51
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Tiotropium for the Treatment of Asthma: Patient Selection and Perspectives. Can Respir J 2018; 2018:3464960. [PMID: 29670674 PMCID: PMC5833870 DOI: 10.1155/2018/3464960] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022] Open
Abstract
Asthma is a chronic disease of airway inflammation with a large global burden. Despite established, guideline-based stepwise therapy, a significant proportion of patients remain symptomatic and poorly controlled. As such, there is a need for additional safe, effective, convenient, and cost-effective therapies that can be broadly applied across a range of asthma phenotypes. Tiotropium is a long-acting muscarinic antagonist (LAMA) that leads to bronchodilation by blocking endogenous acetylcholine receptors in the airways. Tiotropium has long been approved for the treatment of chronic obstructive pulmonary disease, and it has recently been recognized for its safety and efficacy in improving lung function and controlling asthma. Evidence from several Phase III trials in the adult and paediatric population has shown that tiotropium is well tolerated and significantly improves a range of endpoints as an add-on treatment to ICS therapy, regardless of baseline characteristics and clinical phenotypes. Consequently, regulatory authorities worldwide have recently licensed tiotropium as the only LAMA approved for the treatment of asthma. This review provides an overview of safety and efficacy data and discusses the use of tiotropium in patients across the range of asthma severities, ages, and phenotypes.
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52
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Yehia AM, Abo-Elhoda SE, Hassan NY, Badawey AM. Experimental validation of a computationally-designed tiotropium membrane sensor. NEW J CHEM 2018. [DOI: 10.1039/c8nj03507e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This work draws an analogy between theoretical and practical data for innocuous potentiometric sensor optimization.
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Affiliation(s)
- Ali M. Yehia
- Analytical Chemistry Department
- Faculty of Pharmacy
- Cairo University
- El-Kasr El-Aini Street
- Cairo
| | - Soad E. Abo-Elhoda
- Pharmaceutical Chemistry Department
- Faculty of Pharmaceutical Sciences & Pharmaceutical Industries
- Future University in Egypt
- Cairo
- Egypt
| | - Nagiba Y. Hassan
- Analytical Chemistry Department
- Faculty of Pharmacy
- Cairo University
- El-Kasr El-Aini Street
- Cairo
| | - Amr M. Badawey
- Analytical Chemistry Department
- Faculty of Pharmacy
- Cairo University
- El-Kasr El-Aini Street
- Cairo
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53
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Abstract
Asthma is the most common chronic disease in children. As suggested by international guidelines, the main goals of asthma treatment are symptoms control and lung function preservation, through a stepwise and control-based approach. The first line therapy based on inhaled corticosteroids may fail to reach control in more than one third of patients, especially adolescents, and in these lung function and quality of life may progressively worsen. Treatment with omalizumab, the first anti-immunoglobulin E recombinant humanized monoclonal antibody, has been definitely approved in pediatric uncontrolled asthma. In this review, we discuss the mechanisms and potential roles of emerging therapies for pediatric severe asthma. Novel biologic drugs (i.e., dupilumab, mepolizumab, reslizumab, and benralizumab) seem to be promising in reducing annual exacerbation rates and steroid-use in glucocorticoid-dependent cases, but available data are few and limited to adolescents and adults. Evidences on the use of the muscarinic antagonist tiotropium as controller medication in pediatric settings are progressively growing, sustaining an application as asthma maintenance treatment in children aged >6 years and in preschool children with persistent asthmatic symptoms, but well powered trials are needed to confirm its safety and efficacy. New inhaled corticosteroids (i.e., ciclesonide and mometasone) are effective as once-daily controller therapy, but long-term studies in the different pediatric ages are needed to compare effectiveness and safety to usual treatments. At present, the role of macrolides in pediatric severe asthma is controversial and their administration is not recommended routinely, but may be considered in children with neutrophilic asthma for reducing daily oral steroids administration and improving lung function. Despite the availability of several novel therapeutic strategies for uncontrolled asthma, future trials targeted at specific pediatric age subgroups are needed to support evidences of safety and efficacy also in children.
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Affiliation(s)
- Marco Maglione
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Marco Poeta
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
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54
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Bonini M, Scichilone N. Tiotropium in asthma: back to the future of anticholinergic treatment. Clin Mol Allergy 2017; 15:20. [PMID: 29213218 PMCID: PMC5713051 DOI: 10.1186/s12948-017-0076-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/20/2017] [Indexed: 01/01/2023] Open
Abstract
Asthma is among the most common chronic diseases worldwide; however, despite progresses in the understanding of the patho-physiological mechanisms and advances in the development of new therapeutic options and strategies, the disease remains uncontrolled in a not trivial proportion of subjects. Thus, the need of new molecules to treat the underlying biological and functional abnormalities and to control symptoms is strongly advocated by clinicians. In this scenario, the most recent GINA guidelines have included the use of tiotropium bromide in the most severe and uncontrolled forms of the disease, in addition to treatment with inhaled corticosteroid plus long acting beta adrenergic agents. Indeed, a large body of evidence has accumulated to support the use of tiotropium bromide in asthma. The current review paper provides a state of the art systematic revision of findings on the efficacy and safety of tiotropium in the adult and paediatric asthma population. To this aim, electronic searches were undertaken in the most common scientific databases from the date of inception to March 2017. Robust and high quality evidence showed that tiotropium is effective and safe in both adults and children/adolescents. Predictive markers of response have been also suggested, as well as cost–benefit analyses reported. The tiotropium bronchodilator effect seems to be not solely related to the reduction of the smooth muscle tone. However, the observations on anti-inflammatory properties or reduction in mucus production, despite highly interesting, have been only demonstrated in in vitro studies and animal models, therefore advocating for further specifically designed investigations.
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Affiliation(s)
- Matteo Bonini
- Airways Division, Airways Disease Section, National Heart and Lung Institute (NHLI), Royal Brompton Hospital & Imperial College, Dovehouse Street, London, SW3 6LY UK
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy
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55
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Patel KR, Bai Y, Trieu KG, Barrios J, Ai X. Targeting acetylcholine receptor M3 prevents the progression of airway hyperreactivity in a mouse model of childhood asthma. FASEB J 2017; 31:4335-4346. [PMID: 28619712 PMCID: PMC5602904 DOI: 10.1096/fj.201700186r] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/30/2017] [Indexed: 12/19/2022]
Abstract
Asthma often progresses into adulthood from early-life episodes of adverse environmental exposures. However, how the injury to developing lungs contributes to the pathophysiology of persistent asthma remains poorly understood. In this study, we identified an age-related mechanism along the cholinergic nerve-airway smooth muscle (ASM) axis that underlies prolonged airway hyperreactivity (AHR) in mice. We showed that ASM continued to mature until ∼3 wk after birth. Coinciding with postnatal ASM maturation, there was a critical time window for the development of ASM hypercontractility after cholinergic stimulation. We found that allergen exposure in neonatal mice, but not in adult mice, elevated the level and activity of cholinergic nerves (termed neuroplasticity). We demonstrated that cholinergic neuroplasticity is necessary for the induction of persistent AHR after neonatal exposure during rescue assays in mice deficient in neuroplasticity. In addition, early intervention with cholinergic receptor muscarinic (ChRM)-3 blocker reversed the progression of AHR in the neonatal exposure model, whereas β2-adrenoceptor agonists had no such effect. Together, our findings demonstrate a functional relationship between cholinergic neuroplasticity and ASM contractile phenotypes that operates uniquely in early life to induce persistent AHR after allergen exposure. Targeting ChRM3 may have disease-modifying benefits in childhood asthma.-Patel, K. R., Bai, Y., Trieu, K. G., Barrios, J., Ai, X. Targeting acetylcholine receptor M3 prevents the progression of airway hyperreactivity in a mouse model of childhood asthma.
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Affiliation(s)
- Kruti R Patel
- Division of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yan Bai
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth G Trieu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliana Barrios
- Pulmonary Division, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Xingbin Ai
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
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56
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Clark VL, Gibson PG, Genn G, Hiles SA, Pavord ID, McDonald VM. Multidimensional assessment of severe asthma: A systematic review and meta-analysis. Respirology 2017; 22:1262-1275. [PMID: 28776330 DOI: 10.1111/resp.13134] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/02/2017] [Accepted: 06/02/2017] [Indexed: 01/12/2023]
Abstract
The management of severe asthma is complex. Multidimensional assessment (MDA) of specific traits has been proposed as an effective strategy to manage severe asthma, although it is supported by few prospective studies. We aimed to systematically review the literature published on MDA in severe asthma, to identify the traits included in MDA and to determine the effect of MDA on asthma-related outcomes. We identified 26 studies and classified these based on study type (cohort/cross-sectional studies; experimental/outcome studies; and severe asthma disease registries). Study type determined the comprehensiveness of the assessment. Assessed traits were classified into three domains (airways, co-morbidities and risk factors). The airway domain had the largest number of traits assessed (mean ± SD = 4.2 ± 1.7) compared with co-morbidities (3.6 ± 2.2) and risk factors (3.9 ± 2.1). Bronchodilator reversibility and airflow limitation were assessed in 92% of studies, whereas airway inflammation was only assessed in 50%. Commonly assessed co-morbidities were psychological dysfunction, sinusitis (both 73%) and gastro-oesophageal reflux disease (GORD; 69%). Atopic and smoking statuses were the most commonly assessed risk factors (85% and 86%, respectively). There were six outcome studies, of which five concluded that MDA is effective at improving asthma-related outcomes. Among these studies, significantly more traits were assessed than treated. MDA studies have assessed a variety of different traits and have shown evidence of improved outcomes. This promising model of care requires more research to inform which traits should be assessed, which traits should be treated and what effect MDA has on patient outcomes.
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Affiliation(s)
- Vanessa L Clark
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia.,School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Grayson Genn
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
| | - Sarah A Hiles
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia.,School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and The Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia.,School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
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57
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Jabbal S, Manoharan A, Lipworth BJ. Bronchoprotective tolerance with indacaterol is not modified by concomitant tiotropium in persistent asthma. Clin Exp Allergy 2017; 47:1239-1245. [PMID: 28665534 DOI: 10.1111/cea.12972] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/11/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Tiotropium is a long acting muscarinic antagonist (LAMA), licensed as triple therapy with inhaled corticosteroid and long-acting beta-agonist (ICS/LABA). There may be a synergistic benefit between LAMA and LABA as a consequence of receptor cross-talk, which in turn could modify beta-2 receptor downregulation and associated tolerance induced by LABA. OBJECTIVE We hypothesize this mechanism may result in a reduction of airway hyperresponsiveness (AHR) when using triple therapy. METHODS We evaluated 14 non-smoking asthmatics using an open-label, randomized crossover design. ICS with Indacaterol and Tiotropium (IND/TIO) vs ICS with Indacaterol (IND) over 4 weeks with challenge performed after first and last doses at trough. RESULTS We found no significant difference in mannitol sensitivity, expressed as the provocative dose of mannitol required to reach a 15% drop in FEV1 , or mannitol reactivity, expressed as the response dose ratio (RDR: max % fall in FEV1 /cumulative dose), when comparing ICS/IND/TIO to ICS/IND. Geometric mean fold differences for RDR comparing single and chronic dosing were 3.26-fold (95% CI 1.46-7.29) and 2.51-fold (95% CI 1.32-4.79) for IND and IND/TIO, respectively. Furthermore, salbutamol recovery post-challenge was significantly blunted after chronic compared to single dosing with either ICS/IND (P<.005) or ICS/IND/TIO (P<.05). CONCLUSION AND CLINICAL RELEVANCE Our data suggest that concomitant tiotropium does not modify the bronchoprotective tolerance induced by Indacaterol, in turn suggesting that cross-talk may not be clinically relevant when using triple therapy. This study was registered on clinicaltrials.gov as NCT02039011.
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Affiliation(s)
- S Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - A Manoharan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - B J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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58
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Abstract
Inhaled corticosteroids are the mainstay of asthma treatment using a step-up approach with incremental dosing and additional controller medications in order to achieve symptom control and prevent exacerbations. While most patients respond well to this treatment approach, some patients remain refractory despite high doses of inhaled corticosteroids and a long-acting β-agonist. The problem lies in the heterogeneity of severe asthma, which is further supported by the emergence of severe asthma phenotypes. This heterogeneity contributes to the variability in treatment response. Randomized controlled trials involving add-on therapies in poorly controlled asthma have challenged the idea of a "one size fits all" approach targeting specific phenotypes in their subject selection. This review discusses severe asthma phenotypes from unbiased clustering approaches and the most recent scientific evidence on novel treatments to provide a guide in personalizing severe asthma treatment.
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Affiliation(s)
- Maria Theresa D Opina
- Department of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wendy C Moore
- Department of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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59
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The effect of tiotropium in combination with olodaterol on house dust mite-induced allergic airway disease. Pulm Pharmacol Ther 2017; 45:210-217. [PMID: 28687462 DOI: 10.1016/j.pupt.2017.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/12/2017] [Accepted: 06/29/2017] [Indexed: 11/21/2022]
Abstract
One of the major goals of asthma therapy is to maintain asthma control and prevent acute exacerbations. Long-acting bronchodilators are regularly used for the treatment of asthma patients and in clinical studies the anti-cholinergic tiotropium has recently been shown to reduce exacerbations in patients with asthma. So far it is unclear how tiotropium exerts this effect. For this purpose, we designed an allergen-driven rechallenge model of allergic airway inflammation in mice, to assess the effectiveness of tiotropium and the long-acting β-2 adrenoceptor agonist olodaterol on allergen-induced exacerbations of airway disease. Female C57BL/6J mice were sensitized intranasally (i.n.) with 1 μg of house dust mite (HDM) extract followed by a challenge regime (5 consecutive days 10 μg HDM extract i.n.) after one week. Mice were exposed to a secondary challenge five weeks after sensitization and were treated i.n. with different concentrations of tiotropium or olodaterol (1, 10 and 100 μg/kg) or a combination thereof (10 μg/kg each) prior to and during the secondary challenge period. Three days after the last challenge, bronchoalveolar lavage (BAL) fluid and lung tissue were collected for flow cytometry and histologic analysis, respectively. Secondary challenge with HDM extract strongly induced allergic airway disease reflected by inflammatory cell infiltration and goblet cell metaplasia. Treatment with tiotropium, but not with olodaterol reduced tissue inflammation and goblet cell metaplasia in a dose-dependent manner. The combination of tiotropium and olodaterol was more effective in significantly reducing tissue inflammation compared to tiotropium treatment alone, and also led to a decrease in BAL cell counts. These data suggest that in a model of relapsing allergic airway disease tiotropium directly prevents exacerbations by reducing inflammation and mucus production in the airways. In addition, the combination of tiotropium and olodaterol exerts synergistic effects.
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60
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Radovanovic D, Santus P, Blasi F, Mantero M. The evidence on tiotropium bromide in asthma: from the rationale to the bedside. Multidiscip Respir Med 2017; 12:12. [PMID: 28484598 PMCID: PMC5420159 DOI: 10.1186/s40248-017-0094-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 04/18/2017] [Indexed: 02/06/2023] Open
Abstract
Severe and poorly controlled asthma still accounts for a great portion of the patients affected. Disease control and future risk management have been identified by international guidelines as the main goals in patients with asthma. The need for new treatment approaches has led to reconsider anticholinergic drugs as an option for asthma treatment. Tiotropium is the first anticholinergic drug that has been approved for children and adults with poorly controlled asthma and is currently considered as an option for steps 4 and 5 of the Global Initiative for Asthma. In large randomized clinical trials enrolling patients with moderate to severe asthma, add-on therapy with tiotropium has demonstrated to be efficacious in improving lung function, decreasing risk of exacerbation and slowing the worsening of disease; accordingly, tiotropium demonstrated to be non inferior compared to long acting beta-agonists in the maintenance treatment along with medium to high inhaled corticosteroids. In view of the numerous ancillary effects acting on inflammation, airway remodeling, mucus production and cough reflex, along with the good safety profile and the broad spectrum of efficacy demonstrated in different disease phenotypes, tiotropium can represent a beneficial alternative in the therapeutic management of poorly controlled asthma. The present extensive narrative review presents the pharmacological and pathophysiological basis that guided the rationale for the introduction of tiotropium in asthma treatment algorithm, with a particular focus on its conventional and unconventional effects; finally, data on tiotropium efficacy and safety. from recent randomized clinical trials performed in all age categories will be extensively discussed.
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Affiliation(s)
- Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Pulmonary Unit, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Pulmonary Unit, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Cardio-thoracic unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, Cardio-thoracic unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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61
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Abstract
INTRODUCTION Severe therapy-resistant asthma is an area where there has been recent advances in understanding that is percolating into improvements in management. Areas covered: This review covers the recent definition and approach to the diagnosis of severe asthma and its differentiation from difficult-to-treat asthma. The recent advances in phenotyping severe asthma and in ensuing changes in management approaches together with the introduction of new therapies are covered from a review of the recent literature. Expert commentary: After ascertaining the diagnosis of severe asthma, patients need to be treated adequately with existing therapies. The management approach to severe asthma now comprises of a phenotyping step for the definition of either an allergic or eosinophilic severe asthma for which targeted therapies are currently available. This will lead to a precision medicine approach to the management of severe asthma.
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Affiliation(s)
- Kian Fan Chung
- a Airways Disease , National Heart & Lung Institute, Imperial College London , London , UK.,b Biomedical Research Unit , Royal Brompton & Harefield NHS Trust , London , UK
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62
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Halpin DM, Kaplan AG, Russell RK. Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators. Respir Med 2017; 128:28-41. [PMID: 28610667 DOI: 10.1016/j.rmed.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) and asthma are leading causes of morbidity and mortality. This narrative review provides an appraisal of the pharmacological and clinical characteristics of tiotropium in COPD and asthma, and examines how these compare with other long-acting bronchodilators. The evidence base is placed into context by relating it to factors affecting clinicians' choice of therapy. MAIN FINDINGS Desirable attributes of a long-acting muscarinic antagonist (LAMA) maintenance therapy include effective pharmacological bronchodilation, improved lung function, exacerbation efficacy, and positive effects on symptom control, exercise capacity and quality of life across a broad patient population. Tolerability and convenience of use are also important for patient well-being and treatment adherence. Tiotropium shows higher affinity for muscarinic receptors than ipratropium, and prolonged binding to the M3 receptor compared with other LAMAs. In COPD, tiotropium has demonstrated improved lung function and exacerbation prevention compared with placebo or long-acting β2-agonists, similar exacerbation efficacy to other LAMAs, and enhanced symptom control and health status versus placebo. UniTinA-asthma® showed the benefits of add-on tiotropium in patients with uncontrolled mild to moderate and severe asthma. Tiotropium is well tolerated, with an incidence of adverse events similar to placebo, except for known infrequent side effects of anticholinergics. Tiotropium HandiHaler® and Respimat® augment inhaler choice in COPD. PRINCIPAL CONCLUSIONS With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base than other long-acting bronchodilators, with demonstrated efficacy and safety in COPD and symptomatic asthma.
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Affiliation(s)
- David M Halpin
- Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, United Kingdom.
| | - Alan G Kaplan
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, ON M5G 1V7, Canada.
| | - Richard K Russell
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DS, United Kingdom.
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63
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Long-Acting Muscarinic Antagonists for Difficult-to-Treat Asthma: Emerging Evidence and Future Directions. Drugs 2017; 76:999-1013. [PMID: 27289376 DOI: 10.1007/s40265-016-0599-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Asthma is a complex disease where many patients remain symptomatic despite guideline-directed therapy. This suggests an unmet need for alternative treatment approaches. Understanding the physiological role of muscarinic receptors and the parasympathetic nervous system in the respiratory tract will provide a foundation of alternative therapeutics in asthma. Currently, several long-acting muscarinic antagonists (LAMAs) are on the market for the treatment of respiratory diseases. Many studies have shown the effectiveness of tiotropium, a LAMA, as add-on therapy in uncontrolled asthma. These studies led to FDA approval for tiotropium use in asthma. In this review, we discuss how the neurotransmitter acetylcholine itself contributes to inflammation, bronchoconstriction, and remodeling in asthma. We further describe the current clinical studies evaluating LAMAs in adult and adolescent patients with asthma, providing a comprehensive review of the current known physiological benefits of LAMAs in respiratory disease.
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64
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Wolff A, Joshi RK, Ekström J, Aframian D, Pedersen AML, Proctor G, Narayana N, Villa A, Sia YW, Aliko A, McGowan R, Kerr AR, Jensen SB, Vissink A, Dawes C. A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI. Drugs R D 2017; 17:1-28. [PMID: 27853957 PMCID: PMC5318321 DOI: 10.1007/s40268-016-0153-9] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist. OBJECTIVE Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea. DATA SOURCES Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices. LIMITATIONS While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search. CONCLUSIONS We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.
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Affiliation(s)
- Andy Wolff
- Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Saliwell Ltd, 65 Hatamar St, 60917, Harutzim, Israel.
| | - Revan Kumar Joshi
- Department of Oral Medicine and Radiology, DAPMRV Dental College, Bangalore, India
| | - Jörgen Ekström
- Department of Pharmacology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | | | - Anne Marie Lynge Pedersen
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gordon Proctor
- Mucosal and Salivary Biology Division, Dental Institute, King's College London, London, UK
| | - Nagamani Narayana
- Department of Oral Biology, University of Nebraska Medical Center (UNMC) College of Dentistry, Lincoln, NE, USA
| | - Alessandro Villa
- Division of Oral Medicine and Dentistry, Department of Oral Medicine Infection and Immunity, Brigham and Women's Hospital, Harvard School of Dental Medicine, Boston, MA, USA
| | - Ying Wai Sia
- McGill University, Faculty of Dentistry, Montreal, QC, Canada
| | - Ardita Aliko
- Faculty of Dental Medicine, University of Medicine, Tirana, Albania
- Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | | | - Siri Beier Jensen
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Colin Dawes
- Department of Oral Biology, University of Manitoba, Winnipeg, MB, Canada
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Cazzola M, Ora J, Rogliani P, Matera MG. Role of muscarinic antagonists in asthma therapy. Expert Rev Respir Med 2017; 11:239-253. [PMID: 28140686 DOI: 10.1080/17476348.2017.1289844] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Higher parasympathetic tone has been reported in asthmatics. In general, cholinergic contractile tone is increased by airway inflammation associated with asthma. Nevertheless, the role of muscarinic antagonists for the treatment of asthma has not yet been clearly defined. Areas covered: The use of SAMAs and LAMAs in asthma has been examined and discussed according with the published evidence. Particular attention has been given to the large Phase III clinical trial program designed to evaluate the efficacy and safety of tiotropium respimat added to standard treatment in adults, adolescents and children with persistent asthma across the spectrum of asthma severity. Expert commentary: The current evidence is that in patients with poorly controlled severe asthma despite the use of ICS and LABA, the addition of tiotropium significantly increases the time to the first severe exacerbation and provides a modest but sustained bronchodilation. Identical results should be produced using other LAMAs. In any case, the documentation that, at least in animal or in vitro models, LAMAs show significant anti-inflammatory and anti-proliferative capacities and are able to inhibit airway remodeling induced by allergens makes a strong presumption that the use of LAMAs in asthma may go beyond the simple bronchodilator effect.
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Affiliation(s)
- Mario Cazzola
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Josuel Ora
- b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Paola Rogliani
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy.,b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Maria Gabriella Matera
- c Chair of Pharmacology, Department of Experimental Medicine , Second University of Naples , Naples , Italy
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Hamelmann E, Vogelberg C, Szefler SJ. Tiotropium for the treatment of asthma in adolescents. Expert Opin Pharmacother 2017; 18:305-312. [PMID: 28110558 DOI: 10.1080/14656566.2017.1285906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Asthma is a prevalent disease affecting millions of individuals. Despite receiving guideline therapy with inhaled corticosteroids (ICS) with or without a long-acting β2-agonist (LABA), a proportion of patients remain symptomatic or have suboptimal lung function. There is therefore an unmet need for additional therapies to improve asthma control. The long-acting anticholinergic tiotropium, delivered via the Respimat inhaler, is approved for the treatment of asthma in the EU, the USA, and other countries. Phase III investigation in adults has demonstrated that tiotropium improves lung function and asthma control, with a safety profile comparable with that of placebo. Areas covered: Clinical trials in adolescent patients (aged 12-17 years) with moderate or severe symptomatic asthma have shown that tiotropium Respimat as add-on to ICS, with or without other maintenance therapies, is a well-tolerated and efficacious bronchodilator showing trends toward improved asthma control, similar to data in adult patients. Expert opinion: Tiotropium Respimat may be of benefit as add-on maintenance therapy to medium- or high-dose ICS with or without LABA; however, further data are needed to directly compare the efficacy of ICS plus tiotropium versus ICS plus LABA in adolescents with symptomatic asthma, and to establish the long-term effects on airway modeling.
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Affiliation(s)
- Eckard Hamelmann
- a Klinik für Kinder- und Jugendmedizin, Kinderzentrum Bethel, Evangelisches Krankenhaus Bielefeld GmbH , Akademisches Lehrkrankenhaus der Universität Münster , Bielefeld , Germany
| | - Christian Vogelberg
- b Department of Pulmonology and Allergy , University Hospital Carl Gustav Carus, Technical University of Dresden , Dresden , Germany
| | - Stanley J Szefler
- c Pediatric Asthma Research Program, Children's Hospital Colorado, Breathing Institute , Department of Pediatrics, Section of Pulmonary Medicine , Aurora , CO , USA.,d University of Colorado School of Medicine , Aurora , CO , USA
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Asthma Yardstick. Ann Allergy Asthma Immunol 2017; 118:133-142.e3. [DOI: 10.1016/j.anai.2016.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/13/2023]
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Leung E, Al Efraij K, FitzGerald JM. The safety of mepolizumab for the treatment of asthma. Expert Opin Drug Saf 2017; 16:397-404. [PMID: 28116937 DOI: 10.1080/14740338.2017.1286327] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Asthma is an airway disease characterized by airway inflammation. It is associated with significant morbidity, mortality, and costs to the healthcare system and society. Interleukin-5 (IL-5) was identified for its role in eosinophil development, maturation, and survival in tissues, which has been related to disease severity and airway eosinophilia. Areas covered: In this review, we will present the pharmacokinetics and dynamics of mepolizumab in addition to efficacy and safety data. Expert Opinion: Mepolizumab is novel, new, first-in-class therapy targeting IL-5. It has been found to be particularly effective in the management of patients with asthma whose peripheral blood eosinophil count is at a well-defined cut point within the normative range. This easily available biomarker, along with a history of asthma exacerbations, has translated into a clinically significant reduction in asthma exacerbations and the dose of oral corticosteroids in patients who previously have been prednisone-dependent. The pivotal studies indicate that mepolizumab was well tolerated, with the most frequently reported adverse events being headache, nasopharyngitis, worsening of asthma, and local injection reactions. These study investigators did not report any deaths or anaphylaxis related to mepolizumab.
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Affiliation(s)
- E Leung
- a Department of Internal Medicine , University of British Columbia , Vancouver , Canada
| | - K Al Efraij
- b Department of Integrative Oncology , British Columbia Cancer Research Centre , Vancouver , Canada
| | - J M FitzGerald
- c Department of Respirology , Vancouver General Hospital - Respirology, The Lung Centre, 7th Floor Gordon and Leslie Diamond Health Care Centre , Vancouver , Canada
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Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane Database Syst Rev 2017; 1:CD001284. [PMID: 28076656 PMCID: PMC6465060 DOI: 10.1002/14651858.cd001284.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Inhaled short-acting anticholinergics (SAAC) and short-acting beta₂-agonists (SABA) are effective therapies for adult patients with acute asthma who present to the emergency department (ED). It is unclear, however, whether the combination of SAAC and SABA treatment is more effective in reducing hospitalisations compared to treatment with SABA alone. OBJECTIVES To conduct an up-to-date systematic search and meta-analysis on the effectiveness of combined inhaled therapy (SAAC + SABA agents) vs. SABA alone to reduce hospitalisations in adult patients presenting to the ED with an exacerbation of asthma. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, SCOPUS, LILACS, ProQuest Dissertations & Theses Global and evidence-based medicine (EBM) databases using controlled vocabulary, natural language terms, and a variety of specific and general terms for inhaled SAAC and SABA drugs. The search spanned from 1946 to July 2015. The Cochrane Airways Group provided search results from the Cochrane Airways Group Register of Trials which was most recently conducted in July 2016. An extensive search of the grey literature was completed to identify any other potentially relevant studies. SELECTION CRITERIA Included studies were randomised or controlled clinical trials comparing the effectiveness of combined inhaled therapy (SAAC and SABA) to SABA treatment alone to prevent hospitalisations in adults with acute asthma in the emergency department. Two independent review authors assessed studies for inclusion using pre-determined criteria. DATA COLLECTION AND ANALYSIS For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RR) or odds ratios (OR) with 95% confidence intervals (CI) using a random-effects model and reporting heterogeneity (I²). For continuous outcomes, we reported individual trial results using mean differences (MD) and pooled results as weighted mean differences (WMD) or standardised mean differences (SMD) with 95% CIs using a random-effects model. MAIN RESULTS We included 23 studies that involved a total of 2724 enrolled participants. Most studies were rated at unclear or high risk of bias.Overall, participants receiving combination inhaled therapy were less likely to be hospitalised (RR 0.72, 95% CI 0.59 to 0.87; participants = 2120; studies = 16; I² = 12%; moderate quality of evidence). An estimated 65 fewer patients per 1000 would require hospitalisation after receiving combination therapy (95% 30 to 95), compared to 231 per 1000 patients receiving SABA alone. Although combination inhaled therapy was more effective than SABA treatment alone in reducing hospitalisation in participants with severe asthma exacerbations, this was not found for participants with mild or moderate exacerbations (test for difference between subgroups P = 0.02).Participants receiving combination therapy were more likely to experience improved forced expiratory volume in one second (FEV₁) (MD 0.25 L, 95% CI 0.02 to 0.48; participants = 687; studies = 6; I² = 70%; low quality of evidence), peak expiratory flow (PEF) (MD 36.58 L/min, 95% CI 23.07 to 50.09; participants = 1056; studies = 12; I² = 25%; very low quality of evidence), increased percent change in PEF from baseline (MD 24.88, 95% CI 14.83 to 34.93; participants = 551; studies = 7; I² = 23%; moderate quality of evidence), and were less likely to return to the ED for additional care (RR 0.80, 95% CI 0.66 to 0.98; participants = 1180; studies = 5; I² = 0%; moderate quality of evidence) than participants receiving SABA alone.Participants receiving combination inhaled therapy were more likely to experience adverse events than those treated with SABA agents alone (OR 2.03, 95% CI 1.28 to 3.20; participants = 1392; studies = 11; I² = 14%; moderate quality of evidence). Among patients receiving combination therapy, 103 per 1000 were likely to report adverse events (95% 31 to 195 more) compared to 131 per 1000 patients receiving SABA alone. AUTHORS' CONCLUSIONS Overall, combination inhaled therapy with SAAC and SABA reduced hospitalisation and improved pulmonary function in adults presenting to the ED with acute asthma. In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild-moderate exacerbations, who were at a lower risk to be hospitalised. A single dose of combination therapy and multiple doses both showed reductions in the risk of hospitalisation among adults with acute asthma. However, adults receiving combination therapy were more likely to experience adverse events, such as tremor, agitation, and palpitations, compared to patients receiving SABA alone.
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Affiliation(s)
- Scott W Kirkland
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | | | - Britt Voaklander
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Taylor Nikel
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
| | - Sandra Campbell
- University of AlbertaJohn W. Scott Health Sciences LibraryEdmontonABCanada
| | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineEdmontonABCanada
- University of AlbertaSchool of Public HeathEdmontonCanada
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Hamelmann E, Bernstein JA, Vandewalker M, Moroni-Zentgraf P, Verri D, Unseld A, Engel M, Boner AL. A randomised controlled trial of tiotropium in adolescents with severe symptomatic asthma. Eur Respir J 2017; 49:13993003.01100-2016. [PMID: 27811070 PMCID: PMC5298196 DOI: 10.1183/13993003.01100-2016] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/04/2016] [Indexed: 11/13/2022]
Abstract
We present results from the first phase III trial of once-daily tiotropium add-on to inhaled corticosteroids (ICS) plus one or more controller therapies in adolescents with severe symptomatic asthma. In this double-blind, parallel-group trial (NCT01277523), 392 patients aged 12–17 years were randomised to receive once-daily tiotropium 5 µg or 2.5 µg, or placebo, as an add-on to ICS plus other controller therapies over 12 weeks. The primary and key secondary end-points were change from baseline (response) in peak forced expiratory volume in 1 s (FEV1) within 3 h post-dosing (FEV1(0–3h)) and trough FEV1, respectively, after 12 weeks of treatment. Tiotropium 5 µg provided numerical improvements in peak FEV1(0–3h) response, compared with placebo (90 mL; p=0.104), and significant improvements were observed with tiotropium 2.5 µg (111 mL; p=0.046). Numerical improvements in trough FEV1 response and asthma control were observed with both tiotropium doses, compared with placebo. The safety and tolerability of tiotropium were comparable with those of placebo. Once-daily tiotropium Respimat add-on to ICS plus one or more controller therapies in adolescents with severe symptomatic asthma was well tolerated. The primary end-point of efficacy was not met, although positive trends for improvements in lung function and asthma control were observed. Tiotropium add-on therapy provided numerical improvements in outcomes in adolescents with asthmahttp://ow.ly/eL8g304a9XV
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Affiliation(s)
- Eckard Hamelmann
- Klinik für Kinder- und Jugendmedizin, Kinderzentrum Bethel, Evangelisches Krankenhaus Bielefeld, Akademisches Lehrkrankenhaus der Universität Münster, Bielefeld, Germany
| | - Jonathan A Bernstein
- Bernstein Allergy Group, Cincinnati, OH, USA.,Department of Internal Medicine, Immunology, Allergy and Rheumatology, University of Cincinnati, Cincinnati, OH, USA
| | | | | | - Daniela Verri
- Clinical Operations, Medical Department, Boehringer Ingelheim Italia, Milan, Italy
| | - Anna Unseld
- Global Biometrics and Data Sciences, Boehringer Ingelheim Pharma KG, Biberach an der Riss, Germany
| | | | - Attilio L Boner
- U.O.C. di Pediatria, Dipartimento di Scienze Chirurgiche Odontostomatologiche e Materno Infantili, Policlinico "G. Rossi", Verona, Italy
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71
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Aalbers R, Park HS. Positioning of Long-Acting Muscarinic Antagonists in the Management of Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:386-393. [PMID: 28677351 PMCID: PMC5500692 DOI: 10.4168/aair.2017.9.5.386] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/09/2017] [Indexed: 01/13/2023]
Abstract
Despite a range of efficacious therapies for asthma, including inhaled corticosteroids (ICS) and long-acting β2-agonists (LABA), a significant proportion of patients have poor asthma control and retain a risk of future worsening of their symptoms. Long-acting muscarinic antagonist (LAMA) bronchodilators offer a well-tolerated, efficacious, and cost-effective add-on to a patient's treatment. Of the LAMAs currently under investigation or available for the treatment of asthma, evidence from a comprehensive clinical trial program in adults and children shows that once-daily treatment with tiotropium provides benefits for patients with uncontrolled asthma despite the use of ICS and LABAs. Tiotropium is included in the Global Initiative for Asthma (GINA) strategy document as an add-on therapy option for patients at Step 4 or 5 with a history of asthma exacerbations. Tiotropium Respimat® has demonstrated safety and efficacy in patients with a range of disease severities, ages, and phenotypes. This review describes the evidence for the use of LAMA as add-on therapy for patients with asthma who remain uncontrolled despite the use of ICS and LABA treatments.
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Affiliation(s)
- René Aalbers
- Department of Pulmonology, Martini Hospital, Groningen, The Netherlands
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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72
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Fajt ML, Wenzel SE. Development of New Therapies for Severe Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:3-14. [PMID: 27826957 PMCID: PMC5102833 DOI: 10.4168/aair.2017.9.1.3] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 12/11/2022]
Abstract
Persistent asthma has long been treated with inhaled corticosteroids (CSs), as the mainstay of therapy. However, their efficacy in patients with more severe disease is limited, which led to the incorporation of poor response to ICSs (and thereby use of high doses of ICS) into recent definitions of severe asthma. Several studies have suggested that severe asthma might consist of several different phenotypes, each with ongoing symptoms and health care utilization, despite the use of high doses of ICS, usually in combination with a second or third controller. Several new therapies have been approved for severe asthma. Long-acting muscarinic agents have recently been approved as an additional controller agent and appear to improve lung function, although their effect on symptoms and exacerbations is less. Although bronchial thermoplasty (BT) has emerged as a therapy for severe asthma, little is understood regarding the appropriate selection of these patients. Considerable data have emerged to support the presence of a group of patients with severe asthma who have ongoing Type 2 inflammation. These patients appear to respond to targeted biologic approaches which are at the current time mostly investigational. In contrast, few effective therapies for patients with less or no evidence for Type 2 inflammation have emerged. Many new and exciting therapies are at the forefront for severe asthma therapy and, in conjunction with precision medicine approaches to identify the group of patients likely to respond to these approaches, will change the way we think about treating severe asthma.
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Affiliation(s)
- Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Asthma Institute at UPMC/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sally E Wenzel
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Asthma Institute at UPMC/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Martin Alonso A, Saglani S. Mechanisms Mediating Pediatric Severe Asthma and Potential Novel Therapies. Front Pediatr 2017; 5:154. [PMID: 28725641 PMCID: PMC5497140 DOI: 10.3389/fped.2017.00154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/20/2017] [Indexed: 12/21/2022] Open
Abstract
Although a rare disease, severe therapy-resistant asthma in children is a cause of significant morbidity and results in utilization of approximately 50% of health-care resources for asthma. Improving control for children with severe asthma is, therefore, an urgent unmet clinical need. As a group, children with severe asthma have severe and multiple allergies, steroid resistant airway eosinophilia, and significant structural changes of the airway wall (airway remodeling). Omalizumab is currently the only add-on therapy that is licensed for use in children with severe asthma. However, limitations of its use include ineligibility for approximately one-third of patients because of serum IgE levels outside the recommended range and lack of clinical efficacy in a further one-third. Pediatric severe asthma is thus markedly heterogeneous, but our current understanding of the different mechanisms underpinning various phenotypes is very limited. We know that there are distinctions between the factors that drive pediatric and adult disease since pediatric disease develops in the context of a maturing immune system and during lung growth and development. This review summarizes the current data that give insight into the pathophysiology of pediatric severe asthma and will highlight potential targets for novel therapies. It is apparent that in order to identify novel treatments for pediatric severe asthma, the challenge of undertaking mechanistic studies using age appropriate experimental models and airway samples from children needs to be accepted to allow a targeted approach of personalized medicine to be achieved.
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Affiliation(s)
- Aldara Martin Alonso
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sejal Saglani
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Respiratory Pediatrics, The Royal Brompton Hospital, London, United Kingdom
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Busse WW, Dahl R, Jenkins C, Cruz AA. Long-acting muscarinic antagonists: a potential add-on therapy in the treatment of asthma? Eur Respir Rev 2016; 25:54-64. [PMID: 26929422 DOI: 10.1183/16000617.0052-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory disorder of the airways that is a major global burden on both individuals and healthcare systems. Despite guideline-directed treatment, a significant proportion of patients with asthma do not achieve control. This review focuses on the potential use of long-acting anticholinergics as bronchodilators in the treatment of asthma, with results published from clinical trials of glycopyrrolate, umeclidinium and tiotropium. The tiotropium clinical trial programme is the most advanced, with data available from a number of phase II and III studies of tiotropium as an add-on to inhaled corticosteroid maintenance therapy, with or without a long-acting β2-agonist, in patients across asthma severities. Recent studies using the Respimat Soft Mist inhaler have identified 5 µg once daily as the preferred dosing regimen, which has shown promising results in adults, adolescents and children with asthma. Tiotropium Respimat has recently been incorporated into the Global Initiative for Asthma 2015 treatment strategy as a recommended alternative therapy at steps 4 and 5 in adult patients with a history of exacerbations. The increasing availability of evidence from ongoing and future clinical trials will be beneficial in determining where long-acting anticholinergic agents fit in future treatment guidelines across a variety of patient populations and disease severities.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Dahl
- Allergy Centre, Odense University Hospital, Odense, Denmark
| | | | - Alvaro A Cruz
- ProAR - Universidade Federal da Bahia, Bahia, Brazil
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Albertson TE, Chenoweth JA, Adams JY, Sutter ME. Muscarinic antagonists in early stage clinical development for the treatment of asthma. Expert Opin Investig Drugs 2016; 26:35-49. [PMID: 27927039 DOI: 10.1080/13543784.2017.1264388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Parasympathetic neurons utilize the neurotransmitter acetylcholine to modulate and constrict airway smooth muscles at the muscarinic acetylcholine receptor. Inhaled agents that antagonize the muscarinic (M) acetylcholine receptor, particularly airway M3 receptors, have increasing data supporting use in persistent asthma. Areas covered: Use of inhaled long-acting muscarinic antagonists (LAMA) in asthma is explored. The LAMA tiotropium is approved for maintenance in symptomatic asthma patients despite the use of inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA) and/or long-acting beta2 agonists (LABA). LAMA agents currently approved for chronic obstructive pulmonary disease (COPD) include tiotropium, glycopyrrolate/glycopyrronium, umeclidinium and aclidinium. These agents are reviewed for their pharmacological differences and clinical trials in asthma. Expert opinion: Current guidelines place inhaled LAMAs as adjunctive maintenance therapy in symptomatic asthma not controlled by an ICS and/or a LTRA. LAMA agents will play an increasing role in moderate to severe symptomatic asthma patients. Additional LAMA agents are likely to seek a maintenance indication perhaps as a combined inhaler with an ICS or with an ICS and a LABA. These fixed-dose combination inhalers are being tested in COPD and asthma patients. Once-a-day dosing of inhaled LAMA agents in severe asthma patients will likely become the future standard.
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Affiliation(s)
- Timothy E Albertson
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA.,b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - James A Chenoweth
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - Jason Y Adams
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA
| | - Mark E Sutter
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
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Canonica GW, Senna G, Mitchell PD, O'Byrne PM, Passalacqua G, Varricchi G. Therapeutic interventions in severe asthma. World Allergy Organ J 2016; 9:40. [PMID: 27942351 PMCID: PMC5125042 DOI: 10.1186/s40413-016-0130-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/04/2016] [Indexed: 12/29/2022] Open
Abstract
The present paper addresses severe asthma which is limited to 5-10% of the overall population of asthmatics. However, it accounts for 50% or more of socials costs of the disease, as it is responsible for hospitalizations and Emergency Department accesses as well as expensive treatments. The recent identification of different endotypes of asthma, based on the inflammatory pattern, has led to the development of tailored treatments that target different inflammatory mediators. These are major achievements in the perspective of Precision Medicine: a leading approach to the modern treatment strategy. Omalizumab, an anti-IgE antibody, has been the only biologic treatment available on the market for severe asthma during the last decade. It prevents the linkage of the IgE and the receptors, thereby inhibiting mast cell degranulation. In clinical practice omalizumab significantly reduced the asthma exacerbations as well as the concomitant use of oral glucocorticoids. In the "Th2-high asthma" phenotype, the hallmarks are increased levels of eosinophils and other markers (such as periostin). Because anti-IL-5 in this condition plays a crucial role in driving eosinophil inflammation, this cytokine or its receptors on the eosinophil surface has been studied as a potential target for therapy. Two different anti-IL-5 humanized monoclonal antibodies, mepolizumab and reslizumab, have been proven effective in this phenotype of asthma (recently they both came on the market in the United States), as well as an anti-IL-5 receptor alpha (IL5Rα), benralizumab. Other monoclonal antibodies, targeting different cytokines (IL-13, IL-4, IL-17 and TSLP) are still under evaluation, though the preliminary results are encouraging. Finally, AIT, Allergen Immunotherapy, a prototype of Precision Medicine, is considered, also in light of the recent evidences of Sublingual Immunotherapy (SLIT) tablet efficacy and safety in mite allergic asthma patients. Given the high costs of these therapies, however, there is an urgent need to identify biomarkers that can predict the clinical responders.
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Affiliation(s)
- Giorgio Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genova, Italy
| | - Gianenrico Senna
- Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Patrick D Mitchell
- Firestone Institute of Respiratory Health and Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Paul M O'Byrne
- Firestone Institute of Respiratory Health and Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Giovanni Passalacqua
- Allergy & Respiratory Disease Clinic, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genova, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Division of Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
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Yoshida M, Kaneko Y, Ishimatsu A, Komori M, Iwanaga T, Inoue H. Effects of tiotropium on lung function in current smokers and never smokers with bronchial asthma. Pulm Pharmacol Ther 2016; 42:7-12. [PMID: 27888045 DOI: 10.1016/j.pupt.2016.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/19/2016] [Accepted: 11/21/2016] [Indexed: 11/19/2022]
Abstract
The effects of tiotropium, an inhaled long-acting muscarinic antagonist, on lung function were investigated in current smokers and nonsmokers with asthma treated with inhaled corticosteroids (ICSs) and other asthma controllers: inhaled long-acting β2 agonists, leukotriene receptor antagonists, and/or theophylline. We conducted a double-blind, placebo-controlled study of an inhaled single dose of tiotropium in 9 asthmatics currently smoking and 9 asthmatics who have never smoked in a crossover manner. Lung function was measured before and 1, 3, and 24 h after inhalation of 18 μg of tiotropium or a placebo. The primary outcome was a change in forced expiratory volume in 1 s (FEV1) from the baseline, and the secondary outcomes were changes in peak expiratory flow rate (PEFR), V˙50, and V˙25. At baseline, asthmatics with and without a smoking history had a mean FEV1 of 2590 ml and 2220 ml and were taking a mean dose of ICSs of 1208 and 1000 μg/day, respectively. The increase from the baseline FEV1 was 169 ml and 105 ml higher at 3 h after tiotropium than after the placebo in current smokers and nonsmokers, respectively. PEFR, V˙50, and V˙25 were also significantly increased after tiotropium as compared with the placebo in both study groups. Changes in FEV1 and PEFR tended to be greater in asthmatics currently smoking than in subjects who have never smoked, although there were no statistical differences at any time points. Tiotropium resulted in improved lung function and symptoms both in current smoker and nonsmoker asthmatics. These findings suggest that tiotropium will provide a new strategy for the treatment of bronchial asthma.
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Affiliation(s)
- Makoto Yoshida
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, 4-39-1 Yakatabaru, Minami-ku, Fukuoka 811-1394, Japan.
| | - Yasuko Kaneko
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, 4-39-1 Yakatabaru, Minami-ku, Fukuoka 811-1394, Japan; Division of Respiratory Medicine, Nishi-Fukuoka Hospital, 3-18-8 Ikinomatsubara, Nishi-ku, Fukuoka 819-8555, Japan
| | - Akiko Ishimatsu
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, 4-39-1 Yakatabaru, Minami-ku, Fukuoka 811-1394, Japan
| | - Masashi Komori
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, 4-39-1 Yakatabaru, Minami-ku, Fukuoka 811-1394, Japan
| | - Tomoaki Iwanaga
- Division of Respiratory Medicine, National Hospital Organization Fukuoka Hospital, 4-39-1 Yakatabaru, Minami-ku, Fukuoka 811-1394, Japan
| | - Hiromasa Inoue
- Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
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78
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Abstract
Asthma is one of the most frequent chronic respiratory diseases worldwide, with an increase in its prevalence in the last decade. Ongoing studies continue to search for better diagnostic tools and advanced treatment options in an effort to decrease the morbidity and mortality associated with it. Unfortunately, many asthmatic patients still suffer from poorly controlled asthma, which may lead to life-threatening situations. This article reviews the basics of asthma and highlights the current guidelines in making accurate diagnosis and initiating therapeutic plan.
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79
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Tiotropium Respimat Is Effective for the Treatment of Asthma at a Dose Lower Than That for Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2016; 13:173-9. [PMID: 26650145 DOI: 10.1513/annalsats.201510-712ps] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Anticholinergic drug products are not part of the current treatment paradigm for asthma, despite their widespread availability for chronic obstructive pulmonary disease (COPD) and interest in their use for asthma. Published study results, mostly of short duration and primarily with ipratropium and tiotropium, have revealed inconsistent efficacy results. Consequently, the role of inhaled anticholinergic drugs in the treatment of asthma has been unclear. This commentary discusses and comments on data from five clinical trials in adults that were submitted by Boehringer Ingelheim to the U.S. Food and Drug Administration to support approval of tiotropium delivered by the Respimat device (Spiriva Respimat) for the treatment of asthma. These trials provided substantial evidence that supported the approval of Spiriva Respimat at a recommended dose of 2.5 μg once daily for asthma. Notably, in trials that evaluated two doses of tiotropium, 2.5 μg and 5 μg (the dose approved for COPD), pulmonary function measures for Spiriva Respimat 2.5 μg once daily were better overall than those obtained for the 5-μg once-daily dose, thus justifying selection of the lower dose for asthma. Spiriva Respimat represents the first new class of drug approved by the U.S. Food and Drug Administration for the treatment of asthma in more than a decade. The availability of Spiriva Respimat for asthma along with other novel therapies currently under development has the potential to impact asthma treatment guidelines.
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80
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Tan CK, Say GQ, Geake JB. Long-term safety of tiotropium delivered by Respimat ® SoftMist™ Inhaler: patient selection and special considerations. Ther Clin Risk Manag 2016; 12:1433-1444. [PMID: 27703365 PMCID: PMC5036544 DOI: 10.2147/tcrm.s109011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tiotropium bromide is a long-acting inhaled muscarinic antagonist used in patients with chronic respiratory disease. It has been available since 2002 as a single-dose dry powder formulation via the HandiHaler® dry powder inhaler (DPI) device, and since 2007 as the Respimat® SoftMist™ Inhaler (SMI). The latter is a novel method of medication delivery that utilizes a multidose aqueous solution to deliver the drug as a fine mist. Potential benefits include more efficient drug deposition throughout the respiratory tract, reduced systemic exposure, and greater ease of use and patient satisfaction compared with the use of HandiHaler DPI. Although tiotropium bromide delivered via the HandiHaler DPI has been clearly shown to improve lung function, dyspnea, and quality of life and to reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD), there is accumulating evidence regarding the use of tiotropium HandiHaler in other respiratory diseases characterized by airflow limitation, such as asthma and cystic fibrosis. Developed more recently, tiotropium delivered via the Respimat SMI appears to have a similar efficacy and safety profile to the HandiHaler DPI, and early data raising the possibility of safety concerns with its use in COPD have been refuted by more recent evidence. The benefits over the HandiHaler DPI, however, remain unclear. This paper will review the evidence for tiotropium delivered via the Respimat SMI inhaler, in particular as an alternative to the HandiHaler DPI, and will focus on the safety profile for each of the chronic lung diseases in which it has been trialed, as well as an approach to appropriate patient selection.
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Affiliation(s)
- Ching Kuo Tan
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - Gui Quan Say
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - James B Geake
- Department of Respiratory Medicine, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
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81
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Vogelberg C. Tiotropium in the add-on treatment of asthma in adults: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10:525-533. [PMID: 27612491 PMCID: PMC5933593 DOI: 10.1177/1753465816662571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease, and its treatment is frequently
challenging despite detailed national and international guidelines. While basic
anti-inflammatory therapy usually consists of inhaled corticosteroids in doses
adapted to the asthma severity, add-on treatment with bronchodilators is
essential in more severe asthma. Only recently, the long-acting anticholinergic
tiotropium was introduced into the GINA guidelines. This review reports on the
studies that have been performed with tiotropium in adult asthmatic patients.
Following early proof-of-concept studies, several studies with tiotropium as an
add-on therapy to inhaled corticosteroids (ICS), with or without a long-acting
beta agonist (LABA), demonstrated convincing clinical benefit for patients.
Important lung function parameters and quality of life scores significantly
improved shortly after onset of the add-on therapy with tiotropium, and some
studies even demonstrated non-inferiority against salmeterol. All studies
reported an excellent safety profile of tiotropium. The still growing body of
tiotropium studies, both in adults and children, will help to identify the
position of tiotropium in future asthma guidelines and might also indicate which
patients benefit most from an add-on therapy with tiotropium.
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Affiliation(s)
- Christian Vogelberg
- University Hospital Carl Gustav Carus, Department of Pediatric Pulmonology and Allergology, Fetscherstr. 74, 01307 Dresden, Germany
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82
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Slater MG, Pavord ID, Shaw DE. Step 4: stick or twist? A review of asthma therapy. BMJ Open Respir Res 2016; 3:e000143. [PMID: 27651907 PMCID: PMC5020663 DOI: 10.1136/bmjresp-2016-000143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 12/03/2022] Open
Abstract
Many people with asthma do not achieve disease control, despite bronchodilators and inhaled corticosteroid therapy. People with uncontrolled asthma are at higher risk of an asthma attack and death, with mortality rates estimated at 1000 deaths/year in England and Wales. The recent National Review of Asthma Deaths (NRAD) report, ‘Why asthma still kills’, recommended that patients at step 4 or 5 of the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidance must be referred to a specialist asthma service. This article reviews the 2014 evidence base for therapy of asthma patients at BTS/SIGN step 4 of the treatment cascade, in response to key findings of the NRAD report and lack of preferred treatment option at this step.
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Affiliation(s)
- Mariel G Slater
- Medical Department , Boehringer Ingelheim Ltd , Bracknell, Berkshire , UK
| | - Ian D Pavord
- Nuffield Department of Medicine Research Building , University of Oxford , Oxford, Oxfordshire , UK
| | - Dominick E Shaw
- Division of Respiratory Medicine , University of Nottingham, Nottingham City Hospital , Nottingham , UK
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83
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Kerstjens HAM, Moroni-Zentgraf P, Tashkin DP, Dahl R, Paggiaro P, Vandewalker M, Schmidt H, Engel M, Bateman ED. Tiotropium improves lung function, exacerbation rate, and asthma control, independent of baseline characteristics including age, degree of airway obstruction, and allergic status. Respir Med 2016; 117:198-206. [PMID: 27492532 DOI: 10.1016/j.rmed.2016.06.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/07/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many patients with asthma remain symptomatic despite treatment with inhaled corticosteroids (ICS) with or without long-acting β2-agonists (LABAs). Tiotropium add-on to ICS plus a LABA has been shown to improve lung function and reduce exacerbation risk in patients with symptomatic asthma. OBJECTIVE To determine whether the efficacy of tiotropium add-on therapy is dependent on patients' baseline characteristics. METHODS Two randomized, double-blind, parallel-group, twin trials (NCT00772538 and NCT00776984) of once-daily tiotropium Respimat(®) 5 μg add-on to ICS plus a LABA were performed in parallel in patients with severe symptomatic asthma. Exploratory subgroup analyses of peak forced expiratory volume in 1 s (FEV1), trough FEV1, time to first severe exacerbation, time to first episode of asthma worsening, and seven-question Asthma Control Questionnaire responder rate were performed to determine whether results were influenced by baseline characteristics. RESULTS 912 patients were randomized: 456 received tiotropium and 456 received placebo. Tiotropium improved lung function, reduced the risk of asthma exacerbations and asthma worsening, and improved asthma symptom control, compared with placebo, independent of baseline characteristics including gender, age, body mass index, disease duration, age at asthma onset, and FEV1 % predicted at screening and reversibility. CONCLUSION Once-daily tiotropium 5 μg compared with placebo improved lung function, reduced the risk of asthma exacerbations and asthma worsening, and improved asthma symptom control, independent of a broad range of baseline characteristics, as add-on to ICS plus LABAs in patients with severe symptomatic asthma. TRIAL REGISTRY ClinicalTrials.gov; numbers NCT00772538 and NCT00776984 URL: www.clinicaltrials.gov.
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Affiliation(s)
- Huib A M Kerstjens
- University of Groningen, Department of Pulmonary Medicine, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, Postbox 30.001, 9700 RB Groningen, The Netherlands.
| | - Petra Moroni-Zentgraf
- TA Respiratory Diseases, Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Straße 173, 55216 Ingelheim am Rhein, Germany.
| | - Donald P Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 37-131 Center for Health Sciences, 10833 Le Conte Avenue, Los Angeles, CA 90095-1690, USA.
| | - Ronald Dahl
- Odense University Hospital, University of Southern Denmark, Sdr Boulevard, DK 5000 Odense C, Denmark.
| | - Pierluigi Paggiaro
- Dipartimento Cardio-Toracico e Vascolare, SD Fisiopatologia e Riabilitazione Respiratoria, AOUP, via Paradisa 2, 56124 Pisa, Italy.
| | - Mark Vandewalker
- Clinical Research of the Ozarks, 601 W Nifong Blvd, Suite 2A, Columbia, MO 65203, USA.
| | - Hendrik Schmidt
- Global Biometrics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Straße 65, 88400 Biberach an der Riss, Germany.
| | - Michael Engel
- TA Respiratory Diseases, Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Straße 173, 55216 Ingelheim am Rhein, Germany.
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Mowbray 7700, Cape Town, South Africa.
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84
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Pera T, Penn RB. Bronchoprotection and bronchorelaxation in asthma: New targets, and new ways to target the old ones. Pharmacol Ther 2016; 164:82-96. [PMID: 27113408 PMCID: PMC4942340 DOI: 10.1016/j.pharmthera.2016.04.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/07/2016] [Indexed: 01/01/2023]
Abstract
Despite over 50years of inhaled beta-agonists and corticosteroids as the default management or rescue drugs for asthma, recent research suggests that new therapeutic options are likely to emerge. This belief stems from both an improved understanding of what causes and regulates airway smooth muscle (ASM) contraction, and the identification of new targets whose inhibition or activation can relax ASM. In this review we discuss the recent findings that provide new insight into ASM contractile regulation, a revolution in pharmacology that identifies new ways to "tune" G protein-coupled receptors to improve therapeutic efficacy, and the discovery of several novel targets/approaches capable of effecting bronchoprotection or bronchodilation.
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Affiliation(s)
- Tonio Pera
- Center for Translational Medicine and Jane and Leonard Korman Lung Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Raymond B Penn
- Center for Translational Medicine and Jane and Leonard Korman Lung Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States.
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85
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Blais CM, Davis BE, Cockcroft DW. Duration of bronchoprotection of the long-acting muscarinic antagonists tiotropium & glycopyrronium against methacholine-induced bronchoconstriction in mild asthmatics. Respir Med 2016; 118:96-101. [PMID: 27578477 DOI: 10.1016/j.rmed.2016.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED The duration of bronchoprotection against methacholine-induced bronchoconstriction by long-acting muscarinic antagonists (LAMA's) in asthmatics and whether these drugs differ in their pharmacodynamic properties remain to be determined. The most recent published guidelines for methacholine challenge testing (MCT) suggest that LAMA's should be abstained from for 48 h prior to testing, perhaps one week in the case of tiotropium. The objectives were to determine and compare the duration of protection of a single dose of two different LAMA's, tiotropium and glycopyrronium, against methacholine-induced bronchoconstriction. Thirteen mild-to-moderate asthmatics [with a forced expiratory volume in 1 s (FEV1) > 65% of predicted and a baseline methacholine provocation concentration causing a 20% reduction in FEV1 (PC20) ≤ 8 mg/mL] completed this double-blind, double-dummy, crossover study. Methacholine challenges were performed before treatment (5 μg tiotropium or 50 μg glycopyrronium) and at 1, 24, 48, 72, 96 and 168 h post-treatment. The minimum duration between treatment administration was 11 days. Both drugs provided significant bronchoprotection, each producing greater than a 16-fold increase in mean PC20 by 1 h. Tiotropium still provided statistically significant protection at 7 days (p = 0.0282) while glycopyrronium provided bronchoprotection until day 7 (p = 0.0590). Tiotropium provided statistically superior bronchoprotection at 24 and 72 h compared to glycopyrronium. To minimize the occurrence of false negatives, MCT guidelines should be updated to recommend a minimum one-week abstinence period from all LAMA's. MCT was also able to statistically differentiate between tiotropium and glycopyrronium with respect to the degree and duration of bronchoprotection provided by each. CLINICAL TRIAL REGISTRATION NUMBER NCT02622243.
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Affiliation(s)
- Christianne M Blais
- University of Saskatchewan, College of Medicine, Department of Physiology, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Beth E Davis
- University of Saskatchewan, College of Medicine, Department of Physiology, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada; University of Saskatchewan, Department of Medicine, Division of Respirology, Critical Care and Sleep Medicine, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada
| | - Donald W Cockcroft
- University of Saskatchewan, College of Medicine, Department of Physiology, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada; University of Saskatchewan, Department of Medicine, Division of Respirology, Critical Care and Sleep Medicine, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada.
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86
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Lin CH, Cheng SL. A review of omalizumab for the management of severe asthma. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:2369-78. [PMID: 27528798 PMCID: PMC4970638 DOI: 10.2147/dddt.s112208] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Despite the expansion of the understanding in asthma pathophysiology and the continual advances in disease management, a small subgroup of patients remain partially controlled or refractory to standard treatments. Upon the identification of immunoglobulin E and other inflammatory mediators, investigations and developments of targeted agents have thrived. Omalizumab is a humanized monoclonal antibody that specifically targets the circulating immunoglobulin E, which in turn impedes and reduces subsequent releases of the proinflammatory mediators. In the past decade, omalizumab has been proven to be efficacious and well-tolerated in the treatment of moderate-to-severe asthma in both trials and real-life studies, most notably in reducing exacerbation rates and corticosteroid use. While growing evidence has demonstrated that omalizumab may be potentially beneficial in treating other allergic diseases, its indication remains confined to treating severe allergic asthma and chronic idiopathic urticaria. Future efforts may be focused on determining the optimal length of omalizumab treatment, seeking biomarkers that could better predict treatment response, as well as extending its indications.
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Affiliation(s)
- Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan, Republic of China; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan, Republic of China; School of Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan, Republic of China; Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli City, Taoyuan County, Taiwan, Republic of China
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87
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Affirmation of the adoration of the vagi and role of tiotropium in asthmatic patients. J Allergy Clin Immunol 2016; 138:1011-1013. [PMID: 27527265 DOI: 10.1016/j.jaci.2016.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/01/2016] [Accepted: 06/16/2016] [Indexed: 11/20/2022]
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88
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Lee CH, Choi S, Jang EJ, Kim DW, Yoon HI, Kim YJ, Kim J, Yim JJ, Kim DK. The effects of inhaled respiratory drugs on the risk of stroke: A nested case-control study. Pulm Pharmacol Ther 2016; 40:7-14. [PMID: 27418383 DOI: 10.1016/j.pupt.2016.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/07/2016] [Accepted: 07/09/2016] [Indexed: 11/19/2022]
Abstract
Although there have been concerns that inhaled long-acting muscarinic antagonists increase the risk of stroke, controversies exist. We investigated whether respiratory drugs including long-acting muscarinic antagonists are associated with the risk of stroke. A nested case-control study using the nationwide insurance claims database of the Health Insurance Review and Assessment Service (Seoul, Republic of Korea) was conducted. Overall, 16,354 stroke cases and 74,451 matched (up to 1:5) controls were identified from 809,684 subjects without acute major cardiovascular events in the past year between January 1, 2010, and December 31, 2011. To determine whether the use of inhaled respiratory drugs is associated with the risk of stroke, conditional logistic regression analysis adjusted by comorbidities, cardiovascular drugs and healthcare utilization was performed. After adjusting for covariates, there were no statistically significant effects of the inhaled drugs on stroke incidence, except for inhaled corticosteroids without a long-acting β2-agonists, which was significantly associated with hemorrhagic stroke. Inhaled respiratory medications, including long-acting muscarinic antagonists, did not affect the risk of stroke in the inhaled respiratory drug users.
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Affiliation(s)
- Chang-Hoon Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seongmi Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Department of Statistics, Kyungpook National University College of Natural Sciences, Daegu, Republic of Korea
| | - Eun Jin Jang
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Department of Information Statistics, Colloge of Natural Science, Andong National University, Andong, Republic of Korea
| | - Dong-Wook Kim
- Department of Neurology, College of Medicine, Konkuk University, Seoul, Republic of Korea
| | - Ho Il Yoon
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea
| | - Yun Jung Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jimin Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jae-Joon Yim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Deog Kyeom Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.
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89
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Safety and tolerability of once-daily tiotropium Respimat(®) as add-on to at least inhaled corticosteroids in adult patients with symptomatic asthma: A pooled safety analysis. Respir Med 2016; 118:102-111. [PMID: 27578478 DOI: 10.1016/j.rmed.2016.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/10/2016] [Accepted: 07/01/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tiotropium, a long-acting anticholinergic bronchodilator, has demonstrated efficacy and safety as add-on therapy to inhaled corticosteroids (ICS), with or without other maintenance therapies, in patients with symptomatic asthma. OBJECTIVE To evaluate safety and tolerability of tiotropium delivered via the Respimat(®) device, compared with placebo, each as add-on to at least ICS therapy, in a pooled sample of adults with symptomatic asthma at different treatment steps. METHODS Data were pooled from seven Phase II and III, randomised, double-blind, parallel-group trials of 12-52 weeks' treatment duration, which investigated once-daily tiotropium Respimat(®) (5 μg, 2.5 μg) versus placebo as add-on to different background maintenance therapy including at least ICS. Adverse events (AEs) including serious AEs were assessed throughout treatment + 30 days after the last dose of trial medication. RESULTS Of 3474 patients analysed, 2157 received tiotropium. The percentage of patients with AEs was comparable between treatment groups: tiotropium 5 μg, 60.8%; placebo 5 μg pool, 62.5%; tiotropium 2.5 μg, 57.1%; placebo 2.5 μg pool, 55.1%. Consistent with the disease profile, the most frequent AEs overall were asthma, decreased peak expiratory flow rate (both less frequent with tiotropium) and nasopharyngitis. Overall incidence of dry mouth, commonly associated with use of anticholinergics, was low: tiotropium 5 μg, 1.0%; placebo 5 μg pool, 0.5%; tiotropium 2.5 μg, 0.4%; placebo 2.5 μg pool, 0.5%. The percentage of cardiac disorder AEs was comparable between tiotropium and placebo: tiotropium 5 μg, 1.4%; placebo 5 μg pool, 1.4%; tiotropium 2.5 μg, 1.4%; placebo 2.5 μg pool, 1.1%. The proportions of patients with serious AEs were balanced across groups: tiotropium 5 μg, 4.0%; placebo 5 μg pool, 4.9%; tiotropium 2.5 μg, 2.0%; placebo 2.5 μg pool, 3.3%. CONCLUSION Tiotropium Respimat(®) demonstrated safety and tolerability comparable with those of placebo, as add-on to at least ICS therapy, at different treatment steps in adults with symptomatic asthma.
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90
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Wenzel S, Castro M, Corren J, Maspero J, Wang L, Zhang B, Pirozzi G, Sutherland ER, Evans RR, Joish VN, Eckert L, Graham NMH, Stahl N, Yancopoulos GD, Louis-Tisserand M, Teper A. Dupilumab efficacy and safety in adults with uncontrolled persistent asthma despite use of medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist: a randomised double-blind placebo-controlled pivotal phase 2b dose-ranging trial. Lancet 2016; 388:31-44. [PMID: 27130691 DOI: 10.1016/s0140-6736(16)30307-5] [Citation(s) in RCA: 643] [Impact Index Per Article: 80.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dupilumab, a fully human anti-interleukin-4 receptor α monoclonal antibody, inhibits interleukin-4 and interleukin-13 signalling, key drivers of type-2-mediated inflammation. Adults with uncontrolled persistent asthma who are receiving medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist require additional treatment options as add-on therapy. We aimed to assess the efficacy and safety of dupilumab as add-on therapy in patients with uncontrolled persistent asthma on medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist, irrespective of baseline eosinophil count. METHODS We did this randomised, double-blind, placebo-controlled, parallel-group, pivotal phase 2b clinical trial at 174 study sites across 16 countries or regions. Adults (aged ≥18 years) with an asthma diagnosis for 12 months or more based on the Global Initiative for Asthma 2009 Guidelines receiving treatment with medium-to-high-dose inhaled corticosteroids plus a long-acting β2 agonist were eligible for participation. Patients were randomly assigned (1:1:1:1:1) to receive subcutaneous dupilumab 200 mg or 300 mg every 2 weeks or every 4 weeks, or placebo, over a 24-week period. The primary endpoint was change from baseline at week 12 in forced expiratory volume in 1 s (FEV1 in L) in patients with baseline blood eosinophil counts of at least 300 eosinophils per μL assessed in the intention-to-treat population. Safety outcomes were assessed in all patients that received at least one dose or part of a dose of study drug. This trial is registered at ClinicalTrials.gov, number NCT01854047, and with the EU Clinical Trials Register, EudraCT number 2013-000856-16. FINDINGS 769 patients (158 in the placebo group and 611 in the dupilumab groups) received at least one dose of study drug. In the subgroup with at least 300 eosinophils per μL, the greatest increases (200 mg every 2 weeks, p=0·0008; 300 mg every 2 weeks, p=0·0063) in FEV1 compared with placebo were observed at week 12 with doses every 2 weeks in the 300 mg group (mean change 0·39 L [SE 0·05]; mean difference 0·21 [95% CI 0·06-0·36; p=0·0063]) and in the 200 mg group (mean change 0·43 L [SE 0·05]; mean difference 0·26 [0·11-0·40; p=0·0008]) compared with placebo (0·18 L [SE 0·05]). Similar significant increases were observed in the overall population and in the fewer than 300 eosinophils per μL subgroup (overall population: 200 mg every 2 weeks, p<0·0001; 300 mg every 2 weeks, p<0·0001; <300 eosinophils per μL: 200 mg every 2 weeks, p=0·0034; 300 mg every 2 weeks, p=0·0086), and were maintained to week 24. Likewise, dupilumab every 2 weeks produced the greatest reductions in annualised rates of exacerbation in the overall population (70-70·5%), the subgroup with at least 300 eosinophils per μL (71·2-80·7%), and the subgroup with fewer than 300 eosinophils per μL (59·9-67·6%). The most common adverse events with dupilumab compared with placebo were upper respiratory tract infections (33-41% vs 35%) and injection-site reactions (13-26% vs 13%). INTERPRETATION Dupilumab increased lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count and had a favourable safety profile, and hence in addition to inhaled corticosteroids plus long-acting β2-agonist therapy could improve the lives of patients with uncontrolled persistent asthma compared with standard therapy alone. FUNDING Sanofi-Genzyme and Regeneron Pharmaceuticals.
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Affiliation(s)
- Sally Wenzel
- Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Mario Castro
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Jonathan Corren
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jorge Maspero
- Allergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | - Neil Stahl
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
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91
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Kim DK, Park YB, Oh YM, Jung KS, Yoo JH, Yoo KH, Kim KH. Korean Asthma Guideline 2014: Summary of Major Updates to the Korean Asthma Guideline 2014. Tuberc Respir Dis (Seoul) 2016; 79:111-20. [PMID: 27433170 PMCID: PMC4943894 DOI: 10.4046/trd.2016.79.3.111] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/20/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022] Open
Abstract
Asthma is a prevalent and serious health problem in Korea. Recently, the Korean Asthma Guideline has been updated by The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD) in an effort to improve the clinical management of asthma. This guideline focuses on adult patients with asthma and aims to deliver up to date scientific evidence and recommendations to general physicians for the management of asthma. For this purpose, this guideline was updated following systematic review and meta-analysis of recent studies and adapting some points of international guidelines (Global Initiative for Asthma [GINA] report 2014, National Asthma Education and Prevention Program [NAEPP] 2007, British Thoracic Society [BTS/SIGN] asthma guideline 2012, and Canadian asthma guideline 2012). Updated issues include recommendations derived using the population, intervention, comparison, and outcomes (PICO) model, which produced 20 clinical questions on the management of asthma. It also covers a new definition of asthma, the importance of confirming various airflow limitations with spirometry, the epidemiology and the diagnostic flow of asthma in Korea, the importance and evidence for inhaled corticosteroids (ICS) and ICS/formoterol as a single maintenance and acute therapy in the stepwise management of asthma, assessment of severity of asthma and management of exacerbation, and an action plan to cope with exacerbation. This guideline includes clinical assessments, and treatment of asthma–chronic obstructive pulmonary disease overlap syndrome, management of asthma in specific conditions including severe asthma, elderly asthma, cough variant asthma, exercise-induced bronchial contraction, etc. The revised Korean Asthma Guideline is expected to be a useful resource in the management of asthma.
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Affiliation(s)
- Deog Kyeom Kim
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Bum Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Yeon-Mok Oh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Suck Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Hong Yoo
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kwang-Ha Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kwan Hyung Kim
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
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92
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Kerstjens HAM, O'Byrne PM. Tiotropium for the treatment of asthma: a drug safety evaluation. Expert Opin Drug Saf 2016; 15:1115-24. [PMID: 27279414 DOI: 10.1080/14740338.2016.1199682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Tiotropium, a once-daily long-acting anticholinergic bronchodilator, has recently been approved for use in the treatment of asthma in a number of countries, including the EU and the USA, and was incorporated into the 2015 update of the Global Initiative for Asthma treatment guidelines. Here we review safety data from published clinical trials to help inform the use of tiotropium in the treatment of patients with asthma. AREAS COVERED Safety data from recently published clinical trials, which compared tiotropium with placebo or an active control, were reviewed. Trials included children, adolescents, and adults across severities of symptomatic asthma, and assessed tiotropium delivered via the Respimat and HandiHaler devices. EXPERT OPINION Based on the reviewed scientific evidence, tiotropium is a safe and well-tolerated long-acting anticholinergic bronchodilator for use in the treatment of asthma. In the trials assessed, the safety of tiotropium was found to be comparable with that of placebo and alternative therapeutic options, including a doubling in the dose of inhaled corticosteroids and the long-acting β2-agonist salmeterol.
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Affiliation(s)
- Huib A M Kerstjens
- a Department of Pulmonary Medicine and Tuberculosis and Groningen Research Institute for Asthma and COPD , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Paul M O'Byrne
- b Department of Medicine , Firestone Institute for Respiratory Health, McMaster University , Hamilton , ON , Canada
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93
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Abstract
Tiotropium solution for inhalation (Spiriva Respimat - Boehringer Ingelheim) is the first long-acting muscarinic antagonist to be marketed in the UK for the management of asthma. It is licensed as add-on maintenance bronchodilator treatment in adults with asthma who are using an inhaled corticosteroid (≥800μg budesonide/day or equivalent) and a long-acting beta2 agonist, and who have had one or more severe exacerbations in the previous year. This corresponds to use at step 4 of both the British asthma guideline and the Global Initiative for Asthma (GINA) strategy for the treatment of asthma in adults. Here we consider the evidence for tiotropium in the management of asthma and whether it offers any advantages over existing therapeutic options at step 4.
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94
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Liccardi G, Salzillo A, Calzetta L, Cazzola M, Matera MG, Rogliani P. Can bronchial asthma with an highly prevalent airway (and systemic) vagal tone be considered an independent asthma phenotype? Possible role of anticholinergics. Respir Med 2016; 117:150-3. [PMID: 27492525 DOI: 10.1016/j.rmed.2016.05.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/20/2016] [Accepted: 05/30/2016] [Indexed: 12/26/2022]
Abstract
Recently, we studied occurrence and role of non-respiratory symptoms (n-RSs) before a worsening of asthma symptoms. Some n-RSs such as anxiety, reflux, heartburn, abdominal pain, which appeared within 3 h before the onset of an asthma attack, are the likely result of an imbalance between sympathetic/parasympathetic systems with an increase in cholinergic tone. Therefore, it is likely that some of these n-RSs induced by the increased cholinergic tone might be present related with specific parasympathetic-associated respiratory symptoms such as those elicited by airway narrowing. It is likely that, at least in some categories of asthmatics, an increased cholinergic tone, rather than other well-known factors, might play a prevalent role in triggering bronchospasm. If this is the case, it is possible to speculate that the use of anticholinergic agents (mainly those with long-acting activity) in patients suffering from asthma should be more beneficial in individuals characterized by a higher degree of cholinergic tone that, consequently might be the ideal target for the use of long-acting anticholinergics and, possibly, represent a novel asthma phenotype. The presence of parasympathetic-associated n-RSs might help the physician to identify this type of patients, although this might be followed by a more detailed assessment.
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Affiliation(s)
- Gennaro Liccardi
- Department of Pulmonology, Haematology and Oncology, Division of Pneumology and Allergology, High Speciality "A.Cardarelli" Hospital, Naples, Italy; Postgraduate School of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Antonello Salzillo
- Department of Pulmonology, Haematology and Oncology, Division of Pneumology and Allergology, High Speciality "A.Cardarelli" Hospital, Naples, Italy
| | - Luigino Calzetta
- Postgraduate School of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mario Cazzola
- Postgraduate School of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Paola Rogliani
- Postgraduate School of Respiratory Medicine, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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95
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Abstract
Viral exacerbations continue to represent the major burden in terms of morbidity, mortality and health care costs associated with asthma. Those at greatest risk for acute asthma are those with more severe airways disease and poor asthma control. It is this group with established asthma in whom acute exacerbations triggered by virus infections remain a serious cause of increased morbidity. A range of novel therapies are emerging to treat asthma and in particular target this group with poor disease control, and in most cases their efficacy is now being judged by their ability to reduce the frequency of acute exacerbations. Critical for the development of new treatment approaches is an improved understanding of virus-host interaction in the context of the asthmatic airway. This requires research into the virology of the disease in physiological models in conjunction with detailed phenotypic characterisation of asthma patients to identify targets amenable to therapeutic intervention.
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Affiliation(s)
- Hock Tay
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia
| | - Peter A B Wark
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia.,c Centre of Excellence in Severe Asthma , The University of Newcastle , Australia.,d Department of Respiratory and Sleep Medicine , John Hunter Hospital , Newcastle , Australia
| | - Nathan W Bartlett
- a Hunter Medical Research Institute , Newcastle , Australia.,b Priority Research Centre for Healthy Lungs , The University of Newcastle , Australia.,e National Heart and Lung Institute , Imperial College London , London , UK
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96
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Donohue JF, Wise R, Busse WW, Garfinkel S, Zubek VB, Ghafouri M, Manuel RC, Schlenker-Herceg R, Bleecker ER. Efficacy and safety of ipratropium bromide/albuterol compared with albuterol in patients with moderate-to-severe asthma: a randomized controlled trial. BMC Pulm Med 2016; 16:65. [PMID: 27130202 PMCID: PMC4851785 DOI: 10.1186/s12890-016-0223-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 04/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many patients with asthma require frequent rescue medication for acute symptoms despite appropriate controller therapies. Thus, determining the most effective relief regimen is important in the management of more severe asthma. This study's objective was to evaluate whether ipratropium bromide/albuterol metered-dose inhaler (CVT-MDI) provides more effective acute relief of bronchospasm in moderate-to-severe asthma than albuterol hydrofluoroalkaline (ALB-HFA) alone after 4 weeks. METHODS In this double-blind, crossover study, patients who had been diagnosed with asthma for ≥1 year were randomized to two sequences of study medication "as needed" for symptom relief (1-7 day washout before second 4-week treatment period): CVT-MDI/ALB-HFA or ALB-HFA/CVT-MDI. On days 1 and 29 of each sequence, 6-hour serial spirometry was performed after administration of the study drug. Co-primary endpoints were FEV1 area under the curve (AUC0-6) and peak (post-dose) forced expiratory volume in 1 s (FEV1) response (change from test day baseline) after 4 weeks. The effects of "as needed" treatment with ALB-HFA/CVT-MDI were analyzed using mixed effect model repeated measures (MMRM). RESULTS A total of 226 patients, ≥18 years old, with inadequately controlled, moderate-to-severe asthma were randomized. The study met both co-primary endpoints demonstrating a statistically significant treatment benefit of CVT-MDI versus ALB-HFA. FEV1 AUC0-6h response was 167 ml for ALB-HFA, 252 ml for CVT-MDI (p <0.0001); peak FEV1 response was 357 ml for ALB-HFA, 434 ml for CVT-MDI (p <0.0001). Adverse events were comparable across groups. CONCLUSIONS CVT-MDI significantly improved acute bronchodilation over ALB-HFA alone after 4 weeks of "as-needed" use for symptom relief, with a similar safety profile. This suggests additive bronchodilator effects of β2-agonist and anticholinergic treatment in moderate-to-severe, symptomatic asthma. TRIAL REGISTRATION ClinicalTrials.gov No.: NCT00818454 ; Registered November 16, 2009.
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Affiliation(s)
- James F Donohue
- Division of Pulmonary Diseases & Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Robert Wise
- Pulmonary and Critical Care Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William W Busse
- Department of Medicine, University of Wisconsin, Wisconsin, WI, USA
| | | | | | - Mo Ghafouri
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA.,Previously of Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | | | - Eugene R Bleecker
- Wake Forest School of Medicine, Center for Genomics and Personalized Medicine, Winston-Salem, NC, 27157, USA.
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97
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Raherison C, Bourdin A, Bonniaud P, Deslée G, Garcia G, Leroyer C, Taillé C, De Blic J, Dubus JC, Tillié-Leblond I, Chanez P. Updated guidelines (2015) for management and monitoring of adult and adolescent asthmatic patients (from 12 years and older) of the Société de Pneumologie de Langue Française (SPLF) (Full length text). Rev Mal Respir 2016; 33:279-325. [PMID: 27147308 DOI: 10.1016/j.rmr.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Raherison
- Inserm U1219, ISPED, service des maladies respiratoires, pôle cardio-thoracique, CHU de Bordeaux, université de Bordeaux, 33000 Bordeaux, France.
| | - A Bourdin
- Inserm U1046, département de pneumologie et addictologie, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, université Montpellier 1, 34000 Montpellier, France
| | - P Bonniaud
- Inserm U866, service de pneumologie et soins intensifs respiratoires, CHU de Bourgogne, université de Bourgogne, 21079 Dijon, France
| | - G Deslée
- Service de pneumologie, CHU Maison-Blanche, université de Reims - Champagne-Ardennes, 51000 Reims, France
| | - G Garcia
- Inserm, UMRS 999, service de pneumologie, département hospitalo-universitaire (DHU) thorax innovation, hôpital de Bicêtre, Centre national de référence de l'hypertension pulmonaire sévère, faculté de médecine, université Paris-Sud, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - C Leroyer
- Département de médecine interne et de pneumologie, CHU de la Cavale-Blanche, université de Bretagne Occidentale, 29000 Brest, France
| | - C Taillé
- Service de pneumologie, département hospitalo-universitaire FIRE, centre de compétence des maladies pulmonaires rares, hôpital Bichat, université Paris-Diderot, AP-HP, 75018 Paris, France
| | - J De Blic
- Service de pneumologie et allergologie pédiatriques, hôpital Necker-Enfants-Malades, 75743 Paris, France
| | - J-C Dubus
- Unité de pneumologie et médecine infantile, hôpital Nord, 13000 Marseille, France
| | - I Tillié-Leblond
- Service de pneumo-allergologie, CHRU de Lille, 59000 Lille, France
| | - P Chanez
- UMR 7333 Inserm U 1067, service de pneumologie, hôpital Nord, université Aix Marseille, AP-HM, 13000 Marseille, France
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98
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Carvalho TC, McConville JT. The function and performance of aqueous aerosol devices for inhalation therapy. ACTA ACUST UNITED AC 2016; 68:556-78. [PMID: 27061412 DOI: 10.1111/jphp.12541] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In this review paper, we explore the interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations for several types of devices, namely jet, ultrasonic and vibrating-mesh nebulizers; colliding and extruded jets; electrohydrodynamic mechanism; surface acoustic wave microfluidic atomization; and capillary aerosol generation. KEY FINDINGS Nebulization is the transformation of bulk liquids into droplets. For inhalation therapy, nebulizers are widely used to aerosolize aqueous systems, such as solutions and suspensions. The interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations plays a significant role in the performance of aerosol generation appropriate for pulmonary delivery. Certain types of nebulizers have consistently presented temperature increase during the nebulization event. Therefore, careful consideration should be given when evaluating thermo-labile drugs, such as protein therapeutics. We also present the general approaches for characterization of nebulizer formulations. SUMMARY In conclusion, the interplay between the dosage form (i.e. aqueous systems) and the specific type of device for aerosol generation determines the effectiveness of drug delivery in nebulization therapies, thus requiring extensive understanding and characterization.
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Affiliation(s)
- Thiago C Carvalho
- Bristol-Myers Squibb, Drug Product Science & Technology, New Brunswick, NJ, USA
| | - Jason T McConville
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
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99
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Abstract
PURPOSE OF REVIEW Although the use of inhaled anticholinergics in obstructive airway disease has been established for several years, the clinical experience using these medications in treating patients with asthma is limited. Only few studies so far have included pediatric patients with asthma, but these studies demonstrate relevant therapeutic effects. This review will explore the pharmacological effects of inhaled anticholinergics, provide an overview about current adult and pediatric asthma studies using tiotropium, and describe future research needs. RECENT FINDINGS In a phase II study with tiotropium as add-on to maintenance treatment to inhaled corticosteroids (ICSs) in moderate persistent adolescent with asthma, significant improvement of peak and trough forced expiratory volume in 1 s (FEV1) with a good safety profile could be demonstrated. A pediatric phase II study in symptomatic patients with asthma aged 6-11with comparable study design also demonstrated significant improvement of peak FEV1 with no serious adverse events. However, both studies could not document a significant clinical improvement analyzed by standardized scores. SUMMARY Tiotropium might become an add-on treatment option in symptomatic pediatric and adolescent patients with asthma despite adequate therapy with ICS and long-acting β2-agonist (LABA) or as an alternative to LABA in patients with safety concerns related to LABA. For a better assessment of the clinical effect, long-term studies are needed.
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100
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Hamelmann E, Bateman ED, Vogelberg C, Szefler SJ, Vandewalker M, Moroni-Zentgraf P, Avis M, Unseld A, Engel M, Boner AL. Tiotropium add-on therapy in adolescents with moderate asthma: A 1-year randomized controlled trial. J Allergy Clin Immunol 2016; 138:441-450.e8. [PMID: 26960245 DOI: 10.1016/j.jaci.2016.01.011] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/21/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Results from phase III clinical trials in adults and phase II clinical trials in children and adolescents demonstrate that tiotropium is an effective treatment when added to inhaled corticosteroid (ICS) maintenance therapy. OBJECTIVE We sought to assess the efficacy and safety of once-daily tiotropium Respimat added to ICSs with or without a leukotriene receptor antagonist in a phase III trial in adolescent patients with moderate symptomatic asthma. METHODS In this 48-week, double-blind, placebo-controlled, parallel-group study, 398 patients aged 12 to 17 years were randomized to receive 5 μg (2 puffs of 2.5 μg) or 2.5 μg (2 puffs of 1.25 μg) of once-daily tiotropium or placebo (2 puffs) administered through the Respimat device every evening, each as add-on treatment to ICS background therapy, with or without a leukotriene receptor antagonist; long-acting β2-agonist therapy was not permitted during the study. RESULTS Improvement in peak FEV1 within 3 hours after dosing at 24 weeks (primary end point) was statistically significant with both tiotropium doses compared with placebo: 5 μg of tiotropium, 174 mL (95% CI, 76-272 mL); 2.5 μg of tiotropium, 134 mL (95% CI, 34-234 mL). Significant improvements in trough FEV1 at week 24 (a secondary end point) were observed with the 5-μg dose only. Trends for improvement in asthma control and health-related quality of life over the 48-week treatment period were observed. CONCLUSIONS Once-daily tiotropium significantly improved lung function and was safe and well tolerated when added to at least ICS maintenance therapy in adolescent patients with moderate symptomatic asthma. Larger responses were observed with the 5-μg tiotropium dose.
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Affiliation(s)
- Eckard Hamelmann
- Klinik für Kinder- und Jugendmedizin, Kinderzentrum Bethel, Evangelisches Krankenhaus Bielefeld GmbH, Akademisches Lehrkrankenhaus der Universität Münster, Bielefeld, Germany.
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christian Vogelberg
- University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Stanley J Szefler
- Department of Pediatrics, The Breathing Institute, Children's Hospital Colorado, Aurora, Colo
| | | | - Petra Moroni-Zentgraf
- TA Respiratory Diseases, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Mandy Avis
- Boehringer Ingelheim bv, Alkmaar, The Netherlands
| | - Anna Unseld
- Global Biometrics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Michael Engel
- TA Respiratory Diseases, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Attilio L Boner
- U.O. di Pediatria, S.S.O. Dipartimento Sperimentale di Pediatria, Policlinico "G. Rossi," Verona, Italy
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