Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids

Components of asthma control and treatment response of individual control criteria in children: analysis of the PEACE study

BACKGROUND

The aim of asthma management is to achieve and maintain clinical control. Control data for children is sparse.

OBJECTIVE

This analysis evaluated factors associated with not achieving well-controlled (WC) asthma using data from a study in 548 children with uncontrolled asthma.

METHODS

Post hoc analysis of factors affecting the probability of not achieving WC asthma in children receiving salmeterol/fluticasone propionate 50/100 µg bd (SFC) or montelukast 5 mg od (MON), included: reasons for patients failing the asthma control criteria; achievement of overall asthma control; time course of improvement in individual outcomes and composite score; factors associated with not achieving WC asthma.

RESULTS

The proportion of patients failing individual control criteria at baseline was: β2-agonist rescue use: 96%, peak expiratory flow (PEF): 91%, symptoms: 78%, and night-time awakenings: 66%. Most patients failed the composite control score for more than one reason with 482 (99%), 387 (80%), and 249 (52%) failing 2, 3, or 4 control criteria, respectively. Overall asthma control was achieved by 166 (59%) patients in the SFC group and 96 (36%) in the MON group (P < 0.001). Time course of control differed between individual control components with symptoms responding most rapidly and PEF most slowly. Factors significantly influencing the probability of not achieving WC asthma were treatment with MON, country, and night-time awakenings at baseline, treatment being the most important.

CONCLUSION

Different outcomes improve at different rates. Assessment of one or a few outcomes over-estimates the level of asthma control. An overall composite score in combination with the proportion of patients failing on three or more criteria seemed to most accurately reflect the level of control. Compared with SFC treatment, MON was three times less likely to result in good asthma control.

Controversies regarding long-acting β2-agonists

PURPOSE OF REVIEW

This review examines the literature regarding the efficacy and safety of long-acting β2-agonists as add-on therapy to inhaled corticosteroids.

RECENT FINDINGS

The Global Initiative for Asthma (GINA) 2009 guidelines and the National Heart, Lung, and Blood Institute (NHLBI) 2007 asthma guidelines recommend adding long-acting β2-agonists to patients inadequately controlled on inhaled corticosteroids. These recommendations must be balanced against published data which demonstrate a signal of increased morbidity and mortality with use of long-acting β2-agonists. These conflicting data raise the question of whether or not there may be genotypic or phenotypic discriminators leading to disparate responses to long-acting β2-agonists.

SUMMARY

The combination of long-acting β2-agonists and inhaled corticosteroids demonstrates improvement in asthma control and exacerbation rates; however, long-acting β2-agonists are not recommended for use as monotherapy or without optimization of inhaled corticosteroid dose. Although the majority of asthmatic patients appear to benefit from the addition of long-acting β2-agonists, there are concerns that a small proportion of patients, including steroid-naïve patients and African Americans, may not obtain such benefits. Thus far, studies have not clearly demonstrated genotypic or phenotypic differences explaining the variability in response.

Approaches to stepping up and stepping down care in asthmatic patients

The variability in symptom control is a challenging feature of asthma that necessitates careful monitoring and the need to step up and step down individualized therapeutic regimens over time. This stepwise concept in asthma therapy can be considered in at least 3 contexts. For lack of control that is persistent over long periods of time, an increase in the overall medication or a step-up long-term strategy is indicated. A second approach, the step-up short-term strategy, can be used during a temporary loss of acceptable control, such as at the onset of a viral respiratory tract illness. In these cases a step-up in therapy is usually terminated in 3 to 10 days once asthma control has been satisfactorily achieved. Finally, for treating symptoms related to the variability of asthma on a day-to-day basis, inhaled corticosteroids used concomitantly with a β-agonist have been evaluated, although this treatment is not currently approved in the United States. We will term this particular intervention a step-up intermittent strategy. Here we summarize the existing data regarding these 3 approaches to step up care and step down management, as well as to identify areas where more comparative studies are necessary to provide further guidance to clinicians regarding proper step-up and step-down strategies in the care of asthma.

How the practice of allergy shows the promise and challenge of personalized medicine

Personalized medicine seeks to stratify therapies according to individual characteristics, and by so doing improve effectiveness and reduce complications. However, there are not many models of care that is highly stratified within a single diagnosis in this manner. One potential model is the practice of allergy, in which care is tailored to specific allergens for individual patients within the broader context of care for rhinitis or asthma. Allergists have already confronted many of the same regulatory issues anticipated for personalized medicine. The history of allergy practice also anticipates some of the patient safety concerns that may arise from tracking and using highly personalized medical information. Finally, the therapy of allergy and asthma has been at the forefront of attempts to incorporate pharmacogenomics information into patient care. Individualized therapy has always been central to the practice of allergy, and so provides a useful proving ground for personalized medicine as a concept of care.

The role of the primary care physician in helping adolescent and adult patients improve asthma control

Many adolescents and adults with asthma continue to have poorly controlled disease, often attributable to poor adherence to asthma therapy. Failure to adhere to recommended treatment may result from a desire to avoid regular reliance on medications, inappropriate high tolerance of asthma symptoms, failure to perceive the chronic nature of asthma, and poor inhaler technique. Primary care physicians need to find opportunities and methods to address these and other issues related to poor asthma control. Few adolescents or adults with asthma currently have asthma "checkup" visits, usually seeking medical care only with an exacerbation. Therefore, nonrespiratory-related office visits represent an important opportunity to assess baseline asthma control and the factors that most commonly lead to poor control. Tools such as the Asthma Control Test, the Asthma Therapy Assessment Questionnaire, the Asthma Control Questionnaire, and the Asthma APGAR provide standardized, patient-friendly ways to capture necessary asthma information. For uncontrolled asthma, physicians can refer to the stepwise approach in the 2007 National Asthma Education and Prevention Program guidelines to adjust medication use, but they must consider step-up decisions in the context of quality of the patient's inhaler technique, adherence, and ability to recognize and avoid or eliminate triggers. For this review, a literature search of PubMed from 2000 through August 31, 2010, was performed using the following terms (or a combination of these terms): asthma, asthma control, primary care, NAEPP guidelines, assessment, uncontrolled asthma, burden, impact, assessment tools, triggers, pharmacotherapy, safety. Studies were limited to human studies published in English. Articles were also identified by a manual search of bibliographies from retrieved articles and from article archives of the author.

Episodic viral wheeze and multiple trigger wheeze in preschool children: a useful distinction for clinicians?

Accumulating evidence suggest that splitting preschool recurrent wheezing disorders into Episodic (Viral) Wheeze (EVW) and Multiple Trigger Wheeze (MTW) is an oversimplification. There is little evidence that the EVW and MTW phenotypes are related to the longitudinal patterns of wheeze, or to different underlying pathological processes. As the clinical response to inhaled corticosteroids and montelukast varies considerably between individual children with EVW, and between individual patients with MTW, the clinical usefulness of the EVW-MTW approach is doubtful. Based on the currently available evidence, we propose to describe preschool wheeze symptoms not only in terms of temporal pattern, but also in terms of frequency and severity, and age of onset. Relevant associated clinical parameters like atopy and eczema should be described with recognition of age of onset, pattern, and severity. Comparing these data to biomarkers and histopathology may help to improve our understanding of preschool wheezing disorders in the future. Until phenotypes can be described that are associated with different pathobiological process, are related to different longitudinal outcomes, or are clearly different in terms of response to therapy, clinicians are encouraged to take a trial and error approach of different therapeutic agents in preschool children with troublesome recurrent wheeze.

[Therapeutic approach to the distal airways in asthma]

Bronchial asthma is a chronic inflammatory disease that affects both the large-caliber airways and the smaller-caliber bronchioles. In the last few years, a major therapeutic advance has been made with the development of new systems of inhalation solutions, which produce extra-fine particles, achieving better lung deposition throughout the airways and reducing oropharyngeal deposition. These formulations have improved the effectiveness of bronchodilation and particularly the antiinflammatory effect. The use of long-acting b2-adrenergic steroids in extra-fine formulation, whether alone or in combinations of fixed doses, improves drug distribution throughout the bronchial tree, enhancing the therapeutic effect with lower doses of drugs. Leukotriene receptor antagonists have shown their effect on the small airways in asthmatic patients, both in studies of pulmonary resistance and pulmonary volumes and in imaging studies.

Asthma diagnosis and treatment: filling in the information gaps

Current approaches to the diagnosis and management of asthma are based on guideline recommendations, which have provided a framework for the efforts. Asthma, however, is emerging as a heterogeneous disease, and these features need to be considered in both the diagnosis and management of this disease in individual patients. These diverse or phenotypic features add complexity to the diagnosis of asthma, as well as attempts to achieve control with treatment. Although the diagnosis of asthma is often based on clinical information, it is important to pursue objective criteria as well, including an evaluation for reversibility of airflow obstruction and bronchial hyperresponsiveness, an area with new diagnostic approaches. Furthermore, there exist a number of treatment gaps (ie, exacerbations, step-down care, use of antibiotics, and severe disease) in which new direction is needed to improve care. A major morbidity in asthmatic patients occurs with exacerbations and in patients with severe disease. Novel approaches to treatment for these conditions will be an important advance to reduce the morbidity associated with asthma.

New insights into asthma pathogenesis and treatment

Although national asthma guidelines help organize standards for asthma care, current asthma management is still primarily symptom based. Recent reports provide insights on how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, manage inner city asthma, and some potential new ways to use available medications to improve asthma control. Despite many significant gains in managing asthma, we must now find improved strategies to prevent asthma exacerbations, alter the natural history of the disease, and to reduce health disparities in asthma care. Perhaps new directions in personalized medicine including a systems biology approach, along with improved health care access and communication will lead to better methods to alleviate the burden of asthma. This review will discuss the benefits and limitations of the current approach to asthma management, new studies that could impact new directions in asthma management, and new insights related to mechanisms of asthma and allergic airways inflammation that could eventually lead to improved asthma control.

Pharmacotherapy of patients with mild persistent asthma: strategies and unresolved issues

In studies comparing regular versus on-demand treatment for patients with mild persistent asthma, on-demand treatment seems to have a similar efficacy on clinical and functional outcomes, but it does not suppress chronic airway inflammation or airway hyper-responsiveness (AHR) associated with asthma. Data on the efficacy of a continuous treatment with inhaled corticosteroids (ICS) in preventing the progression of asthma are conflicting. There is the possibility that patients without a regular treatment with ICS may develop a more severe asthma associated with airway structural changes (remodeling) and a progressive loss of lung function. However, the possible clinical and functional consequences of persistent, not controlled, airway inflammation in patients with asthma have to be established. Assessment of asthma control should include inflammatory outcomes, such as fraction of exhaled nitric oxide and sputum eosinophil counts. Until the relationships between symptoms, lung function tests, AHR, airway inflammation, exacerbations, and airway remodeling are clarified, regular treatment seems to be generally more appropriate than on-demand treatment to warrant a greater control of asthma. Select subgroups of patients with mild asthma who are well controlled by regular treatment might adopt the on-demand treatment plan as an intermediate step toward the suspension of controller medication. The increasing evidence for heterogeneity of asthma, the growing emphasis on asthma subphenotypes, including molecular phenotypes identified by omics technologies, and their possible implications for different asthma severity and progression and therapeutic response, are changing the paradigm of treating patients with asthma only based on classification of their disease severity to a pharmacological strategy more focused on the individual asthmatic patient. Pharmacological treatment of asthma is going toward a personalized approach.

Montelukast in childhood asthma: what is the evidence for its use?

Asthma is a complex process involving extensive infiltration of the airway mucosa and lumen by activated inflammatory cells and release of mediators that result in airway inflammation and bronchoconstriction. Leukotrienes are mediators believed to play a major role in this process. At present, inhaled corticosteroids are the cornerstone of asthma management. However, asthma control may remain suboptimal and there is well-documented concern regarding adverse events with the use of inhaled corticosteroids in children. Leukotriene receptor antagonists, such as montelukast, provide a safe and effective treatment option with ease of administration, particularly in preschool children and as add-on therapy in patients with difficult-to-control asthma.

Inhaled corticosteroid dosing: double for nothing?

Two recent trials from the National Heart, Lung, and Blood Institute's asthma clinical trials networks raise a concern about using double the dose of an inhaled corticosteroid (ICS) as a positive control arm in clinical trials of add-on therapy. The literature evaluating the response to doubling the dose of an ICS is briefly reviewed. The vast majority of studies do not demonstrate a significant positive benefit from doubling the dose of an ICS but do show improvement with 4-fold increases that is equal to or greater than that of add-on long-acting bronchodilators. It is recommended that doubling the dose of an ICS no longer be considered a positive comparator arm in clinical trials, although it might be beneficial in individual patients.

Safety of formoterol in adults and children with asthma: a meta-analysis

BACKGROUND

The safety of long-acting β2 agonists (LABA) for the treatment of persistent asthma remains a topic of ongoing debate.

OBJECTIVE

To evaluate the risk of serious asthma-related events among patients treated with formoterol, a meta-analysis of all Novartis-sponsored controlled clinical trials was conducted.

METHODS

Forty-five randomized, placebo- and active-controlled, parallel-group or crossover studies with formoterol were included. Background inhaled corticosteroid (ICS) use was permitted in all studies; however, in only 2 studies was ICS randomized as study medication. Sub-analyses of the pooled data were performed according to age (5-12; 13-18; >18 years), baseline ICS use, and lung function. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated between formoterol (twice-daily), albuterol (salbutamol) 4 times per day (active control), and placebo.

RESULTS

Patients were randomized to formoterol (n = 5,367), placebo (n = 2,026), and albuterol (n = 976). Two deaths were reported, 1 each in the formoterol (asthma exacerbation) and the placebo (hemorrhagic pancreatitis) groups. No statistically significant differences in serious asthma exacerbations were observed compared with placebo in adolescents and adults. In children, a higher frequency of hospitalizations was observed among patients treated with formoterol compared with placebo (OR 8.4; 95% CI: 1.1-65.3). A trend toward fewer exacerbations was observed among subjects reporting concomitant ICS use at baseline.

CONCLUSIONS

This analysis supports current guideline recommendations for the use of LABAs only as add-on therapy to ICS.

The addition of long-acting beta-agonists to inhaled corticosteroids in asthma

PURPOSE OF REVIEW

although long-acting beta-agonists (LABAs) have been used for two decades, with many studies showing benefit versus increasing inhaled corticosteroid (ICS), controversy regarding safety has resulted in the United States Food and Drug Administration (FDA) recently mandating label changes restricting LABA use. This review addresses these safety concerns together with clinical studies and meta-analyses assessing the appropriate use of LABAs.

RECENT FINDINGS

effective use of LABAs requires sufficient ICS to control inflammation. Underuse of ICS, which is often manifest by exacerbations, may reflect undue emphasis on alleged steroid-sparing effects of LABAs. The FDA meta-analysis found that LABA with mandatory ICS was not associated with increased risks of serious adverse events. The role of LABA with ICS as initial therapy in steroid-naïve patients is debated, as is LABA use in children, with data indicating less benefit than in adults. The FDA recommendation that LABA be withdrawn once control is achieved remains problematic, as greater ICS reduction can be achieved when LABA is continued.

SUMMARY

the safe use of LABAs, which are clearly effective in many patients with moderate to severe asthma, requires high compliance with ICS therapy, which is best assured if ICS and LABA are provided in a single inhaler.

Factors predicting inhaled corticosteroid responsiveness in African American patients with asthma

BACKGROUND

African American patients disproportionately experience uncontrolled asthma. Treatment with an inhaled corticosteroid (ICS) is considered first-line therapy for persistent asthma.

OBJECTIVE

We sought to determine the degree to which African American patients respond to ICS medication and whether the level of response is influenced by other factors, including genetic ancestry.

METHODS

Patients aged 12 to 56 years who received care from a large health system in southeast Michigan and who resided in Detroit were recruited to participate if they had a diagnosis of asthma. Patients were treated with 6 weeks of inhaled beclomethasone dipropionate, and pulmonary function was remeasured after treatment. Ancestry was determined by genotyping ancestry-informative markers. The main outcome measure was ICS responsiveness defined as the change in prebronchodilator FEV(1) over the 6-week course of treatment.

RESULTS

Among 147 participating African American patients with asthma, average improvement in FEV(1) after 6 weeks of ICS treatment was 11.6%. The mean proportion of African ancestry in this group was 78.4%. The degree of baseline bronchodilator reversibility was the only factor consistently associated with ICS responsiveness, as measured by both an improvement in FEV(1) and patient-reported asthma control (P = .001 and P = .021, respectively). The proportion of African ancestry was not significantly associated with ICS responsiveness.

CONCLUSIONS

Although baseline pulmonary function parameters appear to be associated with the likelihood to respond to ICS treatment, the proportion of genetic African ancestry does not. This study suggests that genetic ancestry might not contribute to differences in ICS controller response among African American patients with asthma.

Leukotriene modifiers for asthma treatment

Leukotrienes (LTs), including cysteinyl LTs (CysLTs) and LTB(4) , are potent lipid mediators that have a role in the pathophysiology of asthma. At least two receptor subtypes for CysLTs, CysLT(1) and CysLT(2) , have been identified. The activation of the CysLT(1) receptor is responsible for most of the pathophysiological effects of CysLTs in asthma, including increased airway smooth muscle activity, microvascular permeability, and airway mucus secretion. LTB(4) might have a role in severe asthma, asthma exacerbations, and the development of airway hyperresponsiveness. CysLT(1) receptor antagonists can be given orally as monotherapy in patients with mild persistent asthma, but these drugs are generally less effective than inhaled glucocorticoids. Combination of CysLT(1) receptor antagonists and inhaled glucocorticoids in patients with more severe asthma may improve asthma control and enable the dose of inhaled glucocorticoids to be reduced while maintaining similar efficacy. The identification of subgroups of asthmatic patients who respond to CysLT(1) receptor antagonists is relevant for asthma management as the response to these drugs is variable. CysLT(1) receptor antagonists have a potential anti-remodelling effect that might be important for preventing or reversing airway structural changes in patients with asthma. This review discusses the role of LTs in asthma and the role of LT modifiers in asthma treatment.

Pediatric asthma controller therapy

The treatment of children with asthma has historically relied upon expert opinion using data extrapolated from adult studies. Over the past few years, landmark studies have been completed providing healthcare professionals with evidence on which a reasonable approach can be made for children suffering from this common and serious disease. Asthmatic phenotype in children, unlike adults, tends to differ according to age, which must be taken into account as well as triggers, severity, and level of control. The care of the child with asthma is complex, but accumulating data have demonstrated that we are on the right path for optimizing control while reducing the burden of side effects. The newest Global Initiative for Asthma (GINA) guidelines, as well as recent updates from the landmark CAMP (Childhood Asthma Management Program) study and information from the PACT (Pediatric Asthma Control Trial) and budesonide/formoterol controller and reliever studies, along with recent comparisons of higher dose inhaled corticosteroids (ICS), and ICS/long-acting β(2)-adrenoceptor agonist (LABA) combination and leukotriene receptor antagonist (LTRA) therapies in children have clarified a few of the big questions in pediatric asthma. For children with asthma aged 5 years and older, the CAMP trial demonstrated that regular use of ICS reduces the frequency of symptoms; however, height was adversely affected and there is no evidence for altering the natural history of asthma. In patients aged 6 years and over whose asthma is uncontrolled on ICS alone, combination therapy with ICS and a LABA has been recently compared with the use of higher dose ICS and the addition of an LTRA in pediatric patients. The addition of a LABA statistically will be of most benefit; however, some children will have optimal control with doubling the baseline dose of ICS or addition of an LTRA. Use of budesonide/formoterol as a controller and reliever therapy extends the time to first exacerbation versus contemporary use of this medication in patients aged 4 years and older. Ciclesonide, a newer ICS, has demonstrated acceptable efficacy but has the added benefit of not affecting growth. Certainly, with mounting evidence, the care-map in pediatric asthma control is becoming clearer.

A20 regulation of nuclear factor-κB: perspectives for inflammatory lung disease

Persistent activation of NF-κB is central to the pathogenesis of many inflammatory lung disorders, including cystic fibrosis, asthma, and chronic obstructive pulmonary disease. A20 is an endogenous negative regulator of NF-κB signaling, which has been widely described in autoimmune and inflammatory disorders, including diabetes and Crohn's disease, but which has received little attention in terms of chronic lung disorders. This review examines the existing body of research on A20 regulation of NF-κB signaling and details the mechanism and regulation of A20 action focusing, where possible, on pulmonary inflammation. A20 and its associated signaling molecules are highlighted as being of potential therapeutic interest for the treatment of inflammatory disorders, and a proposed model of A20 activity in inflammatory lung disease is provided.

Advances in pediatric asthma in 2010: addressing the major issues

Last year's "Advances in pediatric asthma" concluded with the following statement: "If we can close these [remaining] gaps through better communication, improvements in the health care system and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children." This year's summary will focus on recent advances in pediatric asthma that take steps moving forward as reported in Journal of Allergy and Clinical Immunology publications in 2010. Some of these recent reports show us how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, and manage inner-city asthma and some potential new ways to use available medications to improve asthma control. It is clear that we have made many significant gains in managing asthma in children, but we have a ways to go to prevent asthma exacerbations, alter the natural history of the disease, and reduce health disparities in asthma care. Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children.

Tiotropium bromide step-up therapy for adults with uncontrolled asthma

BACKGROUND

Long-acting beta-agonist (LABA) therapy improves symptoms in patients whose asthma is poorly controlled by an inhaled glucocorticoid alone. Alternative treatments for adults with uncontrolled asthma are needed.

METHODS

In a three-way, double-blind, triple-dummy crossover trial involving 210 patients with asthma, we evaluated the addition of tiotropium bromide (a long-acting anticholinergic agent approved for the treatment of chronic obstructive pulmonary disease but not asthma) to an inhaled glucocorticoid, as compared with a doubling of the dose of the inhaled glucocorticoid (primary superiority comparison) or the addition of the LABA salmeterol (secondary noninferiority comparison).

RESULTS

The use of tiotropium resulted in a superior primary outcome, as compared with a doubling of the dose of an inhaled glucocorticoid, as assessed by measuring the morning peak expiratory flow (PEF), with a mean difference of 25.8 liters per minute (P<0.001) and superiority in most secondary outcomes, including evening PEF, with a difference of 35.3 liters per minute (P<0.001); the proportion of asthma-control days, with a difference of 0.079 (P=0.01); the forced expiratory volume in 1 second (FEV1) before bronchodilation, with a difference of 0.10 liters (P=0.004); and daily symptom scores, with a difference of -0.11 points (P<0.001). The addition of tiotropium was also noninferior to the addition of salmeterol for all assessed outcomes and increased the prebronchodilator FEV1 more than did salmeterol, with a difference of 0.11 liters (P=0.003).

CONCLUSIONS

When added to an inhaled glucocorticoid, tiotropium improved symptoms and lung function in patients with inadequately controlled asthma. Its effects appeared to be equivalent to those with the addition of salmeterol. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00565266.).

Recent advances in antileukotriene therapy

PURPOSE OF REVIEW

Despite profound effects of leukotrienes in experimental models, clinical responses to antileukotriene drugs are highly heterogeneous. This review discusses recent advances concerning the molecular mechanisms of antileukotrienes as well as their efficacy in various clinical scenarios and patient groups.

RECENT FINDINGS

Appreciation of the role of leukotriene E4 and the existence of its distinct receptors may explain the limited efficacy of current leukotriene receptor antagonists. Pharmacogenetic studies highlight the influence of several leukotriene pathway genes on clinical responsiveness. Benefits of addition of antileukotrienes to inhaled corticosteroids in chronic adult asthmatics have been shown, but their role in acute asthma is unclear. Evidence suggests they are not a first-line treatment for allergic rhinitis or urticaria, but may provide useful additional therapy. In children antileukotrienes provide symptomatic benefit in preschool wheezers, but have no clear role in bronchiolitis or acute asthma. Adherence to montelukast appears superior to inhaled corticosteroids. Use in sleep-disordered breathing and eosinophilic gastroenteropathies warrants further investigation. Despite recent concerns thorough analysis of existing data suggests antileukotrienes are well tolerated drugs. The possible link with Churg-Strauss syndrome requires further investigation.

SUMMARY

The leukotriene pathway remains an attractive target in asthma and allergic disease, particularly in light of renewed appreciation of the role of leukotriene E4. Clarification of the clinical role of antileukotrienes is needed.

Asthma control in adolescents: role of leukotriene inhibitors

Asthma is a chronic inflammatory disease of the airways and is a big burden worldwide. It affects both children and adults, but it is insufficiently studied in adolescents, although this age group has important peculiarities and is challenging to treat, due to, but not exclusively because of, lack of adherence to treatment instructions. Evidence-based guidelines for the treatment of asthma targeting specifically adolescents are lacking, due to the fact that most studies are conducted either on children or in adults. Exercise-induced asthma occurs commonly in adolescents, leading to impaired physical activity. This review describes current treatment options for asthma in adolescents, focusing on leukotriene receptor antagonists, both as a monotherapy and as an add-on therapy for optimal asthma control.

A call for action: Comparative effectiveness research in asthma

Comparative effectiveness research (CER) has received considerable research attention in recent months, and efforts to promote CER are part of the newly enacted Patient Protection and Affordable Care Act. In this article we define CER and how it complements traditional efficacy research in asthma and discuss how CER can help provide the basis for rational decision making about the care of individual patients with asthma and how best to deliver this care in real-world settings. We present information about the challenges and opportunities to conduct CER, including enhanced patient registries for observational CER and effectiveness trials (also called pragmatic trials). We discuss the urgent need to define the appropriate methodologies for CER and to develop and prioritize a research agenda for CER studies in asthmatic subjects with the help of a diverse group of stakeholders.

Management of severe asthma in children

Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

Viral respiratory tract infections and asthma: the course ahead

Inquiries into the relationships between viral respiratory tract illnesses and the inception and exacerbation of asthma are being facilitated by recent advances in research approaches and technology. In this article we identify important knowledge gaps and future research questions, and we discuss how new investigational tools, including improved respiratory tract virus detection techniques, will permit current and future researchers to define these relationships and the host, virus, developmental, and environmental mechanisms that regulate them. A better understanding of these processes should facilitate the development of improved strategies for the prevention and treatment of virus-induced wheezing illnesses and asthma exacerbations and, possibly, the ultimate goal of discovering effective approaches for the primary prevention of asthma.

Genetic ancestry in lung-function predictions

BACKGROUND

Self-identified race or ethnic group is used to determine normal reference standards in the prediction of pulmonary function. We conducted a study to determine whether the genetically determined percentage of African ancestry is associated with lung function and whether its use could improve predictions of lung function among persons who identified themselves as African American.

METHODS

We assessed the ancestry of 777 participants self-identified as African American in the Coronary Artery Risk Development in Young Adults (CARDIA) study and evaluated the relation between pulmonary function and ancestry by means of linear regression. We performed similar analyses of data for two independent cohorts of subjects identifying themselves as African American: 813 participants in the Health, Aging, and Body Composition (HABC) study and 579 participants in the Cardiovascular Health Study (CHS). We compared the fit of two types of models to lung-function measurements: models based on the covariates used in standard prediction equations and models incorporating ancestry. We also evaluated the effect of the ancestry-based models on the classification of disease severity in two asthma-study populations.

RESULTS

African ancestry was inversely related to forced expiratory volume in 1 second (FEV(1)) and forced vital capacity in the CARDIA cohort. These relations were also seen in the HABC and CHS cohorts. In predicting lung function, the ancestry-based model fit the data better than standard models. Ancestry-based models resulted in the reclassification of asthma severity (based on the percentage of the predicted FEV(1)) in 4 to 5% of participants.

CONCLUSIONS

Current predictive equations, which rely on self-identified race alone, may misestimate lung function among subjects who identify themselves as African American. Incorporating ancestry into normative equations may improve lung-function estimates and more accurately categorize disease severity. (Funded by the National Institutes of Health and others.)

Combination therapy salmeterol/fluticasone versus doubling dose of fluticasone in children with asthma

RATIONALE

For children with symptomatic asthma despite low to moderate doses of inhaled corticosteroids, evidence is still lacking whether to add a long-acting bronchodilator or to increase the dose of inhaled corticosteroids.

OBJECTIVE

To evaluate whether salmeterol/fluticasone propionate (SFP), 50/100 μg twice a day, is noninferior regarding symptom control compared with fluticasone propionate (FP), 200 μg twice a day Diskus in children with symptomatic asthma.

METHODS

A multicenter, randomized, parallel-group, double-blind study was performed comparing SFP and FP treatment during 26 weeks on asthma control and lung function.

MEASUREMENTS AND MAIN RESULTS

A total of 158 children, 6-16 years old, still symptomatic on FP, 100 μg twice a day, during a 4-week run-in period, were included. Percentage of symptom-free days during the last 10 weeks of the treatment period did not differ between treatment groups (per protocol analysis: adjusted mean difference [FP minus SFP] 2.6%; 95% confidence interval, -8.1 to 13.4). Both groups showed substantial improvements of about 25 percent points in symptom-free days (both P < 0.001 from baseline). Lung function measurements (FEV(1), FVC, PEF rate, and maximal expiratory flow) did not differ between groups except for a slight advantage in maximal expiratory flow in the SFP group at 1 week. No differences were found between FP and SFP regarding exacerbation rates, adverse events, or growth.

CONCLUSIONS

In our study the efficacy on symptom control and lung function of the combination of a long-acting bronchodilator with inhaled corticosteroid is equal to doubling the dose of the inhaled corticosteroid in children still symptomatic on a moderate dose of inhaled corticosteroid.

FDA LABA warning: is there anything new here?

The FDA advisory on long-acting beta-agonists (LABAs) is not based on new data but on ongoing safety concerns about this class of medication. Not to be ignored are the potential safety risks of short-acting beta-agonists (SABAs).

Role of Leukotrienes and Leukotriene Modifiers in Asthma

Leukotrienes (LTs), including cysteinyl LTs (CysLTs) and LTB₄, are potent lipid mediators that are pivotal in the pathophysiology of asthma phenotypes. At least two receptor subtypes for CysLTs - CysLT1 and CysLT₂ - have been identified. Most of the pathophysiological effects of CysLTs in asthma, including increased airway smooth muscle activity, microvascular permeability and airway mucus secretion, are mediated by the activation of the CysLT1 receptor. LTB₄ may have a role in the development of airway hyperresponsiveness, severe asthma and asthma exacerbations. Although generally less effective than inhaled glucocorticoids, CysLT₁ receptor antagonists can be given orally as monotherapy in patients with persistent mild asthma. In patients with more severe asthma, CysLT₁ receptor antagonists can be combined with inhaled glucocorticoids. This therapeutic strategy improves asthma control and enables the dose of inhaled glucocorticoids to be reduced, while maintaining similar efficacy. The identification of subgroups of patients with asthma who respond to CysLT₁ receptor antagonists is relevant for asthma management, as the response to these drugs is variable. The potential anti-remodeling effect of CysLT₁ receptor antagonists might be important for preventing or reversing airway structural changes in patients with asthma. This review discusses the role of LTs in asthma and the therapeutic implications of the pharmacological modulation of the LT pathway for asthma.

Use and safety of long-acting β2-agonists for pediatric asthma

Asthma guidelines recommend the use of long-acting β2-agonists (LABAs) as the preferred add-on therapy for adults and children over 5 years of age when asthma is inadequately controlled by inhaled corticosteroids alone. It has been suggested that LABA use may be associated with an increased risk of morbidity and mortality; however, this view is controversial since study findings have been inconsistent. While the safety profile of LABA monotherapy has been questioned, the value of concomitant inhaled corticosteroids to eliminate possible risks remains unproven. There is a paucity of efficacy and safety data for LABA use in children, and existing evidence is not sufficiently convincing to demonstrate a clear position for LABAs in the management of childhood asthma. The main aims of this article are to place LABAs in context in the management of childhood asthma and evaluate the current evidence for safety and efficacy.

Prescribing patterns of asthma controller therapy for children in UK primary care: a cross-sectional observational study

Background

Asthma management guidelines recommend a stepwise approach to instituting and adjusting anti-inflammatory controller therapy for children with asthma. The objective of this retrospective observational study was to describe prescribing patterns of asthma controller therapies for children in a primary care setting.

Methods

Data from the UK General Practice Research Database were examined for children with recorded asthma or recurrent wheezing who, from September 2006 through February 2007, were ≤ 14 years old at the time of a first asthma controller prescription after ≥ 6 months without a controller prescription. We evaluated demographic characteristics, asthma duration, comorbidities, asthma-related health care resource use, and prescribed daily dose of controller medication. In addition, physicians for 635 randomly selected patients completed a survey retrospectively classifying asthma severity at the prescription date and describing therapy and health care utilization for 6 prior months.

Results

We identified 10,004 children, 5942 (59.4%) of them boys, of mean (SD) age of 8.0 (3.8) years. Asthma controller prescriptions were for inhaled corticosteroid (ICS) monotherapy for 9059 (90.6%) children; ICS plus long-acting β2-agonist (LABA) for 698 (7.0%); leukotriene antagonist monotherapy for 91 (0.9%); ICS plus leukotriene antagonist for 55 (0.6%); and other therapy for 101 (1.0%), including 45 (0.45%) children who were prescribed LABA as monotherapy. High doses of ICS (> 400 μg) were prescribed for 44/2140 (2.1%) children < 5 years old and for 420/7452 (5.6%) children ≥ 5 years. Physicians reported asthma severity as intermittent for 346/635 (55%) patients and as mild, moderate, and severe persistent for 159 (25%), 71 (11%), and 11 (2%), respectively (severity data missing for 48 [8%]). The baseline characteristics and controller therapy prescriptions of the survey cohort were similar to those of the full cohort.

Conclusions

Physician classifications of asthma severity did not always correspond to guideline recommendations, as leukotriene receptor antagonists were rarely used and high-dose ICS or add-on LABA was prescribed even in intermittent and mild disease. In UK primary care, monotherapy with ICS is the most common controller therapy at all levels of asthma severity.

Cost effectiveness of leukotriene receptor antagonists versus long-acting beta-2 agonists as add-on therapy to inhaled corticosteroids for asthma: a pragmatic trial

BACKGROUND

Information is lacking on the relative effectiveness and cost effectiveness--in a real-life primary-care setting--of leukotriene receptor antagonists (LTRAs) and long-acting beta2 adrenergic receptor agonists (beta2 agonists) as add-on therapy for patients whose asthma symptoms are not controlled on low-dose inhaled corticosteroids (ICS).

OBJECTIVE

To estimate the cost effectiveness of LTRAs compared with long-acting beta2 agonists as add-on therapy for patients whose asthma symptoms are not controlled on low-dose ICS.

METHODS

An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma insufficiently controlled with ICS (n = 361) were randomly assigned to add-on LTRAs (n = 176) or long-acting beta2 agonists (n = 185). The main outcome measures were the incremental cost per point improvement in the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), per point improvement in the Asthma Control Questionnaire (ACQ) and per QALY gained from perspectives of the UK NHS and society.

RESULTS

Over 2 years, the societal cost per patient receiving LTRAs was pounds sterling 1157 versus pounds sterling 952 for long-acting beta2 agonists, a (significant, adjusted) increase of pounds sterling 214 (95% CI 2, 411) [year 2005 values]. Patients receiving LTRAs experienced a non-significant incremental gain of 0.009 QALYs (95% CI -0.077, 0.103). The incremental cost per QALY gained from the societal (NHS) perspective was pounds sterling 22,589 (pounds sterling 11,919). Uncertainty around this point estimate suggested that, given a maximum willingness to pay of pounds sterling 30,000 per QALY gained, the probability that LTRAs are a cost-effective alternative to long-acting beta2 agonists as add-on therapy was approximately 52% from both societal and NHS perspectives.

CONCLUSIONS

On balance, these results marginally favour the repositioning of LTRAs as a cost-effective alternative to long-acting beta2 agonists as add-on therapy to ICS for asthma. However, there is much uncertainty surrounding the incremental cost effectiveness because of similarity of clinical benefit and broad confidence intervals for differences in healthcare costs.

TRIAL REGISTRATION

UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.