Efficacy of once-daily versus twice-daily administration of budesonide by Turbuhaler(R) in children with stable asthma

Once-Daily vs. Twice-Daily Administration of Inhaled Budesonide for Mild and Moderate Well-Controlled Childhood Asthma: A Randomized, Controlled Trial

OBJECTIVES

To compare median change in morning peak expiratory flow rate (PEFR) and clinical asthma control in children receiving total daily dosage of inhaled budesonide administered either as once-daily or divided twice-daily dose.

METHODS

It was a randomized, parallel group, open label, noninferiority trial on 80 children aged 5-12 y with mild or moderate well-controlled asthma. Baseline parameters were recorded and subjects received inhaled budesonide either as once-daily or divided twice-daily dose. Primary outcome was median change in morning PEFR. Secondary outcomes included median change in evening and diurnal variation in PEFR, asthma symptom control as per Global Initiative for Asthma, 2017 and Asthma Control Questionnaire, and spirometric measurements taken at the clinic.

RESULTS

The median [interquartile range (IQR)] increase in morning PEFR was more in children receiving once-daily as compared to those receiving twice-daily inhaled budesonide (by 6:00 L/min; IQR: -44.00-63.00 L/min vs. 4:00 L/min; IQR: -67.50-67.50 L/min, p 0.222; 95% CI: -1.37 to 19.08). Other spirometric variables and symptoms scores were also nonsignificant except median change in evening PEFR which was in favor of twice-daily regimen.

CONCLUSION

Once-daily administration of inhaled budesonide is noninferior to twice-daily administration of equivalent daily dosage of inhaled budesonide.

Exploring how non-inferiority and equivalence are assessed in paediatrics: a systematic review

OBJECTIVE

To review characteristics, methodology and reporting of non-inferiority and equivalence trials in the specific context of paediatrics.

DESIGN

PubMed and Cochrane databases were searched (up to September 2016) for non-inferiority/equivalence randomised controlled trials conducted in children published in high-impact-factor journals (>5.0 for general/specialist medical journals; >2.2 for paediatric journals).

RESULTS

We found that the statistical hypothesis was inconsistent with the objective in 12 (10%) of the 125 reports included. Non-inferiority (n=98) and equivalence trials (n=27) were mostly used to evaluate interventions with easier administration (45%, n=54/120) and/or better safety profile (34%, n=41/120). All the data needed for targeted sample size recalculation were available for 39 reports (31%). The margin-representing the largest difference between arms that would be clinically acceptable-was reported in 119 (95%), and 44/119 (37%) reported the method used for margin determination. The median sample size was 268 (IQR 125-531). Margins were wider in smaller trials (<125 randomised patients) than in larger trials (p=0.04/p<0.01 for binary/continuous outcomes, respectively). We did not agree with the authors' conclusions in 11% (11/103) of the reports that provided sufficient information.

CONCLUSIONS

There is still a need to improve the quality of methodology, reporting and interpretation of non-inferiority/equivalence trials in paediatrics. In particular, the margins were often not justified and the conclusion was often not supported by the design and/or the results. As researchers have to cope with small sample size and with lack of evidence, methods for non-inferiority/equivalence trials need to be used and/or developed in this vulnerable population.

Increasing adherence to inhaled steroid therapy among schoolchildren: randomized, controlled trial of school-based supervised asthma therapy

OBJECTIVE

We aimed to determine the effectiveness of school-based supervised asthma therapy in improving asthma control. The primary hypothesis was that the supervised-therapy group would have a smaller proportion of children experiencing an episode of poor asthma control each month, compared with those in the usual-care group.

METHODS

Children were eligible if they had physician-diagnosed persistent asthma, the need for daily controller medication, and the ability to use a dry-powder inhaler and a peak flowmeter. The trial used a 2-group, randomized, longitudinal design with a 15-month follow-up period. A total of 290 children from 36 schools were assigned randomly to either school-based, supervised therapy or usual care. Ninety-one percent of the children were black, and 57% were male. The mean age was 11 years (SD: 2.1 years). An episode of poor asthma control was defined as > or =1 of the following each month: (1) an absence from school attributable to respiratory illness/asthma; (2) average use of rescue medication >2 times per week (not including preexercise treatment); or (3) > or =1 red or yellow peak flowmeter reading.

RESULTS

Two hundred forty children completed the study. There were no differences in the likelihood of an episode of poor asthma control between the baseline period and the follow-up period for the usual-care group. For the supervised-therapy group, however, the odds of experiencing an episode of poor asthma control during the baseline period were 1.57 times the odds of experiencing an episode of poor asthma control during the follow-up period. Generalized estimating equation modeling revealed a marginally significant intervention-time period interaction, indicating that children in the supervised-therapy group showed greater improvement in asthma control.

CONCLUSIONS

Supervised asthma therapy improves asthma control. Clinicians who have pediatric patients with asthma with poor outcomes that may be attributable to nonadherence should consider supervised therapy.

Safety of inhaled budesonide: clinical manifestations of systemic corticosteroid-related adverse effects

Inhaled corticosteroid (ICS) therapy is central to the long-term management of asthma and is extensively used in the management of chronic obstructive pulmonary disease (COPD). While administration via inhalation limits systemic exposure compared with oral or injected corticosteroids and, therefore, the risk of systemic corticosteroid-related adverse effects, concerns over the long-term safety of ICS persist. The assessment of the long-term effects of ICS therapy requires considerable research effort over years or even decades. Surrogate markers/predictors for clinical endpoints such as adrenal crisis, reduced final height and fractures have been identified for use in relatively short-term studies. However, the predictive value of such markers remains questionable.Inhaled budesonide has been available since the early 1980s and there is a considerable evidence base investigating the safety of this agent. To assess the long-term safety of inhaled budesonide therapy in terms of the actual incidence of the clinical endpoints adrenal crisis/insufficiency, reduced final height, fractures and pregnancy complications, we undertook a review of the scientific literature. The external databases BIOSIS, Cochrane Central Register of Controlled Trials, Current Contents, EMBASE, International Pharmaceutical Abstracts and MEDLINE were searched, in addition to AstraZeneca's internal product literature database Planet, up to 29 February 2008. Only original articles of epidemiological studies, national surveys, clinical trials and case reports concerning inhaled budesonide were included.Eight surveys of adrenal crisis were found. The only survey with specified criteria for diagnosis involved 2912 paediatricians and endocrinologists and revealed 33 patients with adrenal crisis associated with ICS therapy; only one patient used budesonide (in co-treatment with fluticasone propionate). In addition, 14 case reports of adrenal crisis in budesonide-treated patients were found. In only two of these, budesonide was used at recommended doses and in the absence of interacting medication.Three retrospective studies and one prospective study assessing final height were found. None of them showed any reduced final height in patients receiving inhaled budesonide during childhood or adolescence.Seventeen epidemiological studies investigating the risk of fractures were found. When adjusting for confounding factors, they did not provide any unequivocal data for an increased fracture risk with budesonide. Four prospective placebo-controlled clinical trials of 2-6 years duration with inhaled budesonide in patients with asthma or COPD were found. None of the studies identified any association between inhaled budesonide and increased risk for fractures.Four studies using data from the Swedish birth and health registries showed there was no increased risk for congenital malformations, cardiovascular defects, decreased gestational age, birth weight or birth length among infants born to women using inhaled budesonide during pregnancy compared with the general population. This was confirmed by five observational studies in Australia, Canada, Hungary, Japan and the US. Similarly, one randomized clinical trial comparing pregnancy outcomes among asthma patients receiving inhaled budesonide or placebo did not demonstrate any difference in outcome of pregnancy.In summary, based on 25 years of experience with different doses and in different populations, inhaled budesonide therapy only in very rare cases appears to be associated with an increased risk of adrenal crisis, reduction in final height, increases in the number of fractures or complications during pregnancy.

Once versus twice daily budesonide metered-dose inhaler in children with mild to moderate asthma: effect on symptoms and bronchial responsiveness

BACKGROUND

Simplifying dosing regimens could improve both adherence and asthma-related morbidity. However, there is little information on the effectiveness of once-daily budesonide, administered through a metered dose inhaler (MDI) plus spacer, on asthma symptoms and pulmonary function in asthmatic children.

METHODS

The aim of this study was to compare the effect of once-daily versus twice-daily doses of inhaled budesonide on symptoms, lung function and bronchial hyperresponsiveness (BHR) in asthmatic children. This study was a randomized, single-blind, parallel clinical trial. Patients received budesonide from an MDI either 800 microg as a daily dose or fractionated in 400 microg twice a day for 12 weeks. Statistical analysis was performed using tests for independent and paired samples.

RESULTS

In both groups, asthma symptoms significantly decreased. However, the improvement in asthma symptoms, decrease in BHR and treatment adherence were significantly greater in the once-daily group than in the twice-daily group (p < 0.05). No significant differences were found between the two groups in spirometric parameters, morning peak expiratory flow or plasma cortisol values.

CONCLUSIONS

Once-daily administration of 800 microg of inhaled budesonide administered by MDI plus spacer was more effective in controlling symptoms and improving BHR than fractionating the dose to 400 microg twice daily. The differences observed in this study could have been due to the greater adherence to treatment in patients in the once-daily group.

Once-daily fluticasone propionate in stable asthma: study on airway inflammation

Children with stable asthma receiving twice-daily fluticasone propionate (FP) were studied. Spirometry, exhaled nitric oxide (eNO) and sputum eosinophils were measured at baseline and 8 weeks after FP was changed to once-daily use while keeping the same total dosage. Visual analogue scores on asthma severity, symptoms, and dosing regimen preference were obtained. Twenty-nine children of mean age 10.6 years (SD 2.5) were recruited. There was significant improvement in eNO (47.1 ppb [30.3] vs. 39.9 ppb [27.1], p = 0.037), and sputum eosinophils (5.7% [6.5] vs. 2.5% [3.9], p = 0.024] after 8 weeks. All subjects preferred the once-daily dosing regimen. Once-daily FP is effective in controlling airway inflammation. This frequency of medication use is also the preferred regimen.

Budesonide once versus twice-daily administration: meta-analysis

OBJECTIVES

The aim of this study was to examine the efficacy of budesonide administered once daily compared to twice daily in asthma.

METHODOLOGY

Meta-analysis of randomised controlled trials comparing budesonide administered once versus twice a day that presented data on at least one clinical outcome measure was conducted.

RESULTS

A total of 10 studies, with 1922 children and adults with asthma, met the inclusion criteria. These studies were performed predominantly with mild to moderate asthmatic patients, using doses of budesonide ranging from 200 to 800 microg per day. There was no significant difference between daily dosing once or twice for all the clinical outcome variables, including withdrawals due to asthma, for which the odds ratio was 1.0 (95% confidence interval, 0.65-1.52).

CONCLUSIONS

In mild to moderate asthma a once-daily budesonide regimen has a similar efficacy to a twice-daily regimen in doses up to 800 microg per day. A once-daily regimen has potential advantages in terms of patient compliance and satisfaction, when used in clinical practice.

[Asthma treatment in childhood: from guidelines to practice]

Aims for the management of asthma in children are to optimize quality of life and to maintain normal lung functions. International guidelines recommend rapid-acting inhaled beta2-agonist as needed in children with intermittent asthma. Once asthma is persistent, mild, moderate or severe, daily long-term therapy with inhaled corticosteroids should be started. Association with long-acting inhaled beta2-agonist or leukotriene inhibitors are required in children not enough controlled with inhaled corticosteroids alone. Management of the asthmatic child should not be restricted to antiasthmatic drug prescription but should include patient and patient's family education as well as adequate health of life.

Once-daily inhaled budesonide for the treatment of asthma: clinical evidence and pharmacokinetic explanation

BACKGROUND

Budesonide, a widely used inhaled corticosteroid (ICS) with a favorable therapeutic ratio, is available via a dry powder inhaler (Pulmicort Turbuhaler) and as a suspension for nebulization (Pulmicort Respules).

METHODS

MEDLINE and an AstraZeneca database were searched to identify relevant controlled clinical trials published between 1986 and 2002 using the key words budesonide OR inhaled corticosteroid, AND once daily.

RESULTS

Thirty-four controlled clinical studies involving once-daily administration of budesonide to asthmatic patients were identified. Excluding long-term studies, this review presents data from 23 controlled studies for 4466 adults or adolescents and 1532 children with asthma and demonstrates efficacy of budesonide in both corticosteroid-naïve patients and patients previously treated with ICS. Once-daily administration of budesonide achieves clinical efficacy comparable with that of twice-daily regimens in patients with mild-to-moderate asthma and is equally effective when given in the morning or evening. Once-daily administration simplifies treatment regimens and may improve patient compliance. The tolerability profiles of budesonide once-daily via Turbuhaler or as budesonide inhalation suspension are good and comparable with those for twice-daily dosing.

CONCLUSIONS

Once-daily budesonide is effective and well tolerated as initial treatment for adults and children with mild asthma and as maintenance therapy in patients with more severe asthma once asthma control has been achieved.

Optimizing inhaled corticosteroid therapy in children with chronic asthma

Asthma is the most common chronic illness among children, and inhaled corticosteroids (ICS) are the most effective long-term therapy available for suppressing airway inflammation in persistent asthma. While the primary aim of ICS therapy is good efficacy with minimal side effects, early diagnosis and treatment of asthma can also improve asthma control and normalize lung function, and may prevent irreversible airway injury. Poor patient compliance is a major barrier to treatment. Simplified dosing regimens (e.g., once-daily administration), good inhaler technique, and education of the patient/caregiver should improve patient compliance. Concerns over ICS therapy are often based on the potential for systemic effects associated with oral corticosteroids (e.g., effects on bone mineral density, or growth suppression in children). Since adverse events are associated with high doses of ICS, the dose in all patients should be titrated to the minimum effective dose required to maintain control. Optimal distribution of an ICS in the lungs rather than the systemic compartment is affected by several factors, including the drug's pharmacokinetic profile, inhaler type, inhaler technique, and drug particle size. For young patients unable to use a dry-powder inhaler or pressurized metered-dose inhaler, a nebulizer facilitates drug delivery through passive inhalation; ICS therapy in the form of budesonide inhalation suspension can be given to children with persistent asthma from 12 months of age. In conclusion, selecting a drug with good efficacy and minimal side effects, such as budesonide, together with an easy-to-use delivery system and ongoing patient/caregiver education, is important in optimizing ICS therapy for children with persistent asthma.

The role of budesonide in adults and children with mild-to-moderate persistent asthma

Asthma, a chronic and potentially life-threatening disease of the airways, affects patients of all ages. Inhaled corticosteroids (ICS) are the recommended first-line therapy for patients with persistent asthma. To review the clinical efficacy and tolerability data available on budesonide in the treatment of mild-to-moderate persistent asthma, a MEDLINE database search was performed for 1996-2003 using the following key words: budesonide, inhaled corticosteroid, efficacy, safety, systemic. When administered once or twice daily, budesonide effectively controls asthma in children, adolescents, and adults with mild-to-moderate asthma. Budesonide can be delivered effectively via a dry powder inhaler (Pulmicort Turbuhaler) in patients aged > or = 6 years or as an inhalation suspension (Pulmicort Respules) in children as young as 12 months. With over 20 years' clinical exposure, budesonide has been demonstrated to be well tolerated in the treatment of chronic asthma in patients as young as 12 months. Specifically, at doses required to treat mild or moderate persistent asthma, budesonide does not affect hypothalamic-pituitary-adrenal axis function, bone mineral density, cataract formation, or final adult height. As Pulmicort Turbuhaler, budesonide is the only ICS to achieve a Food and Drug Administration pregnancy category B rating. Early intervention with budesonide is recommended in asthma management: maximum benefit from therapy is reported in patients treated within 2 years of disease recognition. Budesonide is effective and well tolerated in the control of mild-to-moderate persistent asthma in patients aged 12 months and older. There is no evidence for variation in efficacy in population subgroups.

Treatment of childhood asthma: how do the available options compare?

The National Asthma Council of Australia suggests that "the aim of preventive therapy should be to enable patients to enjoy a normal life (comparable with that of non-asthmatic children), with the least amount of medication and at minimal risk of adverse events. The level of maintenance therapy should be determined by symptom control and lung function in the interval periods." The British Thoracic Society/Scottish Intercollegiate Guidelines Network states that the aims of the pharmacological treatment of asthma should be to control symptoms, prevent exacerbations and achieve the best possible lung function with minimal adverse effects. We have used the current published international guidelines to highlight the international differences in management recommendations, and compared the possible pharmacological options with a focus on the above ideals. Cromones have been used for many years in childhood asthma. Most evidence suggests they now have little role. Regarding inhaled corticosteroids (ICS), beclomethasone and budesonide are essentially similar in their efficacy. Fluticasone propionate is equally as effective at one-half the equivalent dose of budesonide or beclomethasone. Adverse effects are rare in dosages <400 microg/day of budesonide and beclomethasone or <200 microg/day of fluticasone propionate, but may occur in individual patients. Relevant clinical adverse effects are rare and pharmacological systemic effects are less noticeable with budesonide and fluticasone propionate than with beclomethasone, but data are conflicting. Long-acting beta2-adrenoceptor agonists (beta2-agonists) are recommended once low-dose ICS have failed to control symptoms. The main pharmacological difference between the agents is that formoterol is a full beta2-adrenergic agonist, whereas salmeterol is a partial agonist at the beta2-adrenoceptor and has a unique pharmacological action. The main clinical distinction between these two agents is that their onset of bronchodilation differs. Bronchodilation begins at about 3 minutes after inhalation of formoterol, which is similar to the short-acting agents, whereas salmeterol has a much slower onset of action at about 15-30 minutes. The many in vitro differences between the two drugs are probably not clinically relevant. There are no comparative pediatric data on the leukotriene modifiers to make clear recommendations.

Once-daily inhaled corticosteroids for the treatment of asthma

PURPOSE OF REVIEW

Inhaled corticosteroids (ICS) are the mainstay of asthma therapy. Although compliance to this type of medication is often suboptimal and once-daily dosing can help to improve adherence to the treatment, the clinical implications of such a mode of administration should be determined.

RECENT FINDINGS

This review summarizes the recent studies on comparative efficacy of once-versus twice-daily administration of ICS, in light of previous reports.

SUMMARY

Although twice-daily administration of ICS is often better to optimize asthma parameters, in many patients, asthma can be sufficiently controlled by a once-daily regimen of most ICS. An increased frequency of dosing seems preferable if asthma becomes uncontrolled or is severe, although this requires further study. A therapeutic trial should, however, be done to ensure that asthma control is adequate. Comparative long-term effects of such a strategy on inflammatory and remodeling parameters remain to be determined, as does the proportion of patients who can adequately control their asthma with once-daily administration of the various ICS available.

The role of intracellular esterification in budesonide once-daily dosing and airway selectivity

BACKGROUND

Since their introduction in the 1970s, inhaled corticosteroids (ICSs) have been used to control airway inflammation associated with asthma. Budesonide is one of the ICSs recommended as first-line therapy for mild to moderate persistent asthma.

OBJECTIVE

This article describes the esterification of budesonide and how it results in prolonged, location-specific retention of drug in the airways, allowing once-daily dosing.

RESULTS

Studies conducted over the past decade have shown that budesonide forms reversible fatty acid esters within the cells of airway tissue, resulting in the formation of an intracellular depot pool of inactive drug. As the intracellular concentration of free budesonide decreases, these budesonide esters are hydrolyzed back to their active state. This process increases budesonide's retention in the airways, prolongs its duration of action, and lowers the risk of systemic effects.

CONCLUSIONS

By extending budesonide's local anti-inflammatory effect and increasing its airway selectivity, the esterification process appears to contribute to the drug's efficacy, particularly during once-daily administration. Reducing the number of required daily inhalations may increase patient compliance with asthma therapy, although this remains to be evaluated.

Preclinical properties of budesonide: translation to the clinical setting

BACKGROUND

Since the introduction of inhaled corticosteroids (ICSs) nearly 30 years ago, the management of asthma has been transformed. It is now understood that asthma is primarily a disease of chronic inflammation, even in its milder forms, and that to delay treatment may lead to deterioration in lung function. International treatment guidelines for asthma recommend early intervention with a potent ICS, with the greatest benefit observed when treatment is started within 2 years of the onset of symptoms. Each of the currently available ICSs has distinct physical and pharmacokinetic properties and is delivered via different devices.

OBJECTIVE

This article brings together the findings and concepts presented in this supplement. It provides an overview of budesonide's predicted clinical efficacy and tolerability in patients with asthma based on its physical properties and pharmacokinetic and pharmacodynamic characteristics.

CONCLUSIONS

Budesonide's physical properties and pharmacokinetic and pharmacodynamic profiles help predict its clinical efficacy and tolerability when used as early intervention in asthma. Study results indicate that lung deposition of budesonide is increased by delivery via dry-powder inhaler, enhancing the drug's efficacy in patients with newly diagnosed mild persistent asthma. The preclinical, clinical, and safety data support budesonide's predicted performance in the clinical setting.

Review of the unique properties of budesonide

BACKGROUND

The aim of inhaled corticosteroid (ICS) therapy for asthma is to attain high therapeutic activity in the airways while keeping the risk of systemic adverse effects relatively low. However, the physicochemical and pharmacokinetic properties of various ICSs affect this ratio, thereby influencing their ability to fulfill the requirements of an ideal agent.

OBJECTIVE

This article reviews the physical and pharmacokinetic properties of budesonide, outlining how they, safety data, and use of different inhalation devices enable budesonide to meet many of the clinical requirements of an ideal ICS for the treatment of asthma.

RESULTS

ICS efficacy is influenced by lipophilicity, lung deposition, and retention in airway tissue, whereas the rate of elimination determines systemic activity. Budesonide is retained in the airways to a greater extent than other ICSs because of an esterification process that increases its lipophilicity. The prolonged retention of budesonide in the airways may contribute to its efficacy when administered QD. In addition to a pressurized metered-dose inhaler, budesonide is available as a dry-powder inhaler and in nebulized form, which can be used by asthma patients aged > or =6 months.

CONCLUSIONS

When combined with delivery devices suitable for a spectrum of patient groups, the physical and pharmacokinetic properties of budesonide lend it many of the characteristics of an ideal ICS, including favorable efficacy and tolerability profiles.

A review of once-daily delivery of anti-asthmatic drugs in children

Determining which drug is suitable for, and which patient can benefit from, a once-daily dose of prophylactic treatment is important for practitioners who want to improve therapeutic compliance in children with asthma. According to the literature, once-daily delivery of cromolyn sodium, nedocromil or beclomethasone dipropionate must be avoided. On the other hand, switching from a twice-daily to a once-daily regimen is efficient and safe only in children with well-controlled asthma using nebulized or dry-powder budesonide, dry-powder fluticasone propionate, flunisolide, or sustained-release theophylline. Such information is not available for long-acting beta2-agonists, except for oral bambuterol. Initiating a once-daily treatment in previously untreated children can only be based on low doses of inhaled budesonide or on an oral drug, montelukast. Further studies in children with severe asthma or treated with metered-dose inhalers and spacer devices are required before recommending a once-daily drug delivery in such situations.

Once-daily administration of budesonide Turbuhaler was as effective as twice-daily treatment in patients with mild to moderate persistent asthma

In a double-blind, randomized, placebo-controlled trial, 288 patients with mild to moderate persistent asthma currently on inhaled glucocorticosteroids (GCSs) were treated with budesonide Turbuhaler, 200 microg once every night (q.n.), 100 microg twice-daily (b.i.d.), or placebo b.i.d. After 12 weeks, morning peak expiratory flow (PEF) increased in both groups treated with budesonide but decreased in placebo-treated patients. Symptom scores and bronchodilator use were significantly reduced in both groups receiving active treatment (p = 0.023-0.0001) compared with patients treated with placebo. There was no significant difference in outcome measurements between the two budesonide regimens. Thus, patients with mild to moderate persistent asthma receiving b.i.d. treatment with inhaled GCSs can usually be switched to budesonide Turbuhaler, 200 microg, q.n. without loss of asthma control.

The antiinflammatory activity of budesonide on human airway epithelial cells is lasting after removal of the drug from cultures

Because of its ability to conjugate extensively with fatty acids within lung cells, it has been suggested that budesonide (Bud) may have a prolonged pharmacologic activity, related to retention of the drug in airway tissues. Using human bronchial epithelial cells (HBECs) as target cells, we evaluated whether Bud could have a long-lasting inhibitory effect on ICAM-1 expression and GM-CSF release. HBECs were cultured in Bud (10 microM) or in medium alone (Ctr) for 24 hr, then extensively washed (to remove Bud) and incubated for an additional 6, 12, or 24 hr with IFN-gamma. ICAM-1 expression and GM-CSF release were then measured by flow cytometric analysis. In Ctr HBECs, IFN-gamma induced a time-dependent upregulation of ICAM-1 expression, significant at 6, 12, or 24 hr (p < 0.05, each comparison), and an increase in GM-CSF release, significant at 24 hr (p < 0.05). The inhibitory effects of Bud preexposure on IFN-gamma-induced ICAM-1 expression and GM-CSF release were then compared with those of a continuous exposure to the drug during IFN-gamma stimulation. Preexposure to Bud (1 and 10 microM) induced a significant inhibition of IFN-gamma-induced ICAM-1 expression (p < 0.05, each comparison), but lower than that observed in HBECs continuously exposed at the same Bud concentrations (p < 0.01, each comparison). In contrast, the inhibition of GM-CSF release was similar in preexposed and in exposed HBECs and statistically significant only at the highest Bud concentration tested (p < 0.05, each comparison). Thus, Bud is effective in vitro in inducing a downregulation lasting 24 hr of mechanisms involved in leukocyte recruitment.

The inhaled Steroid Treatment as Regular Therapy in early asthma (START) study: rationale and design

Although the beneficial effects of treatment with inhaled steroids in asthma are widely accepted, the role of early intervention in patients with mild asthma remains unsettled. Conventional efficacy trials are often of short duration and involve highly selected patient populations that exclude many patients typical of those encountered in routine clinical practice. Hence, a large "real-world" effectiveness study is needed to evaluate the benefits of early intervention with inhaled steroids in patients with mild, persistent asthma. In the START (inhaled Steroid Treatment As Regular Therapy in early asthma) study, patients ages 6-60 years, from 31 countries and districts worldwide with mild persistent asthma, have been randomized to once-daily treatment with budesonide, 200 microg (for patients < 11 years) or 400 microg (for patients > or = 11 years), or placebo via Turbuhaler for 3 years. The double-blind treatment period will be followed by a 2-year period of open budesonide treatment. Throughout the study, other asthma medication including glucocorticosteroids can be given as judged appropriate by the investigator. Lung function will be measured by spirometry using standardized techniques at 3-month intervals throughout the study, and bronchodilator reversibility will be measured annually. The primary outcome measures are the time to the first severe asthma-related event during the first 3 years of the study and the change in postbronchodilator forced expiratory volume in 1 second (FEV(1)) from baseline during the entire 5-year study period. These measures have been chosen to reflect the progression of mild asthma toward more severe asthma and the extent of irreversible airflow limitation, which should reflect the degree of airway remodeling.

Once-daily inhaled corticosteroids in children with asthma: dry powder inhalers

The cornerstone of pharmacological management of asthma in childhood is inhaled corticosteroids. These drugs are intended for long term treatment and, consequently, compliance is a major issue. Once-daily administration of maintenance medication would simplify treatment and it is likely that it would lead to better compliance. Moreover, the excellent safety profile of inhaled corticosteroid treatment tailored to disease severity may, theoretically, be further improved with once-daily administration. Studies comparing inhaled corticosteroids given once or twice daily to patients with asthma indicate that unstable asthma is best treated with at least 2 daily doses. On the other hand, it has been demonstrated that, if the asthma is stabilised, most children can be treated with inhaled corticosteroids once daily without loss of efficacy. Thus, the data suggest that newly diagnosed asthma, or asthma after deterioration, should first be reliably controlled with inhaled corticosteroids divided into at least 2 daily doses. Once-daily maintenance treatment should then be tried with the aim of improving compliance and quality of life. A dry powder inhalation device is probably the best choice for children from the age of 5 years.