Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial

A review of standard pharmacological therapy for adult asthma – Steps 1 to 5

The aim of pharmacological therapy for asthma is to improve symptoms and lung function and minimize the risk of asthma attacks. The intensity of treatment is based on the level of asthma control and the potential risk of future deterioration. In the British asthma guidelines, treatments are divided into steps 1 to 5, with each step signifying a need for an increase in therapy in response to symptoms or to prevent exacerbations. Treatments comprise of inhaled or systemic medications. Inhaled therapy includes short-acting and long-acting medication to improve symptoms and inhaled corticosteroids that reduce airway inflammation. Systemic treatments include medications that act on specific biological pathways, such as the leukotriene or immunoglobulin E pathways, or systemic corticosteroids. In choosing a particular therapy, treatment benefits are balanced by the potential risks of medication-related adverse effects. This review will provide a practical guide to the key pharmacological therapies for adult asthma at steps 1 to 5 based on British guidelines and consider future options for new treatments.

Nitric oxide suppresses LPS-induced inflammation in a mouse asthma model by attenuating the interaction of IKK and Hsp90

A feature of allergic airway disease is the observed increase of nitric oxide (NO) in exhaled breath. Gram-negative bacterial infections have also been linked with asthma exacerbations. However, the role of NO in asthma exacerbations with gram-negative bacterial infections is still unclear. In this study, we examined the role of NO in lipopolysaccharide (LPS)-induced inflammation in an ovalbumin (OVA)-challenged mouse asthma model. To determine whether NO affected the LPS-induced response, a NO donor (S-nitroso-N-acetylpenicillamine, SNAP) or a selective inhibitor of NO synthase (1400W) was injected intraperitoneally into the mice before the LPS stimulation. Decreased levels of proinflammatory cytokines were demonstrated in the bronchoalveolar lavage fluid from mice treated with SNAP, whereas increased levels of cytokines were found in the 1400W-treated mice. To further explore the molecular mechanism of NO-mediated inhibition of proinflammatory responses in macrophages, RAW 264.7 cells were treated with 1400W or SNAP before LPS stimulation. LPS-induced inflammation in the cells was attenuated by the presence of NO. The LPS-induced IκB kinase (IKK) activation and the expression of IKK were reduced by NO through attenuation of the interaction between Hsp90 and IKK in the cells. The IKK decrease in the lung immunohistopathology was verified in SNAP-treated asthma mice, whereas IKK increased in the 1400W-treated group. We report for the first time that NO attenuates the interaction between Hsp90 and IKK, decreasing the stability of IKK and causing the down-regulation of the proinflammatory response. Furthermore, the results suggest that NO may repress LPS-stimulated innate immunity to promote pulmonary bacterial infection in asthma patients.

Emerging issues in pediatric asthma: gaps in EPR-3 guidelines for infants and children

There are many complexities to the treatment of infants and children with recurrent wheezing and asthma. The National Heart, Lung and Blood Institute's (NHLBI's) Expert Panel Report-3 (EPR-3), published in 2007, provides guidance to clinicians who care for infants and children with asthma. Since that time, many important clinical trials have further informed the evidence base available to clinicians. In this manuscript, new approaches to long-term therapy, intermittent fixed-dose and dynamic dose therapies, and emerging therapies for asthma are reviewed. Further, additional gaps in guideline-based care and areas for future research are discussed.

Daily versus intermittent inhaled corticosteroid treatment for mild persistent asthma

PURPOSE OF REVIEW

Guidelines recommend the use of daily inhaled corticosteroids as preferred treatment for preschoolers, children, adolescents, and adults with recurrent wheezing and mild persistent asthma. However, intermittent or as-needed inhaled corticosteroids treatment in response to symptoms is an emerging strategy. This review is focused on the analysis (clinical efficacy and safety) of this approach in comparison with the current daily-based therapy.

RECENT FINDINGS

Recently, some authors favored the use of inhaled corticosteroids based on symptoms. It has been suggested that a symptom-based approach could reduce the amount of drug used, minimize the risk of adverse events, and reduce healthcare costs. In contrast, physicians prescribing intermittent inhaled corticosteroids would give the wrong message to their patients about the chronicity of the disease. Currently, there is a significant body of high-quality clinical studies and systematic reviews that have addressed this important controversy, and whose analysis allows us to extract some important conclusions.

SUMMARY

Present evidence does not support a change in the direction of an intermittent or symptom-based use approach for recurrent wheezing and mild-to-moderate persistent asthma. At this point, there is no convincing basis to alter the current strategy to inhaled corticosteroids dosing, and more studies are needed comparing these two approaches.

Novel biomarkers for asthma stratification and personalized therapy

A stepwise pharmacological treatment is currently recommended for all asthma patients and is personalized mainly on disease severity, aiming for the lowest disease-controlling step. Nevertheless, asthma comprises several related pathologies with similar clinical manifestations resulting from distinct underlying mechanisms. Therefore novel biomarkers could lead to asthma stratification and thus improve upon the current stepwise approach. The aim of this review is to update the reader with regard to different assays proposed in the recent asthma literature for measuring potential biomarkers for patient stratification and treatment personalization. Promising biomarkers are sputum eosinophils, serum periostin and exhaled nitric oxide. Periostin could differentiate between Th2-high and Th2-low asthma (Th2-high patients are more responsive to glucocorticoids) and the less-defined asthma types which often present a therapeutic challenge. Several other biomarkers, mainly cytokines, leukotrienes and exhaled air components, can be quantified in body fluids and exhaled breath and could also be useful for asthma stratification.

Contribution of exhaled nitric oxide measurement in airway inflammation assessment in asthma. A position paper from the French Speaking Respiratory Society

Nitric oxide (NO) is both a gas and a ubiquitous inter- and intracellular messenger with numerous physiological functions. As its synthesis is markedly increased during inflammatory processes, NO can be used as a surrogate marker of acute and/or chronic inflammation. It is possible to quantify fractional concentration of NO in exhaled breath (FENO) to detect airway inflammation, and thus improve the diagnosis of asthma by better characterizing asthmatic patients with eosinophilic bronchial inflammation, and eventually improve the management of targeted asthmatic patients. FENO measurement can therefore be viewed as a new, reproducible and easy to perform pulmonary function test. Measuring FENO is the only non-invasive pulmonary function test allowing (1) detecting, (2) quantifying and (3) monitoring changes in inflammatory processes during the course of various respiratory disorders, including corticosensitive asthma.

Getting control of uncontrolled asthma

Despite various treatment modalities, a large proportion of patients have asthma that remains uncontrolled. These patients remain at an increased risk of developing severe exacerbations, have a poor quality of life, and pose a high economic healthcare burden, with an estimated mean annual cost more than double that of patients with good symptom control. It is therefore important to accurately diagnose asthma and continually assess asthma control. Several validated tools are available to do this, including questionnaires, biomarker analysis, and bronchoscopy. Current guidelines advise physicians to establish a self-management program for the patient to assess and monitor asthma control. A further recommendation is the establishment of an educational action plan to increase treatment adherence and to improve asthma control. National and international guidelines provide long-term management strategies for these patients and recommend a stepwise approach for achieving and maintaining asthma control. Despite availability of a wide range of controller and reliever therapies, uncontrolled asthma remains a challenge and reflects the need for new therapeutic options. This review discusses current global guidelines for the assessment and management of asthma control and summarizes the broad spectrum of novel therapeutic agents currently under development for the treatment of asthma, including anticholinergics, chemoattractant receptor-homologous molecules expressed on T-helper 2 lymphocyte antagonists, and anti-interleukin (IL)-5, anti-IL-13, and anti-IL-4 agents.

Empowering the child and caregiver: yellow zone Asthma Action Plan

Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.

Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care

BACKGROUND

Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment.

OBJECTIVE

We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa).

METHODS

In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate.

RESULTS

Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate.

CONCLUSION

A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.

Adult asthma biomarkers

PURPOSE OF REVIEW

A variety of novel asthma treatments have been developed based on phenotypes, and the clinical trial results show promising responses. This review summarizes the current knowledge of biomarkers for the determination of asthma phenotypes.

RECENT FINDINGS

Eosinophilic inflammation is the most focused phenotype because most novel asthma treatments have targeted T-helper type 2 (Th2) pathway. Fractional-exhaled nitric oxide (FeNO) is a new method that represents an eosinophilic airway inflammation with a significant correlation with sputum eosinophilia and asthma severity instead of sputum eosinophil count that easily influenced by corticosteroid therapy. However, some reports indicated the discordance between treatment response or adjustment and FeNO levels. Serum periostin is a strong serum biomarker for eosinophilic airway inflammation and an indicator of Th2-targeted therapy (such as lebrikizumab or omalizumab) and airflow limitation. YKL-40 is associated with asthma severity and airway remodeling. In addition, genetic and metabolomic approaches have been made to determine asthma phenotypes and severity.

SUMMARY

Biomarkers such as FeNO and serum periostin represent eosinophilic airway inflammation, together with eosinophil-derived neurotoxin and osteopontin (OPN) needed more replication studies. Periostin, YKL-40, OPN and some metabolites (choline, arginine, acetone and protectin D1) are related to asthma severity and airflow limitation.

Asthma control: how it can be best assessed?

PURPOSE OF REVIEW

A control-based asthma assessment is recommended by guidelines, but questions remain about how to assess the level of asthma control, and how current control status relates to future risks and biomarkers of disease pathogenesis. This review summarizes recent published data relating to asthma control and describes the challenges created by currently available instruments.

RECENT FINDINGS

The current literature continues to show the widespread use of various assessment instruments for asthma control, in particular those with composite scores. However, poor correlations exist between the different assessment tools, and these instruments lack diagnostic accuracy to differentiate uncontrolled asthma. Whereas the concept of asthma control has been extended to add an assessment of future risks to the clinical control, clinical asthma control as measured by current available assessment tools does not necessary relate to the intrinsic disease activity which is typically characterized by inflammation in asthma.

SUMMARY

The application of asthma control assessment represents an improvement in asthma management. The measurement of underlying disease activity potentially by biomarkers to assess disease control will lead to an improved assessment of the overall control of asthma, and further studies addressing this are needed.

Revisiting the role of exhaled nitric oxide in asthma

PURPOSE OF REVIEW

This review focuses on the most recent studies investigating fractional nitric oxide concentration in exhaled breath (FeNO) as a useful biomarker for identifying specific phenotypes in asthma and as a tool for asthma diagnosis, monitoring and clinical decision-making.

RECENT FINDINGS

On the basis of the current literature, it has been highlighted that FeNO is a clinically relevant marker in various clinical aspects of asthma: FeNO is a predictor for developing asthma in persistent rhinitis or in infants with respiratory symptoms; FeNO contributes to identification of asthma phenotypes in both children and adults, also in relation to severity; FeNO is useful in monitoring the effectiveness of inhaled corticosteroids (including compliance) and biologic treatments like omalizumab; FeNO, in conjunction with symptom registration and lung function measurements, contributes to asthma diagnosis and optimizes asthma management.

SUMMARY

FeNO provides further information in distinguishing different phenotypes in asthma, allowing a much more appropriate control of the disease, especially in patients with difficult/severe asthma. In the future, it would be interesting to shed light on the hidden biological mechanisms responsible for low or normal FeNO values in symptomatic asthmatic patients.

FeNO as a predictor of asthma control improvement after starting inhaled steroid treatment

INTRODUCTION

The fraction of NO in exhaled air (FeNO) is a marker of inflammation in asthma. The aim of the present study was to assess, in a real-world setting, whether only high (⩾50 ppb) FeNO levels predict improvement in asthma control when being treated with inhaled corticosteroids (ICS), as suggested by current guidelines on the clinical use of FeNO.

METHODS

FeNO and asthma control were assessed in a retrospective observational study in 153 non-smoking, steroid-naïve, adult subjects with asthma with a mean age of 40 years both before and after 6 weeks (median follow-up time) of treatment with 500 μg beclomethasone (median).

RESULTS

Having at the initial visit intermediate FeNO (⩾25 and <50 ppb) and high FeNO (⩾50 ppb), compared to normal FeNO (<25 ppb), were associated with a larger proportion of subjects achieving an improvement of Asthma Control Questionnaire (ACQ) score with ⩾1 (78% and 67% vs 43%, p<0.05) or both ⩾1 improvement and asthma control at follow-up (31% and 37% vs 4%, p<0.05). These associations were consistent in multiple logistic regression models after adjustments for confounders.

CONCLUSIONS

It is not only high but also intermediate FeNO levels that are associated with a significant improvement in asthma control after starting ICS treatment. This challenges current clinical guidelines stating that only high FeNO levels predict response to ICS treatment.

The risks, benefits, and uncertainties of stepping down asthma medications

Stepwise adjustments have been suggested as a framework to manage chronic asthma over time. In this framework, individuals with good asthma control and a low risk for future asthma exacerbations may be considered for a reduction or "step down" of their chronic asthma medications. In this article, we discuss how patients may benefit or be harmed by stepping down asthma medications. Based on the literature presented in this article, we recommend that clinicians discuss the option of stepping down with patients when symptoms are stable, lung function is near normal, and biomarkers (if measured) are near normal. Other factors that should be considered in the decision to step down include the length of asthma stability, age of the patient, time of year, and patient preferences. Reducing the dose of inhaled corticosteroid by 25% to 50% appears to be the safest method of stepping down. A clear plan of care and follow-up is needed when stepping down asthma medications because many patients are likely to have recurrent exacerbations.

Changing roles of eosinophils in health and disease

OBJECTIVE

To review and highlight the unappreciated roles of eosinophils suggested by recent studies.

DATA SOURCES

The literature, unpublished observations, and insights by the authors.

STUDY SELECTIONS

Basic studies of mouse models and patient-based clinical studies of disease.

RESULTS

Eosinophils are often thought of as destructive end-stage effector cells primarily linked to parasite host defense and dysregulated immune responses associated with allergic diseases, such as asthma. However, recent studies (ie, research focused on mechanisms of action and translational studies examining disease/inflammatory pathways) are suggesting far more complex roles for eosinophils. The goal of this review is 3-fold. (1) The authors examine the dynamic history of eosinophils and how physicians over time used this information to formulate defining hypotheses. Particular emphasis is placed on recent studies challenging the parochial view of host defense in favor of roles maintaining homeostasis through immune modulation and tissue remodeling/repair. (2) They discuss diagnostic approaches to assess eosinophils in clinical settings as a means of disease identification and subsequently as a measurement of disease severity. (3) They examine how contemporary views of eosinophils and their perceived roles in diseases have led to specific therapeutic strategies. The emphasis is to review the successes and failures of these strategies as the basis of formulating future clinical studies targeting eosinophils as potential therapies of disease.

CONCLUSION

Despite the complexities of eosinophil-mediated activities and the less than overwhelming success of initial attempts targeting these cells, eosinophils remain a potentially important focal target of disease diagnosis and subsequent treatment strategies.

The risk of asthma exacerbation after reducing inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Asthma guidelines suggest reducing controller medications when asthma is stable.

METHODS

The purpose of the study is to estimate the risk of asthma exacerbation in stable asthmatics who reduce inhaled corticosteroids (ICS) compared to those who maintain a stable ICS dose. We identified articles from a systematic review of English and non-English articles using MEDLINE, EMBASE, Web of Science, and CENTRAL (inception to May 25, 2013). We included randomized controlled trials (RCTs) with a stable asthma run-in period of 4 weeks or more, an intervention to reduce ICS, and a follow-up period of at least 3 months.

RESULTS

The search strategy identified 2253 potential articles, of which 206 were reviewed at the full-text level and 6 met criteria for inclusion. The relative risk of an asthma exacerbation in individuals who reduced ICS compared to those who maintained the same ICS dose was 1.25 (95% CI 0.96, 1.62; P = 0.10; I(2)  = 0%) in studies with a mean follow-up of 22 weeks. Individuals who reduced ICS had a decreased% predicted FEV1 of 0.87% (95% CI -1.58%,3.33%; P = 0.49, I(2)  = 58%) and a decreased mean morning peak expiratory flow of 9.57 l/min (95% CI 1.25, 17.90; P = 0.02; I(2)  = 74%) compared to those individuals who maintained a stable ICS dose.

CONCLUSIONS

Asthma exacerbations were statistically no more likely among individuals who reduced ICS compared to those who maintained their ICS dose, supporting current guidelines which recommend decreasing ICS by 50% after a period of asthma stability.

Respiratory reviews in asthma 2013

From January 2012 up until March 2013, many articles with huge clinical importance in asthma were published based on large numbered clinical trials or meta-analysis. The main subjects of these studies were the new therapeutic plan based on the asthma phenotype or efficacy along with the safety issues regarding the current treatment guidelines. For efficacy and safety issues, inhaled corticosteroid tapering strategy or continued long-acting beta agonists use was the major concern. As new therapeutic trials, monoclonal antibodies or macrolide antibiotics based on inflammatory phenotypes have been under investigation, with promising preliminary results. There were other issues on the disease susceptibility or genetic background of asthma, particularly for the "severe asthma" phenotype. In the era of genome and pharmacogenetics, there have been extensive studies to identify susceptible candidate genes based on the results of genome wide association studies (GWAS). However, for severe asthma, which is where most of the mortality or medical costs develop, it is very unclear. Moreover, there have been some efforts to find important genetic information in order to predict the possible disease progression, but with few significant results up until now. In conclusion, there are new on-going aspects in the phenotypic classification of asthma and therapeutic strategy according to the phenotypic variations. With more pharmacogenomic information and clear identification of the "severe asthma" group even before disease progression from GWAS data, more adequate and individualized therapeutic strategy could be realized in the future.

Designing clinical trials to address the needs of childhood and adult asthma: the National Heart, Lung, and Blood Institute's AsthmaNet

In 2008, the National Heart, Lung, and Blood Institute announced its intent to support a new asthma network known as AsthmaNet. This clinical trials consortium, now in its fifth year, has been charged with developing and executing clinical trials to address the most important asthma management questions and identify new treatment approaches in pediatric and adult patients. This review will discuss the organization of AsthmaNet and the scientific context in which the network was developed and began its work, report the results of an internal priority-setting exercise designed to guide the network's scientific strategy, and highlight the portfolio of clinical trials, proof-of-concept studies, and mechanistic studies planned for the 7-year period of the network to update the global asthma community regarding the progress and processes of the network.

Combination corticosteroid/β-agonist inhaler as reliever therapy: a solution for intermittent and mild asthma?

The recommended treatment of mild asthma is regular maintenance inhaled corticosteroids (ICSs) with a short-acting β-agonist as a separate inhaler used when needed for symptom relief. However, the benefits of regular ICS use in actual clinical practice are limited by poor adherence and low prescription rates. An alternative strategy would be the symptom-driven (as-required or "prn") use of a combination ICS/short-acting β-agonist or ICS/long-acting β-agonist inhaler as a reliever rather than regular maintenance use. The rationale for this approach is to titrate both the ICS and β-agonist dose according to need and enhance ICS use in otherwise poorly adherent patients who overrely on their reliever β-agonist inhaler. This strategy will only work if the β-agonist component has a rapid onset of action for symptom relief. There is evidence to suggest that this regimen has advantages over regular ICS therapy and might represent an effective, safe, and novel therapy for the treatment of intermittent and mild asthma. In this commentary we review this evidence and propose that randomized controlled trials investigating different combination ICS/β-agonist inhaler products prescribed according to this regimen in intermittent and mild asthma are an important priority.

Current evidence and future research needs for FeNO measurement in respiratory diseases

Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.

Symptom-based controller therapy: a new paradigm for asthma management

Appropriate management of persistent asthma, according to US and international guidelines, requires daily use of controller medications, most generally, inhaled corticosteroids (ICS). This approach, although effective and well established, imposes burdens of treatment and side effects onto asthma patients. A growing body of evidence suggests that patients with persistent asthma need not be managed with daily ICS, but rather can use them on an intermittent basis, occasioned by the occurrence of symptoms sufficient to warrant treatment with a rescue inhaler. Large, randomized, controlled studies, over a range of asthma severity, and in a range of ages from pediatrics to adults, suggest that, in well-selected patients, a symptom-based approach to administering controller therapy may produce equivalent outcomes, while reducing exposure to ICS. The concept of providing anti-inflammatory treatment to the patient, at the time inflammation is developing, is termed 'temporal personalization'. The evidence to date suggests that symptom-based controller therapy is broadly useful in selected asthma patients, and is a management approach that could be incorporated into US and international guidelines for asthma.

Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma

BACKGROUND

Predictors of improvement in asthma control and lung function to step 3 therapy in children with persistent asthma have not been identified despite reported heterogeneity in responsiveness.

OBJECTIVE

We sought to evaluate potential predictors of asthma control and lung function responsiveness to step 3 therapy.

METHODS

A post hoc analysis from the Best Add-On Giving Effective Response (BADGER) study tested the association between baseline biological, asthma control, pulmonary function, and demographic markers and responsiveness to step-up to a higher dose of inhaled corticosteroid (ICS step-up therapy) or addition of leukotriene receptor antagonist (LTRA step-up therapy) or long-acting β₂-agonist (LABA step-up therapy).

RESULTS

In multivariate analyses higher impulse oscillometry reactance area was associated (P = .048) with a differential FEV₁ response favoring LABA over ICS step-up therapy, whereas higher urinary leukotriene E₄ levels were marginally (P = .053) related to a differential FEV₁ response favoring LTRA over LABA step-up therapy. Predictors of differential responses comparing ICS with LTRA step-up therapy were not apparent, probably because of suppression of allergic markers with low-dose ICS treatment. Minimal overlap was seen across FEV₁ and asthma control day predictors, suggesting distinct mechanisms related to lung function and asthma control day responses.

CONCLUSION

Levels of impulse oscillometry reactance area indicating peripheral airway obstruction and urinary leukotriene E₄ levels indicating cysteinyl leukotriene inflammation can differentiate LABA step-up responses from responses to LTRA or ICS step-up therapy. Further studies with physiologic, genetic, and biological markers related to these phenotypes will be needed to predict individual responses to LABA step-up therapy.

Using fractional exhaled nitric oxide (FeNO) to diagnose steroid-responsive disease and guide asthma management in routine care

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation and good predictor of corticosteroid response.

AIM

To evaluate how FeNO is being used to guide primary care asthma management in the United Kingdom (UK) with a view to devising practical algorithms for the use of FeNO in the diagnosis of steroid-responsive disease and to guide on-going asthma management.

METHODS

Eligible patients (n = 678) were those in the Optimum Patient Care Research Database (OPCRD) aged 4-80 years who, at an index date, had their first FeNO assessment via NIOX MINO® or Flex®. Eligible practices were those using FeNO measurement in at least ten patients during the study period. Patients were characterized over a one-year baseline period immediately before the index date. Outcomes were evaluated in the year immediately following index date for two patient cohorts: (i) those in whom FeNO measurement was being used to identify steroid-responsive disease and (ii) those in whom FeNO monitoring was being used to guide on-going asthma management. Outcomes for cohort (i) were incidence of new ICS initiation at, or within the one-month following, their first FeNO measurement, and ICS dose during the outcome year. Outcomes for cohort (ii) were adherence, change in adherence (from baseline) and ICS dose.

OUTCOMES

In cohort (i) (n = 304) the higher the FeNO category, the higher the percentage of patients that initiated ICS at, or in the one month immediately following, their first FeNO measurement: 82%, 46% and 26% of patients with high, intermediate and low FeNO, respectively. In cohort (ii) (n = 374) high FeNO levels were associated with poorer baseline adherence (p = 0.005) but greater improvement in adherence in the outcome year (p = 0.017). Across both cohorts, patients with high FeNO levels were associated with significantly higher ICS dosing (p < 0.001).

CONCLUSIONS

In the UK, FeNO is being used in primary practice to guide ICS initiation and dosing decisions and to identify poor ICS adherence. Simple algorithms to guide clinicians in the practical use of FeNO could improved diagnostic accuracy and better tailored asthma regimens.

Inhaled corticosteroids for asthma: on-demand or continuous use

Continuous inhaled corticosteroid treatment is highly effective in children and adults with mild persistent asthma, although some therapeutic benefits are not lost if treatment is delayed. Many patients do not adhere to continuous treatment with inhaled corticosteroids, but rather take them intermittently, usually at the time of increased symptoms. Based on these observations it has been proposed that for patients with mild persistent asthma inhaled corticosteroids should be used on-demand when symptoms are troublesome, rather than on a continuous basis. The article reviews the pharmacological properties of inhaled corticosteroids used in clinical trials of on-demand treatment, as well as the evidence for the efficacy and safety of on-demand compared with continuous inhaled corticosteroid treatment of mild persistent asthma in adults and children. The place of on-demand treatment with inhaled corticosteroids in the management of asthma is discussed, as well as future directions for different management strategies for this group.

Anti-inflammatory treatment of atopic asthma guided by exhaled nitric oxide: a randomized, controlled trial

BACKGROUND

Atopic asthma is characterized by Th2 cytokine-driven inflammation of the airway mucosa, which is signaled by the fraction of exhaled nitric oxide (FENO).

OBJECTIVE

We tested whether an FENO-guided anti-inflammatory treatment algorithm could improve asthma-related quality of life and asthma symptom control, and reduce exacerbations in atopic asthmatics within primary care.

METHODS

Altogether, 187 patients with asthma and who were nonsmokers (age range, 18-64 years) with perennial allergy and who were on regular inhaled corticosteroid treatment were recruited at 17 primary health care centers, randomly assigned to 2 groups and followed up for 1 year. For the controls (n = 88), FENO measurement was blinded to both operator and patient, and anti-inflammatory treatment was adjusted according to usual care. In the active group (n = 93), treatment was adjusted according to FENO. Questionnaires on asthma-related quality of life (Mini Asthma Quality of Life Questionnaire) and asthma control (Asthma Control Questionnaire) were completed, and asthma events were noted.

RESULTS

The Asthma Control Questionnaire score change over 1 year improved significantly more in the FENO-guided group (-0.17 [interquartile range {IQR}, -0.67 to 0.17] vs 0 [-0.33 to 0.50]; P = .045), whereas the Mini Asthma Quality of Life Questionnaire score did not (0.23 [IQR, 0.07-0.73] vs 0.07 [IQR, -0.20 to 0.80]; P = .197). The change in Asthma Control Questionnaire was clinically important in subpopulations with poor control at baseline (P = .03). Furthermore, the exacerbation rate (exacerbations/patient/y) was reduced by almost 50% in the FENO-guided group (0.22 [CI, 0.14-0.34] vs 0.41 [CI, 0.29-0.58]; P = .024). Mean overall inhaled corticosteroid use was similar in both groups (P = .95).

CONCLUSION

Use of FENO to guide anti-inflammatory treatment within primary care significantly reduced the exacerbation rate and improved asthma symptom control without increasing overall inhaled corticosteroid use.

Adherence monitoring and e-health: how clinicians and researchers can use technology to promote inhaler adherence for asthma

In the past decade, rapid technological developments have advanced electronic monitoring devices (EMD) for asthma inhalers beyond simple recording of actuations to providing adherence promotion features and detailed information about patterns of medication use. This article describes currently available EMDs, discusses their utility and limitations in assessing adherence, and describes the potential for EMD-based adherence promotion interventions in clinical settings. To date, the main use of EMDs has been in clinical research. In selected populations, simple EMD-based adherence interventions, delivered either through clinician-to-patient feedback about medication use or by direct-to-patient reminders for missed doses, can significantly improve adherence. Further work is now needed to determine the impact of EMDs on clinical outcomes and their cost-effectiveness and feasibility for different clinical settings, including in disadvantaged populations. If this evidence can be provided, then the use of EMDs could expand into the management of asthma in populations with high health care costs, eg, severe asthma. In the future, medication monitoring could help distinguish poor treatment response from poor adherence, guide prescribing decisions, and prompt providers to discuss barriers to adherence; electronic health records may provide the gateway for integrating medication-use monitoring into digital chronic care management.

Biomarker surrogates do not accurately predict sputum eosinophil and neutrophil percentages in asthmatic subjects

BACKGROUND

Sputum eosinophil percentages are a strong predictor of airway inflammation and exacerbations and aid asthma management, whereas sputum neutrophil percentages indicate a different severe asthma phenotype that is potentially less responsive to TH2-targeted therapy. Variables, such as blood eosinophil counts, total IgE levels, fraction of exhaled nitric oxide (Feno) levels, or FEV1 percent predicted, might predict airway eosinophil percentages, whereas age, FEV1 percent predicted, or blood neutrophil counts might predict sputum neutrophil percentages. Availability and ease of measurement are useful characteristics, but accuracy in predicting airway eosinophil and neutrophil percentages either individually or combined is not established.

OBJECTIVES

We sought to determine whether blood eosinophil counts, Feno levels, and IgE levels accurately predict sputum eosinophil percentages and whether age, FEV1 percent predicted, and blood neutrophil counts accurately predict sputum neutrophil percentages.

METHODS

Subjects in the Wake Forest Severe Asthma Research Program (n = 328) were characterized by blood and sputum cell counts, health care use, lung function, Feno levels, and IgE levels. Multiple analytic techniques were used.

RESULTS

Despite significant association with sputum eosinophil percentages, blood eosinophil counts, Feno levels, and total IgE levels did not accurately predict sputum eosinophil percentages, and combinations of these variables did not improve prediction. Age, FEV1 percent predicted, and blood neutrophil counts were similarly unsatisfactory for the prediction of sputum neutrophil percentages. Factor analysis and stepwise selection found Feno levels, IgE levels, and FEV1 percent predicted, but not blood eosinophil counts, correctly predicted 69% of sputum eosinophil percentages of less than 2% or 2% and greater. Likewise, age, asthma duration, and blood neutrophil counts correctly predicted 64% of sputum neutrophil percentages of less than 40% or 40% and greater. A model to predict both sputum eosinophil and neutrophil percentages accurately assigned only 41% of samples.

CONCLUSION

Despite statistically significant associations, Feno levels, IgE levels, blood eosinophil and neutrophil counts, FEV1 percent predicted, and age are poor surrogates, both separately and combined, for accurately predicting sputum eosinophil and neutrophil percentages.

Inhaled corticosteroids in lung diseases

Inhaled corticosteroids (ICSs) are used extensively in the treatment of asthma and chronic obstructive pulmonary disease (COPD) due to their broad antiinflammatory effects. They improve lung function, symptoms, and quality of life and reduce exacerbations in both conditions but do not alter the progression of disease. They decrease mortality in asthma but not COPD. The available ICSs vary in their therapeutic index and potency. Although ICSs are used in all age groups, younger and smaller children may be at a greater risk for adverse systemic effects because they can receive higher mg/kg doses of ICSs compared with older children. Most of the benefit from ICSs occurs in the low to medium dose range. Minimal additional improvement is seen with higher doses, although some patients may benefit from higher doses. Although ICSs are the preferred agents for managing persistent asthma in all ages, their benefit in COPD is more controversial. When used appropriately, ICSs have few adverse events at low to medium doses, but risk increases with high-dose ICSs. Although several new drugs are being developed and evaluated, it is unlikely that any of these new medications will replace ICSs as the preferred initial long-term controller therapy for asthma, but more effective initial controller therapy could be developed for COPD.

Advances in adult asthma diagnosis and treatment in 2012: potential therapeutics and gene-environment interactions

In the Journal of Allergy and Clinical Immunology in 2012, research reports related to asthma in adults clustered around mechanisms of disease, with a special focus on their potential for informing new therapies. There was also consideration of the effect of the environment on health from pollution, climate change, and epigenetic influences, underlining the importance of understanding gene-environment interactions in the pathogenesis of asthma and response to treatment.

Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults

BACKGROUND

Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. However, often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations.

OBJECTIVES

The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov web site up to October 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1. Quality of the evidence was assessed using GRADE.

MAIN RESULTS

Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32; the large confidence interval translates into a risk of exacerbations in the intermittent ICS group varying between 17% and 25%, assuming a 19% risk with daily ICS). Age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β2-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV1), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment.

AUTHORS' CONCLUSIONS

In children and adults with persistent asthma and in preschool children suspected of persistent asthma, there was low quality evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and the rate of severe adverse health events. The strength of the evidence means that we cannot currently assume equivalence between the two options.. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. Clinicians should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.

Industry Update: The latest developments in therapeutic delivery

The present industry update covers the period 15 September–15 October 2012, with information sourced from company press releases, regulatory and patent agencies as well as the scientific literature. In the world´s largest healthcare market, the USA, this time-period was dominated by the presidential election held in early November, with the future of the healthcare system being a significant part of the political discussion. Regardless of who emerged victorious in the US presidential election, the country’s healthcare system is set for further changes. Bloated spending on medical services is widely acknowledged and will receive further attention during the ‘fiscal cliff’, when taxes will rise and government spending will decrease, to reduce the trillion-dollar deficit. Any significant amendment to healthcare in the world’s largest economy will have undoubted far-reaching effects on pharmaceutical companies, medical device companies, hospital chains and managed care firms/health insurers. Due to this public discussion and the device sales tax introduced in the course of the Affordable Care Act, a number of manufacturers are already taking corrective measure, such as NuPathe (PA, USA) while others focus entirely on new drug launches such as Orexo (Uppsala, Sweden) and Dyamid Medical (Stockholm, Sweden). While Abbott announced its launch of the first ever bioresorbable stent, the USA was shaken by New England Compounding Center, which had to recall all compounded products due to a meningitis outbreak – this received significant media attention. Several successful clinical trials using drug device combination and nano-delivery solutions by Radius Health (MA, USA), OptiNose Inc. (PA, USA) and Fuizs Pharma (FL, USA) demonstrate the ever increasing convergence between classical pharmaceutical and device companies, which meet in the sweet spot of drug delivery.

P2X7-regulated protection from exacerbations and loss of control is independent of asthma maintenance therapy

RATIONALE

The function of the P2X(7) nucleotide receptor protects against exacerbation in people with mild-intermittent asthma during viral illnesses, but the impact of disease severity and maintenance therapy has not been studied.

OBJECTIVES

To evaluate the association between P2X(7), asthma exacerbations, and incomplete symptom control in a more diverse population.

METHODS

A matched P2RX7 genetic case-control was performed with samples from Asthma Clinical Research Network trial participants enrolled before July 2006, and P2X(7) pore activity was determined in whole blood samples as an ancillary study to two trials completed subsequently.

MEASUREMENTS AND MAIN RESULTS

A total of 187 exacerbations were studied in 742 subjects, and the change in asthma symptom burden was studied in an additional 110 subjects during a trial of inhaled corticosteroids (ICS) dose optimization. African American carriers of the minor G allele of the rs2230911 loss-of-function single nucleotide polymorphism were more likely to have a history of prednisone use in the previous 12 months, with adjustment for ICS and long-acting β(2)-agonists use (odds ratio, 2.7; 95% confidence interval, 1.2-6.2; P = 0.018). Despite medium-dose ICS, attenuated pore function predicted earlier exacerbations in incompletely controlled patients with moderate asthma (hazard ratio, 3.2; confidence interval, 1.1-9.3; P = 0.033). After establishing control with low-dose ICS in patients with mild asthma, those with attenuated pore function had more asthma symptoms, rescue albuterol use, and FEV(1) reversal (P < 0.001, 0.03, and 0.03, respectively) during the ICS adjustment phase.

CONCLUSIONS

P2X(7) pore function protects against exacerbations of asthma and loss of control, independent of baseline severity and the maintenance therapy.