Inhaled corticosteroids and decline of lung function in community residents with asthma

Lost to follow-up in asthmatics does not mean treatment failure: causes and clinical outcomes of non-adherence to outpatient treatment in adult asthma

Purpose

Long-term asthma management is recommended to asthmatics; however, many patients do not adhere to follow-up treatment. It is unclear why many asthmatics do not adhere to follow-up treatment and long-term clinical course after discontinuation of asthma management. This study investigates the factors associated with loss to follow-up and observes the clinical course in asthmatics who discontinued asthma treatment.

Methods

A retrospective investigation was conducted after reviewing medical records of adult patients who were newly diagnosed with asthma at a university hospital in Seoul, South Korea from January 2005 to March 2007. We compared baseline demographics and the clinical and laboratory profiles of patients to see if they successfully adhered to the treatment at an outpatient clinic for at least 3 years. The clinical course and asthma control status were surveyed by telephone for patients who were lost to follow-up within 3 years.

Results

A total of 351 (73.9%) out of 475 patients were lost to follow-up within 3 years of asthma diagnosis. Patients lost to follow-up were younger and had clinical features of less severe asthma at time of diagnosis (higher FEV1 and PC20, and lower grade treatments) compared to patients who adhered to the follow-up for longer than 3 years (all P<0.05). Among the 198 responders to the telephone survey, 124 responders (62.6%) answered that they eventually discontinued asthma medication. A significantly higher proportion of the 124 responders who discontinued asthma treatment maintained symptom improvement compared to the 74 responders who continued asthma medication (77.4% vs. 55.4%, P=0.003).

Conclusions

Almost three quarters of newly diagnosed asthmatics discontinued asthma medication within 3 years despite a medical recommendation. There are considerable numbers of asthmatics who can maintain long-term asthma control status without medication.

CD8(+) T cells characterize early smoking-related airway pathology in patients with asthma

BACKGROUND

Smoking in asthma occurs frequently and is associated with increased symptom severity, an impaired response to corticosteroids, and accelerated lung function decline. Airway pathology in smoking asthmatics is characterized by neutrophilia and epithelial changes such as goblet cell hyperplasia and increased proliferation. Bronchial CD8(+) T cells are implicated in lung function decline in asthma and COPD. We hypothesized that smoking modifies airway inflammation in asthma by increasing the number of CD8(+) T cells at an early stage.

OBJECTIVES & METHODS

To study effects of smoking on airway pathology in bronchial biopsies from atopic patients with controlled intermittent or mild persistent asthma (12 smokers, 9.7 py and 11 never-smokers, 0.0 py; 20-50 yrs; FEV1 > 70% predicted; PC20MCh < 8 mg/mL, no ICS) using immunohistochemistry.

RESULTS

Smoking asthmatics showed higher numbers of bronchial CD8(+) T cells (55.8 vs 23.9 cells/0.1 mm(2); p = 0.001) and CD68(+) macrophages (7.5 vs 4.6 cells/0.1 mm(2), p = 0.012), and a lower CD4(+)/CD8(+) cell ratio (0.16 vs 0.40; p = 0.007) compared with non-smoking asthmatics, but no difference in neutrophils. Furthermore, the % intact epithelium was higher in smoking asthmatics (49.3 vs 23.3, p = 0.001).

CONCLUSION

Smoking asthmatics with a limited smoking history show a distinct pattern of airway pathology characterized by a bronchial infiltrate of CD8(+) T cells and CD68(+) macrophages, and epithelial remodelling resembling COPD-like features. This raises the hypothesis that early presence of CD8(+) T cells contributes to disease progression in smoking asthmatics.

The safety of long-acting β2-agonists in the treatment of stable chronic obstructive pulmonary disease

BACKGROUND

Inhaled long-acting bronchodilators are the mainstay of pharmacotherapy for chronic obstructive pulmonary disease (COPD). Both the twice-daily long-acting β(2)-adrenoceptor agonists (LABAs) salmeterol and formoterol and the once-daily LABA indacaterol are indicated for use in COPD. This review examines current evidence for the safety of LABAs in COPD, focusing on their effect on exacerbations and deaths.

METHODS

We searched PubMed for placebo-controlled studies evaluating long-term (≥24 weeks) use of formoterol, salmeterol, or indacaterol in patients with stable COPD, published between January 1990 and September 2012. We summarized data relating to exacerbations and adverse events, particularly events related to COPD.

RESULTS

From 20 studies examined (8774 LABA-treated patients), there was no evidence of an association between LABA treatment and increased exacerbations, COPD-related adverse events, or deaths. Where analyzed as an efficacy outcome, LABA treatment was generally associated with significant or numerical reductions in COPD exacerbations compared with placebo. Incidences of COPD-related adverse events were similar for active and placebo treatments. The incidence of adverse events typically associated with the β(2)-agonist drug class such as skeletal muscle tremors and palpitations was low (often <1% of patients), and there were no reports of increased incidence of cardiac arrhythmias. The systemic effects of β(2)-adrenoceptor stimulation, such as high glucose and potassium levels, were considered minor.

CONCLUSION

Current evidence from clinical studies of the safety and tolerability profile of LABAs supports their long-term use in COPD.

Asthma

This article presents the complexity of asthma and its ensuing management. The author details the clinical presentation of asthma, discussing its variability of presentation over time and within and among individuals. Pathophysiology is discussed, including immunohistopathologic features and inflammatory mediators, risk factors, comorbid conditions, natural history, and triggers. Diagnosis is presented in light of the challenging history of patients suspected of the disorder; pulmonary function testing, symptom assessment, impairment assessment, and risk assessment. Categories of asthma severity, controlling triggers, pharmacotherapy, stepwise approaches, and ongoing assessment are discussed, with a review of a clinical trial assessing efficacy of management.

Asthma and COPD in alpha-1 antitrypsin deficiency. Evidence for the Dutch hypothesis

This review summarizes the current information on the relationship between severe alpha-1 antitrypsin deficiency (AATD), asthma and COPD. AATD is a genetic predisposition to the development of early COPD in susceptible individuals and reduction in known factors that enhance lung function loss is the paramount aim of management. Asthma is one controllable condition that leads to the accelerated decline in lung function. Current literature indicates that asthma signs and symptoms are common in those AATD with or without COPD and that bronchodilator response is a risk factor for FEV(1) decline. Furthermore AATD itself predisposes to airway hyper responsiveness, an essential ingredient for reversible airflow obstruction. In the absence of well-characterized markers to distinguish COPD from asthma, clinical diagnosis leads to a delay in the recognition that asthma symptoms such as wheezing can be an early manifestation of COPD in AATD. In addition failure to appreciate asthma overlap in AATD may lead to inadequate suppression of airway inflammation leading to the development of airflow obstruction. The implications of this are discussed as are potential approaches and recommendations for treatment.

Annual change of respiratory functions in adult patients with asthma: the potential of antiasthma treatments for many years to repair irreversible changes of the airway

BACKGROUND

Little is known regarding annual changes of respiratory functions among patients with asthma after asthma symptoms enter remission.

OBJECTIVE

Annual changes of respiratory function and influence of patient characteristics and treatment variables on these changes were assessed in patients with adult asthma.

METHODS

Respiratory function (pre- and postbronchodilator forced expiratory volume in one second [FEV₁] and reversibility by short-acting β₂-agonist) and their changes were retrospectively investigated and relationships between these changes, after symptomatic remission, and patient characteristics and treatments were analyzed in adult outpatients with asthma who had undergone spirometry (including a reversibility test) ≥5 times in >5 years.

RESULTS

In patients ≥40 years old, or with disease duration ≥10 years or receiving treatment for severe asthma (steps 4-5, high-dose inhaled glucocorticosteroids, or addition of other medications), both pre- and postbronchodilator FEV₁ values were significantly lower (p < .05). Mean annual change of prebronchodilator FEV₁ (Δpre-FEV₁), annual change of postbronchodilator FEV₁ (Δpost-FEV₁), and annual change of reversibility (Δ reversibility) were -13.8 ± 59.7 ml/year, -25.9 ± 51.0 ml/year, and -0.56% ± 1.89%/year, respectively. Multivariate analysis after stepwise selection for variables in patient characteristics or treatments showed that disease duration ≥10 years contributed to annual improvement of respiratory functions (Δpre-FEV₁: odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.46; Δpost-FEV₁: OR 2.13, 95% CI 1.25-3.66), treatment with long-acting β₂-agonists (LABAs) contributed to annual improvement of respiratory function (Δpre-FEV₁: OR 2.05, 95% CI 1.23-3.16; Δpost-FEV₁: OR 1.78, 95% CI 1.11-2.87), and poor compliance contributed to annual worsening of respiratory functions (Δpre-FEV₁: OR 0.43, 95% CI 0.24-0.76; Δpost-FEV₁: OR 0.39, 95% CI 0.22-0.70). In addition, duration of disease ≥10 years and severe treatment (steps 4-5) from the beginning contributed to decreasing Δreversibility (OR 0.55, 95% CI 0.34-0.87 and OR 0.50, 95% CI 0.29-0.83, respectively).

CONCLUSIONS

Long-term treatments for asthma are expected to normalize respiratory dysfunction, which cannot be repaired in the short term. Treatment with LABAs and patient compliance may be the most important factors associated with annual improvement of respiratory functions.

An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease

RATIONALE

Although cigarette smoking is the most important cause of chronic obstructive pulmonary disease (COPD), a substantial proportion of COPD cases cannot be explained by smoking alone.

OBJECTIVES

To evaluate the risk factors for COPD besides personal cigarette smoking.

METHODS

We constituted an ad hoc subcommittee of the American Thoracic Society Environmental and Occupational Health Assembly. An international group of members was invited, based on their scientific expertise in a specific risk factor for COPD. For each risk factor area, the committee reviewed the literature, summarized the evidence, and developed conclusions about the likelihood of it causing COPD. All conclusions were based on unanimous consensus.

MEASUREMENTS AND MAIN RESULTS

The population-attributable fraction for smoking as a cause of COPD ranged from 9.7 to 97.9%, but was less than 80% in most studies, indicating a substantial burden of disease attributable to nonsmoking risk factors. On the basis of our review, we concluded that specific genetic syndromes and occupational exposures were causally related to the development of COPD. Traffic and other outdoor pollution, secondhand smoke, biomass smoke, and dietary factors are associated with COPD, but sufficient criteria for causation were not met. Chronic asthma and tuberculosis are associated with irreversible loss of lung function, but there remains uncertainty about whether there are important phenotypic differences compared with COPD as it is typically encountered in clinical settings.

CONCLUSIONS

In public health terms, a substantive burden of COPD is attributable to risk factors other than smoking. To prevent COPD-related disability and mortality, efforts must focus on prevention and cessation of exposure to smoking and these other, less well-recognized risk factors.

The importance of airway remodelling in the natural course of asthma

INTRODUCTION

Asthma is associated with airflow limitation and increased decline in lung function. The underlying mechanism for this was probably that persisting inflammation leads to remodelling of the airways.

OBJECTIVES

To review the importance of different factors which are related to airflow limitation and lung function decline in asthma.

METHODS

Case report and literature review.

RESULTS

Asthma severity, smoking, bronchial hyperresponsiveness and eosinophil inflammation were the variables that were most convincingly related to decline in forced expiratory volume in 1 s (FEV(1)) in asthma. Treatment with inhaled corticosteroids probably decreased the rate of FEV(1) decline, although this was more uncertain because of the lack of randomised double blind studies that show such an effect. Progress in the field of the genetics of asthma may, in the near future, elucidate the role of gene-environment interaction in lung function decline in asthma.

CONCLUSION

Regular treatment with inhaled corticosteroids may partly have a beneficial effect on airway remodelling in asthma. Improved understanding of the processes leading to airway remodelling is, however, important in order to prevent a large number of asthmatics from developing irreversible airflow obstruction.

Multidimensional analyses of long-term clinical courses of asthma and chronic obstructive pulmonary disease

Asthma and chronic obstructive pulmonary disease (COPD) are chronic respiratory disorders involving obstructive airway defects. There have been many discussions on their similarities and differences. Although airflow limitation expressed as forced expiratory volume in one second (FEV(1)) has been considered to be the main diagnostic assessment in both diseases, it does not reflect the functional impairment imparted to the patients by these diseases. Therefore, multidimensional approaches using multiple measurements in assessing disease control or severity have been recommended, and multiple endpoints in addition to FEV(1) have been set recently in clinical trials so as not to miss the overall effects. In particular, as improving symptoms and health status as well as pulmonary function are important goals in the management of asthma and COPD, some patient-reported measurements such as health-related quality of life or dyspnea should be included. Nonetheless, there have been few reviews on the long-term clinical course comparing asthma and COPD as predicted by measurements other than airflow limitation. Here, we therefore analyzed and compared longitudinal changes in both physiological measurements and patient-reported measurements in asthma and COPD. Although both diseases showed similar long-term progressive airflow limitation similarly despite guideline-based therapies, disease progression was different in asthma and COPD. In asthma, patient-reported assessments of health status, disability and psychological status remained clinically stable over time, in contrast to the significant deterioration of these parameters in COPD. Thus, because a single measurement of airflow limitation is insufficient to monitor these diseases, multidimensional analyses are important not only for disease control but also for understanding disease progression in asthma and COPD.

Inhaled Corticosteroids

Inhaled corticosteroids (ICS) are the most effective controllers of asthma. They suppress inflammation mainly by switching off multiple activated inflammatory genes through reversing histone acetylation via the recruitment of histone deacetylase 2 (HDAC2). Through suppression of airway inflammation ICS reduce airway hyperresponsiveness and control asthma symptoms. ICS are now first-line therapy for all patients with persistent asthma, controlling asthma symptoms and preventing exacerbations. Inhaled long-acting β₂-agonists added to ICS further improve asthma control and are commonly given as combination inhalers, which improve compliance and control asthma at lower doses of corticosteroids. By contrast, ICS provide much less clinical benefit in COPD and the inflammation is resistant to the action of corticosteroids. This appears to be due to a reduction in HDAC2 activity and expression as a result of oxidative stress. ICS are added to bronchodilators in patients with severe COPD to reduce exacerbations. ICS, which are absorbed from the lungs into the systemic circulation, have negligible systemic side effects at the doses most patients require, although the high doses used in COPD has some systemic side effects and increases the risk of developing pneumonia.

The irreversible component of persistent asthma

Irreversible airflow obstruction or limitation occurs in some patients with asthma, can develop early in life, and becomes more common as asthma becomes more severe. Efforts to understand irreversible airflow obstruction or limitation have been hampered by the lack of a standardized definition of the phenotype and by the lack of appropriate research models. Unfortunately, it appears that currently available asthma treatments do not prevent this important asthma complication. Herein, the evidence of an irreversible component of asthma, its underlying pathology, and the limitations of current asthma treatments are reviewed.

The association between family history of asthma and the prevalence of asthma among US adults: National Health and Nutrition Examination Survey, 1999-2004

PURPOSE

To assess the overall prevalence of asthma and the association between family history of asthma and the prevalence of asthma among US adults.

METHODS

We analyzed National Health and Nutrition Examination Survey data from 1999 to 2004 for 15,008 respondents aged 20 years or older with no history of emphysema. We divided respondents into three familial risk groups (high, moderate, and average) on the basis of the number and closeness of relatives, that they reported as having asthma and then assessed the asthma prevalence in each. We also assessed associations between asthma prevalence and age, sex, race/ethnicity, income, body mass index, smoking status, household smoking exposure, and physical activity.

RESULTS

By our definitions, 2.3% of respondents were at high, 13.0% at moderate, and 84.7% at average familial risk for asthma. The crude prevalence of self-reported lifetime asthma was 11.5% (95% confidence interval [CI]: 10.7-12.3%) among all respondents, and 37.6% (95% CI: 30.4-45.4%), 20.4% (95% CI: 18.2-22.7%), and 9.4% (95% CI: 8.7-10.2%) among those at high, moderate, and average familial risk, respectively. Among all risk factors we looked at, family history had the strongest association with lifetime asthma prevalence, and the association remained significant after adjustments for other risk factors. Compared with average familial risk, the adjusted odds ratios for lifetime asthma were 2.4 (95% CI: 2.0 -2.8) for moderate and 4.8 (95% CI: 3.5-6.7) for high familial risk.

CONCLUSION

Our findings showed that a family history of asthma is an important risk factor for asthma and that familial risk assessments can help identify people at highest risk for developing asthma. Additional research is needed to assess how health care professionals can use family history information in the early detection and management of asthma.

Outcomes and costs of patients with persistent asthma treated with beclomethasone dipropionate hydrofluoroalkane or fluticasone propionate

OBJECTIVE

Examine outcomes and costs of patients with persistent asthma who initiated treatment with beclomethasone dipropionate hydrofluoroalkane (BDP-HFA) or fluticasone propionate (FP).

METHODS

MedStat's Commercial Claims and Encounters database (July 1, 2002-June 30, 2007) was utilized. Patients (n=13,968) were included if they initiated treatment with BDP-HFA or FP (first use=index date). Patients also met these criteria: (a) no receipt of other study medication in the 1-year post-period; (b) persistent asthma in the 1-year pre-period; (c) age 5-64 years; (d) no diagnosis of chronic obstructive pulmonary disease; and (e) continuous insurance coverage from 1 year pre-period to 1 year post-period. Multivariate regressions examined the probability of an ER visit or hospitalization, probability of reaching alternative adherence thresholds, and costs.

RESULTS

Receipt of BDP-HFA, compared with FP, was associated with a 17% reduction in the odds of an ER visit (OR=0.834, 95% CI 0.751 to 0.925), a 30% reduction in the odds of an asthma-related ER visit (OR=0.697, 95% CI 0.571 to 0.852), and an increase in the odds of obtaining a medication possession ratio (MPR) of at least 50% (OR=1.324; 95% CI 1.164 to 1.506) or 75% (OR=1.311; 95% CI 1.072 to 1.604). Total medical costs ($5063 vs. $5377, P=0.0042), prescription drug costs ($2336 vs. $2581, P<0.0001), and ER costs ($185 vs. $249, P<0.0001) were significantly lower among the BDP-HFA cohort. Asthma-related outpatient ($191 vs. $224, P<0.0001) and ER costs ($28 vs. $45, P<0.001) were significantly lower in the BDP-HFA group, while asthma-related inpatient ($101 vs. $59, P<0.0001) and drug costs ($451 vs. $540, P<0.0001) were significantly lower in the FP cohort.

CONCLUSIONS

Results indicate that receipt of BDP-HFA, compared with receipt of FP, is associated with a decreased probability of ER visits or asthma-related ER visits and higher odds of reaching a medical possession ratio threshold of 50% or 75%. Receipt of BDP-HFA was also associated with lower total drug costs and lower total medical costs.

Body mass index, weight gain, and other determinants of lung function decline in adult asthma

BACKGROUND

Little is known about factors associated with lung function decline in asthma.

OBJECTIVE

To identify the determinants of FEV(1) decline in adults with asthma with and without airflow obstruction at baseline.

METHODS

An international cohort of 638 subjects with asthma (20-44 years old) was identified in the European Community Respiratory Health Survey (1991-1993) and followed up from 1998 to 2002. Spirometry was performed on both occasions. FEV(1) decline was related to potential determinants evaluated at baseline and during the follow-up by random intercept linear regression models. The analyses were stratified by the presence of airflow obstruction (FEV(1)/forced vital capacity < 0.70) at baseline.

RESULTS

In the group of individuals without airflow obstruction (n = 544), a faster FEV(1) decline was observed for subjects with intermediate body mass index (BMI) than for lean and obese subjects. FEV(1) decline was associated with weight gain independently of baseline BMI, and this association was stronger in men (20; 95% CI, 10-30, mL/y/kg gained) than in women (6; 95% CI, 1-11, mL/y). In the group of individuals with airflow obstruction (n = 94), the absence of allergen sensitization and a low BMI at baseline were associated with a faster FEV(1) decline, whereas weight gain was not associated with decline.

CONCLUSIONS

The detrimental effect of weight gain on FEV(1) decline is particularly relevant in subjects with asthma who still do not have an established airflow obstruction. Our findings support the importance of weight management in asthma and recommend weight loss in overweight or obese individuals with asthma.

Asthma in smokers: challenges and opportunities

PURPOSE OF REVIEW

Cigarette smoking in asthma is associated with poor symptom control and reduced sensitivity to corticosteroids. We summarize recent evidence supporting the adverse effects of smoking in asthma and consider strategies to manage these patients.

RECENT FINDINGS

Smokers have more severe symptoms and are more likely to be admitted to hospital due to poorly controlled asthma compared with nonsmokers with asthma. Possible causes of reduced sensitivity to inhaled corticosteroids in smokers with asthma are noneosinophilic airway inflammation, impaired glucocorticoid receptor function, and/or reduced histone deacetylase activity. Smoking cessation improves asthma control, but quit rates are low. The optimal drug therapy for smokers with asthma is not established due, in part, to the small number of clinical trials performed in these patients. Preliminary data, however, suggest that leukotriene-receptor antagonists may have a beneficial effect in smokers with mild asthma.

SUMMARY

Cigarette smoking in asthma is a risk factor for poor asthma control and reduced sensitivity to corticosteroids. Every effort should be made to encourage individuals with asthma who smoke to quit. Clinical trials are required to identify therapies that restore corticosteroid sensitivity or directly improve symptom control in individuals with asthma who are unable to stop smoking.

Treating patients with respiratory disease who smoke

The high prevalence of cigarette smoking in patients with respiratory disease puts them at risk of developing clinically important drug interactions. Cigarette smoking reduces the therapeutic response to certain drugs such as theophyllines through the induction of hepatic cytochrome P450 isoenzymes. Smokers with asthma and patients with COPD have reduced sensitivity to corticosteroids, possibly due to non-eosinophilic airway inflammation, altered glucocorticoid receptor activity or reduced histone deacetylase activity. Although all smokers should be encouraged to stop smoking, there is limited information on the influence of smoking cessation on the therapeutic and anti-inflammatory effects of a number of the drugs used in the treatment of respiratory disease.

Asthma worsenings: approaches to prevention and management from the Asthma Worsenings Working Group

Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.

The course of persistent airflow limitation in subjects with and without asthma

RATIONALE

Most patients who develop persistent airflow limitation do so either as a manifestation of chronic obstructive pulmonary disease that is largely related to smoking or as a consequence of persistent asthma. We sought to compare the natural course of lung function associated with persistent airflow limitation in subjects with and without asthma from early to late adult life.

METHODS

We studied 2552 participants aged 25 or more who had multiple questionnaire and lung function data from the long-term prospective population-based Tucson Epidemiological Study of Airway Obstructive Disease. Persistent airflow limitation was defined as FEV(1)/FVC ratio consistently < 70% in all completed surveys subsequent to the first survey with airflow limitation. Participants were divided into nine groups based on the combination of their physician-confirmed asthma status (never, onset < or = 25 years, or onset > 25 years) and the presence of airflow limitation during the study follow-up (never, inconsistent, or persistent).

RESULTS

Among subjects with an asthma onset < or = 25 years, blood eosinophilia increased significantly the odds of developing persistent airflow limitation (adjusted ORs: 3.7, 1.4-9.5), whereas cigarette smoking was the strongest risk factor for persistent airflow limitation among non-asthmatics and among subjects with asthma onset after age 25 years. Among subjects with persistent airflow limitation, the natural course of lung function differed between subjects with asthma onset < or = 25 years and non-asthmatics, with the former having lower FEV(1) levels at age 25 (predicted value for a 175-cm tall male of 3400 versus 4090 ml, respectively; p<0.001) and the latter having greater FEV(1) loss between age 25 and 75 (1590 versus 2140 ml; p=0.003).

CONCLUSION

In subjects who have asthma onset before 25 years of age and persistent airflow limitation in adult life, the bulk of the FEV(1) deficit is already established before age 25 years.

Response of older patients with IgE-mediated asthma to omalizumab: a pooled analysis

Asthma in older adults is under-recognized and possibly associated with allergic triggers. We conducted a pooled analysis of omalizumab double-blind, placebo-controlled trials to evaluate efficacy in older adults. Data for the total study population and subjects aged > or = 50 years with moderate-severe allergic asthma were examined. We used Poisson regression to analyze the number of asthma exacerbations and logistic regression to evaluate treatment effectiveness. Symptom scores and total rescue medication puffs were evaluated by analysis of covariance. Omalizumab reduced the risk of clinically significant asthma exacerbations, led to a significantly greater response in patient/investigator-reported global effectiveness, improved asthma symptom scores, and reduced rescue medication use in adults > or = 50 years with moderate-severe allergic asthma.

Clinical assessment of asthma progression in children and adults

Asthma is a heterogeneous disorder with a variable course, characterized by episodes of cough, wheezing and shortness of breath, reversible airflow limitation, and bronchial hyperresponsiveness. It begins early in life in many subjects with intermittent symptoms occurring with viral respiratory tract infections. Over time, and in genetically susceptible children (those with an atopic predisposition), the disease becomes more persistent with symptoms occurring in the absence of respiratory tract infections. Children with persistent wheezing are eventually diagnosed with asthma, with those at greatest risk having developed allergic sensitization early in life. Among children with asthma, some will have lifelong asthma with active symptoms and progressive loss of lung function over time, whereas other children will undergo asthma remission in adolescence. Once in remission, the disease may remain quiescent, or it may relapse in midadult life. This review focuses on studies that have enhanced our understanding of the progression of asthma from infancy to adulthood. Studies evaluating progressive loss of lung function, the best-studied measure of asthma progression, are also reviewed, followed by a brief discussion of whether asthma progression can be modified by inhaled glucocorticoid therapy.

The Inhaled Steroid Treatment As Regular Therapy in Early Asthma (START) study 5-year follow-up: effectiveness of early intervention with budesonide in mild persistent asthma

BACKGROUND

The Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START) study enrolled 7241 patients aged 5 to 66 years with recent-onset, mild persistent asthma to assess early intervention with the inhaled corticosteroid budesonide on long-term asthma control.

OBJECTIVE

The open-label phase of the START study was included to determine the effect on lung function and asthma control of adding budesonide to the reference group patients who had not initially received inhaled corticosteroids.

METHODS

Patients were randomized to double-blind treatment with budesonide, 200 mug (those aged < 11 years) or 400 mug once daily, or placebo plus the usual asthma therapy for 3 years, after which all patients received 2 years of open-label treatment with budesonide once daily.

RESULTS

During the full 5-year study period, postbronchodilator FEV(1) percent predicted decreased, irrespective of randomized treatment during the double-blind phase, by an average of 2.22% (SE, 0.15%). However, patients with inhaled budesonide in the double-blind phase had a significantly lower risk (odds ratio, 0.61; P < .001) of a severe asthma-related event during the full 5-year study period than those in the reference group. Moreover, patients in the reference group used more additional asthma medications during both the open-label and double-blind phases.

CONCLUSIONS

In mild persistent asthma early intervention with inhaled budesonide was associated with improved asthma control and less additional asthma medication use.

Insights into early treatment of mild asthma: do inhaled corticosteroids make a difference?

Approaches to the management of moderate-to-severe persistent asthma in both children and adults are widely accepted but the treatment of mild persistent asthma remains controversial because of the lack of agreement on what constitutes mild asthma and whether regular treatment is required at all. Recent evidence indicates that 'mild asthma' may not be as benign a condition as was widely believed and should be treated to improve asthma control and to prevent the significant burden of exacerbation and progression of disease. This is supported by compelling evidence from histologic and clinical studies that have attributed irreversible pathologic and functional airway changes to consequences of persistent airway inflammation and under-treated asthma. This article focuses on the rationale of early treatment of mild persistent asthma, and discusses the various findings from the largest randomized, early-intervention trial with inhaled corticosteroids as regular treatment in patients with asthma of recent onset--the START (inhaled Steroid Treatment As Regular Therapy in early asthma) study. A brief review of the background of the natural history of asthma, the findings from key longitudinal epidemiologic studies on disease progression in children and adults, and the effect of inhaled corticosteroids on this progression are included, to provide further insight into the impact of early treatment on asthma management guidelines.

Determinants of lung function and airway hyperresponsiveness in asthmatic children

BACKGROUND

Asthma patients exhibit an increased rate of loss of lung function. Determinants to such decline are largely unknown and the modifying effect of steroid therapy is disputed. This cross-sectional study aimed to elucidate factors contributing to such decline and the possible modifying effect of steroid treatment.

METHODS

We analyzed determinants of lung function and airway hyperresponsiveness (AHR) in a Scandinavian study of 2390 subjects from 550 families. Families were selected for the presence of two or more asthmatic children as part of a genetic study, Scandinavian Asthma Genetic Study (SAGA).

RESULTS

The primary analysis studied the association between the lung function and delay of inhaled corticosteroids (ICS) after asthma diagnosis among asthmatic children and young adults with a history of regular ICS treatment (N=919). FEV(1) percent predicted (FEV(1)% pred) was 0.25% lower per year of delay from diagnosis until treatment (p=0.039). This association was significantly greater in allergy skin prick test negative children. There was no significant influence of gender, age at asthma onset, or smoking. In the secondary analysis of the whole population of 2390 asthmatics and non-asthmatics, FEV(1)% pred was inversely related to having asthmatic siblings (-7.9%; p<0.0001), asthma diagnosis (-2.7%; p=0.0007), smoking (-3.5%; p=0.0027), and positive allergy skin prick test (-0.47% per test; p=0.012), while positively related to being of female gender (1.8%; p=0.0029). Risk of AHR was higher by having asthmatic siblings (OR 2.7; p<0.0001), being of female gender (OR 2.0; p<0.0001), and having asthma (OR 2.0; p<0.0001).

CONCLUSIONS

These data suggest that lung function is lower in asthmatics with delayed introduction of ICS therapy, smoking, and positive allergy skin prick test. Lung function is lower and AHR higher in female asthmatics and subjects with asthmatic siblings or established asthma.

A Pooled Analysis of FEV 1 Decline in COPD Patients Randomized to Inhaled Corticosteroids or Placebo

BACKGROUND

There is controversy about whether therapy with inhaled corticosteroids (ICSs) modifies the natural history of COPD, characterized by an accelerated decline in FEV(1).

METHODS

The Inhaled Steroids Effect Evaluation in COPD (ISEEC) study is a pooled study of patient-level data from seven long-term randomized controlled trials of ICS vs placebo lasting >/= 12 months in patients with moderate-to-severe COPD. We have previously reported a survival benefit for ICS therapy in COPD patients using ISEEC data. We aimed to determine whether the regular use of ICSs vs placebo improves FEV(1) decline in COPD patients, and whether this relationship is modified by gender and smoking.

RESULTS

There were 3,911 randomized participants (29.2% female) in this analysis. In the first 6 months after randomization, ICS use was associated with a significant mean (+/- SE) relative increase in FEV(1) of 2.42 +/- 0.19% compared with placebo (p < 0.01), which is quantifiable in absolute terms as 42 mL in men and 29 mL in women over 6 months. From 6 to 36 months, there was no significant difference between placebo and ICS therapy in terms of FEV(1) decline (-0.01 +/- 0.09%; p = 0.86). The initial treatment effect was dependent on smoking status and gender. Smokers who continued to smoke had a smaller increase in FEV(1) during the first 6 months than did ex-smokers. Female ex-smokers had a larger increase in FEV(1) with ICS therapy than did male ex-smokers.

CONCLUSIONS

We conclude that in COPD in the first 6 months of treatment, ICS therapy is more effective in ex-smokers than in current smokers with COPD in improving lung function, and women may have a bigger response to ICSs than men. However, it seems that after 6 months, ICS therapy does not modify the decline in FEV(1) among those who completed these randomized clinical trials.

Inhaled steroids are associated with reduced lung function decline in subjects with asthma with elevated total IgE

BACKGROUND

Few studies have investigated the long-term association between inhaled corticosteroids (ICSs) and lung function decline in asthma.

OBJECTIVE

To evaluate whether prolonged treatment with ICSs is associated with FEV(1) decline in adults with asthma.

METHODS

An international cohort of 667 subjects with asthma (20-44 years old) was identified in the European Community Respiratory Health Survey (1991-1993) and followed up from 1999 to 2002. Spirometry was performed on both occasions. FEV(1) decline was analyzed according to age, sex, height, body mass index, total IgE, time of ICS use, and smoking, while adjusting for potential confounders.

RESULTS

As ICS use increased, the decline in FEV(1) was lower (P trend = .025): on average, decline passed from 34 mL/y in nonusers (half of the sample) to 20 mL/y in subjects treated for 48 months or more (18%). When adjusting for all covariates, there was an interaction (P = .02) between ICS use and total IgE: in subjects with high (>100 kU/L) IgE, ICS use for 4 years or more was associated with a lower FEV(1) decline (23 mL/y; 95% CI, 8-38 compared with nonusers). This association was not seen in those with lower IgE.

CONCLUSION

Although confirming a beneficial long-term association between ICSs and lung function in asthma, our study suggests that subjects with high IgE could maximally benefit from a prolonged ICS treatment.

CLINICAL IMPLICATIONS

This study adds further evidence to the beneficial effect of inhaled steroids on lung function in asthma; future studies will clarify whether calibrating the corticosteroid dose according to the level of total IgE is a feasible approach in asthma management.

Asthma treatment and asthma prevention: a tale of 2 parallel pathways

Three recent clinical trials used different study designs to test the hypothesis that early introduction of inhaled corticosteroids in infants and young children at high risk for the development of asthma could change the natural course of the disease. All 3 trials reached the same conclusion: treatment requirement, symptom frequency while off treatment, and lung function did not differ between children receiving active drug or placebo, with outcomes measured 2 to 4 years after randomization. These findings challenge the concept that the inflammatory processes that cause asthma symptoms and are responsive to inhaled corticosteroids are also responsible for the chronic changes in airway structure and function that are believed to predispose to the development of persistent asthma. This conclusion is supported by studies showing that bronchial hyperresponsiveness, independent of current asthma symptoms, is associated with subsequent deficits in airway function growth during childhood. Successful strategies for the prevention of asthma will require a better understanding of the genetic, environmental, and developmental factors that predispose toward inappropriate responses to airway injury. Abnormal airway remodeling and persistent dysregulation of airway tone might be the final common pathway for different disease mechanisms, and this might explain the heterogeneity of clinical phenotypic syndromes that go under the common label of "asthma."