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Gupta N, Malhotra N, Kunal S, Ish P. Management of bronchial asthma in 2021. Monaldi Arch Chest Dis 2022; 92. [DOI: 10.4081/monaldi.2022.2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/30/2022] [Indexed: 11/23/2022] Open
Abstract
To The Editor,
The Global Initiative for Asthma (GINA) 2021 update was published on the 28th of April, 2021. There are significant changes, including treatment of mild asthma, the role of azithromycin, treatment of asthma in COVID-19 times, and role of biologics...
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Guidelines for the management of asthma in adults and adolescents: Position statement of the South African Thoracic Society - 2021 update. Afr J Thorac Crit Care Med 2022; 27. [PMID: 35118373 PMCID: PMC8802209 DOI: 10.7196/ajtccm.2021.v27i4.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma prevalence is increasing worldwide, and surveys indicate that most patients in developed and developing countries, including
South Africa, do not receive optimal care and are therefore not well controlled. Standard management guidelines adapted to in-country
realities are important to support optimal care. The South African Thoracic Society (SATS) first published a guideline for the management
of chronic persistent asthma in 1992, which has subsequently been revised several times.
The main aim of the present document was to revise and update SATS’ statement on the suggested management of chronic asthma, based
on the need to promote optimal care and control of asthma, together with the incorporation of new concepts and drug developments. This
revised document reinforces optimal care and incorporates the following primary objectives to achieve the recent advances in asthma care:
continued emphasis on the use of inhaled corticosteroids (ICS) as the foundation of asthma treatment to reduce the reliance on short-acting beta-2 agonist (SABA) monotherapy for asthma symptoms to incorporate the evidence and strategy for the use of the combination of an ICS and formoterol for acute symptom relief (instead of
a SABA) to incorporate the evidence and strategy for the use of as-needed ICS-long-acting beta agonists (LABA) for patients with infrequent
symptoms or ‘mild’ asthma to incorporate the evidence and strategy for the use of a long-acting muscarinic antagonist (LAMA) in combination with ICS-LABA; and to incorporate the evidence and strategy for the use of and management with a biologic therapy in severe asthma.
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Kim SH, Lee H, Park SY, Park SY, Song WJ, Kim JH, Park HW, Cho YS, Yoon HJ. The Korean Severe Asthma Registry (KoSAR): real world research in severe asthma. Korean J Intern Med 2022; 37:249-260. [PMID: 35184515 PMCID: PMC8925953 DOI: 10.3904/kjim.2021.403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022] Open
Abstract
Severe asthma constitutes a serious health burden with significant morbidity and socioeconomic costs. The development and introduction of new biologics targeting type 2 inflammation changed the paradigm for management of severe asthma and initiated a biological era. These changes impose a challenge to clinicians in managing difficult-to-treat and severe asthma. To understand the characteristics and heterogeneity of severe asthma and to develop a better strategy to manage it, the Korean Academy of Asthma, Allergy and Clinical Immunology, Working Group on Severe Asthma, has organized the Korean Severe Asthma Registry (KoSAR). In this review, we describe the challenges of severe asthma management regarding diagnosis, disease burden, heterogeneity, guidelines, and organization of severe asthma clinics. This review also examines the current global activities of national and regional registries and study groups. In addition, we present the KoSAR vision and organization and describe the findings of KoSAR in comparison with those of other countries.
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Affiliation(s)
- Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - So-Young Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - So Young Park
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Heung-Woo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
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Plaza V, Alobid I, Alvarez C, Blanco M, Ferreira J, García G, Gómez-Outes A, Gómez F, Hidalgo A, Korta J, Molina J, Pellegrini FJ, Pérez M, Plaza J, Praena M, Quirce S, Sanz J. [Translated article] Spanish Asthma Management Guidelines (GEMA) v.5.1. Highlights and Controversies. Arch Bronconeumol 2022; 58:T150-T158. [PMID: 35971814 DOI: 10.1016/j.arbres.2021.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control; INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed; MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids; SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma; OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis.
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Affiliation(s)
- Vicente Plaza
- Comité Ejecutivo GEMA, Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Isam Alobid
- Sociedad Española de Otorrinolaringología (SEORL), Hospital Clinic, Universidad de Barcelona, Barcelona, Spain
| | - Cesáreo Alvarez
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Hospital de Verín, Orense, Spain
| | - Marina Blanco
- Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Jorge Ferreira
- Sociedad Portuguesa de Pneumologia (SPP), Hospital de São Sebastião • CHEDV, Santa Maria da Feira, Portugal
| | - Gabriel García
- Asociación Latinoamericana del Tórax (ALAT), Hospital Rossi La Plata, Buenos Aires, Argentina
| | - Antonio Gómez-Outes
- Sociedad Española de Farmacología Clínica (SEFC), Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Spain
| | - Fernando Gómez
- Sociedad Española de Médicos Generales y de Familia (SEMG), Centro de Salud de Bargas, Toledo, Spain
| | - Antonio Hidalgo
- Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Centro de Salud Lucena I. Lucena, Córdoba, Spain
| | - Javier Korta
- Sociedad Española de Neumología Pediátrica (SENP), Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Jesús Molina
- Sociedad Española de Medicina Familiar y Comunitaria (semFYC) y Sociedad de Respiratorio de Atención Primaria (GRAP), Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, Spain
| | - Francisco Javier Pellegrini
- Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Centro de Salud de Pizarrales, Salamanca, Spain
| | - Montserrat Pérez
- Sociedad Española de Farmacia Hospitalaria (SEFH), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Javier Plaza
- Sociedad Española de Farmacia Clínica, Familiar y Comunitaria (SEFAC), Farmacia Dres. Zamora Navarro, Mazarrón, Murcia, Spain
| | - Manuel Praena
- Asociación Española de Pediatría de Atención Primaria (AEPap), Centro de Salud La Candelaria, Sevilla, Spain
| | - Santiago Quirce
- Sociedad Española de Alergia e Inmunología Clínica (SEAIC), Hospital Universitario La Paz, Madrid, Spain
| | - José Sanz
- Sociedad Española de Inmunología Clínica•Alergología y Asma Pediátrica (SEICAP), Hospital Católico Universitario Casa de Salud, Valencia, Spain
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma Strategy 2021. Executive Summary and Rationale for Key Changes. Arch Bronconeumol 2022; 58:35-51. [DOI: 10.1016/j.arbres.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022]
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Al-Moamary M, Al-Lehebi R, Idrees M, Zeitouni M. When single-inhaler triple therapy is a preferred option in asthma management? Ann Thorac Med 2022; 17:185-188. [DOI: 10.4103/atm.atm_341_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/28/2022] [Indexed: 11/04/2022] Open
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Pelaia C, Crimi C, Crimi N, Ricciardi L, Scichilone N, Valenti G, Bonavita O, Andaloro S, Morini P, Rizzi A, Pelaia G. Indacaterol/glycopyrronium/mometasone fixed dose combination for uncontrolled asthma. Expert Rev Respir Med 2021; 16:183-195. [PMID: 34845963 DOI: 10.1080/17476348.2021.2011222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Asthma symptoms can be relieved through a maintenance treatment combining long-acting β2-agonist and inhaled corticosteroids (LABA/ICS). However, for patients with inadequately controlled asthma, the LABA/ICS combination might not be sufficient, and clinical guidelines recommend the administration of inhaled long-acting muscarinic antagonists (LAMA) as an add-on therapy to better control asthma and improve lung function. For nearly two decades, the only LAMA to be approved on the market has been tiotropium. AREAS COVERED We reviewed recent clinical studies evaluating the safety and efficacy of LABA/LAMA/ICS fixed dose combinations by searching the PubMed database. Molecular mechanisms and clinical data support the use of a once-daily, single-inhaler fixed dose combination of the LABA/LAMA/ICS indacaterol/glycopyrronium/mometasone (IND/GLY/MF), the first therapy combining three agents in a fixed dose approved in Europe for the treatment of uncontrolled asthma. EXPERT OPINION IND/GLY/MF was superior to both IND/MF and salmeterol/fluticasone, a well-established LABA/ICS combination improving the lung function in uncontrolled asthma. Moreover, IND/GLY/MF, delivered through the Breezhaler inhaler in a single inhalation, is the first inhaled therapy prescribed alongside a digital companion, a sensor and the Propeller app, allowing for improved treatment adherence, reduced rescue inhaler usage and hospitalizations, increased patient satisfaction and asthma control.
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Affiliation(s)
- Corrado Pelaia
- Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Claudia Crimi
- Respiratory Disease Unit, University Hospital of Catania, Catania, Italy
| | - Nunzio Crimi
- Respiratory Disease Unit, University Hospital of Catania, Catania, Italy
| | - Luisa Ricciardi
- Allergy and Clinical Immunology Unit, A.O.U. Policlinico "G. Martino", Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Nicola Scichilone
- Medicine of the Respiratory System, Hospital 'P. Giaccone', University of Palermo, Palermo, Italy
| | - Giuseppe Valenti
- Allergology and Pulmonology Unit, Pta Biondo, ASP Palermo, Italy
| | | | | | - Paolo Morini
- Medical Department, Novartis Farma Origgio, Varese, Italy
| | - Andrea Rizzi
- Medical Department, Novartis Farma Origgio, Varese, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
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58
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Braido F, Tiotiu A, Guidos-Fogelbach G, Baiardini I, Cosini F, Correia de Sousa J, Bikov A, Novakova S, Labor M, Kaidashev I, Nedeva D, Kowal K, Mihaicuta S, Urrutia Pereira M, Solé D, Novakova P, Chong-Neto H, Vrzy L, Ansotegui IJ, Bernstein JA, Boulet LP, Canonica GW, Dubuske L, Nunes C, Ivancevich JC, Santus P, Rosario N, Emelyanov A, Steiropoulos P. Manifesto on inhaled triple therapy in asthma: an Interasma (Global Asthma Association - GAA) document. J Asthma 2021; 59:2402-2412. [PMID: 34936532 DOI: 10.1080/02770903.2021.2022160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The optimal use of drug combinations for the management of asthma is providing significant results. This has prompted INTERASMA (Global Asthma Association) to take a position on inhaled triple therapy in asthma. Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto, developed by Interasma scientific network (INES) members. The manifesto describes the evidence gathered to date and states, advocates, and proposes issues on Inhaled corticosteroid (ICS) plus Long-acting beta 2 agonist (LABA) and long-acting muscarinic antagonists (LAMA) with the aim of challenging assumptions, fostering commitment, and bringing about change.
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Affiliation(s)
- Fulvio Braido
- IRCCS, Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France.,EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control, University of Lorraine, Nancy, France
| | - Guillermo Guidos-Fogelbach
- Instituto Politécnico Nacional, E.N.M.H/S.E.P.I, Laboratorio de Bioquímica Estructural, Ciudad de México, México
| | - Ilaria Baiardini
- Department of Internal Medicine, University of Genoa, Genova, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Andras Bikov
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Sylvia Novakova
- Allergy Unit of Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
| | | | - Igor Kaidashev
- Ukrainian Medical Stomatological Academy, Poltava, Ukraine
| | | | - Krzysztof Kowal
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Stefan Mihaicuta
- Pulmonology Department, Cardio Prevent Foundation, University of Medicine and Pharmacy "Dr Victor Babes", Timisoara, Romania
| | - Marilyn Urrutia Pereira
- Federal University of Pampa - campus Uruguaiana, Pediatic Program of Asthma Prevention (PIPA), Pontifícia Universidade Católica do Rio Grande do Sul, Universidad Nacional de Córdoba
| | - Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, Sociedade Brasileira de Pediatria, Universidade Federal de São Paulo
| | | | - Herberto Chong-Neto
- Division of Allergy and Immunology, Department of Pediatrics, Federal University of Paraná, Curitiba, Brazil
| | | | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section University of Cincinnati, Cincinnati, OH, USA
| | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Lawrence Dubuske
- Division of Allergy and Immunology, Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Carlos Nunes
- Centro de ImmunoAlergologia de Algarve, Porto, Portugal
| | - Juan Carlos Ivancevich
- Immunology Department, Faculty of Medicine, del Salvador University, Buenos Aires, Argentina
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences, University of Milan, Division of Respiratory Diseases "L. Sacco" Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University named after I.I.Mechnikov, St-Petersburg, Russia
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, University General Hospital Dragana, Alexandroupolis, Greece
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Kong-Cardoso B, Ribeiro A, Aguiar R, Pité H, Morais-Almeida M. Understanding and Managing Severe Asthma in the Context of COVID-19. Immunotargets Ther 2021; 10:419-430. [PMID: 34926333 PMCID: PMC8675091 DOI: 10.2147/itt.s342636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/25/2021] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) continues to spread across the world. Since the beginning of the pandemic, the question of whether asthma is a risk factor for getting the infection or for poor outcomes motivated a great debate. In the field of severe asthma and its treatment during COVID-19 pandemic, several issues are also pending. A literature review focused on the management of severe asthma patients in the context of COVID-19 is performed. The available evidence suggests that severe asthma patients do not have an increased risk of poor COVID-19 outcomes and that it is safe to treat asthmatic patients with inhaled corticosteroids (ICS) and biologics during the pandemic, even though some studies indicate that high doses of ICS may predispose to COVID-19. The chronic use of oral corticosteroid (OCS) might be associated with poor COVID-19 outcomes, although there is no complete agreement. There is very limited evidence concerning the use of triple therapy for asthma in the context of this pandemic. Ultimately, severe asthma patients should maintain their medication during the COVID-19 pandemic, including biologic agents. More studies are needed to address the role of asthma medications and asthma’s different phenotypes on the incidence and course of COVID-19.
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Affiliation(s)
- Bárbara Kong-Cardoso
- Allergy Center, CUF Descobertas Hospital and CUF Tejo Hospital, Lisbon, Portugal
| | - Amélia Ribeiro
- Pneumology Department, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
| | - Rita Aguiar
- Allergy Center, CUF Descobertas Hospital and CUF Tejo Hospital, Lisbon, Portugal
| | - Helena Pité
- Allergy Center, CUF Descobertas Hospital and CUF Tejo Hospital, Lisbon, Portugal
| | - Mário Morais-Almeida
- Allergy Center, CUF Descobertas Hospital and CUF Tejo Hospital, Lisbon, Portugal
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60
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de Carvalho-Pinto RM, Cançado JED, Pizzichini MMM, Fiterman J, Rubin AS, Cerci A, Cruz ÁA, Fernandes ALG, Araujo AMS, Blanco DC, Cordeiro G, Caetano LSB, Rabahi MF, de Menezes MB, de Oliveira MA, Lima MA, Pitrez PM. 2021 Brazilian Thoracic Association recommendations for the management of severe asthma. J Bras Pneumol 2021; 47:e20210273. [PMID: 34932721 PMCID: PMC8836628 DOI: 10.36416/1806-3756/e20210273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/20/2022] Open
Abstract
Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.
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Affiliation(s)
- Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração − InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Jussara Fiterman
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS) Brasil
| | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre − UFCSPA − Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci
- . Universidade Estadual de Londrina − UEL − Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná − PUCPR − Londrina (PR) Brasil
| | - Álvaro Augusto Cruz
- . Universidade Federal da Bahia − UFBA − Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Ana Maria Silva Araujo
- . Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro − IDT/UFRJ − Rio de Janeiro (RJ) Brasil
| | - Daniela Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS), Brasil
| | - Gediel Cordeiro
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
- . Hospital Madre Teresa, Belo Horizonte (MG) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás − UFG − Goiânia (GO) Brasil
| | - Marcelo Bezerra de Menezes
- . Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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de Llano LP, Naval E, Mejía N, Domínguez-Ortega J. Inhaled indacaterol/glycopyrronium/mometasone furoate fixed-dose combination in moderate-to-severe asthma. Expert Rev Respir Med 2021; 16:1-15. [PMID: 34783265 DOI: 10.1080/17476348.2021.2005585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fixed-dose long-acting beta2-agonist (LABA)/inhaled corticosteroid (ICS) combinations and add-on therapies as needed are the mainstay for maintenance therapy in asthma. However, more than 40% of patients have an inadequately controlled disease. The development of triple fixed-dose combinations consisting of long-acting muscarinic antagonist (LAMA)/LABA/ICS has paved the way for a new approach to reach therapeutic goals of an optimal control of symptoms and an effective prevention of future exacerbations. AREAS COVERED A search was conducted on PubMed (MEDLINE), using the MeSH terms [asthma] + [indacaterol] + [glycopyrronium] +[mometasone furoate] + [treatment], until October 2021. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Clinical studies with IND/MF/GLY (Enerzair Breezhaler) are summarized, and its place in current asthma therapy is examined. EXPERT OPINION Triple therapy has been shown to be an effective and safe therapeutic option for asthma patients who remain uncontrolled despite ICS/LABA combination. The recently approved single-inhaler indacaterol/glycopyrronium/mometasone fixed dose combination has demonstrated to significantly reduce exacerbations, improve FEV1, symptoms and quality of life compared to ICS/LABA, including, salmeterol/fluticasone combination. Moreover, once-daily dosing may improve adherence.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte, Lugo, Spain
| | - Elsa Naval
- Pneumology Service, Hospital Universitario de la Ribera, Alzira, Valencia, Spain
| | - Natalia Mejía
- Medical Affairs Department. Novartis Farmacéutica, Barcelona, Spain
| | - Javier Domínguez-Ortega
- Allergy Department, Hospital La Paz Institute for Health Research, Madrid, Spain.,Respiratory Disease Network Biomedical Research Centre (CIBERES), Madrid, Spain
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Agache I, Eguiluz‐Gracia I, Cojanu C, Laculiceanu A, Giacco S, Zemelka‐Wiacek M, Kosowska A, Akdis CA, Jutel M. Advances and highlights in asthma in 2021. Allergy 2021; 76:3390-3407. [PMID: 34392546 DOI: 10.1111/all.15054] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/09/2021] [Indexed: 12/12/2022]
Abstract
Last year brought a significant advance in asthma management, unyielding to the pressure of the pandemics. Novel key findings in asthma pathogenesis focus on the resident cell compartment, epigenetics and the innate immune system. The precision immunology unbiased approach was supplemented with novel tools and greatly facilitated by the use of artificial intelligence. Several randomised clinical trials and good quality real-world evidence shed new light on asthma treatment and supported the revision of several asthma guidelines (GINA, Expert Panel Report 3, ERS/ATS guidelines on severe asthma) and the conception of new ones (EAACI Guidelines for the use of biologicals in severe asthma). Integrating asthma management within the broader context of Planetary Health has been put forward. In this review, recently published articles and clinical trials are summarised and discussed with the goal to provide clinicians and researchers with a concise update on asthma research from a translational perspective.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Ibon Eguiluz‐Gracia
- Allergy Unit IBIMA‐Regional University Hospital of MalagaUMA, RETICS ARADyALBIONAND Malaga Spain
| | | | | | - Stefano Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | | | - Anna Kosowska
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐MED Medical Research Institute Wroclaw Poland
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐MED Medical Research Institute Wroclaw Poland
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Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S1-S18. [PMID: 34718211 DOI: 10.1016/j.jaip.2021.10.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Eur Respir J 2021; 59:13993003.02730-2021. [PMID: 34667060 PMCID: PMC8719459 DOI: 10.1183/13993003.02730-2021] [Citation(s) in RCA: 232] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes.GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA.Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4.Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia.
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Respirology 2021; 27:14-35. [PMID: 34668278 DOI: 10.1111/resp.14174] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive Summary and Rationale for Key Changes. Am J Respir Crit Care Med 2021; 205:17-35. [PMID: 34658302 PMCID: PMC8865583 DOI: 10.1164/rccm.202109-2205pp] [Citation(s) in RCA: 163] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults/adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The University of Sydney, 4334, Woolcock Institute of Medical Research,, Sydney, New South Wales, Australia;
| | - Leonard B Bacharier
- Vanderbilt University Medical Center, 12328, Monroe Carell Jr Children's Hospital , Nashville, Tennessee, United States
| | - Eric D Bateman
- University of Cape Town Department of Medicine, 71984, Observatory, Western Cape, South Africa
| | - Christopher E Brightling
- NIHR Leicester Biomedical Research Centre, 573772, Leicester, United Kingdom of Great Britain and Northern Ireland
| | - Guy G Brusselle
- University Hospital Ghent, 60200, Ghent, Belgium and Erasmus MC University Medical Center, Rotterdam, Belgium
| | - Roland Buhl
- Mainz University Hospital, Pulmonary Department, Mainz, Germany
| | - Alvaro A Cruz
- Universidade Federal da Bahia, 28111, ProAR-Center of Excellence in Asthma, Salvador, Brazil
| | - Liesbeth Duijts
- Erasmus MC, 6993, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - J Mark FitzGerald
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Louise J Fleming
- Imperial College London, 4615, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Fanny W Ko
- The Chinese University of Hong Kong, 26451, Hong Kong, Hong Kong
| | - Jerry A Krishnan
- University of Illinois at Chicago, 14681, Breathe Chicago Center, Chicago, Illinois, United States
| | - Mark L Levy
- Locum GP, London, United Kingdom of Great Britain and Northern Ireland
| | - Jiangtao Lin
- Peking University, 12465, China-Japan Friendship Hospital, Beijing, China
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, 9655, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Paulo M Pitrez
- Hospital Moinhos de Vento, 156417, Porto Alegre, Rio Grande do Sul, Brazil
| | - Aziz Sheikh
- The University of Edinburgh, 3124, Usher Institute, Edinburgh, United Kingdom of Great Britain and Northern Ireland
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Treatment Patterns and Disease Burden Associated with Multiple-Inhaler Triple-Therapy Use in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:485-494.e5. [PMID: 34626859 DOI: 10.1016/j.jaip.2021.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Addition of a long-acting muscarinic antagonist is recommended for patients with asthma uncontrolled on inhaled corticosteroid/long-acting β2-agonist therapy. This is the first large-scale, real-world study examining multiple-inhaler triple-therapy (MITT) use in asthma. OBJECTIVE To describe real-world prevalence, outcomes, and treatment patterns associated with MITT. METHODS This retrospective cohort study used medical and pharmacy claims from the Optum Research Database. Patients were diagnosed with asthma between January 01, 2013, and July 31, 2018, with evidence of MITT use (≥1 overlapping days' supply of inhaled corticosteroid, long-acting β2-agonist, and long-acting muscarinic antagonist). Annual MITT prevalence (primary end point) was assessed in the prevalent population; eligible patients were 18 years or older with 2 or more asthma diagnoses during the study period, and continuous enrollment for the entire year. Secondary outcomes (adherence [proportion of days covered], MITT persistence, health care resource utilization, costs) were assessed in the incident MITT population; eligible patients were 18 years or older, with 2 or more asthma diagnoses and continuous enrollment during both the 12-month baseline and 12-month follow-up periods. Patients with chronic obstructive pulmonary disease or cystic fibrosis were excluded. RESULTS MITT prevalence was low but increased from 0.35% (95% CI, 0.32-0.37) in 2014/2015 to 1.00% (95% CI, 0.96-1.04) in 2017/2018. Among 1831 incident MITT users, there was a substantial disease burden, demonstrated by high health care resource utilization and exacerbation rates. Adherence and persistence to MITT was low (mean proportion of days covered, 0.31 ± 0.27), and 12% (n = 216) remained on MITT 12 months postinitiation. CONCLUSIONS Overall, MITT use among patients with asthma is low. Patients initiating MITT have substantial disease burden and significant unmet needs.
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Cella M, Täubel J, Delestre-Levai I, Tulard A, Vele A, Georges G. Ethnic Sensitivity Study of the Extrafine, Single-Inhaler, Triple Therapy Beclomethasone Dipropionate, Formoterol Fumarate, and Glycopyrronium Bromide Pressurized Metered Dose Inhaler in Japanese and Caucasian Healthy Individuals: A Randomized, Double-Blind, Single-Dose Crossover Study. Clin Ther 2021; 43:1934-1947.e4. [PMID: 34600734 DOI: 10.1016/j.clinthera.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/24/2021] [Accepted: 09/01/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE A number of single-inhaler, fixed-dose, triple combinations are available for the management of chronic obstructive pulmonary disease and/or asthma. One of these is the extrafine formulation beclomethasone dipropionate, formoterol fumarate, glycopyrronium bromide (BDP/FF/GB). Given that differences in ethnicity can result in differences in systemic exposure, we evaluated the relative pharmacokinetic (PK) profiles of BDP/FF/GB in Japanese vs Caucasian healthy volunteers to assess the need for dose adjustment. METHODS This randomized, double-blind, single-dose, 4-way crossover study recruited healthy men and women 20 to 55 years of age; for each Japanese person a Caucasian was enrolled who matched in terms of sex, age, and weight. Study treatments included BDP/FF/GB 200/12/25 and 400/12/25 μg (therapeutic), 800/48/100 μg (supratherapeutic), and placebo. PK blood samples were taken up to 24 hours for evaluation of BDP, beclomethasone 17-monopropionate (B17MP, an active metabolite of BDP), and formoterol and up to 48 h for GB. The primary objective was to characterize the PK profiles of BDP, FF, and GB after administration of a single dose of BDP/FF/GB in Caucasian and Japanese healthy volunteers in terms of the AUC0-t and Cmax of B17MP, formoterol, and GB. FINDINGS Of the 32 recruited participants (16 Japanese and 16 Caucasian ), 30 completed the study. A clear plasma exposure dose-response relationship was found for all 4 molecules. B17MP Cmax geometric mean ratios for Japanese vs Caucasian participants for the 3 study treatments ranged from 1.17 to 1.26, and AUC0-t ratios ranged from 1.16 to 1.22; thus, the findings were comparable between the ethnicities. Formoterol exposure was higher in Japanese than Caucasian participants (Cmax, 1.22-1.53; AUC0-t, 1.23-1.40). The GB Cmax with BDP/FF/GB 400/12/25 μg (1.09) and AUC0-t values for all three doses (0.98-1.17) were comparable in the 2 populations, but Cmax with 200/12/25 and 800/48/100 μg were higher in Japanese participants (1.32 and 1.42, respectively). Pharmacodynamic (cortisol, potassium, glucose, blood pressure, heart rate, and QT interval with the Fridericia correction) and safety profile results were similar in the 2 ethnicities, with most patients not experiencing any adverse events. IMPLICATIONS Exposure to BDP/FF/GB pressurized metered dose inhaler at therapeutic and supratherapeutic doses was associated with higher plasma levels in Japanese versus Caucasian healthy volunteers. These PK differences did not translate into meaningful differences in the safety or pharmacodynamic parameters assessed in this study and were consistent with the results of other long-term (52-week) published studies. Dose adjustments in Japanese people are not deemed necessary. CLINICALTRIALS. GOV IDENTIFIER NCT03859414.
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Affiliation(s)
- Massimo Cella
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy.
| | - Jörg Täubel
- Richmond Pharmacology, London, United Kingdom; St. George's University, London, United Kingdom
| | | | - Anne Tulard
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
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Nakamura Y, Hozawa S, Sagara H, Ohbayashi H, Lee LA, Crawford J, Tamaoki J, Nishi T, Fowler A. Efficacy and safety of once-daily, single-inhaler fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol in Japanese patients with inadequately controlled asthma: the CAPTAIN study. Curr Med Res Opin 2021; 37:1657-1665. [PMID: 34162298 DOI: 10.1080/03007995.2021.1944849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE In CAPTAIN, a double-blind, parallel-group, Phase IIIA study, fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) improved lung function, symptoms and asthma control versus FF/VI in patients with inadequately controlled asthma. Here, we report efficacy and safety from a Japanese cohort in CAPTAIN. METHODS Adults with inadequately controlled asthma despite inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) were randomized (1:1:1:1:1:1) to once-daily FF/VI (100/25 mcg or 200/25 mcg) or FF/UMEC/VI (100/31.25/25 mcg, 100/62.5/25 mcg, 200/31.25/25 mcg, or 200/62.5/25 mcg) for ≥24 weeks. Endpoints included change from baseline in clinic trough FEV1 (primary), annualized rate of moderate/severe asthma exacerbations (key secondary), clinic FEV1 3 h post-dose, and Asthma Control Questionnaire (ACQ)-7, St George's Respiratory Questionnaire (SGRQ) (all Week 24), Evaluating Respiratory Symptoms (E-RS): Asthma total scores (Weeks 21-24) (all secondary). Adverse events and adverse events of special interest were monitored. Clinical trials.gov registry no: NCT02924688. RESULTS Overall, 229 of 2436 patients in the intention-to-treat (ITT) population were from Japan. In this cohort, change from baseline in trough FEV1 for FF/UMEC/VI 100/62.5/25 mcg versus FF/VI 100/25 mcg was 105 mL (95% confidence interval -5, 216) and 69 mL (-42, 179) for 200/62.5/25 mcg versus 200/25 mcg. These observations were supported by clinic FEV1 at 3 h post-dose. Moderate/severe exacerbation incidence was low and similar across pooled treatment groups (FF/VI, FF/UMEC 31.25 mcg/VI, FF/UMEC 62.5 mcg/VI). All pooled groups demonstrated clinically important improvements from baseline in ACQ-7, SGRQ and E-RS: Asthma total scores. Safety profiles were consistent with the overall ITT population, with no new safety concerns. CONCLUSION FF/UMEC/VI is an effective option with a favorable risk-benefit profile in Japanese patients with uncontrolled moderate or severe asthma on ICS/LABA.
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Affiliation(s)
- Yoichi Nakamura
- Medical Center for Allergic and Immune Diseases, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
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Kerwin E, Dorinsky P, Patel M, Rossman K, Reisner C, Maes A, Darken P, Griffis D, Fjällbrant H. A randomized controlled trial of glycopyrrolate administered by metered dose inhaler in patients with uncontrolled asthma despite ICS/LABA treatment. J Asthma 2021; 59:1420-1432. [PMID: 34338132 DOI: 10.1080/02770903.2021.1938603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of three doses of glycopyrrolate metered dose inhaler (GP MDI) in patients with uncontrolled asthma despite treatment with inhaled corticosteroid/long-acting β2-agonists (ICS/LABA) with or without tiotropium, to characterize the benefit of triple therapy. METHOD This phase II/III, double-blind study randomized patients to 24 weeks' treatment with twice-daily GP MDI 36 µg, 18 µg, 9 µg, or placebo MDI (all delivered via Aerosphere inhalers), or once-daily open-label tiotropium 2.5 µg. Patients continued their own ICS/LABA regimen throughout the study. The primary endpoint was change from baseline in forced expiratory volume in 1 s (FEV1) area under the curve from 0 - 4 h (AUC0 - 4) at Week 24. Secondary endpoints included patient questionnaires to measure asthma control or symptoms. Safety was also assessed. RESULTS The primary analysis (modified intent-to-treat) population included 1066 patients. The primary study endpoint was not met (changes from baseline in FEV1 AUC0 - 4 at Week 24 were 294 mL, 284 mL, 308 mL, 240 mL, and 347 mL for GP MDI 36 µg, GP MDI 18 µg, GP MDI 9 µg, placebo, and open-label tiotropium, respectively). There were no significant differences between treatment and placebo in secondary endpoints at Week 24. Post-hoc analyses using post-bronchodilator FEV1 as the baseline measurement, or averaging values across multiple baseline visits, showed a dose-related response to GP MDI. The incidence of adverse events was low and similar across treatments. CONCLUSION Although this study did not meet its primary endpoint, post hoc analyses identified a dose-related response to GP MDI when alternative definitions of baseline FEV1 were used in the analyses.
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Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul Dorinsky
- BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Mehul Patel
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Kimberly Rossman
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Colin Reisner
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Andrea Maes
- Formerly of Biopharmaceuticals R&D, AstraZeneca, Wilmington, DE, USA
| | - Patrick Darken
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
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Murphy RC, Pavord ID, Alam R, Altman MC. Management Strategies to Reduce Exacerbations in non-T2 Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2588-2597. [PMID: 34246435 DOI: 10.1016/j.jaip.2021.04.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
There have been considerable advances in our understanding of asthmatic airway inflammation, resulting in a paradigm shift of classifying individuals on the basis of either the presence or the absence of type 2 (T2) inflammatory markers. Several novel monoclonal antibody therapies targeting T2 cytokines have demonstrated significant clinical effects including reductions in acute exacerbations and improvements in asthma-related quality of life and lung function for individuals with T2-high asthma. However, there have been fewer advancements in developing therapies for those without evidence of T2 airway inflammation (so-called non-T2 asthma). Here, we review the heterogeneity of molecular mechanisms responsible for initiation and regulation of non-T2 inflammation and discuss both current and potential future therapeutic options for individuals with non-T2 asthma.
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Affiliation(s)
- Ryan C Murphy
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Wash; Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash.
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rafeul Alam
- Division of Allergy and Immunology, Department of Medicine, National Jewish Health and University of Colorado, Denver, Colo
| | - Matthew C Altman
- Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash; Division of Allergy and Immunology, University of Washington, Seattle, Wash
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72
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Chacón P, Vega-Rioja A, Doukkali B, Del Valle Rodríguez A, Bellido V, Puente Y, Alcañiz L, Rodríguez D, Palacios R, Cornejo-García JA, Monteseirín J, Rivas-Pérez D. Targeted inhibition of allergen-induced histamine production by neutrophils. FASEB J 2021; 35:e21483. [PMID: 33788304 DOI: 10.1096/fj.202001912r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/11/2022]
Abstract
Histamine is a critical inflammatory mediator in allergic diseases. We showed in a previous work that neutrophils from allergic patients produce histamine in response to allergens to which the patients were sensitized. Here, we investigate the molecular mechanisms involved in this process using peripheral blood neutrophils. We challenged these cells in vitro with allergens and analyzed histamine release in the culture supernatants. We also explored the effect of common therapeutic drugs that ameliorate allergic symptoms, as well as allergen-specific immunotherapy. Additionally, we examined the expression of histidine decarboxylase and diamine oxidase, critical enzymes in the metabolism of histamine, under allergen challenge. We show that allergen-induced histamine release is dependent on the activation of the phosphoinositide 3-kinase, mitogen-activated protein kinase p38, and extracellular signal-regulated kinase 1/2 signaling pathways. We also found a contribution of the phosphatase calcineurin to lesser extent. Anti-histamines, glucocorticoids, anti-M3-muscarinic receptor antagonists, and mainly β2 -receptor agonists abolished the allergen-dependent histamine release. Interestingly, allergen-specific immunotherapy canceled the histamine release through the downregulation of histidine decarboxylase expression. Our observations describe novel molecular mechanisms involved in the allergen-dependent histamine release by human neutrophils and provide new targets to inhibit histamine production.
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Affiliation(s)
- Pedro Chacón
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Antonio Vega-Rioja
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Bouchra Doukkali
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Virginia Bellido
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Yolanda Puente
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Lorena Alcañiz
- UGC de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | | | | | - Javier Monteseirín
- UGC de Alergología, Hospital Universitario Virgen Macarena, Sevilla, Spain.,Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
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73
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Ora J, Calzetta L, Ritondo BL, Matera MG, Rogliani P. Current long-acting muscarinic antagonists for the treatment of asthma. Expert Opin Pharmacother 2021; 22:2343-2357. [PMID: 34219573 DOI: 10.1080/14656566.2021.1952182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The role of long-acting muscarinic antagonists (LAMAs) is well established in uncontrolled asthma, but not in milder stages. AREAS COVERED This review examines the main randomized controlled trials (RCTs) that have investigated LAMAs administered as monotherapy or in combination to asthmatic patients, according to the different phenotypes. It offers an overview of the role of LAMAs or their fixed dose combinations (FDCs) in the treatment across all the different stages of asthma. EXPERT OPINION Tiotropium is now widely recognized as treatment for moderate to severe uncontrolled asthma (step 4-5) in adults and children. The most recent new evidence is: a) in adults, three different LAMA/long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) FDCs have been recently approved, extending the treatment options for these patients; b) therapy with LAMAs does not depend on patient's Th2 status and justifies the indication regardless of patient's phenotyping; c) in the milder stages, the high variability of response to LAMAs and the lack of a good phenotyping of patients represents the main obstacle in prescribing LAMAs. A better characterization of parasympathetic tone activity could improve LAMAs prescription.
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Affiliation(s)
- Josuel Ora
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paola Rogliani
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy.,Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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74
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Amison RT, Page CP. Novel pharmacological therapies for the treatment of bronchial asthma. Minerva Med 2021; 113:31-50. [PMID: 34236157 DOI: 10.23736/s0026-4806.21.07559-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Asthma has long been recognised as a chronic inflammatory disease of the airways, often in response to inhaled allergens prompting inappropriate activation of the immune response. involving a range of cells including mast cells, Th2 lymphocytes and eosinophils and a wide range of inflammatory mediators. First-line therapy for treatment of persistent asthma involves the use of inhaled corticosteroids (ICS) in combination with inhaled β2-agonists enabling both the control of the underlying airways inflammation and a reduction of airway hyperresponsiveness. However, many patients remain symptomatic despite high-dose therapy. There is therefore a continued unmet clinical need to develop specifically new anti-inflammatory therapies for patients with asthma, either as an add-on therapy to ICS or as replacement monotherapies. The success of fixed dose combination inhalers containing both a bronchodilator and an anti-inflammatory drug has also led to the development of "bifunctional" drugs which are molecules specifically designed to have two distinct pharmacological actions based on distinct pharmacophores. In this review we will discuss these different pharmacological approaches under development for the treatment of bronchial asthma and the available pre-clinical and clinical data.
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Affiliation(s)
- Richard T Amison
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK -
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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75
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Cazzola M, Calzetta L, Matera MG. Long-acting muscarinic antagonists and small airways in asthma: Which link? Allergy 2021; 76:1990-2001. [PMID: 33559139 DOI: 10.1111/all.14766] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 12/14/2022]
Abstract
Involvement of small airways, those of <2 mm in internal diameter, is present in all stages of asthma and contributes substantially to its pathophysiologic expression. Therefore, small airways are a potential target to achieve optimal asthma control. Airway tone, which is increased in asthma, is mainly controlled by the vagus nerve that releases acetylcholine (ACh) and activates muscarinic ACh receptors (mAChRs) post-synaptically on airway smooth muscle (ASM). In small airways, M3 mAChRs are expressed, but there is no vagal innervation. Non-neuronal ACh released from the epithelial cells that may express choline acetyltransferase in response to inflammatory stimuli, as well as from other structural cells in the airways, including fibroblasts and mast cells, can activate mAChRs. By antagonizing M3 mAChR, the contraction of the ASM is prevented and, potentially, local inflammation can be reduced and the progression of remodeling may be averted. In fact, ACh also contributes to inflammation and remodeling of the airways and regulates the growth of ASM. Several experimental studies have demonstrated the potential benefit derived from the use of mAChR antagonists, mainly long-acting mAChR antagonists (LAMAs), on small airways in asthma. However, there are several confounding factors that may cause a wrong estimation of the relationship between LAMAs and small airways in asthma. Further studies are needed to differentiate broncholytic and anti-inflammatory effects of LAMAs and to better understand the interaction between LAMAs and corticosteroids, also in the context of a triple therapy that includes a β2 -AR agonist, at different levels of the bronchial tree.
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Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine University of Rome “Tor Vergata” Rome Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit Department of Medicine and Surgery University of Parma Parma Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine University of Campania “Luigi Vanvitelli” Naples Italy
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76
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Abellard A, Pappalardo AA. Overview of severe asthma, with emphasis on pediatric patients: a review for practitioners. J Investig Med 2021; 69:1297-1309. [PMID: 34168068 DOI: 10.1136/jim-2020-001752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/03/2022]
Abstract
Asthma is the most common life-threatening chronic disease in children. Although guidelines exist for the diagnosis and treatment of asthma, treatment of severe, pediatric asthma remains difficult. Limited studies in the pediatric population on new asthma therapies, complex issues with adolescence and adherence, health disparities, and unequal access to guideline-based care complicate the care of children with severe, persistent asthma. The purpose of this review is to provide an overview of asthma, including asthma subtypes, comorbidities, and risk factors, to discuss diagnostic considerations and pitfalls and existing treatments, and then present existing and emerging therapeutic approaches to asthma management. An improved understanding of asthma heterogeneity, clinical characteristics, inflammatory patterns, and pathobiology can help further guide the management of severe asthma in children. More studies are needed in the pediatric population to understand emerging therapeutics application in children. Effective multimodal strategies tailored to individual characteristics and a commitment to address risk factors, modifiers, and health disparities may help reduce the burden of asthma in the USA.
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Affiliation(s)
- Arabelle Abellard
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea A Pappalardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA .,Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA
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77
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Kim LHY, Saleh C, Whalen-Browne A, O’Byrne PM, Chu DK. Triple vs Dual Inhaler Therapy and Asthma Outcomes in Moderate to Severe Asthma: A Systematic Review and Meta-analysis. JAMA 2021; 325:2466-2479. [PMID: 34009257 PMCID: PMC8135065 DOI: 10.1001/jama.2021.7872] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE The benefits and harms of adding long-acting muscarinic antagonists (LAMAs) to inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs) for moderate to severe asthma remain unclear. OBJECTIVE To systematically synthesize the outcomes and adverse events associated with triple therapy (ICS, LABA, and LAMA) vs dual therapy (ICS plus LABA) in children and adults with persistent uncontrolled asthma. DATA SOURCES MEDLINE, Embase, CENTRAL, ICTRP, FDA, and EMA databases from November 2017, to December 8, 2020, without language restriction. STUDY SELECTION Two investigators independently selected randomized clinical trials (RCTs) comparing triple vs dual therapy in patients with moderate to severe asthma. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analyses, including individual patient-level exacerbation data, were used. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess certainty (quality) of the evidence. MAIN OUTCOMES AND MEASURES Severe exacerbations, asthma control (measured using the Asthma Control Questionnaire [ACQ-7], a 7-item list with each item ranging from 0 [totally controlled] to 6 [severely uncontrolled]; minimal important difference, 0.5), quality of life (measured using the Asthma-related Quality of Life [AQLQ] tool; score range, 1 [severely impaired] to 7 [no impairment]; minimal important difference, 0.5), mortality, and adverse events. RESULTS Twenty RCTs using 3 LAMA types that enrolled 11 894 children and adults (mean age, 52 years [range, 9-71 years]; 57.7% female) were included. High-certainty evidence showed that triple therapy vs dual therapy was significantly associated with a reduction in severe exacerbation risk (9 trials [9932 patients]; 22.7% vs 27.4%; risk ratio, 0.83 [95% CI, 0.77 to 0.90]) and an improvement in asthma control (14 trials [11 230 patients]; standardized mean difference [SMD], -0.06 [95% CI, -0.10 to -0.02]; mean difference in ACQ-7 scale, -0.04 [95% CI, -0.07 to -0.01]). There were no significant differences in asthma-related quality of life (7 trials [5247 patients]; SMD, 0.05 [95% CI, -0.03 to 0.13]; mean difference in AQLQ score, 0.05 [95% CI, -0.03 to 0.13]; moderate-certainty evidence) or mortality (17 trials [11 595 patients]; 0.12% vs 0.12%; risk ratio, 0.96 [95% CI, 0.33 to 2.75]; high-certainty evidence) between dual and triple therapy. Triple therapy was significantly associated with increased dry mouth and dysphonia (10 trials [7395 patients]; 3.0% vs 1.8%; risk ratio, 1.65 [95% CI, 1.14 to 2.38]; high-certainty evidence), but treatment-related and serious adverse events were not significantly different between groups (moderate-certainty evidence). CONCLUSIONS AND RELEVANCE Among children (aged 6 to 18 years) and adults with moderate to severe asthma, triple therapy, compared with dual therapy, was significantly associated with fewer severe asthma exacerbations and modest improvements in asthma control without significant differences in quality of life or mortality.
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Affiliation(s)
- Lisa H. Y. Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carol Saleh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Paul M. O’Byrne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Derek K. Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St Joe’s Hamilton, Hamilton, Ontario, Canada
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78
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Jansen EM, van de Hei SJ, Dierick BJH, Kerstjens HAM, Kocks JWH, van Boven JFM. Global burden of medication non-adherence in chronic obstructive pulmonary disease (COPD) and asthma: a narrative review of the clinical and economic case for smart inhalers. J Thorac Dis 2021; 13:3846-3864. [PMID: 34277075 PMCID: PMC8264677 DOI: 10.21037/jtd-20-2360] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/18/2021] [Indexed: 12/14/2022]
Abstract
Medication non-adherence to asthma and chronic obstructive pulmonary disease therapy poses a significant burden for patients and societies. Non-adherence encompasses poor initiation, implementation (including poor inhalation technique) and non-persistence. Globally, non-adherence is associated with poor clinical outcomes, reduced quality of life and high healthcare and societal costs. Costs are mainly caused by excess hospitalizations and impaired work productivity. Multiple intervention programs to increase adherence in patients with asthma and chronic obstructive pulmonary disease have been conducted. However, these intervention programs are generally not as effective as intended. Additionally, adherence outcomes are mostly examined with non-objective or non-granular measures (e.g., self-report, dose count, pharmacy records). Recently developed smart inhalers could be the key to objectively diagnose and manage non-adherence effectively in patients with asthma and chronic obstructive pulmonary disease. Smart inhalers register usage of the inhaler, record time and date, send reminders, give feedback about adherence and some are able to assess inhaler technique and predict exacerbations. Still, some limitations need to be overcome before smart inhalers can be incorporated in usual care. For example, their cost-effectiveness and budget impact need to be examined. It is likely that smart inhalers are particularly cost-effective in specific asthma and chronic obstructive pulmonary disease subgroups, including patients with asthma eligible for additional GINA-5 therapy (oral corticosteroids or biologics), patients with severe asthma in GINA-5, patients with asthma with short-acting beta2 agonists overuse, patients with asthma and chronic obstructive pulmonary disease with frequent exacerbations and patients with asthma and chronic obstructive pulmonary disease of working-age. While there is high potential and evidence is accumulating, a final push seems needed to cost-effectively integrate smart inhalers in the daily management of patients with asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- Evalyne M Jansen
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Susanne J van de Hei
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
| | - Boudewijn J H Dierick
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands
| | - Janwillem W H Kocks
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands.,General Practitioners Research Institute (GPRI), Groningen, The Netherlands.,Observational and Pragmatic Research Institute (OPRI), Singapore
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands
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79
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Plaza V, Alobid I, Alvarez C, Blanco M, Ferreira J, García G, Gómez-Outes A, Gómez F, Hidalgo A, Korta J, Molina J, Pellegrini FJ, Pérez M, Plaza J, Praena M, Quirce S, Sanz J. Spanish Asthma Management Guidelines (GEMA) VERSION 5.1. Highlights and Controversies. Arch Bronconeumol 2021; 58:150-158. [PMID: 34167859 DOI: 10.1016/j.arbres.2021.05.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022]
Abstract
In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control; INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed; MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids; SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma; OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis.
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Affiliation(s)
- Vicente Plaza
- Comité Ejecutivo GEMA, Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - Isam Alobid
- Sociedad Española de Otorrinolaringología (SEORL), Hospital Clinic, Universidad de Barcelona, Barcelona, España
| | - Cesáreo Alvarez
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Hospital de Verín, Orense, España
| | - Marina Blanco
- Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Complejo Hospitalario Universitario A Coruña, A Coruña, España
| | - Jorge Ferreira
- Sociedad Portuguesa de Pneumologia (SPP), Hospital de São Sebastião - CHEDV, Santa Maria da Feira, Portugal
| | - Gabriel García
- Asociación Latinoamericana del Tórax (ALAT), Hospital Rossi La Plata, Buenos Aires, Argentina
| | - Antonio Gómez-Outes
- Sociedad Española de Farmacología Clínica (SEFC), Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Fernando Gómez
- Sociedad Española de Médicos Generales y de Familia (SEMG), Centro de Salud de Bargas, Toledo, España
| | - Antonio Hidalgo
- Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Centro de Salud Lucena I. Lucena, Córdoba, España
| | - Javier Korta
- Sociedad Española de Neumología Pediátrica (SENP), Hospital Universitario Donostia, Donostia-San Sebastián, España
| | - Jesús Molina
- Sociedad Española de Medicina Familiar y Comunitaria (semFYC) y Sociedad de Respiratorio de Atención Primaria (GRAP), Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | - Francisco Javier Pellegrini
- Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Centro de Salud de Pizarrales, Salamanca, España
| | - Montserrat Pérez
- Sociedad Española de Farmacia Hospitalaria (SEFH), Hospital Universitario Fundación Alcorcón, Madrid, España
| | - Javier Plaza
- Sociedad Española de Farmacia Clínica, Familiar y Comunitaria (SEFAC), Farmacia Dres. Zamora Navarro, Mazarrón, Murcia, España
| | - Manuel Praena
- Asociación Española de Pediatría de Atención Primaria (AEPap), Centro de Salud La Candelaria, Sevilla, España
| | - Santiago Quirce
- Sociedad Española de Alergia e Inmunología Clínica (SEAIC), Hospital Universitario La Paz, Madrid, España
| | - José Sanz
- Sociedad Española de Inmunología Clínica-Alergología y Asma Pediátrica (SEICAP), Hospital Católico Universitario Casa de Salud, Valencia, España
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80
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Beier J, Watz H, Diamant Z, Hohlfeld JM, Singh D, Pinot P, Jones I, Tillmann HC. Lung function improvements following inhaled indacaterol/glycopyrronium/mometasone furoate are independent of dosing time in asthma patients: a randomised trial. ERJ Open Res 2021; 7:00425-2020. [PMID: 33898609 PMCID: PMC8053816 DOI: 10.1183/23120541.00425-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/14/2020] [Indexed: 01/12/2023] Open
Abstract
Once-daily asthma treatment should prevent night-time deterioration, irrespective of the time of dosing. IND/GLY/MF, a fixed-dose combination of inhaled indacaterol acetate (IND, long-acting β2-agonist (LABA)), glycopyrronium bromide (GLY, long-acting muscarinic antagonist) and mometasone furoate (MF, inhaled corticosteroid (ICS)) delivered by Breezhaler, is indicated in adult asthma patients inadequately controlled on LABA/ICS. A randomised, double-blind, placebo-controlled, three-period, crossover, phase II study was performed to investigate the bronchodilator effect of IND/GLY/MF (150/50/80 μg) dosed morning and evening versus placebo in patients with mild-moderate asthma. The primary end-point was weighted mean forced expiratory volume in 1 s (FEV1) over 24 h following 14 days of IND/GLY/MF dosed a.m. and p.m. versus placebo. Secondary end-points included the effect of dosing time on peak expiratory flow (PEF) and safety/tolerability. Of 37 randomised patients (age 18–72 years; 21 male, 16 female) 34 completed all three treatment periods. At screening, median (range) pre-bronchodilator FEV1 was 75.8% (60–96%). Patients were using stable low- (83.8%) or medium-dose (16.2%) ICS. Morning and evening dosing of IND/GLY/MF improved FEV1 (area under the curve from 0 to 24 h) by 610 mL (90% CI 538–681 mL) and 615 mL (90% CI 544–687 mL), respectively, versus placebo. Mean PEF over 14 days increased by 70.7 L·min−1 (90% CI 60.5–80.9 L·min−1) following a.m. dosing, and by 59.7 L·min−1 (90% CI 49.5–69.9 L·min−1) following p.m. dosing of IND/GLY/MF versus placebo. IND/GLY/MF demonstrated a safety profile comparable with placebo. Once-daily inhaled IND/GLY/MF was well tolerated and provided sustained lung function improvements over 24 h, irrespective of a.m. or p.m. dosing, in patients with mild–moderate asthma. This randomised study found single-inhaler indacaterol/glycopyrronium/mometasone furoate improved respiratory parameters FEV1 and PEF in asthma patients, and showed similar efficacy when taken once daily in the morning or eveninghttps://bit.ly/3fH0I1K
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Affiliation(s)
- Jutta Beier
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Zuzana Diamant
- Dept of Respiratory Medicine and Allergology, Institute for Clinical Science, Skåne University Hospital, Lund, Sweden.,Dept of Microbiology, Immunology and Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium.,Dept of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre and QPS-NL, Groningen, The Netherlands
| | - Jens M Hohlfeld
- German Center for Lung Research (BREATH), Hannover, Germany.,Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Pascale Pinot
- Novartis Institutes for Biomedical Research, Basel, Switzerland
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81
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Buhl R, Bals R, Baur X, Berdel D, Criée CP, Gappa M, Gillissen A, Greulich T, Haidl P, Hamelmann E, Horak F, Kardos P, Kenn K, Klimek L, Korn S, Magnussen H, Nowak D, Pfaar O, Rabe KF, Riedler J, Ritz T, Schultz K, Schuster A, Spindler T, Taube C, Vogelmeier C, von Leupoldt A, Wantke F, Wildhaber J, Worth H, Zacharasiewicz A, Lommatzsch M. [Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]. Pneumologie 2021; 75:191-200. [PMID: 33728628 DOI: 10.1055/a-1352-0296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.
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Affiliation(s)
- R Buhl
- Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Schwerpunkt Pneumologie, III. Medizinische Klinik, Mainz
| | - R Bals
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin V, Homburg/Saar
| | - X Baur
- Haut- und Lasercentrum, Standort Berlin, Berlin
| | | | - C-P Criée
- Evangelisches Krankenhaus Göttingen Weende, Abteilung für Pneumologie, Bovenden-Lenglern
| | - M Gappa
- Evangelisches Krankenhaus Düsseldorf, Klinik für Kinder und Jugendmedizin, Düsseldorf
| | - A Gillissen
- Klinikum Am Steinenberg, Ermstalklinik, Medizinische Klinik III/Innere Medizin und Pneumologie, Reutlingen-Bad Urach
| | - T Greulich
- Universitätsklinikum Gießen und Marburg, Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Marburg
| | - P Haidl
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg
| | - E Hamelmann
- Universitäts-Klinikum OWL, Universität Bielefeld, Kinderzentrum Bethel, Bielefeld
| | - F Horak
- Allergiezentrum Wien West, Wien
| | - P Kardos
- Lungenpraxis an der Klinik Maingau vom Roten Kreuz, Frankfurt am Main
| | - K Kenn
- Philips Universität Marburg, Lehrstuhl für pneumologische Rehabilitation, Marburg
| | - L Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden
| | - S Korn
- Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Schwerpunkt Pneumologie, III. Medizinische Klinik, Mainz
| | - H Magnussen
- Pneumologisches Forschungsinstitut an der LungenClinic Grosshansdorf GmbH, Großhansdorf
| | - D Nowak
- Klinikum der Universität München, Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - O Pfaar
- Klinik für Hals-, Nasen-und Ohrenheilkunde, Sektion Rhinologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Marburg
| | - K F Rabe
- LungenClinic Grosshansdorf GmbH, Abteilung für Pneumologie, Großhansdorf
| | - J Riedler
- Kardinal Schwarzenberg Klinikum, Kinder- und Jugendmedizin, Schwarzach im Pongau, Österreich
| | - T Ritz
- Southern Methodist University, Department of Psychology, Dallas, USA
| | - K Schultz
- Klinik Bad Reichenhall, Zentrum für Rehabilitation, Pneumologie und Orthopädie, Bad Reichenhall
| | - A Schuster
- Universitätsklinikum Düsseldorf, Zentrum für Kinder- und Jugendmedizin, Düsseldorf
| | - T Spindler
- Hochgebirgsklinik Davos, Abteilung für Kinder und Jugendliche, Davos, Schweiz
| | - C Taube
- Universitätsmedizin Essen, Ruhrlandklinik, Klinik für Pneumologie, Essen
| | - C Vogelmeier
- Universitätsklinikum Gießen und Marburg, Klinik für Innere Medizin mit Schwerpunkt Pneumologie, Marburg
| | - A von Leupoldt
- University of Leuven, Health Psychology, Leuven, Belgien
| | - F Wantke
- Floridsdorfer Allergiezentrum, Wien, Österreich
| | - J Wildhaber
- HFR Freiburg, Kantonsspital, Klinik für Pädiatrie, Freiburg, Schweiz
| | - H Worth
- Facharztzentrum Fürth, Fürth
| | - A Zacharasiewicz
- Klinikum Ottakring, Wilhelminenspital, Lehrkrankenhaus der Medizinischen Universität Wien, Abteilung für Kinder- und Jugendheilkunde, Wien, Österreich
| | - M Lommatzsch
- Universitätsmedizin Rostock, Abteilung für Pneumologie, Rostock
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Kerwin E, Feldman G, Pearle J, De La Cruz L, Edwards M, Beaudot C, Georges G. Efficacy and Safety of Inhaled Glycopyrronium Bromide in COPD: A Randomized, Parallel Group, Dose-Ranging Study (GLIMMER). COPD 2021; 18:181-190. [PMID: 33709856 DOI: 10.1080/15412555.2021.1894111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This Phase II, randomized, parallel group study was conducted as part of US regulatory requirements to identify the most appropriate dose of the long-acting muscarinic antagonist glycopyrronium bromide (GB) for use in a single-inhaler triple-therapy combination with the inhaled corticosteroid beclomethasone dipropionate plus the long-acting β2-agonist formoterol fumarate. Eligible subjects were adults with COPD and post-bronchodilator forced expiratory volume in 1 s (FEV1) 40-80% predicted. Subjects were randomized to receive inhaled double-blind GB 6.25, 12.5, 25 or 50 µg or placebo, all twice daily (BID), or open-label tiotropium 18 µg once daily for six weeks. The primary objective was to evaluate the efficacy of GB versus placebo in terms of FEV1 area under the curve between 0 and 12 h at Week 6. Of 733 subjects randomized, 682 (93.0%) completed the study. For the primary endpoint, all GB doses were superior to placebo (p < 0.05), with a dose-response up to 25 µg BID, and 25 and 50 µg BID both superior to 6.25 µg BID (p < 0.05). Results for the secondary spirometry endpoints were consistent with the primary endpoint. Overall, the efficacy of GB 25 and 50 µg BID was broadly consistent with that of tiotropium. The incidence of adverse events, both overall and for the most common preferred terms, was low and similar in all treatment groups, including placebo (overall, 22.3-29.3%). Based on the totality of the efficacy and safety data, the optimal GB dose is 25 µg BID.
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Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Gregory Feldman
- South Carolina Pharmaceutical Research, Spartanburg, SC, USA
| | - James Pearle
- California Research Medical Group, Inc, Fullerton, CA, USA
| | | | | | | | - George Georges
- Global Clinical Development, Chiesi USA, Inc, Cary, NC, USA
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83
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Pérez de Llano L, Dacal Rivas D, Blanco Cid N, Martin Robles I. Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines. J Asthma Allergy 2021; 14:207-217. [PMID: 33737814 PMCID: PMC7966411 DOI: 10.2147/jaa.s266999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/18/2021] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances in therapy, a substantial proportion of asthmatics remain not well controlled. The classical stepwise approach to pharmacological therapy in adult asthma recommends that treatment is progressively stepped up by increasing the inhaled corticosteroid (ICS) dose or by adding another controller medication- to achieve symptom control and reduce the risk of exacerbations, and stepped down after a period of control. In general, asthma guideline recommendations do not reflect that there are significant differences between ICS in terms of potency. Moreover, they do not consider efficacy and safety separately, incorrectly assuming that "low" and "high" dose categories inevitably correspond with low and high risk of systemic effects. Another point of criticism is the fact that guidelines do not take into account the inflammatory profile of the patient, although substantial groups of patients with mild and moderate asthma have little evidence of "T2-high" inflammation, and by extension are likely to show a poor response to ICS treatment. On the other hand, the latest version of the Global Initiative for Asthma (GINA) equally recommends regular ICS and ICS/formoterol as needed to prevent exacerbations in step 2 patients, without taking into consideration that the therapeutic objectives (exacerbations, symptoms) may differ between individual patients and that different goals may warrant distinct treatment strategies. In this review, we bring to the table several controversial issues concerning asthma treatment and suggest an alternative proposal that takes into consideration the potential side effects of high ICS doses, the patient's inflammatory profile and the therapeutic goals to be achieved.
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Affiliation(s)
- Luis Pérez de Llano
- Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo. C/ Doctor Ulises Romero, nº 1, Lugo, 27003, Spain
| | - David Dacal Rivas
- Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo. C/ Doctor Ulises Romero, nº 1, Lugo, 27003, Spain
| | - Nagore Blanco Cid
- Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo. C/ Doctor Ulises Romero, nº 1, Lugo, 27003, Spain
| | - Irene Martin Robles
- Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo. C/ Doctor Ulises Romero, nº 1, Lugo, 27003, Spain
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84
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Ojanguren I, Pilia MF. Efficacy and safety of once-daily single-inhaler triple therapy in patients with inadequately controlled asthma: the CAPTAIN trial. Breathe (Sheff) 2021; 17:200279. [PMID: 34295395 PMCID: PMC8291932 DOI: 10.1183/20734735.0279-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/12/2021] [Indexed: 11/05/2022] Open
Abstract
Triple therapy with FF/UMEC/VI improved lung function in patients with moderate or severe uncontrolled asthma on ICS/LABA but did not lead to a reduction in moderate and/or severe exacerbations https://bit.ly/38UnuRW.
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Affiliation(s)
- Iñigo Ojanguren
- Servei de Pneumología, Hospital Universitari Vall d´Hebron, Departament de Medicina, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Institut de Recerca (VHIR), Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - María Florencia Pilia
- Servei de Pneumología, Hospital Universitari Vall d´Hebron, Departament de Medicina, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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85
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Papi A, Fabbri LM, Kerstjens HAM, Rogliani P, Watz H, Singh D. Inhaled long-acting muscarinic antagonists in asthma - A narrative review. Eur J Intern Med 2021; 85:14-22. [PMID: 33563506 DOI: 10.1016/j.ejim.2021.01.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 12/13/2022]
Abstract
Long-acting muscarinic antagonists (LAMAs) have a recognised role in the management of chronic obstructive pulmonary disease. In asthma, muscarinic antagonists (both short- and long-acting) were historically considered less effective than β2-agonists; only relatively recently have studies been conducted to evaluate the efficacy of LAMAs, as add-on to either inhaled corticosteroid (ICS) monotherapy or ICS/long-acting β2-agonist (LABA) combinations. These studies led to the approval of the first LAMA, tiotropium, as an add-on therapy in patients with poorly controlled asthma. Subsequently, a number of single-inhaler ICS/LABA/LAMA triple therapies have been approved or are in clinical development for the management of asthma. There is now substantial evidence of the efficacy and safety of LAMAs in asthma that is uncontrolled despite treatment with an ICS/LABA combination. This regimen is recommended by GINA as an optimisation step for patients with severe asthma before any biologic or systemic corticosteroid treatment is initiated. This narrative review summarises the potential mechanisms of action of LAMAs in asthma, together with the initial clinical evidence supporting this use. We also discuss the studies that led to the approval of tiotropium for asthma and the data evaluating the efficacy and safety of the various triple therapies, before considering other potential uses for triple therapy.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S.Anna, Ferrara, Italy.
| | - Leonardo M Fabbri
- Section of Respiratory Medicine, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
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86
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Sagara H, Barbier N, Ishii T, Yoshisue H, Nikolaev I, Hosoe M, Gon Y. Efficacy of one time per day, single-inhaler indacaterol/glycopyrronium/mometasone in patients with inadequately controlled asthma: post hoc analysis of IRIDIUM study in Asian population. BMJ Open Respir Res 2021; 8:e000856. [PMID: 33737310 PMCID: PMC7978265 DOI: 10.1136/bmjresp-2020-000856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The 52-week IRIDIUM study demonstrated the efficacy of indacaterol acetate/glycopyrronium bromide/mometasone furoate (IND/GLY/MF) versus IND/MF and salmeterol xinafoate/fluticasone propionate (SAL/FLU) in patients with symptomatic asthma, despite long-acting β2-agonist/inhaled corticosteroids (LABA/ICS) medium-dose or high-dose, predicted forced expiratory volume in 1 s (FEV1) <80% and at least one exacerbation in the previous year. Here, we present data from a post hoc analysis of the IRIDIUM study in the Asian subpopulation. METHODS This post hoc analysis evaluated improvements in lung function, asthma control and reduction in asthma exacerbations with IND/GLY/MF medium- (150/50/80 µg) and high-dose (150/50/160 µg) versus IND/MF medium- (150/160 µg) and high-dose (150/320 µg), all one time per day and SAL/FLU high-dose (50/500 µg) two times per day, in Asian patients from the IRIDIUM study. RESULTS In total, 258 patients (IND/GLY/MF medium-dose, 52; IND/GLY/MF high-dose, 52; IND/MF medium-dose, 51; IND/MF high-dose, 51; SAL/FLU high-dose, 52) were included. IND/GLY/MF medium- and high-dose showed greater improvement in trough FEV1 at week 26 versus respective doses of IND/MF (Δ, 100 mL and 101 mL; both p<0.05, respectively), and SAL/FLU high-dose (Δ, 125 mL; p=0.0189, and 136 mL; p=0.0118, respectively), which were maintained over 52 weeks. Both doses of IND/GLY/MF showed greater improvement in morning and evening peak expiratory flow versus respective doses of IND/MF and SAL/FLU high-dose at week 52. The changes in Asthma Control Questionnaire-7 scores from baseline were comparable in all treatment groups. IND/GLY/MF medium- and high-dose showed greater reductions in severe (34%, 69%), moderate or severe (18%, 54%) and all exacerbations (21%, 34%) compared with SAL/FLU high-dose over 52 weeks. CONCLUSION One time per day, single-inhaler IND/GLY/MF improved lung function, reduced asthma exacerbations and provided comparable asthma control versus IND/MF and SAL/FLU in Asian patients with inadequately controlled asthma despite LABA/ICS. The results of this analysis were consistent with the overall population in the IRIDIUM study.
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Affiliation(s)
- Hironori Sagara
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University, School of Medicine, Shinagawa-ku, Tokyo, Japan
| | | | | | | | | | | | - Yasuhiro Gon
- Division of Respiratory Medicine, Department of Internal Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
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87
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Lipworth B, RuiWen Kuo C, Jabbal S, Chan R. Inhaled triple therapy and airway hyperresponsiveness in persistent asthma. Ann Allergy Asthma Immunol 2021; 126:597-598. [PMID: 33548471 DOI: 10.1016/j.anai.2021.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/11/2020] [Accepted: 01/25/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Scotland, United Kingdom
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Scotland, United Kingdom
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Scotland, United Kingdom
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital, University of Dundee, Scotland, United Kingdom
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88
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Rogliani P, Ritondo BL, Calzetta L. Triple therapy in uncontrolled asthma: a network meta-analysis of Phase III studies. Eur Respir J 2021; 58:13993003.04233-2020. [PMID: 33509960 DOI: 10.1183/13993003.04233-2020] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/13/2021] [Indexed: 11/05/2022]
Abstract
Conflicting evidence is currently available concerning the impact on asthma exacerbation of triple inhaled corticosteroid (ICS), long-acting β2-adrenoceptor agonist (LABA), and long-acting muscarinic receptor antagonist (LAMA) fixed-dose combination (FDC). Since meta-analyses allow settling controversies of apparently inconsistent results, we performed a network meta-analysis of Phase III randomised controlled trials including 9535 patients to assess the effect of ICS/LABA/LAMA combinations in uncontrolled asthma. Triple combination therapies with an ICS administered at high dose (HD) were more effective (p<0.05) than medium dose (MD) ICS/LABA/LAMA FDC and both MD and HD ICS/LABA FDCs against moderate to severe exacerbation (relative risk [RR] from 0.61 to 0.80) and increasing trough forced expiratory volume in the 1st second (mL from +33 to +114). Triple combination therapies including HD ICS were superior (p<0.05) than MD ICS/LABA/LAMA FDC in preventing severe exacerbation (RR from 0.46 to 0.65), but not with respect to moderate exacerbation (p>0.05). Triple combination therapies were equally effective on asthma control, with no safety concerns. This quantitative synthesis suggests that ICS/LABA/LAMA FDCs are effective and safe in uncontrolled asthma, and that the dose of ICS in the combination represents the discriminating factor to treat patients with a history of moderate or severe exacerbation.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Beatrice Ludovica Ritondo
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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89
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Papi A, Virchow JC, Singh D, Kots M, Vele A, Georges G, Canonica GW. Extrafine triple therapy and asthma exacerbation seasonality: TRIMARAN and TRIGGER post hoc analyses. J Allergy Clin Immunol 2021; 148:262-265.e2. [PMID: 33485959 DOI: 10.1016/j.jaci.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous studies have shown seasonal variation in asthma exacerbations, peaking over the winter months. A single-inhaler triple therapy containing extrafine formulations of the inhaled corticosteroid (ICS) beclomethasone dipropionate (BDP), long-acting β2-agonist formoterol fumarate (FF), and long-acting muscarinic antagonist glycopyrronium (G) is in development for asthma. OBJECTIVE We sought to evaluate whether calendar season impacted the relative effect of BDP/FF/G versus BDP/FF on moderate and severe asthma exacerbations. METHODS TRIMARAN and TRIGGER were double-blind 52-week studies comparing BDP/FF/G with BDP/FF (TRIMARAN medium-dose ICS; TRIGGER high-dose) in adults with uncontrolled asthma (Asthma Control Questionnaire-7 score ≥1.5), prebronchodilator FEV1 less than 80% predicted, history of 1 or more asthma exacerbation, who had been receiving ICS/long-acting β2-agonist for at least 4 weeks before entry. Moderate and severe asthma exacerbations were captured throughout each study. In these post hoc analyses, the annual moderate and severe exacerbation rate was calculated for each month, with rate ratios determined from events grouped by season. RESULTS In patients who received BDP/FF alone, there was a marked seasonal effect on the occurrence of asthma exacerbations, with the rate highest in the winter months. However, the addition of the long-acting muscarinic antagonist component to BDP/FF reduced this seasonal variation, especially during the winter, such that the relative effect of BDP/FF/G versus BDP/FF was greatest in the winter (significant 20.3% reduction [P = .0008]). Reductions in the other seasons ranged between 8.6% and 12.0%. CONCLUSIONS These post hoc analyses indicate that inhaled triple therapy with extrafine BDP/FF/G reduces seasonal peaks in moderate and severe exacerbations, and confirm the overall utility of adding long-acting muscarinic antagonist to ICS/long-acting β2-agonist in the management of asthma.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S. Anna, Ferrara, Italy.
| | - Johann Christian Virchow
- Universitätsmedizin Rostock, Zentrum für Innere Medizin, Abteilung für Pneumologie, Rostock, Germany
| | - Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Giorgio Walter Canonica
- Humanitas University and Research Hospital IRCCS, Center of Personalized Medicine: Asthma and Allergy, Milan, Italy
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90
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Oppenheimer J, Slade DJ, Hahn BA, Zografos L, Gilsenan A, Richardson D, McSorley D, Lima R, Molfino NA, Averell CM. Real-world evidence: Patient views on asthma in respiratory specialist clinics in America. Ann Allergy Asthma Immunol 2020; 126:385-393.e2. [PMID: 33387616 DOI: 10.1016/j.anai.2020.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Approximately 30% to 50% of patients with moderate/severe asthma have inadequately controlled disease despite adherence to inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) therapy. Data on prevalence and burden of uncontrolled asthma in specialty settings are lacking. OBJECTIVE To evaluate the prevalence and burden of uncontrolled asthma in respiratory specialist clinics in the United States. METHODS Adults with physician-diagnosed asthma attending pulmonary and allergy clinics with self-reported ICS use in the previous 4 weeks completed an electronic questionnaire including the Asthma Control Test and St George's Respiratory Questionnaire. Additional information was collected using an electronic case report form. RESULTS Of 774 patients attending 12 pulmonary and 12 allergy clinics, 53% were not well controlled (mean [SD] Asthma Control Test, 14.3 [3.6] vs 22.4 [1.6] in well-controlled patients). Among ICS/LABA users, 56% were not well controlled, which increased with increasing ICS dose (low-dose 45.7%; high-dose 59.7%). The not well-controlled group reported more respiratory illnesses, more comorbidities, and poorer health-related quality of life (mean [SD] St George's Respiratory Questionnaire, 46.1 [18.9] vs 19.8 [12.9] in the well-controlled group). These patients also had more asthma exacerbations (≥1 exacerbation, 68.9% vs 43.1%) and increased health care resource utilization (≥1 asthma-related hospitalization, 10.7% vs 2.7%); 27.3% were also receiving systemic corticosteroids. Approximately 40% of the population were eligible for step-up to ICS/LABA/long-acting muscarinic antagonist triple therapy, and 20% were eligible for biologic therapy. CONCLUSION Substantial unmet needs exist among patients with inadequately controlled asthma managed in United States specialist settings, which may be addressed by improved patient and physician education, better guideline implementation, and improved adherence.
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Affiliation(s)
- John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - David J Slade
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, North Carolina
| | - Beth A Hahn
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, North Carolina
| | - Laurie Zografos
- Surveys and Observational Studies, RTI Health Solutions, Research Triangle Park, North Carolina
| | - Alicia Gilsenan
- Surveys and Observational Studies, RTI Health Solutions, Research Triangle Park, North Carolina
| | - David Richardson
- Surveys and Observational Studies, RTI Health Solutions, Research Triangle Park, North Carolina
| | - David McSorley
- Surveys and Observational Studies, RTI Health Solutions, Research Triangle Park, North Carolina
| | - Robson Lima
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, North Carolina
| | - Nestor A Molfino
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, North Carolina
| | - Carlyne M Averell
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, North Carolina.
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91
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Affiliation(s)
- Stephanie Lovinsky-Desir
- Division of Pediatric Pulmonology, Columbia University Irving Medical Center, New York, New York
| | - George T O'Connor
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston Medical Center, Boston, Massachusetts
- Associate Editor, JAMA
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92
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Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management. NPJ Prim Care Respir Med 2020; 30:50. [PMID: 33177503 PMCID: PMC7658210 DOI: 10.1038/s41533-020-00205-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023] Open
Abstract
The Global Initiative for Asthma recommends a stepwise approach to adjust asthma treatment to the needs of individual patients; inhaled corticosteroids (ICS) remain the core pharmacological treatment. However, many patients remain poorly controlled, and evidence-based algorithms to decide on the best order and rationale for add-on therapies are lacking. We explore the challenges of asthma management in primary care and review outcomes from randomised controlled trials and meta-analyses comparing the long-acting muscarinic antagonist (LAMA) tiotropium with long-acting β2-agonists (LABAs) or leukotriene receptor antagonists (LTRAs) as add-on to ICS in patients with asthma. In adults, LAMAs and LABAs provide a greater improvement in lung function than LTRAs as add-on to ICS. In children, results were positive and comparable between therapies, but data are scarce. This information could aid decision-making in primary care, supporting the use of add-on therapy to ICS to help improve lung function, control asthma symptoms and prevent exacerbations.
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Singh D, Virchow JC, Canonica GW, Vele A, Kots M, Georges G, Papi A. Determinants of response to inhaled extrafine triple therapy in asthma: analyses of TRIMARAN and TRIGGER. Respir Res 2020; 21:285. [PMID: 33121501 PMCID: PMC7597025 DOI: 10.1186/s12931-020-01558-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/23/2020] [Indexed: 01/10/2023] Open
Abstract
Background A number of single-inhaler triple therapies are being developed for asthma, including the extrafine formulation of beclometasone dipropionate (BDP), formoterol fumarate (FF), and glycopyrronium (G). Given asthma is a heterogenous disease, we investigated whether the clinical response to the addition of the long-acting muscarinic antagonist component within inhaled triple therapy was impacted by a range of clinical characteristics. Methods These were pre-specified and post-hoc sub-group analyses of TRIMARAN and TRIGGER, which were double-blind, 52-week studies comparing medium-strength (100/6/10 µg; TRIMARAN) and high-strength (200/6/10 µg; TRIGGER) BDP/FF/G with the respective BDP/FF strengths in adults with uncontrolled asthma and a history of ≥ 1 exacerbation. Co-primary endpoints were pre-dose forced expiratory volume in 1 s (FEV1) at Week 26 and the rate of moderate-to-severe exacerbations over 52 weeks. Key secondary endpoints: peak FEV1 at Week 26 and average morning peak expiratory flow over the first 26 weeks in each study, and severe exacerbation rate over 52 weeks (pooled data). Results Baseline clinical characteristics (pre-specified analyses) had no consistent effect on the lung function improvements with BDP/FF/G. For the exacerbation endpoints, sub-groups with higher reversibility gained greatest relative benefit from BDP/FF/G versus BDP/FF. In post-hoc analyses with patients sub-grouped by screening blood eosinophil values, in TRIMARAN the greatest relative effect of BDP/FF/G versus BDP/FF on the lung function endpoints was in the ≤ 300 cells/µL group; in TRIGGER, eosinophil levels did not markedly influence the relative efficacy of BDP/FF/G versus BDP/FF. Eosinophil levels did not influence relative efficacy on moderate-to-severe or severe exacerbations. Conclusion Overall, the relative efficacy of extrafine BDP/FF/G versus BDP/FF was not influenced by a range of clinical characteristics. However, some patient sub-groups gained additional benefit from BDP/FF/G for certain endpoints. In particular, for exacerbations the relative efficacy of BDP/FF/G was greater in more reversible patients. Trial registration ClinicalTrials.gov: TRIMARAN, NCT02676076 (registered February 8, 2016, https://clinicaltrials.gov/ct2/show/NCT02676076?term=NCT02676076&draw=2&rank=1,); TRIGGER, NCT02676089 (registered February 8, 2016, https://clinicaltrials.gov/ct2/show/NCT02676089?term=NCT02676089&draw=2&rank=1)
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Johann Christian Virchow
- Zentrum Für Innere Medizin, Abteilung Für Pneumologie, Universitätsmedizin Rostock, Rostock, Germany
| | - Giorgio Walter Canonica
- Center of Personalized Medicine: Asthma and Allergy, Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S.Anna, Ferrara, Italy
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94
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Vaidya S, Jauernig J, Ethell B, Abdallah N, Machineni S, Drollmann A, Heudi O, Last S, Hahn M, Radhakrishnan R, Ignatenko S, Tillmann HC. Pharmacokinetics of indacaterol, glycopyrronium and mometasone furoate following once-daily inhalation as a combination in healthy subjects. Pulm Pharmacol Ther 2020; 64:101964. [PMID: 33035700 DOI: 10.1016/j.pupt.2020.101964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/21/2020] [Accepted: 09/30/2020] [Indexed: 02/01/2023]
Abstract
Indacaterol (IND), is co-formulated with glycopyrronium (GLY), and mometasone furoate (MF) as a once-daily (o.d.) inhaled fixed-dose combination (IND/GLY/MF) delivered via the Breezhaler® device for maintenance treatment of asthma. We evaluated the steady state plasma pharmacokinetics (PK) of IND, GLY and MF following inhalation of IND/GLY/MF or as monotherapies. This was a randomized, open-label, four-way crossover study. Subjects received IND/GLY/MF 150/50/160 μg (high-dose), IND 150 μg, GLY 50 μg or MF 190 μg (in vitro fine particle mass comparable to 160 μg MF in IND/GLY/MF) via the Breezhaler® device, o.d. for 14 days in each period, with a washout of at least 7 days. PK was characterized on Day 14, up to 24 h post-dose. In total, 36 healthy subjects were randomized. For IND, the geometric mean ratios (90% CI) for AUC0-24h,ss and Cmax,ss were 0.922 (0.878, 0.969) and 1.02 (0.967, 1.08), respectively for the IND/GLY/MF versus IND monotherapy comparison. For GLY, the geometric mean ratios (90% CI) for AUC0-24h,ss and Cmax,ss were 0.986 (0.944, 1.03) and 1.21 (1.09, 1.34), respectively for the IND/GLY/MF versus GLY comparison. For MF, the geometric mean ratios (90% CI) for AUC0-24h,ss and Cmax,ss were 1.16 (1.09, 1.24) and 1.17 (1.09, 1.25), respectively for IND/GLY/MF versus MF comparison. Similar systemic exposure was noted for IND/GLY/MF versus monotherapy for all three mono-components, indicating a lack of PK interaction. Multiple inhaled doses of IND, GLY and MF were safe and well tolerated, when administered alone or in combination. There was no clinically relevant pharmacokinetic interaction between IND, GLY and MF when administered as IND/GLY/MF.
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Affiliation(s)
- Soniya Vaidya
- Novartis Institutes for BioMedical Research, Cambridge, USA
| | | | - Brian Ethell
- Novartis Institutes for BioMedical Research, Cambridge, USA
| | - Nasri Abdallah
- Novartis Institutes for BioMedical Research, Translational Medicine, Basel, Switzerland
| | | | - Anton Drollmann
- Novartis Institutes for BioMedical Research, Translational Medicine, Basel, Switzerland
| | - Olivier Heudi
- Novartis Institutes for BioMedical Research, Translational Medicine, Basel, Switzerland
| | | | - Michael Hahn
- Novartis Institutes for BioMedical Research, Translational Medicine, Basel, Switzerland
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95
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Lommatzsch M, Buhl R, Korn S. The Treatment of Mild and Moderate Asthma in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:434-444. [PMID: 32885783 DOI: 10.3238/arztebl.2020.0434] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 04/30/2019] [Accepted: 04/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Asthma is a chronic inflammatory airway disease that usually causes variable airway obstruction. It affects 5-10% of the German population. METHODS This review is based on relevant publications retrieved by a selective search, as well as on national and international guidelines on the treatment of mild and moderate asthma in adults. RESULTS The goal of treatment is to attain optimal asthma control with a minimal risk of exacerbations and mortality, loss of pulmonary function, and drug side effects. This can be achieved with a combination of pharmacotherapy and non-drug treatment including patient education, exercise, smoking cessation, and rehabilitation. Pharmacohterapy is based on inhaled corticosteroids (ICS) and bronchodilators. It is recommended that mild asthma should be treated only when needed, either with a fixed combination of ICS and formoterol or with short-acting bronchodilators. For moderate asthma, maintenance treatment is recommended, with an inhaled fixed combinations of ICS and long-acting beta-mimetics, possibly supplemented with longacting anticholinergic agents. Allergen immunotherapy, i.e., desensitization treatment, should be considered if the allergic component of asthma is well documented and the patient is not suffering from uncontrolled asthma. Asthma control should be monitored at regular intervals, and the treatment should be adapted accordingly. CONCLUSION The treatment of asthma in adults should be individually tailored, with anti-inflammatory treatment as its main component.
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Affiliation(s)
- Marek Lommatzsch
- Department of Pneumology/Interdis ciplinary Intensive Care Unit, University of Rostock; Department of Internal Medicine III (Hematology, Oncology, Pneumology), University Medical Center, Johannes Gutenberg University Mainz
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96
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Singh D, Virchow JC, Canonica GW, Vele A, Kots M, Georges G, Papi A. Extrafine triple therapy in patients with asthma and persistent airflow limitation. Eur Respir J 2020; 56:13993003.00476-2020. [PMID: 32430414 DOI: 10.1183/13993003.00476-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/21/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Johann Christian Virchow
- Universitätsmedizin Rostock, Zentrum für Innere Medizin, Abteilung für Pneumologie, Rostock, Germany
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy.,Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
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97
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Chang AB, Beasley R. More options for managing severe asthma in adults. THE LANCET RESPIRATORY MEDICINE 2020; 9:3-5. [PMID: 32918891 DOI: 10.1016/s2213-2600(20)30398-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Anne B Chang
- Centre for Healthcare Transformation, Queensland University of Technology and Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Darwin, NT, Australia.
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
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98
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Lee LA, Bailes Z, Barnes N, Boulet LP, Edwards D, Fowler A, Hanania NA, Kerstjens HAM, Kerwin E, Nathan R, Oppenheimer J, Papi A, Pascoe S, Brusselle G, Peachey G, Sule N, Tabberer M, Pavord ID. Efficacy and safety of once-daily single-inhaler triple therapy (FF/UMEC/VI) versus FF/VI in patients with inadequately controlled asthma (CAPTAIN): a double-blind, randomised, phase 3A trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:69-84. [PMID: 32918892 DOI: 10.1016/s2213-2600(20)30389-1] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite inhaled corticosteroid plus long-acting β2-agonist (ICS/LABA) therapy, 30-50% of patients with moderate or severe asthma remain inadequately controlled. We investigated the safety and efficacy of single-inhaler fluticasone furoate plus umeclidinium plus vilanterol (FF/UMEC/VI) compared with FF/VI. METHODS In this double-blind, randomised, parallel-group, phase 3A study (Clinical Study in Asthma Patients Receiving Triple Therapy in a Single Inhaler [CAPTAIN]), participants were recruited from 416 hospitals and primary care centres across 15 countries. Participants were eligible if they were aged 18 years or older, with inadequately controlled asthma (Asthma Control Questionnaire [ACQ]-6 score of ≥1·5) despite ICS/LABA, a documented health-care contact or a documented temporary change in asthma therapy for treatment of acute asthma symptoms in the year before screening, pre-bronchodilator FEV1 between 30% and less than 85% of predicted normal value, and reversibility (defined as an increase in FEV1 of ≥12% and ≥200 mL in the 20-60 min after four inhalations of albuterol or salbutamol) at screening. Participants were randomly assigned (1:1:1:1:1:1), via central based randomisation stratified by pre-study ICS dose at study entry, to once-daily FF/VI (100/25 μg or 200/25 μg) or FF/UMEC/VI (100/31·25/25 μg, 100/62·5/25 μg, 200/31·25/25 μg, or 200/62·5/25 μg) administered via Ellipta dry powder inhaler (Glaxo Operations UK, Hertfordshire, UK). Patients, investigators, and the funder were masked to treatment allocation. Endpoints assessed in the intention-to-treat population were change from baseline in clinic trough FEV1 at week 24 (primary) and annualised moderate and/or severe asthma exacerbation rate (key secondary). Other secondary endpoints were change from baseline in clinic FEV1 at 3 h post-dose, St George's Respiratory Questionnaire (SGRQ) total score, and ACQ-7 total score, all at week 24. Change from baseline in Evaluating Respiratory Symptoms in Asthma total score at weeks 21-24 was also a secondary endpoint but is not reported here. Exploratory analyses of biomarkers of type 2 airway inflammation on treatment response were also done. This study is registered with ClinicalTrials.gov, NCT02924688, and is now complete. FINDINGS Between Dec 16, 2016, and Aug 31, 2018, 5185 patients were screened and 2439 were recruited and randomly assigned to FF/VI (100/25 μg n=407; 200/25 μg n=406) or FF/UMEC/VI (100/31·25/25 μg n=405; 100/62·5/25 μg n=406; 200/31·25/25 μg n=404; 200/62·5/25 μg n=408), with three patients randomly assigned in error and not included in analyses. In the intention-to-treat population, 922 (38%) patients were men, the mean age was 53·2 years (SD 13·1) and body-mass index was 29·4 (6·6). Baseline demographics were generally similar across all treatment groups. The least squares mean improvement in FEV1 change from baseline for FF/UMEC/VI 100/62·5/25 μg versus FF/VI 100/25 μg was 110 mL (95% CI 66-153; p<0·0001) and for 200/62·5/25 μg versus 200/25 μg was 92 mL (49-135; p<0·0001). Adding UMEC 31·25 μg to FF/VI produced similar improvements (FF/UMEC/VI 100/31·25/25 μg vs FF/VI 100/25 μg: 96 mL [52-139; p<0·0001]; and 200/31·25/25 μg vs 200/25 μg: 82 mL [39-125; p=0·0002]). These results were supported by the analysis of clinic FEV1 at 3 h post-dose. Non-significant reductions in moderate and/or severe exacerbation rates were observed for FF/UMEC 62·5 μg/VI versus FF/VI (pooled analysis), with rates lower in FF 200 μg-containing versus FF 100 μg-containing treatment groups. All pooled treatment groups demonstrated mean improvements (decreases) in SGRQ total score at week 24 compared with baseline in excess of the minimal clinically important difference of 4 points; however, there were no differences between treatment groups. For mean change from baseline to week 24 in asthma control questionnaire-7 score, improvements (decreases) exceeding the minimal clinically important difference of 0·5 points were observed in all pooled treatment groups. Adding UMEC to FF/VI resulted in small, dose-related improvements compared with FF/VI (pooled analysis: FF/UMEC 31·25 μg/VI versus FF/VI, -0·06 (95% CI -0·12 to 0·01; p=0·094) FF/UMEC 62·5 μg/VI versus FF/VI, -0·09 (-0·16 to -0·02, p=0·0084). By contrast with adding UMEC, the effects of higher dose FF on clinic trough FEV1 and annualised moderate and/or severe exacerbation rate were increased in patients with higher baseline blood eosinophil count and exhaled nitric oxide. Occurrence of adverse events was similar across treatment groups (patients with at least one event ranged from 210 [52%] to 258 [63%]), with the most commonly reported adverse events being nasopharyngitis (51 [13%]-63 [15%]), headache (19 [5%]-36 [9%]), and upper respiratory tract infection (13 [3%]-24 [6%]). The incidence of serious adverse events was similar across all groups (range 18 [4%]-25 [6%)). Three deaths occurred, of which one was considered to be related to study drug (pulmonary embolism in a patient in the FF/UMEC/VI 100/31·25/25 μg group). INTERPRETATION In patients with uncontrolled moderate or severe asthma on ICS/LABA, adding UMEC improved lung function but did not lead to a significant reduction in moderate and/or severe exacerbations. For such patients, single-inhaler FF/UMEC/VI is an effective treatment option with a favourable risk-benefit profile. Higher dose FF primarily reduced the rate of exacerbations, particularly in patients with raised biomarkers of type 2 airway inflammation. Further confirmatory studies into the differentiating effect of type 2 inflammatory biomarkers on treatment outcomes in asthma are required to build on these exploratory findings and further guide clinical practice. FUNDING GSK.
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Affiliation(s)
| | - Zelie Bailes
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Neil Barnes
- GSK, Brentford, Middlesex, UK; Barts and the London School of Medicine and Dentistry, London, UK
| | | | - Dawn Edwards
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Huib A M Kerstjens
- University of Groningen and University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, Netherlands
| | - Edward Kerwin
- Crisor, Clinical Research Institute, Medford, OR, USA
| | - Robert Nathan
- Asthma & Allergy Associates, PC and Research Center, Colorado Springs, CO, USA
| | | | | | | | | | - Guy Peachey
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Neal Sule
- GlaxoSmithKline (GSK), Collegeville, PA, USA
| | | | - Ian D Pavord
- Nuffield Department of Medicine and Oxford Respiratory NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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99
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Lee H, Ryu J, Chung SJ, Park DW, Sohn JW, Yoon HJ, Kim SH. Coexisting COPD Increases Mortality in Patients With Corticosteroid-Dependent Asthma: A Nationwide Population-Based Study. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:821-831. [PMID: 32638562 PMCID: PMC7346996 DOI: 10.4168/aair.2020.12.5.821] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Chronic corticosteroid (CS) use is a risk factor for long-term mortality in asthmatic patients, and the presence of coexisting chronic obstructive pulmonary disease (COPD) is associated with a severe presentation and poor prognosis. However, the impact of coexisting COPD on long-term mortality in patients with CS-dependent asthma has not been well elucidated. This study aimed to determine the impact of coexisting COPD on long-term mortality in patients with CS-dependent asthma. METHODS A retrospective cohort of patients with CS-dependent asthma aged 40 years or older was established using records from the Korean National Health Insurance Service database for 2005 to 2015. We classified the subjects into 2 groups according to the presence of COPD and evaluated the hazard ratio (HR) for all-cause mortality in patients with COPD relative to those without COPD. RESULTS Of 8,021 patients with CS-dependent asthma, 3,121 (38.9%) had COPD. All-cause mortality was significantly greater in patients with CS-dependent asthma and COPD than in those without COPD (9,955/100,000 person-years vs. 5,585/100,100 person-years, P < 0.001). The adjusted HRs were 1.29 (95% confidence interval [CI], 1.21-1.38), and the associations were especially significant for chronic lower respiratory diseases (subdistribution HR, 2.30; 95% CI, 2.06-2.57) and lung cancer (subdistribution HR, 1.34; 95% CI, 1.02-1.78). CONCLUSIONS In this population-based retrospective cohort study, the presence of physician-recognized COPD was associated with greater all-cause mortality and greater risk of mortality due to chronic lower respiratory diseases and lung cancer in patients with CS-dependent asthma. Early recognition and appropriate management of COPD can improve treatment outcomes in patients with CS-dependent asthma.
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Affiliation(s)
- Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jiin Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Sung Jun Chung
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jang Won Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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100
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Jabbal S, Kuo CR, Lipworth B. Randomized controlled trial of triple versus dual inhaler therapy on small airways in smoking asthmatics. Clin Exp Allergy 2020; 50:1140-1147. [PMID: 33180376 DOI: 10.1111/cea.13702] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Smoking worsens underlying asthma inflammation and also induces resistance to inhaled corticosteroids (ICS). Small airways dysfunction measured by impulse oscillometry (IOS) is associated with worse control. OBJECTIVES We investigated the effects on small airways of adding long-acting beta-agonist (LABA) alone or with long-acting muscarinic antagonist (LAMA) to ICS in asthmatic smokers. METHODS Sixteen current smokers were enrolled: mean age 44 year, FEV1 84%, FEF25-75 47%, R5 158%, ACQ 1.69, 20 pack year . Patients were converted to a reference ICS as HFA-BDP during initial run-in at median dose of 800 µg/day. Open label olodaterol 5 µg od (OLO) or olodaterol 5 µg/tiotropium 5 µg od (OLO/TIO) was added to HFA-BDP for median duration of 3 weeks in a randomized cross over design, including run-in and washout periods on HFA-BDP. IOS and spirometry were measured after each treatment (BDP/OLO/TIO or BDP/OLO) and at baseline after run-in and washout (BDP). RESULTS After chronic dosing, IOS outcomes at trough except for R20 were all significantly improved with OLO/TIO compared to OLO. For the primary end-point of total airway resistance (as R5), the mean difference (95%CI) at trough was 0.06 (0.015-0.10) kPa/l/s, peripheral airways resistance (as R5-R20) 0.03 (0.003-0.06) kPa/l/s, peripheral lung reactance area (as AX) 0.38 (0.08-0.68) kPa/l and resonant frequency (as RF) 2.28 (0.45-4.12) Hz. FEF25-75 at trough was also better with OLO/TIO vs TIO: 0.93 (0.86 - 0.95) l/s while FEV1 was not different. CONCLUSIONS ICS/LABA/LAMA was superior to ICS/LABA on trough small airway outcomes in asthma patients who smoke.
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Affiliation(s)
- Sunny Jabbal
- Scottish Centre for Respiratory Research, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, Scotland
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, Scotland
| | - Brian Lipworth
- Scottish Centre for Respiratory Research, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, Scotland
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