51
|
Vähätalo I, Ilmarinen P, Tuomisto LE, Tommola M, Niemelä O, Lehtimäki L, Nieminen P, Kankaanranta H. 12-year adherence to inhaled corticosteroids in adult-onset asthma. ERJ Open Res 2020; 6:00324-2019. [PMID: 32211439 PMCID: PMC7086072 DOI: 10.1183/23120541.00324-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/06/2020] [Indexed: 11/14/2022] Open
Abstract
Adherence to inhaled corticosteroids (ICS) has been suggested to be poor but long-term follow-ups are lacking. The objective of the present study was to assess adherence to ICS treatment in patients with adult-onset asthma during 12-year follow-up. A total of 181 patients with clinically confirmed, new-onset adult asthma were followed for 12 years as part of the Seinäjoki Adult Asthma Study. Adherence to ICS was assessed individually as the percentage of true dispensed ICS in micrograms per true prescribed daily ICS in micrograms over 12 years. Mean 12-year adherence to ICS was 69% (mean±sd dispensed 2.5±1.8 g and prescribed 3.6±1.5 g budesonide equivalent per patient for 12 years), annual adherence varying between 81% (year 1) and 67% (year 12). Patients with good 12-year adherence (≥80%) used oral corticosteroids more often, and had add-on drugs in use and asthma-related visits to healthcare more often. In addition, they showed less reversibility in forced expiratory volume in 1 s and had higher peripheral blood neutrophil counts. However, lung function decline was steeper in patients with poorer adherence (<80%) and this association remained in multiple linear regression analysis. No difference was found in symptom scores, blood eosinophil counts, exhaled nitric oxide or immunoglobulin E between the patients with different levels of adherence. In patients with adult-onset asthma, adherence to ICS was moderate. Poorer adherence (<80%) to ICS was associated with more rapid decline in lung function but was not associated to symptoms or markers of inflammatory endotypes. Mean long-term adherence to ICS treatment is 69% in patients with confirmed adult-onset asthma. While good ICS adherence (≥80%) is associated with features of more severe asthma, poorer adherence (<80%) predicts more rapid lung function decline.http://bit.ly/37mvh74
Collapse
Affiliation(s)
- Iida Vähätalo
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Pinja Ilmarinen
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Leena E Tuomisto
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Minna Tommola
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Onni Niemelä
- Dept of Laboratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Pentti Nieminen
- Medical Informatics and Statistics Research Group, University of Oulu, Oulu, Finland
| | - Hannu Kankaanranta
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| |
Collapse
|
52
|
Inhaled corticosteroid-phobia and childhood asthma: Current understanding and management implications. Paediatr Respir Rev 2020; 33:62-66. [PMID: 31053357 DOI: 10.1016/j.prrv.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 02/04/2023]
Abstract
Asthma is the most prevalent chronic disease in children. Inhaled corticosteroids (ICS) is the first-line controller therapy for children with persistent asthma, however, suboptimal compliance to ICS therapy remains as a major obstacle in paediatric asthma management. Steroid-phobia, the fear of side-effects and subsequent aversion of ICS, has been widely reported in parents of asthmatic children. The reported prevalence of steroid-phobia varies widely from 19% to 67% in different populations. The concerns about ICS frequently raised by parents include growth suppression, weight gain, bone weakness, addiction and psychiatric disturbances. Outside of growth suppression, which is statistically significant yet mild in clinical studies, the other concerns are not evidence-based and are misconceptions. Conflicting results have been reported regarding the impact of steroid-phobia on ICS compliance. In contrast, steroid-phobia has consistent and negative effects on asthma control in children. While asthma educational programmes have demonstrable benefits in general paediatric populations, the generalisability of such programmes to steroid-phobic parents remains undetermined. There is a paucity of data on specific educational programmes to clear misconceptions and reduce steroid-phobia. Given the continually raising prevalence of paediatric asthma, high-quality studies are warranted to investigate the prevalence and impact of steroid-phobia, with an ultimate goal of developing effective strategies to tackle steroid-phobia and improve asthma care in children.
Collapse
|
53
|
Weinberger SJ, Cowan KJ, Robinson KJ, Pellegrino CA, Frankowski BL, Chmielewski MV, Shaw JS, Harder VS. A primary care learning collaborative to improve office systems and clinical management of pediatric asthma. J Asthma 2019; 58:395-404. [PMID: 31838923 DOI: 10.1080/02770903.2019.1702199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.
Collapse
Affiliation(s)
- Stanley J Weinberger
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Kelly J Cowan
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Keith J Robinson
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Barbara L Frankowski
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Judith S Shaw
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Valerie S Harder
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
| |
Collapse
|
54
|
Low socioeconomic position and neighborhood deprivation are associated with uncontrolled asthma in elderly. Respir Med 2019; 158:70-77. [PMID: 31610380 DOI: 10.1016/j.rmed.2019.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND While uncontrolled asthma in adults is frequent in Europe, the impact of socioeconomic position (SEP) was little investigated. We aimed to investigate the respective association of individual- and area-level SEP with uncontrolled asthma among French elderly women. METHODS Analyses were conducted in the Asthma-E3N study, among participants with current asthma (i.e., asthma attacks, treatment, or symptoms in previous year). Asthma control was evaluated using Asthma Control Test (uncontrolled: score ≤19); SEP was defined at both individual- and area-level, using educational level (low, medium, high), the French Deprivation index (tertiles defined at national level), and by merging them in a combined-SEP index. Associations between SEP and asthma control were estimated for 2258 women by logistic regression adjusted for age. Analyses were stratified by asthma controller medication use estimated through a drug reimbursement database. RESULTS Women were 70 years on average and 24% had uncontrolled asthma. A low educational level (11%) was associated with an increased risk of uncontrolled asthma [odds ratio (95% confidence interval) = 1.9 (1.4,2.6)], especially among women not using controller medication [3.1 (1.9,5.1)]. Using the combined-SEP index, the highest risk of uncontrolled asthma was observed among women with the most disadvantaged socioeconomic profile (low educational level and low-SEP neighborhood) [2.5 (1.5,4.2)]. CONCLUSIONS Women with low SEP had more often uncontrolled asthma, which might be partly explained by inadequate asthma treatment. To achieve the best management of asthma for elderly patients, a specific attention should be given not only to disadvantaged population and neighborhoods, but also to disadvantaged populations in affluent neighborhoods.
Collapse
|
55
|
Barnes PJ, Szefler SJ, Reddel HK, Chipps BE. Symptoms and perception of airway obstruction in asthmatic patients: Clinical implications for use of reliever medications. J Allergy Clin Immunol 2019; 144:1180-1186. [PMID: 31330221 DOI: 10.1016/j.jaci.2019.06.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma causes the unpleasant sensation of breathlessness (dyspnea) caused by airway obstruction. Patients with poor perception of airway obstruction are at risk of delay in seeking medical attention and undertreatment, which can lead to avoidable deaths. Conversely, those with heightened perception are at risk of overtreatment and iatrogenic adverse effects with reliever medications, anxiety, and unnecessary use of health care resources. OBJECTIVE We sought to review evidence about symptom misperception in asthmatic patients and how to identify and manage affected patients, particularly with regard to reliever medications. METHODS We conducted a systematic literature search for studies of perception of airway function in asthmatic patients. We searched the OVID (Medline and Medline [R] in process [PubMed]), Embase, and Adisearch/Odyssey databases, restricting our search to human studies published in English from 1990-2018, with no restrictions on age, sex, or racial origin. RESULTS We found that both underperception and overperception assessed during induced bronchoconstriction or bronchodilation or during changes in airway resistance were common across all age groups and that aging, disease severity, smoking, sex, ethnicity, psychologic factors, and medication are all associated with differences in perception. Importantly, airway inflammation was associated with impaired perception and a history of severe or near-fatal asthma. We also identified knowledge gaps, such as whether an individual patient's perception varies over time and the influence perception has on patients' use of reliever medication. CONCLUSION We found that abnormal perception of airway obstruction has important clinical implications for the management of patients with asthma.
Collapse
Affiliation(s)
- Peter J Barnes
- National Heart & Lung Institute, Imperial College, London, United Kingdom.
| | - Stanley J Szefler
- Paediatric Asthma Research Program and the Breathing Institute, Children's Hospital Colorado, and the Department of Pediatrics, University Colorado School of Medicine, Aurora, Colo
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | |
Collapse
|
56
|
Reddel HK, FitzGerald JM, Bateman ED, Bacharier LB, Becker A, Brusselle G, Buhl R, Cruz AA, Fleming L, Inoue H, Ko FWS, Krishnan JA, Levy ML, Lin J, Pedersen SE, Sheikh A, Yorgancioglu A, Boulet LP. GINA 2019: a fundamental change in asthma management. Eur Respir J 2019; 53:53/6/1901046. [DOI: 10.1183/13993003.01046-2019] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 11/05/2022]
|
57
|
Mulgirigama A, Barnes N, Fletcher M, Pedersen S, Pizzichini E, Tsiligianni I. A review of the burden and management of mild asthma in adults - Implications for clinical practice. Respir Med 2019; 152:97-104. [PMID: 31128617 DOI: 10.1016/j.rmed.2019.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 11/28/2022]
Abstract
Mild asthma is present in 50-75% of patients with asthma and is defined by the Global Initiative for Asthma as asthma that can be well controlled with low-intensity treatments (Steps 1 and 2). Despite this definition, 'mild' asthma is often not well controlled in reality, and can have a significant impact on an individual's symptom burden and quality of life. We performed a PubMed literature search to investigate the burden of 'mild' asthma in the lives of patients, including future risk and asthma control, and the current management strategies. While clinical guidelines recommend long-term, daily, low-dose inhaled corticosteroids (ICS) for 'mild' asthma, published data suggest that ICS are often under-prescribed or used intermittently as symptoms arise. Furthermore, patients and physicians tend to overestimate disease control, impacting the accuracy of diagnosing 'mild asthma' and subsequent management. This disconnect may be amplified by miscommunication between patients and physicians, limited objective assessment of control, and differences in guidelines. As with moderate and severe asthma, current evidence supports early initiation of regular ICS in 'mild' asthma to address the underlying inflammation, achieve symptom control and reduce risk of exacerbations. Adherence to ICS treatment is key and can be improved by educating both patients and healthcare professionals. The results of this literature search challenge the term 'mild' asthma and suggest strategies to improve the proactive management of the disease to enable patients to live symptom-free.
Collapse
Affiliation(s)
| | - Neil Barnes
- GSK, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK; Bart's and the London School of Medicine and Dentistry, 4 Newark St, London, E1 2AT, UK.
| | - Monica Fletcher
- GSK, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK; University of Edinburgh, 9 Little France Rd, Edinburgh, EH16 4UX, UK.
| | - Søren Pedersen
- Department of Paediatrics, University of Southern Denmark, Kolding Hospital, Sygehusvej 24, 6000, Kolding, Denmark.
| | - Emilio Pizzichini
- GSK, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK; NUPAIVA Asthma Research Centre, Universidade Federal de Santa Catarina (UFSC), Trindade, CEP 88 040 970, Florianópolis, SC, Brazil.
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Voutes, GR71003, Greece.
| |
Collapse
|
58
|
Desjardin A, Garcia G. [New approaches of inhaled steroid asthma management in mild to moderate asthma]. Presse Med 2019; 48:293-302. [PMID: 30954316 DOI: 10.1016/j.lpm.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 11/17/2022] Open
Abstract
Inhaled corticosteroids (ICS) are the cornerstone of the management of asthma. Daily use allows to reduce mortality, intensity and frequency of exacerbations, to increase the control of symptoms of asthma and the quality of life of asthmatics patients and to reduce the decline of the lung function. A daily use of a weak dose of ICS allows to control the symptoms of asthma of the vast majority of mild to moderate asthmatics patients who account for about 75-80 % of the French asthmatic patients. An add-on strategy with a combination by ICS/LABA allows to decrease by 20 % the risk of an exacerbation compared with a treatment by CSI in monotherapy. "SMART" which consists in using a fixed ICS/LABA combination as a maintenance and reliever therapy had showed better results in the prevention of exacerbations that the use of the same combination associated with a SABA as a reliever therapy. This strategy is recommended by GINA at the same level of proof as the classical treatment. An "on-demand" use of a ICS/LABA combination according to symptoms is clearly less efficacious in terms of control of the symptoms than the classical strategy by ICS/LABA; but both strategies are identical in terms of prevention of exacerbations. The daily dose of ICS is 4 to 5 times less than in the daily ICS group. The clinical effectiveness and cost-effectiveness of a standard asthma self-management plan that advises patients to temporarily quadrupling the dose of ICS in case of asthma worsening can be an alternative and allow to reduce 20 % of clinically important asthma exacerbations.
Collapse
Affiliation(s)
- Amaury Desjardin
- CHU de Caen Normandie, service de pneumologie, 14000 Caen, France; CH de Lisieux, service de pneumologie, 14100 Lisieux, France
| | - Gilles Garcia
- Université Paris-Sud, faculté de médecine, 94270 Le Kremlin-Bicêtre, France; Centre chirurgical Marie-Lannelongue, Inserm U999, LabEx LERMIT, 92350 Le Plessis-Robinson, France; Assistance publique-Hôpitaux de Paris, hôpital universitaire de Bicêtre, DHU Thorax Innovation, centre de référence de l'hypertension pulmonaire sévère, service de pneumologie, 78, avenue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
| |
Collapse
|
59
|
Mjid M, Souissi Z, El gueddari Y, Ben Younes A, Raharisson O, Daghfous H, Toujani S, Beji M. Prise en charge thérapeutique des asthmatiques adultes et application des recommandations du GINA dans les pays du Maghreb et à Madagascar. REVUE FRANÇAISE D'ALLERGOLOGIE 2019. [DOI: 10.1016/j.reval.2019.02.213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
60
|
Laba TL, Jan S, Zwar NA, Roughead E, Marks GB, Flynn AW, Goldman MD, Heaney A, Lembke KA, Reddel HK. Cost-Related Underuse of Medicines for Asthma-Opportunities for Improving Adherence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2298-2306.e12. [PMID: 30928659 DOI: 10.1016/j.jaip.2019.03.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/24/2019] [Accepted: 03/14/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND In asthma, underuse of cost-effective preventive treatments increases morbidity and mortality. The cost of medicines contributes to underuse ("nonadherence"), but the extent to which people with asthma skip or reduce doses or let prescriptions go unfilled when faced with cost pressures is unknown. OBJECTIVE To estimate the extent of cost-related underuse behaviors and associated factors. METHODS Using previously validated summary indicators, we conducted an online cross-sectional survey of adults and parents of children 5 to 17 years with asthma in Australia (a high-income country) and developed logistic regression models for adults and children with asthma, controlling for key clinical and demographic factors. RESULTS The survey was completed by n = 792 adults (mean age, 47 [standard deviation, 17] years, male 47%, concession 60%) and n = 609 parents of children (5-10 years 51%, male 60%, concession 59%) with asthma. Cost-related underuse was reported by 52.9% adults and 34.3% parents, predominantly decreasing or skipping doses to make medicines last longer. Higher odds of cost-related underuse were observed with younger adults (adults: odds ratio [OR]: 1.19; 95% confidence interval [CI]: 1.12, 1.27), males (adults: OR: 1.49; 95% CI: 1.06, 2.08), having concerns about medicines (adults: OR: 3.12; 95% CI: 2.17, 4.35; parents: OR: 2.63; 95% CI: 1.56, 4.55), less comfortable talking to prescribers about cost (parents: OR: 1.22; 95% CI: 1.12, 1.33) or changing medicines (adults: OR: 1.12; 95% CI: 1.03, 1.22), feeling less engaged with prescribers about medicine decisions (parents: OR: 1.11; 95% CI: 1.01, 1.23), and with poorer asthma control (adults, poor control: OR: 1.87; 95% CI: 1.13, 3.09; parents, poor control: OR: 3.87; 95% CI: 1.99, 7.54), and requiring specialist (parents: OR: 1.83; 95% CI: 1.16, 2.87) or urgent health care visits (adults: OR: 1.54; 95% CI: 1.06, 2.23). Income and concession card status were not associated with cost-related underuse. CONCLUSIONS Adults and parents of children with asthma indicate high rates of cost-related underuse of asthma medicines, even in the context of national medicines subsidies. Urgent targeting of interventions to promote discussion of medicines and costs between doctor and patients, particularly young adult males, is needed.
Collapse
Affiliation(s)
- Tracey-Lea Laba
- Faculty of Medicine and Health, Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Camperdown, Australia; The George Institute for Global Health, University of New South Wales, Newtown, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Newtown, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Randwick, Australia; Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anthony W Flynn
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Chatswood, Australia
| | - Michele D Goldman
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Chatswood, Australia
| | - Aine Heaney
- Department of Program Design, NPS MedicineWise, Sydney, Australia
| | - Kirsty A Lembke
- Department of Program Design, NPS MedicineWise, Sydney, Australia
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| |
Collapse
|
61
|
Davis SR, Tudball J, Flynn A, Lembke K, Zwar N, Reddel HK. "You've got to breathe, you know" - asthma patients and carers' perceptions around purchase and use of asthma preventer medicines. Aust N Z J Public Health 2019; 43:207-213. [PMID: 30727033 DOI: 10.1111/1753-6405.12865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore influences on patients' purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co-payments. METHODS Semi-structured telephone or face-to-face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory. RESULTS Twenty-four adults and 20 carers for children aged 3-17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision-maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side-effects, perceived benefit and patient behaviours were important. CONCLUSIONS Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health: Asthma patients and carers could benefit from greater involvement and respect within shared decision-making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline-recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS-alone treatment and the rationale behind co-payments, for initiatives around quality use of medicines to succeed.
Collapse
Affiliation(s)
- Sharon R Davis
- Woolcock Institute of Medical Research, University of Sydney, New South Wales
| | | | | | | | - Nicholas Zwar
- School of Medicine; Faculty of Science, Medicine and Health University of Wollongong, New South Wales
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, New South Wales
| |
Collapse
|
62
|
Abstract
Asthma is a serious global health issue and asthma guidelines recommend a stepwise approach to management with goals to achieve control and minimize future risk. Prior to escalation of pharmacotherapy, steps to confirm accurate diagnosis as well as address comorbidities and triggers are critical to effective asthma management. This article provides readers with a structured approach to evaluation and management of asthma of varying severity.
Collapse
Affiliation(s)
- Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mary Parkes Center for Asthma, Allergy and Pulmonary Care, University of Rochester Medical Center, 601 Elmwood Avenue, Box 692, Rochester, NY 14642, USA.
| | - Nizar N Jarjour
- University of Wisconsin School of Medicine and Public Health, K4/914 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-9988, USA
| |
Collapse
|
63
|
Pertzborn MC, Prabhakaran S, Hardy A, Baker D, Robinson MA, Hendeles L. Direct Observed Therapy of Inhaled Corticosteroids for Asthma at School or Daycare. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:226-229. [PMID: 30595951 DOI: 10.1089/ped.2018.0912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/22/2018] [Indexed: 10/27/2022]
Abstract
Background: Poor adherence with inhaled corticosteroid (ICS) medication is common in the pediatric population and can result in poor asthma control with increased frequency of asthma-related complications. The purpose of this study was to determine whether or not the initiation of ICS administration twice per day at school/daycare in patients with poor medication adherence at home improves asthma health care outcomes. Methods: We retrospectively selected patients followed by our Pediatric Pulmonology Clinic who had poorly controlled asthma and had been assigned to receive ICS twice daily at school/daycare due to poor adherence with ICS therapy. We analyzed the number of short courses of oral corticosteroids, hospital admissions, emergency department visits, and intramuscular methylprednisolone administrations for asthma exacerbations for the year before and after the intervention. The Wilcoxon signed rank test with continuity correction was used in the primary analysis. Results: Forty-nine patients who met the inclusion criteria were identified, but only 40 actually started the intervention. The number of oral corticosteroid courses per year decreased from 1.35 ± 1.1 before the intervention to 0.68 ± 1.2 (P = 0.008) postintervention, hospital admissions per year decreased from 0.45 ± 0.7 to 0.10 ± 0.3 (P = 0.006), emergency department visits per year decreased from 0.55 ± 0.8 to 0.28 ± 0.6 (P = 0.084), and intramuscular repository methylprednisolone injections per year for asthma exacerbations decreased from 0.20 ± 0.4 to 0.10 ± 0.3 (P = 0.23). Conclusion: These results indicate that school/daycare administration of ICS may be an effective option to improve indicators of asthma exacerbations in children with poor adherence to ICS at home.
Collapse
Affiliation(s)
- Matthew C Pertzborn
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Sreekala Prabhakaran
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia Hardy
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Dawn Baker
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Matthew A Robinson
- Department of Biostatistics, Epidemiology, and Research Design at CTSI, Gainesville, Florida
| | - Leslie Hendeles
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida.,College of Pharmacy, Gainesville, Florida
| |
Collapse
|
64
|
Wadden D, Allwood Newhook LA, Twells L, Farrell J, Gao Z. Sex-Specific Association between Childhood BMI Trajectories and Asthma Phenotypes. Int J Pediatr 2018; 2018:9057435. [PMID: 30631374 PMCID: PMC6304644 DOI: 10.1155/2018/9057435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/06/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Asthma and obesity are two common health problems in the pediatric population. Obesity is associated with several comorbidities which are of great consequence. Excess adipose tissue has been linked to asthma in a number of studies. However, little is known about childhood body mass index (BMI) trajectories and the development of asthma phenotypes. OBJECTIVE The current study aims to investigate the significance of BMI trajectories over childhood and the risk of asthma phenotypes. METHODS The current study is a prospective cohort of children aged 0-2 years who were followed every two years for eight years through cycles one to five in the National Longitudinal Survey of Children and Youths (NLSCY). Statistical analysis: a latent class growth modelling (LCGM) method was used to identify BMI trajectory patterns from cycles one to five. Multiple imputation (number of imputations=5) was carried out to impute children with missing values on height or weight information. Sampling weights and 1,000 bootstrap weights were used in SAS PROC SURVEYLOGISTIC to examine the association between BMI trajectory and asthma phenotypes (persistent or transient asthma) in a multivariate analysis. RESULTS The study consisted of 571,790 males and 549,230 females. Among them, 46% of children showed an increasing trajectory in terms of change in BMI percentile during childhood, followed by the stable-trajectory group (41%) and decreasing-trajectory group (13%). After controlling for confounding factors, females in the increasing BMI trajectory group were four times more likely to be associated with persistent asthma (OR = 4.09; 95% CI:1.04-16.15; p = 0.0442) than females in the stable BMI trajectory group. No such relationship was found in males. The BMI trajectory was not significantly associated with risk of transient asthma for either sex. CONCLUSION We report a female-specific association between increasing adiposity, measured by BMI, and persistent asthma.
Collapse
Affiliation(s)
- Danny Wadden
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | | | - Laurie Twells
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Jamie Farrell
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Zhiwei Gao
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| |
Collapse
|
65
|
Jean T, Yang SJ, Crawford WW, Takahashi SH, Sheikh J. Development of a pediatric asthma predictive index for hospitalization. Ann Allergy Asthma Immunol 2018; 122:283-288. [PMID: 30476547 DOI: 10.1016/j.anai.2018.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Variation in emergency department (ED) management for asthma exacerbation leads to disparities in care. Current asthma severity scores are insufficient to be used for hospitalization decisions. OBJECTIVE To develop and internally validate an asthma predictive index for hospitalization (APIH) to guide practitioners in their admission decision for children with asthma exacerbations. METHODS Data were collected from 12,066 children between 5 and 18 years old diagnosed with asthma exacerbation in the ED. Epidemiologic findings, number of inhaled corticosteroid canisters, short-acting β-blocker canisters, oral steroids, coexisting atopy, family history of atopy, insurance, and prior asthma ED visits or hospitalizations were compared between patients hospitalized and discharged. We used univariate analysis and multivariate analysis to determine the best predictor variables for hospitalization. Our study internally validated the prediction index to estimate future performance of the prediction rule. RESULTS The highest risk factors associated with asthma hospitalization from the ED are oxygen saturation less than 94%, respiratory rate greater than 31/min, history of pneumonia, and asthma ED visits in past 12 months. With a reduced predictive model that combined these risk factors, the odds ratio was 44.9 (95% CI, 32.8-61.4), which is extremely significant. Our C index of discrimination of 0.77 was similar to the validation C index of 0.78, which confirms a solid prediction model. CONCLUSION We have developed and internally validated a pediatric hospitalization prediction index for acute asthma exacerbation in the ED. Further studies are needed to externally validate the APIH before its implementation into clinical practice.
Collapse
Affiliation(s)
- Tiffany Jean
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
| | - Su-Jau Yang
- Department of Research and Evaluation, Kaiser Permanente, Los Angeles, California
| | - William W Crawford
- Department of Allergy and Immunology, Kaiser Permanente South Bay Medical Center, Harbor City, California
| | - Scott H Takahashi
- Department of Pediatric Ambulatory Care Pharmacy, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Javed Sheikh
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| |
Collapse
|
66
|
Riley IL, Murphy B, Razouki Z, Krishnan JA, Apter A, Okelo S, Kraft M, Feltner C, Que LG, Boulware LE. A Systematic Review of Patient- and Family-Level Inhaled Corticosteroid Adherence Interventions in Black/African Americans. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1184-1193.e3. [PMID: 30395992 DOI: 10.1016/j.jaip.2018.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 10/03/2018] [Accepted: 10/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inhaled corticosteroid (ICS) adherence rates are suboptimal among adult black/African Americans. Comprehensive studies characterizing the effectiveness and the methodological approaches to the development of interventions to improve ICS adherence in adult black/African Americans have not been performed. OBJECTIVES Conduct a systematic review of patient/family-level interventions to improve ICS adherence in adult black/African Americans. METHODS We searched MEDLINE, EMBASE, Web of Science, and CINAHL from inception to August 2017 for English-language US studies enrolling at least 30% black/African Americans comparing patient/family-level ICS adherence interventions with any comparator. Two investigators independently selected, extracted data from, and rated risk of bias. We collected information on intervention characteristics and outcomes, and assessed whether studies were informed by behavior theory, stakeholder engagement, or both. RESULTS Among 1661 abstracts identified, we reviewed 230 full-text articles and identified 4 randomized controlled trials (RCTs) and 1 quasi-experimental (pre-post design) study meeting criteria. Study participants (N range, 17-333) varied in mean age (22-47 years), proportion black/African Americans studied (71%-93%), and sex (69%-82% females). RCTs evaluated problem-solving classes, self-efficacy training, technology-based motivational interviewing program, and the use of patient advocates. The RCT testing self-efficacy training was the only intervention informed by both behavior theory and stakeholder engagement. All 4 RCTs compared interventions with active control and rated as medium risk of bias. No RCTs found a statistically significant improvement in adherence. CONCLUSIONS Few studies assessing asthma adherence interventions focused on adult black/African-American populations. No RCTs demonstrated improved ICS adherence in participants. Future studies that are informed by behavior change theory and stakeholder engagement are needed.
Collapse
Affiliation(s)
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital & Health Sciences System, Chicago, Ill
| | - Andrea Apter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Sande Okelo
- The David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Monica Kraft
- University of Arizona School of Medicine, Tuscson, Ariz
| | - Cindy Feltner
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | |
Collapse
|
67
|
Yong YV, Shafie AA. Using a dynamic adherence Markov model to assess the efficiency of Respiratory Medication Therapy Adherence Clinic (RMTAC) on asthma patients in Malaysia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:36. [PMID: 30377414 PMCID: PMC6195711 DOI: 10.1186/s12962-018-0156-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022] Open
Abstract
Background Respiratory Medication Therapy Adherence Clinic (RMTAC) is an initiative by the Ministry of Health (MOH) Malaysia to improve patients’ medication adherence, as an adjunct to the usual physician care (UC). This study aimed to evaluate the cost-effectiveness of combined strategy of RMTAC and UC (RMTAC + UC) vs. UC alone in asthma patients, from the MOH Malaysia perspective. Methods A lifetime horizon dynamic adherence Markov model with monthly cycle was developed, for quality-adjusted life year (QALY) gained and hospitalization averted outcomes. Transition probabilities of composite asthma control and medication adherence, utilities, costs, and mortality rates due to all causes were measured from local data sources. Effectiveness, exacerbation rates, and asthma mortality rates were taken from non-local data sources. One-way sensitivity analysis (SA) was conducted for assessing parameter uncertainties, whereas probabilistic SA (PSA) was conducted on a different set of utilities and effectiveness data. Costs were adjusted to 2014 US dollars ($). Both costs and benefits were discounted at a 3% rate annually. Results RMTAC + UC was found to be a dominant alternative compared to UC alone; $− 13,639.40 ($− 109,556.90 to $104,445.54) per QALY gained and $− 428.93 ($− 521.27 to ($− 328.69)) per hospitalization averted. These results were found to be robust against changes in all parameters except utilities in the one-way SA, and for both scenarios in PSA. Conclusions RMTAC + UC is more effective and yet cheaper than UC alone, from the MOH perspective. For the benefit of both MOH and patients, RMTAC is thus recommended to be remained, and expanded to more healthcare settings where possible. Electronic supplementary material The online version of this article (10.1186/s12962-018-0156-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yee Vern Yong
- Formulary Management Branch, Pharmaceutical Services Programme, Ministry of Health Malaysia, Selangor, Malaysia
| | - Asrul Akmal Shafie
- 2Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia
| |
Collapse
|
68
|
Kerkhof M, Tran TN, van den Berge M, Brusselle GG, Gopalan G, Jones RCM, Kocks JWH, Menzies-Gow A, Nuevo J, Pavord ID, Rastogi S, Price DB. Association between blood eosinophil count and risk of readmission for patients with asthma: Historical cohort study. PLoS One 2018; 13:e0201143. [PMID: 30044863 PMCID: PMC6059485 DOI: 10.1371/journal.pone.0201143] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/08/2018] [Indexed: 11/18/2022] Open
Abstract
Background Recent studies have demonstrated an association between high blood eosinophil counts and greater risk of asthma exacerbations. We sought to determine whether patients hospitalized for an asthma exacerbation were at greater risk of readmission if they had a high blood eosinophil count documented before the first hospitalization. Methods This historical cohort study drew on 2 years of medical record data (Clinical Practice Research Datalink with Hospital Episode Statistics linkage) of patients (aged ≥5 years) admitted to hospital in England for asthma, with recorded blood eosinophil count within 1 baseline year before admission. We analyzed the association between high blood eosinophil count (≥0.35x109 cells/L) and readmission risk during 1 year of follow-up after hospital discharge, with adjustment for predefined, relevant confounders using forward selection. Results We identified 2,613 eligible patients with asthma-related admission, of median age 51 years (interquartile range, 36–69) and 76% women (1,997/2,613). Overall, 835/2,613 (32.0%) had a preadmission high blood eosinophil count. During the follow-up year, 130/2,613 patients (5.0%) were readmitted for asthma, including 55/835 (6.6%) with vs. 75/1,778 (4.2%) without high blood eosinophil count at baseline (adjusted hazard ratio [HR] 1.49; 95% CI 1.04–2.13, p = 0.029). The association was strongest in never-smokers (n = 1,296; HR 2.16, 95% CI 1.27–3.68, p = 0.005) and absent in current smokers (n = 547; HR 1.00, 95% CI 0.49–2.04, p = 0.997). Conclusions A high blood eosinophil count in the year before an asthma-related hospitalization is associated with increased risk of readmission within the following year. These findings suggest that patients with asthma and preadmission high blood eosinophil count require careful follow-up, with treatment optimization, after discharge.
Collapse
Affiliation(s)
- Marjan Kerkhof
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Trung N Tran
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Gokul Gopalan
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Rupert C M Jones
- The Peninsula College of Medicine and Dentistry, Plymouth, United Kingdom
| | - Janwillem W H Kocks
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Andrew Menzies-Gow
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - David B Price
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| |
Collapse
|
69
|
O'Byrne PM, FitzGerald JM, Bateman ED, Barnes PJ, Zhong N, Keen C, Jorup C, Lamarca R, Ivanov S, Reddel HK. Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma. N Engl J Med 2018; 378:1865-1876. [PMID: 29768149 DOI: 10.1056/nejmoa1715274] [Citation(s) in RCA: 363] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with mild asthma, as-needed use of an inhaled glucocorticoid plus a fast-acting β2-agonist may be an alternative to conventional treatment strategies. METHODS We conducted a 52-week, double-blind trial involving patients 12 years of age or older with mild asthma. Patients were randomly assigned to one of three regimens: twice-daily placebo plus terbutaline (0.5 mg) used as needed (terbutaline group), twice-daily placebo plus budesonide-formoterol (200 μg of budesonide and 6 μg of formoterol) used as needed (budesonide-formoterol group), or twice-daily budesonide (200 μg) plus terbutaline used as needed (budesonide maintenance group). The primary objective was to investigate the superiority of as-needed budesonide-formoterol to as-needed terbutaline with regard to electronically recorded weeks with well-controlled asthma. RESULTS A total of 3849 patients underwent randomization, and 3836 (1277 in the terbutaline group, 1277 in the budesonide-formoterol group, and 1282 in the budesonide maintenance group) were included in the full analysis and safety data sets. With respect to the mean percentage of weeks with well-controlled asthma per patient, budesonide-formoterol was superior to terbutaline (34.4% vs. 31.1% of weeks; odds ratio, 1.14; 95% confidence interval [CI], 1.00 to 1.30; P=0.046) but inferior to budesonide maintenance therapy (34.4% and 44.4%, respectively; odds ratio, 0.64; 95% CI, 0.57 to 0.73). The annual rate of severe exacerbations was 0.20 with terbutaline, 0.07 with budesonide-formoterol, and 0.09 with budesonide maintenance therapy; the rate ratio was 0.36 (95% CI, 0.27 to 0.49) for budesonide-formoterol versus terbutaline and 0.83 (95% CI, 0.59 to 1.16) for budesonide-formoterol versus budesonide maintenance therapy. The rate of adherence in the budesonide maintenance group was 78.9%. The median metered daily dose of inhaled glucocorticoid in the budesonide-formoterol group (57 μg) was 17% of the dose in the budesonide maintenance group (340 μg). CONCLUSIONS In patients with mild asthma, as-needed budesonide-formoterol provided superior asthma-symptom control to as-needed terbutaline, assessed according to electronically recorded weeks with well-controlled asthma, but was inferior to budesonide maintenance therapy. Exacerbation rates with the two budesonide-containing regimens were similar and were lower than the rate with terbutaline. Budesonide-formoterol used as needed resulted in substantially lower glucocorticoid exposure than budesonide maintenance therapy. (Funded by AstraZeneca; SYGMA 1 ClinicalTrials.gov number, NCT02149199 .).
Collapse
Affiliation(s)
- Paul M O'Byrne
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - J Mark FitzGerald
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Eric D Bateman
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Peter J Barnes
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Nanshan Zhong
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Christina Keen
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Carin Jorup
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Rosa Lamarca
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Stefan Ivanov
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Helen K Reddel
- From the Firestone Institute for Respiratory Health, St. Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (P.M.O.), and the Institute for Heart and Lung Health, University of British Columbia, Vancouver (J.M.F.) - both in Canada; the Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa (E.D.B.); Airway Disease Section, National Heart and Lung Institute, Imperial College, London (P.J.B.); State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China (N.Z.); AstraZeneca Research and Development, Gothenburg, Sweden (C.K., C.J., S.I.); AstraZeneca Research and Development, Barcelona (R.L.); and Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| |
Collapse
|
70
|
Tanaka H, Nakatani E, Fukutomi Y, Sekiya K, Kaneda H, Iikura M, Yoshida M, Takahashi K, Tomii K, Nishikawa M, Kaneko N, Sugino Y, Shinkai M, Ueda T, Tanikawa Y, Shirai T, Hirabayashi M, Aoki T, Kato T, Iizuka K, Fujii M, Taniguchi M. Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study. Allergy 2018; 73:1110-1118. [PMID: 29197099 PMCID: PMC6668009 DOI: 10.1111/all.13374] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reducing near-fatal asthma exacerbations is a critical problem in asthma management. OBJECTIVES To determine patterns of factors preceding asthma exacerbations in a real-world setting. METHODS In a nationwide prospective study of 190 patients who had experienced near-fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2-week period before admission. RESULTS Three distinct clusters of symptoms were defined employing the self-reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle-aged patients with low Body mass index and tendency to depression who had stopped anti-asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle-aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild-moderate symptoms. There were no differences in overuse of short-acting beta-agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters. CONCLUSION To reduce severe or life-threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti-type 2 response-targeted therapies should be considered for cluster C.
Collapse
Affiliation(s)
- H. Tanaka
- NPO Sapporo Cough Asthma, and Allergy CenterSapporoJapan
- Formerly at the Department of Respiratory Medicine and AllergologySapporo Medical University School of MedicineSapporoJapan
| | - E. Nakatani
- Translational Research Informatics CenterFoundation for Biomedical Research and InnovationKobeJapan
- Department of Biostatistics and Data ScienceOsaka University Graduate School of MedicineSuitaJapan
| | - Y. Fukutomi
- Clinical Research Center for Allergology and RheumatologySagamihara National HospitalSagamiharaJapan
| | - K. Sekiya
- Clinical Research Center for Allergology and RheumatologySagamihara National HospitalSagamiharaJapan
| | - H. Kaneda
- Department of Biostatistics and Data ScienceOsaka University Graduate School of MedicineSuitaJapan
| | - M. Iikura
- Department of Respiratory MedicineNational Center for Global Health and MedicineTokyoJapan
| | - M. Yoshida
- Division of Respiratory MedicineNational Hospital Organization Fukuoka HospitalFukuokaJapan
| | - K. Takahashi
- Department of Respiratory Diseases and Chest SurgeryOtsu Red Cross HospitalOtsuJapan
| | - K. Tomii
- Department of Respiratory MedicineKobe City Medical Center General HospitalKobeJapan
| | - M. Nishikawa
- Department of Respiratory MedicineFujisawa City HospitalFujisawaJapan
| | - N. Kaneko
- Department of Pulmonary MedicineKameda Medical CenterKamogawaJapan
| | - Y. Sugino
- Department of Respiratory MedicineToyota Memorial HospitalToyotaJapan
| | - M. Shinkai
- Respiratory Disease CenterYokohama City University Medical CenterYokohamaJapan
| | - T. Ueda
- The Department of Respiratory MedicineSaiseikai Nakatsu HospitalOsakaJapan
| | - Y. Tanikawa
- Department of Respiratory Medicine and Clinical ImmunologyToyota Kosei HospitalToyotaJapan
| | - T. Shirai
- Department of Respiratory MedicineShizuoka General HospitalShizuokaJapan
| | - M. Hirabayashi
- Department of Respiratory DiseasesAmagasaki General Medical CenterAmagasakiJapan
| | - T. Aoki
- Department of Internal Medicine, Respiratory DivisionTokai University School of MedicineIseharaJapan
| | - T. Kato
- Department of Respiratory Medicine and AllergologyKariya Toyota General HospitalKariyaJapan
| | - K. Iizuka
- Internal MedicinePublic Tomioka General HospitalTomiokaJapan
| | - M. Fujii
- Formerly at the Department of Respiratory Medicine and AllergologySapporo Medical University School of MedicineSapporoJapan
| | - M. Taniguchi
- Clinical Research Center for Allergology and RheumatologySagamihara National HospitalSagamiharaJapan
| |
Collapse
|
71
|
Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1989-1998.e3. [PMID: 29627457 DOI: 10.1016/j.jaip.2018.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk. OBJECTIVE The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels. METHODS This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils. RESULTS We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients. CONCLUSIONS Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.
Collapse
|
72
|
Specific, but not general beliefs about medicines are associated with medication adherence in patients with COPD, but not asthma: Cohort study in a population of people with chronic pulmonary disease. J Psychosom Res 2018; 107:46-52. [PMID: 29502763 DOI: 10.1016/j.jpsychores.2018.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Beliefs about medicines are regarded as influencing factors on medication adherence (Horne, 1997). Adherence levels in patients with chronic pulmonary diseases are low (Bourbeau and Bartlett, 2008; Sumino and Cabana, 2013). A better understanding of the predictive role of patients' beliefs about medicines for adherence might be a crucial step to improve medication adherence. OBJECTIVE This prospective study investigated the association between beliefs about medicines and medication adherence in patients with asthma and COPD. METHODS The Beliefs about Medicines Questionnaire (BMQ) and the Medication Adherence Rating Scale (MARS) were administered to 402 patients (49% asthma, 51% COPD, 50% female, mean age 56.7 years (SD = 15.9)) at baseline. Follow-ups were carried out after 3 (N = 255) and 12 months (N = 171). Multivariable logistic regression analyses were performed analysing the association between the BMQ subscales at baseline and adherence at each follow-up inquiry. Sociodemographic, psychosocial, and disease related factors were considered as potential confounders. RESULTS One third of the patients showed adherent behavior (18% and 46% of people with asthma and COPD). In the COPD sample, the subscale Specific-necessity showed a significant positive association with adherence at the 3-months-follow-up (OR = 2.6, 95% CI 1.4-5.1) and the subscale Specific-concerns showed a significant inverse association with adherence at the 3-months-follow-up (OR = 0.6, 95% CI 0.3-0.95) and the 12-months-follow-up (OR = 0.4, 95% CI 0.2-0.8). No significant association was found for the asthmatic sample. CONCLUSIONS Beliefs about medicines are important factors predicting future medication adherence in patients with COPD, but not asthma. Physicians should primarily focus on the specific beliefs of their patients in order to diminish medication non-adherence.
Collapse
|
73
|
Porsbjerg C, Ulrik C, Skjold T, Backer V, Laerum B, Lehman S, Janson C, Sandstrøm T, Bjermer L, Dahlen B, Lundbäck B, Ludviksdottir D, Björnsdóttir U, Altraja A, Lehtimäki L, Kauppi P, Karjalainen J, Kankaanranta H. Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults. Eur Clin Respir J 2018. [PMID: 29535852 PMCID: PMC5844041 DOI: 10.1080/20018525.2018.1440868] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.
Collapse
Affiliation(s)
- Celeste Porsbjerg
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Respiratory Research unit, Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Charlotte Ulrik
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Respiratory Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Tina Skjold
- Dept of Respiratory Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Vibeke Backer
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Respiratory Research unit, Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Sverre Lehman
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Crister Janson
- Department of Medical Sciences: Respiratory, Allergy & Sleep Research, Uppsala University, Uppsala, Sweden
| | - Thomas Sandstrøm
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine & Allergology, Skåne University Hospital, Lund, Sweden
| | - Barbro Dahlen
- Division of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Bo Lundbäck
- Institute of Medicine/Krefting Research Centre University of Gothenburg, Gothenburg, Sweden
| | - Dora Ludviksdottir
- Dept. of Allergy, Respiratory Medicine and Sleep Landspitali University Hospital Reykjavik Iceland, University of Iceland, Reykjavik, Iceland
| | - Unnur Björnsdóttir
- Dept. of Allergy, Respiratory Medicine and Sleep Landspitali University Hospital Reykjavik Iceland, University of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Alan Altraja
- Department of Pulmonary Medicine, University of Tartu and Department of Pulmponary Medicine, Tartu University Hospital, Tartu, Estonia
| | - Lauri Lehtimäki
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Paula Kauppi
- Department of Allergy, Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Karjalainen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| |
Collapse
|
74
|
Abstract
Asthma-one of the most common chronic, non-communicable diseases in children and adults-is characterised by variable respiratory symptoms and variable airflow limitation. Asthma is a consequence of complex gene-environment interactions, with heterogeneity in clinical presentation and the type and intensity of airway inflammation and remodelling. The goal of asthma treatment is to achieve good asthma control-ie, to minimise symptom burden and risk of exacerbations. Anti-inflammatory and bronchodilator treatments are the mainstay of asthma therapy and are used in a stepwise approach. Pharmacological treatment is based on a cycle of assessment and re-evaluation of symptom control, risk factors, comorbidities, side-effects, and patient satisfaction by means of shared decisions. Asthma is classed as severe when requiring high-intensity treatment to keep it under control, or if it remains uncontrolled despite treatment. New biological therapies for treatment of severe asthma, together with developments in biomarkers, present opportunities for phenotype-specific interventions and realisation of more personalised treatment. In this Seminar, we provide a clinically focused overview of asthma, including epidemiology, pathophysiology, clinical diagnosis, asthma phenotypes, severe asthma, acute exacerbations, and clinical management of disease in adults and children older than 5 years. Emerging therapies, controversies, and uncertainties in asthma management are also discussed.
Collapse
Affiliation(s)
- Alberto Papi
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy.
| | - Christopher Brightling
- Institute for Lung Health, Leicester National Institute for Health Research Biomedical Research Centre, Department of Infection, Immunity, and Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Søren E Pedersen
- Department of Paediatrics, University of Southern Denmark, Kolding Hospital, Kolding, Denmark
| | - Helen K Reddel
- Clinical Management Group and NHMRC Centre of Research Excellence in Severe Asthma, Woolcock Institute of Medical Research, University of Sydney, NSW, Australia
| |
Collapse
|
75
|
Işık S, Karaman M, Micili SÇ, Çağlayan-Sözmen Ş, Bağrıyanık HA, Arıkan-Ayyıldız Z, Uzuner N, Karaman Ö. Sinomenine ameliorates the airway remodelling, apoptosis of airway epithelial cells, and Th2 immune response in a murine model of chronic asthma. Allergol Immunopathol (Madr) 2018; 46:67-75. [PMID: 28778746 DOI: 10.1016/j.aller.2017.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/12/2017] [Accepted: 05/19/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sinomenine (SIN), an alkaloid isolated from the root of Sinomenium acutum which has a variety of pharmacological effects, including anti-inflammation, immunosuppression and anti-angiogenesis. The present study aimed to evaluate the effects of SIN on airway remodelling, epithelial apoptosis, and T Helper (Th)-2 derived cytokine levels in a murine model of chronic asthma. METHODS Twenty-two BALB/c mice were divided into four groups; I (control), II (placebo), III, IV. Mice in groups III and IV received the SIN (100mg/kg), and dexamethasone (1mg/kg) respectively. Epithelium thickness, sub-epithelial smooth muscle thickness, number of mast and goblet cells of samples isolated from the lung were measured. Immunohistochemical scorings of the lung tissue for matrix metalloproteinase-9 (MMP-9), vascular endothelial growth factor (VEG-F), transforming growth factor-beta (TGF-β), terminal deoxynucleotidyl transferase-mediated dUTP nick endlabeling (TUNEL) and cysteine-dependent aspartate-specific proteases (caspase)-3 were determined. IL-4, IL-5, IL-13, Nitric oxide in bronchoalveolar lavage fluid (BALF) and ovalbumin-specific immunoglobulin (Ig) E in serum were quantified by standard ELISA protocols. RESULTS The dose of 100mg/kg SIN treatment provided beneficial effects on all of the histopathological findings of airway remodelling compared to placebo (p<0.05). All cytokine levels in BALF and serum and immunohistochemical scores were significantly lower in 100mg/kg SIN treated group compared to the placebo (p<0.05). CONCLUSIONS These findings suggested that the dose of 100mg/kg SIN improved all histopathological changes of airway remodelling and its beneficial effects might be related to modulating Th-2 derived cytokines and the inhibition of apoptosis of airway epithelial cells.
Collapse
Affiliation(s)
- S Işık
- Dokuz Eylul University, Department of Pediatric Allergy and Immunology, Izmir, Turkey.
| | - M Karaman
- Dokuz Eylul University, Department of Microbiology, Izmir, Turkey
| | - S Ç Micili
- Dokuz Eylul University, Department of Histology, Izmir, Turkey
| | - Ş Çağlayan-Sözmen
- Dokuz Eylul University, Department of Pediatric Allergy and Immunology, Izmir, Turkey
| | - H A Bağrıyanık
- Dokuz Eylul University, Department of Histology, Izmir, Turkey
| | - Z Arıkan-Ayyıldız
- Dokuz Eylul University, Department of Pediatric Allergy and Immunology, Izmir, Turkey
| | - N Uzuner
- Dokuz Eylul University, Department of Pediatric Allergy and Immunology, Izmir, Turkey
| | - Ö Karaman
- Dokuz Eylul University, Department of Pediatric Allergy and Immunology, Izmir, Turkey
| |
Collapse
|
76
|
Wang IJ, Liang WM, Wu TN, Karmaus WJJ, Hsu JC. Inhaled corticosteroids may prevent lung cancer in asthma patients. Ann Thorac Med 2018; 13:156-162. [PMID: 30123334 PMCID: PMC6073787 DOI: 10.4103/atm.atm_367_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND It is unclear whether inhaled corticosteroids (ICS) have chemopreventive effect on lung cancer (LC) development in humans. We investigated the association between the ICS use in asthma patients and the risk of LC. METHODS We conducted a nationwide, population-based retrospective cohort study using the National Health Insurance database. We identified 4210 asthmatics who were initially free of LC and regularly used ICS between 2001 and 2005 and 37,228 asthmatics without regular ICS use. Patients with documented history of tobacco use were excluded from the analyses. Asthmatics were categorized into a mild and a severe asthma group. Each patient was tracked until the end of 2010 to identify incident cases of LC. Cox proportional hazards models were used to evaluate the effect of ICS on the risk of LC, further stratifying by asthma severity and comorbidities. RESULTS During follow-up, we identified 747 incident cases of LC diagnosed in the asthma cohort. Compared with severe asthmatics without regular ICS use, the risk of LC for those with mild asthma with regular ICS use was lower (adjusted hazard ratio = 0.42, 95% confidence interval = 0.31-0.56, P < 0.0001). The risk of LC was calculated among the following rankings of risk severe asthma without regular ICS use, low severity without regular ICS, high severity with regular ICS, and low severity with regular ICS group showed a decreasing trend of LC incidence (P = 0.041). Analyses stratified by comorbidities revealed that the protective effect of ICS was assessed with better precision and more pronounced in those with renal diseases, stroke, and hyperlipidemia. CONCLUSIONS For patients with asthma, regular ICS use might have a protective effect against LC. Further studies are required to assess this potential association from both immunohistopathological and clinical aspects.
Collapse
Affiliation(s)
- I-Jen Wang
- Department of Pediatrics, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,College of Public Health, China Medical University, Taichung, Taiwan
| | - Wen-Miin Liang
- Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan
| | | | - Wilfried J J Karmaus
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Jiin-Chyr Hsu
- Department of Respiratory Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| |
Collapse
|
77
|
Laforest L, Belhassen M, Devouassoux G, Didier A, Ginoux M, Van Ganse E. Long-Term Inhaled Corticosteroid Adherence in Asthma Patients with Short-Term Adherence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:890-899.e2. [PMID: 27587320 DOI: 10.1016/j.jaip.2016.07.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the use of inhaled corticosteroids (ICS) in asthma is known to be overall erratic, the long-term use of ICS by patients selected during an episode of regular use is poorly documented. OBJECTIVE In a cohort of patients with asthma regularly acquiring ICS therapy over several months, we verified whether these patients remained treated in the following 12 months. The correlates of regular ICS use over this period were investigated. METHODS A historical cohort of patients with asthma was identified from the Echantillon généraliste de bénéficiaires national French health care reimbursement data (2007-2012). Patients (6-40 years) were selected during a regular ICS use episode, with 3 or more ICS refills within 120 days. Continuous multiple-interval measures of medication availability (CMA) were computed for the 12 months after the third dispensation, and the factors associated with a CMA value of 80% or more (adherent patients) were identified. RESULTS Among 5096 patients (42.1% children/teenagers, 48.8% females), only 24.0% had a CMA value of 80% or more (mean CMA = 54.4%) over the 12 months following the ICS selection period. Achieving a CMA value of 80% or more was primarily associated with being a child/teenager (P = .002), having more severe or less controlled asthma (P = .007), more previous dispensing of short-acting beta agonists (P < .0001), and receiving devices with 200 unit doses (P < .0001). Adherent patients had more frequent general practitioner visits (P < .0001), more distinct prescribers of respiratory therapy (P = .0002), and more frequent switches of ICS (P < .0001). CONCLUSIONS Most patients with asthma selected during an episode of regular ICS use did not maintain therapy over the following months. Adherence should be repeatedly monitored, and the reasons for discontinuation should be investigated, at prescriber and patient levels.
Collapse
Affiliation(s)
- Laurent Laforest
- PELyon, Lyon, France; HESPER, EA 7425, Health Services and Performance Research, Université Claude Bernard, Lyon, France
| | - Manon Belhassen
- PELyon, Lyon, France; HESPER, EA 7425, Health Services and Performance Research, Université Claude Bernard, Lyon, France
| | | | - Alain Didier
- Respiratory Medicine, Larrey University Hospital, Toulouse, France
| | - Marine Ginoux
- HESPER, EA 7425, Health Services and Performance Research, Université Claude Bernard, Lyon, France
| | - Eric Van Ganse
- PELyon, Lyon, France; HESPER, EA 7425, Health Services and Performance Research, Université Claude Bernard, Lyon, France; Respiratory Medicine, Croix Rousse University Hospital, Lyon, France.
| |
Collapse
|
78
|
Reddel HK, Ampon RD, Sawyer SM, Peters MJ. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. BMJ Open 2017; 7:e016688. [PMID: 28947448 PMCID: PMC5623555 DOI: 10.1136/bmjopen-2017-016688] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Overuse of asthma relievers, particularly without anti-inflammatory preventers, increases asthma risks. This study aimed to identify how many reliever-only users have urgent healthcare, explore their attitudes and beliefs about asthma and its treatment, and investigate whether purchasing over-the-counter relievers was associated with worse asthma outcomes than by prescription. DESIGN AND SETTING Cross-sectional population-based Internet survey in Australia. PARTICIPANTS Of 2686 participants ≥16 years with current asthma randomly drawn from a web-based panel, 1038 (50.7% male) used only reliever medication. MAIN OUTCOME MEASURES Urgent asthma-related healthcare; Asthma Control Test (ACT); patient attitudes about asthma and medications; reliever purchase (with/without prescription). RESULTS Of 1038 reliever-only participants, 23.3% had required urgent healthcare for asthma in the previous year, and only 36.0% had a non-urgent asthma review. Those needing urgent healthcare were more likely than those without such events to be male (56.5% vs 49.0%, p=0.003) and current smokers (29.4% vs 23.3%, p=0.009). Only 30.6% had well-controlled asthma (ACT ≥20) compared with 71.0% of those with no urgent healthcare (p<0.0001), and 20.8% used relievers regularly to prevent asthma symptoms (vs 5.5% of those without urgent healthcare). Those with urgent healthcare were more frustrated by their asthma and less happy with how they managed it, and they were less confident about their ability to manage worsening asthma, but just as likely as those without urgent healthcare to manage worsening asthma themselves rather than visit a doctor. Reliever-only users purchasing over-the-counter relievers were no more likely than those purchasing relievers by prescription to have uncontrolled asthma (35.9% vs 40.6%, p=0.23) but were less likely to have had a non-urgent asthma review. CONCLUSIONS One-quarter of the reliever-only population had needed urgent asthma healthcare in the previous year, demonstrating the importance of identifying such patients. Their attitudes and beliefs suggest opportunities for targeting this population in the community.
Collapse
Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Rosario D Ampon
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Susan M Sawyer
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Centre for Adolescent Health, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Matthew J Peters
- Department of Respiratory Medicine, Concord Hospital, Macquarie University, Sydney, New South Wales, Australia
| |
Collapse
|
79
|
Jeffery MM, Shah ND, Karaca-Mandic P, Ross JS, Rank MA. Trends in Omalizumab Utilization for Asthma: Evidence of Suboptimal Patient Selection. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1568-1577.e4. [PMID: 28958746 DOI: 10.1016/j.jaip.2017.07.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Utilization trends of omalizumab, a first-in-its-class asthma biologic approved in 2003 for individuals not controlled by inhaled corticosteroids (ICSs), may reveal lessons in patient selection. OBJECTIVE To describe utilization patterns for omalizumab since its introduction in 2003, with a focus on patient-level characteristics of patients for whom omalizumab was initiated. METHODS Using a large US database of administrative claims, we identified privately insured and Medicare Advantage beneficiaries with asthma between 2003 and 2015. Characteristics of incident (no omalizumab use in the previous 12 months) and prevalent users of omalizumab for asthma were described and omalizumab use trends graphed. A comparison cohort (1:5 matching proportion) of nonomalizumab users was compared with incident omalizumab users on demographic characteristics, medication adherence (medication possession ratio [MPR]) for ICSs and/or ICS/long-acting β-agonist (ICS-LABA), exacerbation frequency, and asthma control in the 6 months before omalizumab initiation. RESULTS We identified 7,658 prevalent and 3,399 incident omalizumab users. Omalizumab incidence peaked in the second quarter of 2004 at 0.65 per 1,000 individuals with asthma, whereas prevalence peaked in the fourth quarter of 2006 at 3.22; as of fourth quarter 2015, rates were 0.14 and 1.96, respectively. In the 12 months before omalizumab initiation, 72.5% had low adherence (MPR ≤ 0.75) and 48.6% had very low adherence (MPR ≤ 0.5) to ICSs and/or ICS-LABA. In the period 2003 to 2015, the mean number of exacerbations in the 12 months before incident use ranged from 1.50 to 2.11 and the proportion that had poor asthma control (≥3 rescue inhalers dispensed) ranged from 54% to 67%. Incident omalizumab users were less likely to have good asthma control than the matched cohort of nonusers (adjusted odds ratio, 0.53 [0.48-0.59]). CONCLUSIONS Omalizumab use for asthma has been gradually decreasing following a peak shortly after its market availability. Many omalizumab users have low or very low adherence rates for ICSs and/or ICS-LABA in the 12 months before omalizumab initiation.
Collapse
Affiliation(s)
- Molly M Jeffery
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Pinar Karaca-Mandic
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minn
| | - Joseph S Ross
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn; Department of Health Policy and Management, Yale University School of Public Health, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Conn
| | - Matthew A Rank
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz.
| |
Collapse
|
80
|
Kerkhof M, Tran TN, Soriano JB, Golam S, Gibson D, Hillyer EV, Price DB. Healthcare resource use and costs of severe, uncontrolled eosinophilic asthma in the UK general population. Thorax 2017; 73:116-124. [PMID: 28918400 PMCID: PMC5801646 DOI: 10.1136/thoraxjnl-2017-210531] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022]
Abstract
Background Little is known about the prevalence of severe, uncontrolled eosinophilic asthma (SUEA) and associated costs. Aims We sought to determine the prevalence of SUEA and compare asthma-related healthcare resource use (HCRU) and associated costs with overall means for a general asthma population. Methods This cohort study evaluated anonymised medical record data (December 1989 through June 2015) from the Clinical Practice Research Datalink and the Optimum Patient Care Research Database to study UK patients with active asthma (diagnostic code and one or more drug prescriptions in the baseline year), aged 5 years and older, without concomitant COPD, and with recorded eosinophil count. SUEA was defined as two or more asthma attacks during 1 baseline year preceding a high blood eosinophil count (≥0.3×109/L) for patients prescribed long-acting β2-agonist (LABA) and high-dosage inhaled corticosteroids (ICS) during baseline plus 1 follow-up year. We compared asthma-related HCRU and associated direct costs (2015 pounds sterling, £) during the follow-up year for SUEA versus the general asthma population. Results Of 363 558 patients with active asthma and recorded eosinophil count, 64% were women, mean (SD) age was 49 (21) years; 43% had high eosinophil counts, 7% had two or more attacks in the baseline year and 10% were prescribed high-dosage ICS/LABA for 2 study years. Overall, 2940 (0.81%; 95% CI 0.78% to 0.84%) patients had SUEA. Total mean per-patient HCRU and associated costs were four times greater for SUEA versus all patients (HCRU and cost ratios 3.9; 95% CI 3.7 to 4.1). Conclusions Less than 1% of patients in a general asthma population had SUEA. These patients accounted for substantially greater asthma-related HCRU and costs than average patients with asthma.
Collapse
Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Trung N Tran
- Medical Evidence and Observational Research, AstraZeneca, Gaithersburg, Maryland, USA
| | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - Sarowar Golam
- Global Payer Evidence and Pricing, AstraZeneca, Gothenburg, Sweden
| | | | - Elizabeth V Hillyer
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
81
|
Beneficial effects of ursodeoxycholic acid via inhibition of airway remodelling, apoptosis of airway epithelial cells, and Th2 immune response in murine model of chronic asthma. Allergol Immunopathol (Madr) 2017; 45:339-349. [PMID: 28256288 DOI: 10.1016/j.aller.2016.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/19/2016] [Accepted: 12/03/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS In previous studies, anti-inflammatory, anti-apoptotic and immunomodulatory effects of ursodeoxycholic acid (UDCA) on liver diseases have been shown. In this study, we aimed to investigate the effects of UDCA on airway remodelling, epithelial apoptosis, and T Helper (Th)-2 derived cytokine levels in a murine model of chronic asthma. METHODS Twenty-seven BALB/c mice were divided into five groups; PBS-Control, OVA-Placebo, OVA-50mg/kg UDCA, OVA-150mg/kg UDCA, OVA-Dexamethasone. Mice in groups OVA-50mg/kg UDCA, OVA-150mg/kg UDCA, OVA-Dexamethasone received the UDCA (50mg/kg), UDCA (150mg/kg), and dexamethasone, respectively. Epithelium thickness, sub-epithelial smooth muscle thickness, number of mast and goblet cells of samples isolated from the lung were measured. Immunohistochemical scorings of the lung tissue for matrix metalloproteinase-9 (MMP-9), vascular endothelial growth factor (VEG-F), transforming growth factor-beta (TGF-β), terminal deoxynucleotidyl transferase-mediated dUTP nick endlabeling (TUNEL) and cysteine-dependent aspartate-specific proteases (caspase)-3 were determined. IL-4, IL-5, IL-13, Nitric oxide, ovalbumin-specific immunoglobulin (Ig) E levels were quantified. RESULTS The dose of 150mg/kg UDCA treatment led to lower epithelial thickness, sub-epithelial smooth muscle thickness, goblet and mast cell numbers compared to placebo. Except for MMP-9 and TUNEL all immunohistochemical scores were similar in both UDCA treated groups and the placebo. All cytokine levels were significantly lower in group IV compared to the placebo. CONCLUSIONS These findings suggested that the dose of 150mg/kg UDCA improved all histopathological changes of airway remodelling and its beneficial effects might be related to modulating Th-2 derived cytokines and the inhibition of apoptosis of airway epithelial cells.
Collapse
|
82
|
Belhassen M, Demoly P, Bloch-Morot E, de Pouvourville G, Ginoux M, Chartier A, Laforest L, Serup-Hansen N, Toussi M, Van Ganse E. Costs of perennial allergic rhinitis and allergic asthma increase with severity and poor disease control. Allergy 2017; 72:948-958. [PMID: 27886386 DOI: 10.1111/all.13098] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Perennial allergic rhinitis (PAR) represents a global and public health problem, due to its prevalence, morbidity, and impact on the quality of life. PAR is frequently associated with allergic asthma (AA). Costs of PAR with or without AA are poorly documented. OBJECTIVE Our study aimed to detail medical resource utilization (MRU) and related direct cost for PAR, with or without concomitant AA, in France. METHODS Using Electronic Health Records (EHRs), we identified in 2010 two cohorts of PAR patients, based on General Practitioners' diagnoses and prescribing data, with and without concomitant AA. For each patient, the EHRs were linked to corresponding claims data with MRU and costs during years 2011 to 2013. Predefined subgroup analyses were performed according to severity of PAR and level of AA control. RESULTS The median annual cost reimbursed by social security system for a patient with PAR, and no AA was 159€ in 2013. This varied from 111€ to 188€ depending on PAR severity. For patients with PAR and concomitant AA, the median annual cost varied between 266€ and 375€, and drug treatment accounted for 42-55% of the costs, depending on asthma control. CONCLUSION This study linking diagnoses from EHRs to claims data collected valid information on PAR management, with or without concomitant AA, and on related costs. There was a clear increase in costs with severity of PAR and control of AA.
Collapse
Affiliation(s)
- M. Belhassen
- HESPER 7425; Health Services and Performance Research; University Claude Bernard Lyon 1; Lyon France
- PELyon; PharmacoEpidemiologie Lyon; Lyon France
| | - P. Demoly
- Department of Pulmonology; Division of Allergy; Arnaud de Villeneuve Hospital; University Hospital of Montpellier; Montpellier France
- Sorbonne University; UPMC Paris 06; UMR-S 1136 INSERM; IPLESP; EPAR; Paris France
| | - E. Bloch-Morot
- French Association for Continual Medical Education of Allergists (ANAFORCAL); Reims France
| | | | - M. Ginoux
- HESPER 7425; Health Services and Performance Research; University Claude Bernard Lyon 1; Lyon France
- PELyon; PharmacoEpidemiologie Lyon; Lyon France
| | | | - L. Laforest
- HESPER 7425; Health Services and Performance Research; University Claude Bernard Lyon 1; Lyon France
- PELyon; PharmacoEpidemiologie Lyon; Lyon France
| | | | | | - E. Van Ganse
- HESPER 7425; Health Services and Performance Research; University Claude Bernard Lyon 1; Lyon France
- PELyon; PharmacoEpidemiologie Lyon; Lyon France
- Respiratory Medicine; Croix Rousse University Hospital; Lyon France
| |
Collapse
|
83
|
Qian CJ, Coulombe J, Suissa S, Ernst P. Pneumonia risk in asthma patients using inhaled corticosteroids: a quasi-cohort study. Br J Clin Pharmacol 2017; 83:2077-2086. [PMID: 28425216 DOI: 10.1111/bcp.13295] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/13/2022] Open
Abstract
AIM Studies have linked the use of inhaled corticosteroids (ICSs) to excess pneumonia risk in chronic obstructive pulmonary disease patients. The risk in asthma patients remains unclear. The objective of the present study was to examine the risk of pneumonia with ICSs in asthma patients aged 12-35 years. METHODS We formed a cohort of asthma patients treated from 1990 to 2007 using Quebec health insurance databases. Subjects were considered currently exposed if they had had an ICS dispensed within the 60 days prior to their pneumonia index event or matched person-moment. Secondary analyses investigated the risk of pneumonia according to ICS dose and type. Rate ratios (RRs) and rate differences (RDs) were both estimated through a quasi-cohort approach. RESULTS The cohort included 152 412 subjects, of whom 1928 had a pneumonia event during follow-up. There was an increased risk of pneumonia associated with current use of ICSs [RR 1.83; 95% confidence interval (CI) 1.57, 2.14] or an excess risk of 1.44 cases per 1000 person-years (RD 1.44; 95% CI 1.03, 1.85). There was an excess pneumonia risk with low doses (RR 1.60; 95% CI 1.06, 2.45), moderate doses (RR 1.53; 95% CI 1.12, 2.08) and high doses (RR 1.96; 95% CI 1.64, 2.34) of ICSs, and with budesonide (RR 2.67; 95% CI 2.05, 3.49) and fluticasone (RR 1.93; 95% CI 1.58, 2.36), specifically relative to no use. When accounting for potential protopathic bias, the risk with current use of ICSs was attenuated (RR 1.48; 95% CI 1.22, 1.78). CONCLUSION ICS use in asthma patients appears to be associated with an increased risk of pneumonia and is present for both budesonide and fluticasone.
Collapse
Affiliation(s)
- Christina J Qian
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Janie Coulombe
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Samy Suissa
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Pierre Ernst
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| |
Collapse
|
84
|
Edwards MR, Saglani S, Schwarze J, Skevaki C, Smith JA, Ainsworth B, Almond M, Andreakos E, Belvisi MG, Chung KF, Cookson W, Cullinan P, Hawrylowicz C, Lommatzsch M, Jackson D, Lutter R, Marsland B, Moffatt M, Thomas M, Virchow JC, Xanthou G, Edwards J, Walker S, Johnston SL. Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators. Eur Respir J 2017; 49:49/5/1602448. [PMID: 28461300 DOI: 10.1183/13993003.02448-2016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/13/2017] [Indexed: 12/27/2022]
Abstract
Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rene Lutter
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Benjamin Marsland
- University of Lausanne, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | | | - Georgina Xanthou
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | | | | | | | | |
Collapse
|
85
|
Vitale C, Maglio A, Pelaia C, Vatrella A. Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy. Expert Opin Pharmacother 2017; 18:667-676. [PMID: 28387160 DOI: 10.1080/14656566.2017.1317747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.
Collapse
Affiliation(s)
- Carolina Vitale
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Angelantonio Maglio
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Corrado Pelaia
- b Department of Medical and Surgical Sciences, Section of Respiratory Diseases , University "Magna Graecia" of Catanzaro , Catanzaro , Italy
| | - Alessandro Vatrella
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| |
Collapse
|
86
|
Laforest L, Belhassen M, Devouassoux G, Didier A, Letrilliart L, Van Ganse É. [Therapeutic adherence in asthma in France: A general review]. Rev Mal Respir 2017; 34:194-222. [PMID: 28359651 DOI: 10.1016/j.rmr.2016.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/08/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Adherence in asthma is a paramount issue of disease management. A general review of the French publications on this topic has been conducted. METHODS Research equations used for bibliographic databases (MEDLINE, Science Direct, Banque de données en santé publique, Cochrane and Cairn.info) comprised the following keywords: "asthma", "therapeutic adherence" and "France". These publications unrelated to asthma, focused on asthma management without exploring adherence, or those conducted in populations without French patients were excluded. RESULTS A total of 82 articles have been selected (36 surveys, 4 randomized trials and 42 reviews/syntheses). Whatever the methodology used and publication year, the inadequate therapeutic adherence in asthma was steadily reported, notably for controllers and the quality of use of inhaled devices. CONCLUSION The present review highlights the sustainability of adherence-related issues in asthma and the need to improve patients' knowledge on asthma and the finality of therapy. It also highlights the need of an improved communication between patients and physicians is also advocated. Further studies with more recent data are desirable to assess changes in disease management of asthma and the impact of potential future corrective interventions.
Collapse
Affiliation(s)
- L Laforest
- PELyon (Pharmacoepidemiology Lyon), faculté d'odontologie, 11, rue Guillaume Paradin, 69008 Lyon, France
| | - M Belhassen
- PELyon (Pharmacoepidemiology Lyon), faculté d'odontologie, 11, rue Guillaume Paradin, 69008 Lyon, France
| | - G Devouassoux
- Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 69000, Lyon, France
| | - A Didier
- Pôle des voies respiratoires, hôpital Larrey, CHU de Toulouse, 31000, Toulouse, France
| | - L Letrilliart
- Département de médecine générale, faculté de médecine, université Claude-Bernard Lyon I, 69000, Lyon, France
| | - É Van Ganse
- PELyon (Pharmacoepidemiology Lyon), faculté d'odontologie, 11, rue Guillaume Paradin, 69008 Lyon, France; Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 69000, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France.
| |
Collapse
|
87
|
Reddel HK, Busse WW, Pedersen S, Tan WC, Chen YZ, Jorup C, Lythgoe D, O'Byrne PM. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study. Lancet 2017; 389:157-166. [PMID: 27912982 DOI: 10.1016/s0140-6736(16)31399-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 07/28/2016] [Accepted: 08/10/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low-dose inhaled corticosteroids (ICS) are highly effective for reducing asthma exacerbations and mortality. Conventionally, ICS treatment is recommended for patients with symptoms on more than 2 days per week, but this criterion has scant evidence. We aimed to assess the validity of the previous symptom-based cutoff for starting ICS by establishing whether there was a differential response to budesonide versus placebo for severe asthma exacerbations, lung function, and asthma symptom control across subgroups identified by baseline asthma symptom frequency. METHODS We did a post-hoc analysis of the 3 year inhaled Steroid Treatment As Regular Therapy (START) study, done in 32 countries, with clinic visits every 3 months. Patients (aged 4-66 years) with mild asthma diagnosed within the previous 2 years and no previous regular corticosteroids were randomised to receive once daily, inhaled budesonide 400 μg (those aged <11 years 200 μg) or placebo. Coprimary outcomes for this analysis were time to first severe asthma-related event (SARE; hospital admission, emergency treatment, or death) and change from baseline in lung function after bronchodilator. Interaction with baseline symptom frequency was investigated, with patients grouped by more than two symptom days per week and two or fewer symptom days per week (divided into no days to 1 day, and more than 1 day to 2 days). Analysis was done by intention to treat. FINDINGS Of 7138 patients (n=3577 budesonide; n=3561 placebo), baseline symptom frequency was 0-1 days per week for 2184 (31%) participants, more than 1 and less than or equal to 2 symptom days per week for 1914 (27%) participants, and more than 2 symptom days per week for 3040 (43%) participants. For budesonide versus placebo, time to first SARE was longer across symptom frequency subgroups (hazard ratios 0·54 [95% CI 0·34-0·86] for 0-1 symptom days per week, 0·60 [0·39-0·93] for >1 to ≤2 symptom days per week, 0·57 [0·41-0·79] >2 symptom days per week, pinteraction=0·94), and the decline in postbronchodilator lung function was less at 3 years' follow-up (pinteraction=0·32). For budesonide versus placebo, severe exacerbations requiring oral or systemic corticosteroids were reduced (rate ratio 0·48 [0·38-0·61] 0-1 symptom days per week, 0·56 [0·44-0·71] >1 to ≤2 symptom days per week, and 0·66 [0·55-0·80] >2 symptom days per week, pinteraction=0·11), prebronchodilator lung function was higher, and symptom-free days were more frequent (p<0·0001 for all three subgroups), with no interaction by symptom frequency (prebronchodilator pinteraction=0·43; symptom-free days pinteraction=0·53). Similar results were noted when participants were classified by any guidelines criterion as so-called persistent versus so-called intermittent asthma. INTERPRETATION In mild recent-onset asthma, once daily, low-dose budesonide decreases SARE risk, reduces lung function decline, and improves symptom control similarly across all symptom subgroups. The results do not support restriction of inhaled corticosteroids to patients with symptoms on more than 2 days per week and suggest that treatment recommendations for mild asthma should consider both risk reduction and symptoms. FUNDING AstraZeneca.
Collapse
Affiliation(s)
- Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, NSW, Australia.
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Søren Pedersen
- University of Southern Denmark, Department of Paediatrics, Kolding Hospital, Kolding, Denmark
| | - Wan C Tan
- University of British Columbia, iCapture Centre for Cardiovascular and Pulmonary Research, St Paul's Hospital, Vancouver, BC, Canada
| | - Yu-Zhi Chen
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Carin Jorup
- AstraZeneca Research and Development, Gothenburg, Sweden
| | | | - Paul M O'Byrne
- Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
88
|
O'Byrne PM, FitzGerald JM, Zhong N, Bateman E, Barnes PJ, Keen C, Almqvist G, Pemberton K, Jorup C, Ivanov S, Reddel HK. The SYGMA programme of phase 3 trials to evaluate the efficacy and safety of budesonide/formoterol given 'as needed' in mild asthma: study protocols for two randomised controlled trials. Trials 2017; 18:12. [PMID: 28069068 PMCID: PMC5223341 DOI: 10.1186/s13063-016-1731-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 11/28/2016] [Indexed: 11/22/2022] Open
Abstract
Background In many patients with mild asthma, the low frequency of symptoms and the episodic nature of exacerbations make adherence to regular maintenance treatment difficult. This often leads to over-reliance on short-acting β2-agonist (SABA) reliever medication and under-treatment of the underlying inflammation, with poor control of asthma symptoms and increased risk of exacerbations. The use of budesonide/formoterol ‘as needed’ in response to symptoms may represent an alternative treatment option for patients with mild asthma. Methods/design The SYmbicort Given as needed in Mild Asthma (SYGMA) programme consists of two 52-week, double-blind, randomised, multicentre, parallel-group, phase 3 trials of patients aged 12 years and older with a clinical diagnosis of asthma for at least 6 months, who would qualify for treatment with regular inhaled corticosteroids (ICS). SYGMA1 aims to recruit 3750 patients who will be randomised to placebo twice daily (bid) plus as-needed budesonide/formoterol 160/4.5 μg, placebo bid plus as-needed terbutaline 0.4 mg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the superiority of as-needed budesonide/formoterol over as-needed terbutaline for asthma control, as measured by well-controlled asthma weeks; a secondary objective is to establish the noninferiority of as-needed budesonide/formoterol versus maintenance budesonide plus as-needed terbutaline using the same outcome measure. SYGMA2 aims to recruit 4114 patients who will be randomised to placebo bid plus as-needed budesonide/formoterol 160/4.5 μg, or budesonide 200 μg bid plus as-needed terbutaline 0.4 mg. The primary objective is to demonstrate the noninferiority of as-needed budesonide/formoterol over budesonide bid plus as-needed terbutaline as measured by the annualised severe exacerbation rate. In both studies, use of all blinded study inhalers will be recorded electronically using Turbuhaler® Usage Monitors. Discussion Given the known risks of mild asthma, and known poor adherence with regular inhaled corticosteroids, the results of the SYGMA programme will help to determine the efficacy and safety of as-needed budesonide/formoterol therapy in mild asthma. Patient recruitment is complete, and completion of the phase 3 studies is planned in 2017. Trial registration ClinicalTrials.gov identifiers: NCT02149199 SYGMA1 and NCT02224157 SYGMA2. Registered on 16 May 2014 and 19 August 2014, respectively. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1731-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Paul M O'Byrne
- Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. .,Firestone Institute of Respiratory Health, St Joseph's Healthcare and Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Eric Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter J Barnes
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London, UK
| | | | | | | | | | | | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| |
Collapse
|
89
|
Free asthma medications reduces hospital admissions in Brazil (Free asthma drugs reduces hospitalizations in Brazil). Respir Med 2016; 121:21-25. [PMID: 27888987 DOI: 10.1016/j.rmed.2016.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 10/03/2016] [Accepted: 10/17/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Since June 2011, the Brazilian health system started providing asthma medications (beclomethasone and salbutamol), totally free of charge to patients with asthma. The aim of this study was to evaluate the impact of the provision of free asthma medications on hospital admissions for asthma in Brazil, using a national hospitalization database (DATASUS), comparing the incidence of hospital admissions before and after the free supply of these drugs. METHODS Admissions of patients with 1-49 years of age by the Brazilian public health system with the diagnosis of asthma were compared pre (2008-2010) and post (2012-2014) provision of free medicines (beclomethasone and salbutamol). The number of hospital admissions due to asthma and non-respiratory diseases, as well as the amount spent with asthma hospitalization, were obtained from DATASUS, the Brazilian government open-access public health database system. RESULTS Admission rates for asthma significantly decreased from 90.09/100.000 (2008-2010) to 59.85/100.000 (2012-2014), when the period pre and post provision of free medicines were compared [OR 0.67 (CI 0.48-0.92)]. Non-respiratory admission rates remained stable, when both periods were also compared. CONCLUSION Asthma hospitalization rates significantly decreased in the three-year period after the provision of free medicines to treat asthma. Our findings suggest that the provision of free medications for asthma may have a particular public health impact by its own in developing countries.
Collapse
|
90
|
Rao Bondugulapati LN, Rees DA. Inhaled corticosteroids and HPA axis suppression: how important is it and how should it be managed? Clin Endocrinol (Oxf) 2016; 85:165-9. [PMID: 27038017 DOI: 10.1111/cen.13073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/19/2016] [Accepted: 03/29/2016] [Indexed: 12/12/2022]
Abstract
Inhaled corticosteroids (ICS) are established as a cornerstone of management for patients with bronchoconstrictive lung disease. However, systemic absorption may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis in a significant minority of patients. This is more likely in 'higher risk' patients exposed to high cumulative ICS doses, and in those treated with frequent oral corticosteroids or drugs which inhibit cytochrome p450 3A4. Hypothalamic-pituitary-adrenal axis suppression is frequently unrecognized, such that some patients, notably children, only come to light when an adrenal crisis is precipitated by physical stress. To minimize this risk, 'higher risk' patients and those with previously identified suppressed cortisol responses to Synacthen testing should undergo an education programme to inform them about sick day rules. A review of ICS therapy should also be undertaken to ensure that the dose administered is the minimum required to control symptoms.
Collapse
Affiliation(s)
| | - D A Rees
- Neurosciences and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
91
|
Papi A, Mansur AH, Pertseva T, Kaiser K, McIver T, Grothe B, Dissanayake S. Long-Term Fluticasone Propionate/Formoterol Fumarate Combination Therapy Is Associated with a Low Incidence of Severe Asthma Exacerbations. J Aerosol Med Pulm Drug Deliv 2016; 29:346-61. [PMID: 27104231 PMCID: PMC4965704 DOI: 10.1089/jamp.2015.1255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 01/21/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND A primary goal of asthma management is the reduction of exacerbation risk. We assessed the occurrence of oral corticosteroid-requiring exacerbations (OCS exacerbations) with long-term fluticasone/formoterol therapy, and compared it with the occurrence of similar events reported with other inhaled corticosteroid/long acting β2-agonist (ICS/LABA) combinations. METHODS The occurrence of OCS exacerbations was assessed in two open-label trials of fixed-dose fluticasone/formoterol administered for between 26 to 60 weeks in adults and adolescents with asthma. The incidence of OCS exacerbations with fluticasone/formoterol was compared with those reported in three recent Cochrane meta-analyses of other ICS/LABAs. RESULTS The pooled incidence of OCS exacerbations with long-term fluticasone/formoterol was 2.1% (95% CI: 1.1, 3.2%, n/N = 16/752). In only two of the nineteen treatment arms summarized by Cochrane did OCS exacerbation incidence approximate that seen in the two fluticasone/formoterol trials (single-inhaler fluticasone/salmeterol [2.9%]; separate inhaler budesonide, beclometasone, or flunisolide plus formoterol [3.4%]). In Lasserson's review the pooled incidence of OCS exacerbations for single-inhaler combinations was 9.5% (95% CI: 8.4, 10.6%; n/N = 239/2516) for fluticasone/salmeterol, and 10.6% (95% CI: 9.3, 11.8%; n/N = 257/2433) for budesonide/formoterol. In Ducharme's and Chauhan's meta-analyses (primarily incorporating separate inhaler combinations [fluticasone, budesonide, beclometasone, or flunisolide plus salmeterol or formoterol]), the pooled incidences of OCS exacerbations were 16.0% (95% CI: 14.2, 17.8%, n/N = 258/1615) and 16.7% (95% CI: 14.9, 18.5, n/N = 275/1643), respectively. CONCLUSIONS The incidence of exacerbations in two fixed-dose fluticasone/formoterol studies was low and less than in the majority of comparable published studies involving other ICS/LABA combinations. This difference could not be readily explained by differences in features of the respective studies and may be related to the favorable pharmacological/mechanistic characteristics of the constituent components fluticasone and formoterol compared to other drugs in their respective classes.
Collapse
Affiliation(s)
- Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - Adel H. Mansur
- Chest Research Institute, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | | | - Kirsten Kaiser
- Medicinal and Regulatory Development, Skyepharma AG, Muttenz, Switzerland
| | - Tammy McIver
- Clinical Data Management and Statistics, Mundipharma Research Limited, Cambridge, United Kingdom
| | - Birgit Grothe
- Medical Science—Respiratory, Mundipharma Research Limited, Cambridge, United Kingdom
| | - Sanjeeva Dissanayake
- Medical Science—Respiratory, Mundipharma Research Limited, Cambridge, United Kingdom
| |
Collapse
|
92
|
Nader MA, Gameil N, Abdelaziz RR, Zalata KR, Osman A, Zedan MM, Abo-Elkheir N, Elsiddig AA, Zedan M. Effect of tranilast in comparison with beclomethasone in chronic murine model of asthma. Exp Lung Res 2016; 42:296-306. [PMID: 27450020 DOI: 10.1080/01902148.2016.1207727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM OF THE STUDY The current investigation was taken to scrutinize the action of tranilast on the airway remodeling in chronic asthma in mice. MATERIALS AND METHODS Intraperitoneal injection of ovalbumin was applied to mice for sensitization and subsequent inhalation of 1% ovalbumin three times week for 10 weeks for challenge. Beclomethasone or tranilast were given daily for the 10 week challenge period. At the end of the study, lung weight index, total collagen content, bronchoalveolar lavage level of total and differential cell counts, interleukin-13, in addition to lung tissue nitrate/nitrite and transforming growth beta-1 were measured. Also, histological analysis was done. RESULTS Asthmatic mice demonstrated apparent fibrotic changes. Significant airway fibrosis was demonstrated by hyperplasia of goblet cells and thickening of airway epithelium, increased content of lung collagen, lung and bronchoalveolar lavage of transforming growth factor beta-1 and interleukin-13 mutually accompanied by reduction in nitrate/nitrite generation. CONCLUSIONS Beclomethasone influence on airway remodeling was mediated mainly via suppression of eosinophilic recruitment into the airways and reduction of interleukin-13 cytokine levels. Whereas, tranilast effects on airway remodeling was found to be mainly mediated via its inhibitory effect on transforming growth beta-1. Both beclomethasone and tranilast influence airway remodeling by different degrees and mechanisms.
Collapse
Affiliation(s)
- Manar A Nader
- a Department of Pharmacology & Toxicology , College of Pharmacy, Taibah University , El-Madinah El-Munawarah , Saudi Arabia.,b Department of Pharmacology & Toxicology, Faculty of Pharmacy , Mansoura University , Mansoura , Egypt
| | - Nariman Gameil
- b Department of Pharmacology & Toxicology, Faculty of Pharmacy , Mansoura University , Mansoura , Egypt
| | - Rania R Abdelaziz
- b Department of Pharmacology & Toxicology, Faculty of Pharmacy , Mansoura University , Mansoura , Egypt
| | - Khaled R Zalata
- c Department of Clinical Pathology, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| | - Amal Osman
- d Department of Pediatrics, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| | - Mohamed M Zedan
- d Department of Pediatrics, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| | - Nermin Abo-Elkheir
- c Department of Clinical Pathology, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| | - Abeer Abdalla Elsiddig
- e Department of Pathology, Faculty of Medicine , Taibah University , El-Madinah El-Munawarah , Saudi Arabia
| | - Magdy Zedan
- d Department of Pediatrics, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| |
Collapse
|
93
|
Belhassen M, Langlois C, Laforest L, Dima AL, Ginoux M, Sadatsafavi M, Van Ganse E. Level of Asthma Controller Therapy Before Admission to the Hospital. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:877-83. [PMID: 27452886 DOI: 10.1016/j.jaip.2016.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/08/2016] [Accepted: 06/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND In asthma, choice of controller therapy and adherence to treatment can affect the risk of future severe exacerbations leading to hospitalization. OBJECTIVE Our objective was to characterize treatment dispensation profiles before hospital admission for asthma. METHODS Using a 1/97th random sample of the national French claims data, patients with asthma aged 6 to 40 years were identified between 2006 and 2014. Patients with subsequent asthma-related hospitalization were selected. On the basis of controller therapy dispensed in the 12 months before admission, treatment profiles were categorized into clusters, using Ward's minimum-variance hierarchical clustering method. RESULTS Of 17,846 patients with asthma, we identified 275 patients (1.5%) with an asthma-related hospitalization. Three distinct clusters were identified. The first cluster (63.6%) included patients with few dispensations of any controller medication (<1 unit). The second cluster (32.4%) consisted of patients with frequent dispensations of long-acting beta agonists (LABAs)/inhaled corticosteroids (ICS) in fixed-dose combinations. The third cluster (4%) comprised patients receiving free combinations of ICS and LABAs, with more dispensations of LABAs than of ICS. CONCLUSIONS In France, before an asthma-related hospitalization, more than 60% of patients received little controller therapy and 4% were exposed to higher dispensation of LABAs than of ICS. These results indicate that a large fraction of asthma-related hospitalizations can potentially be prevented with better pharmacotherapy.
Collapse
Affiliation(s)
- Manon Belhassen
- PELyon, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France.
| | - Carole Langlois
- PELyon, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France
| | - Laurent Laforest
- PELyon, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France
| | - Alexandra Lelia Dima
- Department of Communication Science, ASCoR, University of Amsterdam, Amsterdam, The Netherlands
| | - Marine Ginoux
- PELyon, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France
| | - Mohsen Sadatsafavi
- Institute for Heart and Lung Health, Department of Medicine, The University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, Canada
| | - Eric Van Ganse
- PELyon, Lyon, France; HESPER 7425, Health Services and Performance Research, Lyon, France; Respiratory Medicine, Croix Rousse University Hospital, Lyon, France
| |
Collapse
|
94
|
Wu AC, Li L, Fung V, Kharbanda EO, Larkin EK, Butler MG, Galbraith A, Miroshnik I, Davis RL, Horan K, Lieu TA. Mismatching Among Guidelines, Providers, and Parents on Controller Medication Use in Children with Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:910-6. [PMID: 27212379 DOI: 10.1016/j.jaip.2016.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Underuse of controller medicines among children with asthma remains widespread despite national guidelines. OBJECTIVES To (1) assess provider prescribing patterns for asthma controller medications; (2) assess how frequently parents' reports of their child's asthma controller medicine use were mismatched with their provider's recommendations; and (3) evaluate parent attitudes and demographic characteristics associated with these mismatches. METHODS In this cross-sectional study, we conducted linked surveys of parents and providers of children with probable persistent asthma in a Medicaid program and 4 commercial health plans in 2011. Probable persistent asthma was defined as a diagnosis of asthma and 1 or more controller medication dispensing. RESULTS This study included 740 children (mean age, 8.6 years). Providers for 50% of the children reported prescribing controller medications for daily year-round use, 41% for daily use during active asthma months, and 9% for intermittent use for relief. Among parents, 72% knew which class of controller medication the provider prescribed and 49% knew the administration frequency and the medication class. Parents were less likely to report the same controller medication type as the provider, irrespective of dose and frequency, if they were Latino (odds ratio [OR], 0.23; CI, 0.057-0.90), had a household smoker (OR, 2.87; CI, 0.42-19.6), or believed the controller medicine was not helping (OR, 0.15; CI, 0.048-0.45). CONCLUSIONS Mismatches between parent reports and providers intentions regarding how the child was supposed to use inhaled steroids occurred for half of the children. Efforts should focus on ways to reduce mismatches between parent and provider intentions regarding controller medication use.
Collapse
Affiliation(s)
- Ann Chen Wu
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass; Division of General Pediatrics, Department of Pediatrics, Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Lingling Li
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Vicki Fung
- Harvard Medical School, Boston, Mass; Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Mass
| | - Elyse O Kharbanda
- HealthPartners Institute for Education and Research, Minneapolis, Minn
| | - Emma K Larkin
- Vanderbilt University School of Medicine, Nashville, Tenn
| | - Melissa G Butler
- Center for Clinical Outcomes & Research - Southeast, Kaiser Permanente Georgia, Atlanta, Ga; The Argus Group, Hamilton, Bermuda
| | - Alison Galbraith
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass; Division of General Pediatrics, Department of Pediatrics, Children's Hospital, Boston, Mass
| | - Irina Miroshnik
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Robert L Davis
- Center for Biomedical Informatics, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Kelly Horan
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Tracy A Lieu
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| |
Collapse
|
95
|
Reddel HK. Treatment of overlapping asthma-chronic obstructive pulmonary disease: Can guidelines contribute in an evidence-free zone? J Allergy Clin Immunol 2015; 136:546-52. [PMID: 26343938 DOI: 10.1016/j.jaci.2015.06.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/25/2015] [Accepted: 06/30/2015] [Indexed: 01/18/2023]
Abstract
In their most typical forms, asthma and chronic obstructive pulmonary disease (COPD) are clearly distinguishable, but many patients with chronic airflow limitation demonstrate features of both conditions and have worse health outcomes than those with either disease alone. This has been called the asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS), but as yet, it lacks a precise definition. However, given the different pathways by which a patient can come to demonstrate features of both asthma and COPD, ACOS is not thought to represent a single disease but to include several heterogeneous phenotypes with different underlying mechanisms. These issues have important implications for guidelines because some existing treatment recommendations for asthma and COPD are in conflict, and patients with both asthma and COPD have specifically been excluded from major pharmacologic trials. As a result, there is little evidence at present to support specific treatment recommendations for ACOS on the basis of efficacy or effectiveness, yet these patients continue to present for diagnosis and management, mainly in primary care. This article highlights the need for clinical guidance about ACOS, summarizes recommendations about its diagnosis and treatment from a sample of national asthma and COPD guidelines, and proposes a way forward, as suggested in a collaborative Global Initiative for Asthma/Global Initiative for Chronic Obstructive Lung Disease report, to provide health professionals with interim recommendations about syndromic recognition and initial treatment based on both potential effectiveness and potential risk. Additional research in broad populations is urgently needed to develop a precise definition for ACOS, characterize its phenotypes, and identify opportunities for targeted treatment.
Collapse
Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
| |
Collapse
|
96
|
Abstract
RATIONALE Few previous studies have evaluated primary adherence (whether a new prescription is filled within 30 d) to controller medications in individuals with persistent asthma. OBJECTIVE To compare adherence to the major controller medication regimens for asthma. METHODS This was a retrospective cohort study of enrollees from five large health plans. We used electronic medical data on patients of all ages with asthma who had experienced an asthma-related exacerbation in the prior 12 months. We studied adherence measures including proportion of days covered and primary adherence (first prescription filled within 30 d). MEASUREMENTS AND MAIN RESULTS Our population included 69,652 subjects who had probable persistent asthma and were prescribed inhaled corticosteroids (ICSs), leukotriene antagonists (LTRAs), or ICS/long-acting β-agonists (ICS/LABAs). The mean age was 37 years and 58% were female. We found that 14-20% of subjects who were prescribed controller medicines for the first time did not fill their prescriptions. The mean proportion of days covered was 19% for ICS, 30% for LTRA, and 25% for ICS/LABA over 12 months. Using multivariate logistic regression, subjects prescribed LTRA were less likely to be primary adherent than subjects prescribed ICS (odds ratio, 0.82; 95% confidence interval, 0.74-0.92) or ICS/LABA (odds ratio, 0.88; 95% confidence interval, 0.80-0.97). Black and Latino patients were less likely to fill the prescription compared with white patients. CONCLUSIONS Adherence to controller medications for asthma is poor. In this insured population, primary adherence to ICSs was better than to LTRAs and ICS/LABAs. Adherence as measured by proportion of days covered was better for LTRAs and ICS/LABAs than for ICSs.
Collapse
|
97
|
Hoch HE, Szefler SJ. Intermittent steroid inhalation for the treatment of childhood asthma. Expert Rev Clin Immunol 2015; 12:183-94. [PMID: 26561351 DOI: 10.1586/1744666x.2016.1105741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Inhaled corticosteroids have long been considered a mainstay of therapy for asthma in children. However, concerns over long-term side effects of chronic steroid administration have led providers to turn to intermittent dosing of these medications in an attempt to treat exacerbations while limiting total corticosteroid received. The data have been somewhat mixed in this area, likely at least partially due to the difficulty providers have in classifying asthma phenotypes in young children. This review will analyze the evidence for chronic daily inhaled corticosteroid use, intermittent inhaled corticosteroid use, and dynamic dosing approaches utilizing inhaled corticosteroid/long-acting beta agonist combination therapy.
Collapse
Affiliation(s)
- Heather E Hoch
- a Section of Pediatric Pulmonology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Stanley J Szefler
- a Section of Pediatric Pulmonology , University of Colorado School of Medicine , Aurora , CO , USA
| |
Collapse
|
98
|
Marks GB. The challenge of delivering effective care for asthma. Public Health Action 2015; 2:44. [PMID: 26392948 DOI: 10.5588/pha.12.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Guy B Marks
- Department of Respiratory Medicine, Liverpool Hospital and Woolcock Institute of Medical Research, Sydney, NSW, Australia
| |
Collapse
|
99
|
Reddel HK, Bateman ED, Becker A, Boulet LP, Cruz AA, Drazen JM, Haahtela T, Hurd SS, Inoue H, de Jongste JC, Lemanske RF, Levy ML, O'Byrne PM, Paggiaro P, Pedersen SE, Pizzichini E, Soto-Quiroz M, Szefler SJ, Wong GWK, FitzGerald JM. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J 2015; 46:622-39. [PMID: 26206872 PMCID: PMC4554554 DOI: 10.1183/13993003.00853-2015] [Citation(s) in RCA: 547] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/05/2015] [Indexed: 02/07/2023]
Abstract
Over the past 20 years, the Global Initiative for Asthma (GINA) has regularly published and annually updated a global strategy for asthma management and prevention that has formed the basis for many national guidelines. However, uptake of existing guidelines is poor. A major revision of the GINA report was published in 2014, and updated in 2015, reflecting an evolving understanding of heterogeneous airways disease, a broader evidence base, increasing interest in targeted treatment, and evidence about effective implementation approaches. During development of the report, the clinical utility of recommendations and strategies for their practical implementation were considered in parallel with the scientific evidence.This article provides a summary of key changes in the GINA report, and their rationale. The changes include a revised asthma definition; tools for assessing symptom control and risk factors for adverse outcomes; expanded indications for inhaled corticosteroid therapy; a framework for targeted treatment based on phenotype, modifiable risk factors, patient preference, and practical issues; optimisation of medication effectiveness by addressing inhaler technique and adherence; revised recommendations about written asthma action plans; diagnosis and initial treatment of the asthma-chronic obstructive pulmonary disease overlap syndrome; diagnosis in wheezing pre-school children; and updated strategies for adaptation and implementation of GINA recommendations.
Collapse
Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Eric D Bateman
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | | | | | | | - Tari Haahtela
- Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Johan C de Jongste
- Dept of Pediatrics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Paul M O'Byrne
- Firestone Institute of Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
| | | | - Soren E Pedersen
- Pediatric Research Unit, University of Southern Denmark, Kolding Hospital, Kolding, Denmark
| | - Emilio Pizzichini
- Universidade Federal de Santa Catarina, NUPAIVA Asthma Research Centre, Florianópolis, Brazil
| | - Manuel Soto-Quiroz
- National Childreńs Hospital, University of Costa Rica San Jose, San Jose, Costa Rica
| | | | - Gary W K Wong
- Dept of Paediatrics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
100
|
Abstract
PURPOSE OF REVIEW Adherence to asthma therapies is poor leading to unnecessary morbidity and increased use of emergency and hospital resources. Strategies to improve adherence have not been successful. RECENT FINDINGS Asthma adherence disease management is a clinical method to improve adherence for asthma patients. The method includes: diagnosing adherence status; identifying patient barriers leading to nonadherence; selecting specific strategies for the clinician for each barrier identified; use of patient-centered communication skills to enhance the effectiveness of the strategies employed. This approach is now being tested in multiple controlled trials. SUMMARY Clinicians may want to consider these strategies, in whole or in part, to improve asthma patient adherence.
Collapse
|