Inhaled fluticasone versus inhaled beclomethasone or inhaled budesonide for chronic asthma in adults and children

Why aren't we doing better in asthma: time for personalised medicine?

After decades of improvement, asthma outcomes have stalled. Mortality, hospitalisations, exacerbations and symptom control remain sub-optimal. In controlled trials, most patients gain high levels of control, but in ‘real-life’ routine clinical practice most patients do not. Avoidable factors are found in most asthma deaths and hospital admissions. This perspective paper considers and contextualises the factors underlying poor asthma outcomes, and it suggests approaches that could improve the situation. Factors discussed include severe, therapy-resistant disease and the role of new and upcoming pharmacological therapies in improving outcomes. These are likely to be beneficial when targeted on patients with severe disease and discrete phenotypic characteristics, identified through biomarkers. However, for the majority of patients treated in the community, they are unlikely to be used widely, and better use of current therapy classes will be more important. Non-adherence with regular inhaled corticosteroid treatment and over-use of rescue bronchodilators are common, and many patients have poor inhaler technique. Self-management is frequently poor, particularly in those with psychosocial disadvantages and co-morbidities. Communication between clinicians and patients is sometimes poor, with failure to detect avoidable poor control and non-adherence, and failure to provide the necessary information and education to support efficient self-management. Strategies for improving monitoring and clinician–patient interactions to allow personalised treatment are considered. These strategies have the potential to allow individual patient needs to be recognised and efficient targeting of the variety of effective pharmacological and non-pharmacological interventions that we possess, which has the potential to improve both individual and population outcomes.

Comparison of Effectiveness between Beclomethasone Dipropionate and Fluticasone Propionate in Treatment of Children with Moderate Asthma

Asthma is a common chronic disease. Beclomethasone dipropionate (BDP) and Fluticasone propionate (FP) are 2 inhaled corticosteroids that frequently be used in treatment of patients with asthma. In this study, the effectiveness of BDP and FP in management of asthmatic children was investigated. In this trial, 50 children with moderate persistent asthma were randomly selected to receive either BDP 600 μg or FP 500 μg for 3 months. Pulmonary function tests were measured in both groups at the beginning of study and monthly after treatment. Daily and night symptoms and consistency of drugs were also measured. There was significantly better FEV1 in patients receiving FP compared with the BDP group (P < 0.01). There was also statistically significant difference in patients receiving FP compared with BDP group in increment of FVC, FEV1/FVC, FEF25-75 (P < 0.005). Night symptoms were significantly improved in the FP group from the first month (P = 0.001), while improvement of daily symptoms in this group compared with the BDP group was found from the second month (P = 0.001). Although symptoms and pulmonary function tests results were improved in both groups receiving either FP or BDP, this study suggested that FP was more effective than BDP in controlling moderate asthma in children.

Health-related quality of life assessment using St. George's respiratory questionnaire in asthmatics on inhaled corticosteroids

CONTEXT

Chronic diseases like asthma have significant effects on patients' health-related quality of life (HRQoL). HRQoL measures additional indices as compared to objective measurements like spirometry.

AIMS

To assess and compare disease-specific quality of life in asthma patients using St. George's Respiratory Questionnaire (SGRQ) receiving fluticasone, beclomethasone, and budesonide (BUD).

SETTINGS AND DESIGN

A prospective, open label, randomized, parallel group study conducted at a tertiary care teaching hospital in South India.

MATERIALS AND METHODS

A 6-month follow-up of 277 patients with mild, moderate, and severe persistent asthma was randomized to receive fluticasone propionate (FP), BUD, or beclomethasone dipropionate (BDP) in equipotent doses according to their global initiative on asthma (GINA) severity.

STATISTICAL ANALYSIS USED

Data analyzed using SPSS version: 13.0. General linear-repeated measures using the post-hoc bonferroni method assessed significance between treatment groups.

RESULTS

Significant decrease (P < 0.05) in each SGRQ domains and total scores as well as improvement in FEV(1) (P < 0.05) was observed in all study subjects. A significant early response (P < 0.05) was noted after 15 days treatment in patients receiving FP with respect to SGRQ (activity, impact and total) scores and dyspnea indices, but not FEV(1). This improvement with FP was due to its greater effect in patients with moderate and severe persistent asthma. No difference was noted subsequently in all outcome measures studied until 6 months.

CONCLUSIONS

There was evidence for an early QoL improvement to FP as compared to BUD or BDP in moderate and severe persistent asthma. Subsequently, the three ICS showed similar improvements in lung functions and dyspnea indices throughout the study.

An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses

BACKGROUND

Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation.

METHODS

Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms.

RESULTS

In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication.

CONCLUSIONS

More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.

The impact of generic-only drug benefits on patients' use of inhaled corticosteroids in a Medicare population with asthma

Background

Patients face increasing insurance restrictions on prescription drugs, including generic-only coverage. There are no generic inhaled corticosteroids (ICS), which are a mainstay of asthma therapy, and patients pay the full price for these drugs under generic-only policies. We examined changes in ICS use following the introduction of generic-only coverage in a Medicare Advantage population from 2003–2004.

Methods

Subjects were age 65+, with asthma, prior ICS use, and no chronic obstructive pulmonary disorder (n = 1,802). In 2004, 74.0% switched from having a $30 brand-copayment plan to a generic-only coverage plan (restricted coverage); 26% had $15–25 brand copayments in 2003–2004 (unrestricted coverage). Using linear difference-in-difference models, we examined annual changes in ICS use (measured by days-of-supply dispensed). There was a lower-cost ICS available within the study setting and we also examined changes in drug choice (higher- vs. lower-cost ICS). In multivariable models we adjusted for socio-demographic, clinical, and asthma characteristics.

Results

In 2003 subjects had an average of 188 days of ICS supply. Restricted compared with unrestricted coverage was associated with reductions in ICS use from 2003–2004 (-15.5 days-of-supply, 95% confidence interval (CI): -25.0 to -6.0). Among patients using higher-cost ICS drugs in 2003 (n = 662), more restricted versus unrestricted coverage subjects switched to the lower-cost ICS in 2004 (39.8% vs. 10.3%). Restricted coverage was not associated with decreased ICS use (2003–2004) among patients who switched to the lower-cost ICS (18.7 days-of-supply, CI: -27.5 to 65.0), but was among patients who did not switch (-38.6 days-of-supply, CI: -57.0 to -20.3). In addition, restricted coverage was associated with decreases in ICS use among patients with both higher- and lower-risk asthma (-15.0 days-of-supply, CI: -41.4 to 11.44; and -15.6 days-of-supply, CI: -25.8 to -5.3, respectively).

Conclusion

In this elderly population, patients reduced their already low ICS use in response to losing drug coverage. Switching to the lower-cost ICS mitigated reductions in use among patients who previously used higher-cost drugs. Additional work is needed to assess barriers to switching ICS drugs and the clinical effects of these drug use changes.

Cost-effectiveness of salmeterol xinafoate/fluticasone propionate combination inhaler in chronic asthma

OBJECTIVE

To determine where in the treatment steps recommended by the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) Asthma Guideline it is cost-effective to use salmeterol xinafoate/fluticasone propionate combination inhaler (SFC) (Seretide) compared with other inhaled corticosteroid (ICS) containing regimens (with and without a long acting beta-2 agonist (LABA)) for chronic asthma in adults and children.

RESEARCH DESIGN AND METHODS

Meta-analyses of percentage symptom-free days (%SFD) were used within a cost-effectiveness model. Time spent in two asthma control health states, 'symptom-free' and 'with-symptoms' was used as the measure of differential treatment effectiveness. SFC was compared with varying doses of fluticasone propionate (FP) and beclometasone dipropionate (BDP) with or without a separate salmeterol inhaler, and with the budesonide/formoterol combination inhaler (BUD/FORM) (Symbicort). Drug costs, non-drug costs and quality adjusted life years (QALY) were incorporated into the analyses. Results are presented as cost per QALY ratios and uncertainty explored using probabilistic sensitivity analysis.

RESULTS

Compared with an increased dose of FP in adults, SFC either 'dominates' (i.e. cheaper and more effective) FP or the cost per QALY is 6852 pounds sterling. The cost per QALYs estimated in sensitivity analyses using BDP costs range from 5679 pounds sterling to 15,997 pounds sterling. For children the cost per QALY for SFC 50 Evohaler compared with an increased dose of FP is pound 15,739 pounds sterling. SFC is similarly clinically effective in improving %SFDs compared with FP plus salmeterol delivered in separate inhalers (mean differences for each dose comparison of -3.9 (low) (with a 95% confidence interval (CI): -12.96; 5.16); 4.10 (medium) (95% CI: -3.01; 11.21); -0.4 (high) (95% CI: -8.88; 8.08)) and BUD/FORM (mean difference of 0.40 (95% CI -3.69; 4.49)) in adults, and a cheaper SFC option is available at all doses (annual cost savings range from 18 pounds sterling-427 pounds sterling per patient). SFC was similarly effective compared with FP plus salmeterol in separate inhalers in children under 12 and also resulted in annual cost savings of between 47 pounds sterling and 77 pounds sterling. A number of other comparisons were also made and the results are available as electronic supplementary data.

CONCLUSIONS

This is the first analysis to estimate the cost-effectiveness of SFC in chronic asthma compared with multiple comparators and based on a systematic identification of relevant trials and data on %SFDs. The findings suggest that for adults and children uncontrolled on BDP 400 microg/day or equivalent it is a cost-effective option to switch to SFC (at an equivalent ICS dose) compared with increasing the dose of ICS. For adults and children aged 12 years and over who have passed this point and are uncontrolled on BDP 800 microg/day or equivalent, switching to SFC remains a cost-effective approach. Where an adult or child requires an ICS and a LABA to be co-prescribed, SFC is a cost-effective option compared with FP or BDP plus salmeterol delivered in separate inhalers. In adults who require combination therapy, SFC is a cost-effective option compared with BUD/FORM.

Very high dose inhaled corticosteroids: panacea or poison?

Perspective on the paper by Paton et al (see page 808)

Oral xanthines as maintenance treatment for asthma in children

BACKGROUND

Xanthines have been used in the treatment of asthma as a bronchodilator, though they may also have anti-inflammatory effects. The current role of xanthines in the long-term treatment of childhood asthma needs to be reassessed.

OBJECTIVES

To determine the efficacy of xanthines (e.g. theophylline) in the maintenance treatment of paediatric asthma.

SEARCH STRATEGY

A search of the Cochrane Airways Group Specialised Register was undertaken with predefined search terms. Searches are current to May 2005.

SELECTION CRITERIA

Randomised controlled trials,lasting at least four weeks comparing a xanthine with placebo, regular short-acting beta-agonist (SABA), inhaled corticosteroids (ICS), cromoglycate (SCG), ketotifen (KET) or leukotriene antagonist, in children with diagnosed with chronic asthma between 18 months and 18 years old.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected each study for inclusion in the review and extracted data. Primary outcome was percentage of symptom-free days.

MAIN RESULTS

Thirty-four studies (2734 participants) of adequate quality were included. Xanthine versus placebo (17 studies): The proportion of symptom free days was larger with xanthine compared with placebo (7.97% [95% CI 3.41, 12.53]). Rescue medication usage was lower with xanthine, with no significant difference in symptom scores or hospitalisations. FEV1 , and PEF were better with xanthine. Xanthine was associated with non - specific side-effects. Data from behavioural scores were inconclusive. Xanthine versus ICS (four studies) : Exacerbations were less frequent with ICS, but no significant difference on lung function was observed. Individual studies reported significant improvements in symptom measures in favour of steroids, and one study reported a difference in growth rate in favour of xanthine. No difference was observed for study withdrawal or tremor. Xanthine was associated with more frequent headache and nausea. Xanthine versus regular SABA (10 studies): No significant difference in symptoms, rescue medication usage and spirometry. Individual studies reported improvement in PEF with beta-agonist. Beta-agonist treatment led to fewer hospitalisations and headaches. Xanthine was associated with less tremor. Xanthine versus SCG (six studies ): No significant difference in symptoms, exacerbations and rescue medication. Sodium cromoglycate was associated with fewer gastro-intestinal side-effects than xanthine. Xanthine versus KET (one study): No statistical tests of significance between xanthine and ketotifen were reported. Xanthine + ICS versus placebo + same dose ICS (three studies) : Results were conflicting due to clinical/methodological differences, and could not be aggregated.

AUTHORS' CONCLUSIONS

Xanthines as first-line preventer alleviate symptoms and reduce requirement for rescue medication in children with mild to moderate asthma. When compared with ICS they were less effective in preventing exacerbations. Xanthines had similar efficacy as single preventative agent compared with regular SABA and SCG. Evidence on AEs (adverse effects) was equivocal: there was evidence for increased AEs overall, but no evidence that any specific AE (including effects on behaviour and attention) occurred more frequently than with placebo. There is insufficient evidence from available studies to make firm conclusions about the effectiveness of xanthines as add-on preventative treatment to ICS, and there are no published paediatric studies comparing xanthines with alternatives in this role. Our data suggest that xanthines are only suitable as first-line preventative asthma therapy in children when ICS are not available. They may have a role as add-on therapy in more severe asthma not controlled by ICS, but further studies are needed to examine this, and to define the risk-benefit ratio compared with other agents.