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The efficacy of tiotropium as a steroid-sparing agent in severe asthma. Can Respir J 2010; 16:99-101. [PMID: 19557217 DOI: 10.1155/2009/206506] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
People with severe asthma account for 5% to 10% of all asthmatic patients; however, this small group uses the majority of health care resources. Novel methods are needed to cope with the burden that this minority of patients places on the health care system. A severe asthma clinic patient, who was monitored through the University of Alberta's Virtual Asthma Clinic (Edmonton, Alberta) is presented. Despite optimization of his disease and individualized asthma education (provided by a certified asthma educator), the patient remained on oral glucocorticosteroids (OGS) to control his disease. Following optimization and stabilization, a further reduction in the dose of his OGS by the addition of the long-acting anticholinergic agent tiotropium bromide, was demonstrated. The role of tiotropium as a potential 'steroid-sparing agent' in severe refractory asthma is discussed, noting that if patients who are on OGS are not monitored for active inflammation, they may overuse the amount of prescribed systemic steroids, which can result in long-term steroid-related sequelae.
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Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, Robson R, Thabane M, Giangregorio L, Goldsmith CH. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol 2010; 10:1. [PMID: 20053272 PMCID: PMC2824145 DOI: 10.1186/1471-2288-10-1] [Citation(s) in RCA: 1637] [Impact Index Per Article: 116.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Accepted: 01/06/2010] [Indexed: 02/06/2023] Open
Abstract
Pilot studies for phase III trials - which are comparative randomized trials designed to provide preliminary evidence on the clinical efficacy of a drug or intervention - are routinely performed in many clinical areas. Also commonly know as "feasibility" or "vanguard" studies, they are designed to assess the safety of treatment or interventions; to assess recruitment potential; to assess the feasibility of international collaboration or coordination for multicentre trials; to increase clinical experience with the study medication or intervention for the phase III trials. They are the best way to assess feasibility of a large, expensive full-scale study, and in fact are an almost essential pre-requisite. Conducting a pilot prior to the main study can enhance the likelihood of success of the main study and potentially help to avoid doomed main studies. The objective of this paper is to provide a detailed examination of the key aspects of pilot studies for phase III trials including: 1) the general reasons for conducting a pilot study; 2) the relationships between pilot studies, proof-of-concept studies, and adaptive designs; 3) the challenges of and misconceptions about pilot studies; 4) the criteria for evaluating the success of a pilot study; 5) frequently asked questions about pilot studies; 7) some ethical aspects related to pilot studies; and 8) some suggestions on how to report the results of pilot investigations using the CONSORT format.
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Affiliation(s)
- Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
| | - Jinhui Ma
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
| | - Rong Chu
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
| | - Ji Cheng
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
| | - Afisi Ismaila
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Department of Medical Affairs, GlaxoSmithKline Inc., Mississauga ON, Canada
| | - Lorena P Rios
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
| | - Reid Robson
- Department of Medical Affairs, GlaxoSmithKline Inc., Mississauga ON, Canada
| | - Marroon Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton ON, Canada
| | - Lora Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo ON, Canada
| | - Charles H Goldsmith
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton ON, Canada
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Abstract
Severe asthma presents significant management challenges. Patients can be difficult to control despite use of current standard-of-care therapy, including inhaled corticosteroids and long-acting beta-agonists. Alternative diagnoses, noncompliance, and comorbidities all can influence asthma control, future risk, and response to currently available therapy. Definitions of severe asthma evaluate and address these confounding variables, and yet patients are still symptomatic despite aggressive, appropriate therapy. Severe asthma has a distinct pathophysiology including airway remodeling that contributes to the decreased effectiveness of standard therapy. Multiple phenotypes exist within severe asthma that likely require distinct therapeutic approaches to achieve control and improve long-term health outcomes. New therapeutic approaches to these distinct phenotypes will improve our understanding and treatment of this difficult-to-manage disease.
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Affiliation(s)
- Luke Carlstrom
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO 63110-1093, USA
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Heredia JL. Tiotropium bromide: an update. Open Respir Med J 2009; 3:43-52. [PMID: 19461900 PMCID: PMC2684714 DOI: 10.2174/1874306400903010043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 02/13/2009] [Accepted: 02/17/2009] [Indexed: 11/22/2022] Open
Abstract
Tiotropium bromide is a once-daily inhaled anticholinergic bronchodilator. It works by blocking the muscarinic receptors in airway smooth muscle. Tiotropium has a wide therapeutic margin, due to its poor gastrointestinal absorption and its very low systemic bioavailability. The drug is mainly indicated in COPD patients. Clinically relevant outcomes such as significant improvements in spirometry, hyperinflation, dyspnea, heath status, acute exacerbations and mortality have been consistently observed in tiotropium clinical trials, and the drug has been shown to reduce the risk of mortality due to cardiac-vascular disease and respiratory failure. The main side effect reported is dryness of the mouth. Some subgroups of asthmatics also seem to respond to anticholinergic drugs: among them, those with the Arg/Arg genotype for the beta2-adrenergic receptor and those with a high percentage of neutrophils in sputum.
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Affiliation(s)
- Josep Lluis Heredia
- S. Pneumologia, Hospital Mutua de Terrassa, c/ Dr. Robert 5, 08221 Terrassa, Barcelona, Spain
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Current Opinion in Pulmonary Medicine. Current world literature. Curr Opin Pulm Med 2009; 15:79-87. [PMID: 19077710 DOI: 10.1097/mcp.0b013e32831fb1f3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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56
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Bibliography. Current world literature. Model systems. Curr Opin Allergy Clin Immunol 2008; 8:276-85. [PMID: 18560306 DOI: 10.1097/aci.0b013e328303e104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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57
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Baiardini I, Braido F, Brandi S, Tarantini F, Bonini S, Bousquet PJ, Zuberbier T, Demoly P, Canonica GW. The impact of GINA suggested drugs for the treatment of asthma on Health-Related Quality of Life: a GA(2)LEN review. Allergy 2008; 63:1015-30. [PMID: 18691305 DOI: 10.1111/j.1398-9995.2008.01823.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Asthma represents a serious global health problem. People of all ages in countries throughout the world are affected by this chronic airway disorder that, when uncontrolled, can place severe limits on daily life and can even be fatal. Asthma cannot be removed, but asthmatic symptoms can be cured; as for many other chronic diseases, pharmacotherapy is important to reduce the risk of asthma-related mortality, decrease disability and improve symptoms and quality of life. The action of antiasthmatic drugs directly contributes to decrease symptoms severity, improve spirometric results, reduce airway hyperresponsiveness and prevent irreversible airway remodelling. Antiasthmatic therapy is necessary for long-term control of asthma symptoms. Asthma and antiasthmatic drugs can influence patient's quality of life: this is why healthcare systems have recently focused on research studies about Health-Related Quality of Life (HRQL) in asthmatic patients. Numerous validated questionnaires are available and many studies have been performed evaluating HRQL in people affected by asthma, thus testifying a great interest in this topic. The aims of the present review are to examine the scientific literature of the last 4 years (January 2004-December 2007) dealing with the impact of asthma treatments suggested by Global Initiative for Asthma guidelines on patients' quality of life, and to identify the unexplored or not fully investigated areas concerning this issue.
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Affiliation(s)
- I Baiardini
- Allergy & Respiratory Diseases, DIMI - University of Genoa, Genoa, Italy
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