0433
Key Points
Question Are there potential harms associated with oral corticosteroid bursts (defined as the use of oral corticosteroids for 14 or fewer days) in children?
Findings In this nationwide population-based cohort study of 1 064 587 children who received a single corticosteroid burst, a burst was associated with 1.4- to 2.2-fold increased risk of gastrointestinal bleeding, sepsis, and pneumonia within the first month after corticosteroid initiation.
Meaning This study suggests that clinicians should be aware of potentially severe adverse events associated with corticosteroid bursts in children.
Abstract
Importance The adverse effects from the long-term use of oral corticosteroids are known, but, to our knowledge, few studies have reported the risk of corticosteroid bursts, particularly among children.
Objective To quantify the associations of corticosteroid bursts with severe adverse events, including gastrointestinal (GI) bleeding, sepsis, pneumonia, and glaucoma, in children.
Design, Setting, and Participants This cohort study used data derived from the National Health Insurance Research Database in Taiwan from January 1, 2013, to December 31, 2017, on children younger than 18 years of age and used a self-controlled case series design. Data were analyzed from January 1 to July 30, 2020.
FitEyes Commentary on Study Design The design of this study has severe limitations in regard to any conclusions related to glaucoma. The most common form of glaucoma worldwide is open angle glaucoma, which is a chronic rather than acute condition. The important factor to monitor would be intraocular pressure during and following the use of corticosteroid bursts. That was not done in this study. Absent any information on intraocular pressure, it is highly unlikely that a child under 18 (the study population) would be diagnosed with glaucoma during the window defined by this study. Even if (as an illustration only) the use of corticosteroid bursts in the study population increased their risk of developing glaucoma later in life by 100%, this study design would not have detected that. The only thing this study would reliably indicate is an association with angle closure glaucoma events (which is an acute medical emergency).
Exposure Oral corticosteroid bursts (defined as oral corticosteroid use for ≤14 days).
Main Outcomes and Measures Incidence rates were calculated of 4 severe adverse events (GI bleeding, sepsis, pneumonia, and glaucoma) in children who did or did not receive corticosteroid bursts. Conditional fixed-effect Poisson regression was used to estimate incidence rate ratios (IRRs) of severe adverse events within 5 to 30 days and 31 to 90 days after initiation of corticosteroid bursts.
Results Among 4 542 623 children, 23% (1 064 587; 544 268 boys [51.1%]; mean [SD] age, 9.7 [5.8] years) were prescribed a single corticosteroid burst. The most common indications were acute respiratory tract infections and allergic diseases. The incidence rate differences per 1000 person-years between children administered a single corticosteroid burst and those not prescribed corticosteroids were 0.60 (95% CI, 0.55-0.64) for GI bleeding, 0.03 (95% CI, 0.02-0.05) for sepsis, 9.35 (95% CI, 9.19-9.51) for pneumonia, and 0.01 (95% CI, 0.01-0.03) for glaucoma. The IRRs within 5 to 30 days after initiating corticosteroid bursts were 1.41 (95% CI, 1.27-1.57) for GI bleeding, 2.02 (95% CI, 1.55-2.64) for sepsis, 2.19 (95% CI, 2.13-2.25) for pneumonia, and 0.98 (95% CI, 0.85-1.13) for glaucoma; the IRRs within the subsequent 31 to 90 days were 1.10 (95% CI, 1.02-1.19) for GI bleeding, 1.08 (95% CI, 0.88-1.32) for sepsis, 1.09 (95% CI, 1.07-1.11) for pneumonia, and 0.95 (95% CI, 0.85-1.06) for glaucoma.
Conclusions and Relevance This research indicates that corticosteroid bursts, which are widely prescribed for children with respiratory and allergic conditions, are linked to a 1.4- to 2.2-fold increased risk of GI bleeding, sepsis, and pneumonia, but not glaucoma, within the first month after starting corticosteroid therapy that is attenuated during the subsequent 31 to 90 days.