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Spain CV, Dayal P, Ding Y, Iribarren C, Omachi TA, Chen H. Usage of long-acting muscarinic antagonists and biologics as add-on therapy for patients in the United States with moderate-to-severe asthma. J Asthma 2021; 59:1237-1247. [PMID: 33970741 DOI: 10.1080/02770903.2021.1922915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Many asthma patients remain uncontrolled on inhaled corticosteroids (ICS) and long-acting beta agonists (LABAs), but guidance for selecting add-on therapies, including long-acting muscarinic antagonists (LAMAs) or biologics, is limited. We describe how prescribing practices for add-on LAMA and biologic therapy have changed with increased treatment options and revised treatment guidelines. We further identify differences in treatment initiation and discontinuation rates by patient characteristics, including concomitant COPD. This retrospective cohort study analyzed insurance claims in the IBM Marketscan database for adult US asthma patients treated with medium- or high-dose ICS/LABA between 2012 and 2019 (n = 277,373). We used negative binomial regression models to evaluate LAMA and biologic initiation rates and their association with patient characteristics, and survival analysis methods for assessing discontinuation rates. Between 2012 and 2019, LAMA and biologic uptake increased approximately 5-fold and 20-fold, respectively. LAMA initiation was significantly higher among patients with concomitant COPD, a group typically unstudied in clinical trials, versus those with asthma only (rate ratio of 5.90, 95% CI: 5.76-6.04). High-dose ICS/LABA treatment and the need for oral corticosteroid (OCS) bursts had stronger associations with biologic initiation. Probability of discontinuation (i.e. non-persistence) in the first year was 40.5% and 22.7% for those initiating LAMAs and biologics, respectively, with higher LAMA discontinuation rates among patients with asthma only versus those with concomitant COPD. Our results provide insights into how clinicians apply treatment guidelines for initiating add-on LAMA and biologic therapies in moderate-to-severe asthma patients and highlight patients who have an unmet treatment need after discontinuation.
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Affiliation(s)
| | - Parul Dayal
- Genentech, Inc, South San Francisco, CA, USA
| | | | - Carlos Iribarren
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Hubert Chen
- Genentech, Inc, South San Francisco, CA, USA
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O'Shea O, Stovold E, Cates CJ. Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2021; 4:CD007694. [PMID: 33852162 PMCID: PMC8095067 DOI: 10.1002/14651858.cd007694.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness, and cough. Treatment with inhaled steroids and bronchodilators can result in good control of symptoms, prevention of further morbidity, and improved quality of life. However, an increase in serious adverse events with the use of both regular formoterol and regular salmeterol (long-acting beta₂-agonists) compared with placebo for chronic asthma has been demonstrated in previous Cochrane Reviews. This increase was statistically significant in trials that did not randomise participants to an inhaled corticosteroid, but not when formoterol or salmeterol was combined with an inhaled corticosteroid. The confidence intervals were found to be too wide to ensure that the addition of an inhaled corticosteroid renders regular long-acting beta₂-agonists completely safe; few participants and insufficient serious adverse events in these trials precluded a definitive decision about the safety of combination treatments. OBJECTIVES To assess risks of mortality and non-fatal serious adverse events in trials that have randomised patients with chronic asthma to regular formoterol and an inhaled corticosteroid versus regular salmeterol and an inhaled corticosteroid. SEARCH METHODS We searched the Cochrane Airways Register of Trials, CENTRAL, MEDLINE, Embase, and two trial registries to identify reports of randomised trials for inclusion. We checked manufacturers' websites and clinical trial registers for unpublished trial data, as well as Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol. The date of the most recent search was 24 February 2021. SELECTION CRITERIA We included controlled clinical trials with a parallel design, recruiting patients of any age and severity of asthma, if they randomised patients to treatment with regular formoterol versus regular salmeterol (each with a randomised inhaled corticosteroid) and were of at least 12 weeks' duration. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion in the review, extracted outcome data from published papers and trial registries, and applied GRADE rating for the results. We sought unpublished data on mortality and serious adverse events from study sponsors and authors. The primary outcomes were all cause mortality and non-fatal serious adverse events. We chose not to calculate an average result from all the formulations of formoterol and inhaled steroid, as the doses and delivery devices are too diverse to assume a single class effect. MAIN RESULTS Twenty-one studies in 11,572 adults and adolescents and two studies in 723 children met the eligibility criteria of the review. No data were available for two studies; therefore these were not included in the analysis. Among adult and adolescent studies, seven compared formoterol and budesonide to salmeterol and fluticasone (N = 7764), six compared formoterol and beclomethasone to salmeterol and fluticasone (N = 1923), two compared formoterol and mometasone to salmeterol and fluticasone (N = 1126), two compared formoterol and fluticasone to salmeterol and fluticasone (N = 790), and one compared formoterol and budesonide to salmeterol and budesonide (N = 229). In total, five deaths were reported among adults, none of which was thought to be related to asthma. The certainty of evidence for all-cause mortality was low, as there were not enough deaths to permit any precise conclusions regarding the risk of mortality on combination formoterol versus combination salmeterol. In all, 201 adults reported non-fatal serious adverse events. In studies comparing formoterol and budesonide to salmeterol and fluticasone, there were 77 in the formoterol arm and 68 in the salmeterol arm (Peto odds ratio (OR) 1.14, 95% confidence interval (CI) 0.82 to 1.59; 5935 participants, 7 studies; moderate-certainty evidence). In the formoterol and beclomethasone studies, there were 12 adults in the formoterol arm and 13 in the salmeterol arm with events (Peto OR 0.94, 95% CI 0.43 to 2.08; 1941 participants, 6 studies; moderate-certainty evidence). In the formoterol and mometasone studies, there were 18 in the formoterol arm and 11 in the salmeterol arm (Peto OR 1.02, 95% CI 0.47 to 2.20; 1126 participants, 2 studies; moderate-certainty evidence). One adult in the formoterol and fluticasone studies in the salmeterol arm experienced an event (Peto OR 0.05, 95% CI 0.00 to 3.10; 293 participants, 2 studies; low-certainty evidence). Another adult in the formoterol and budesonide compared to salmeterol and budesonide study in the formoterol arm had an event (Peto OR 7.45, 95% CI 0.15 to 375.68; 229 participants, 1 study; low-certainty evidence). Only 46 adults were reported to have experienced asthma-related serious adverse events. The certainty of the evidence was low to very low due to the small number of events and the absence of independent assessment of causation. The two studies in children compared formoterol and fluticasone to salmeterol and fluticasone. No deaths and no asthma-related serious adverse events were reported in these studies. Four all-cause serious adverse events were reported: three in the formoterol arm, and one in the salmeterol arm (Peto OR 2.72, 95% CI 0.38 to 19.46; 548 participants, 2 studies; low-certainty evidence). AUTHORS' CONCLUSIONS Overall, for both adults and children, evidence is insufficient to show whether regular formoterol in combination with budesonide, beclomethasone, fluticasone, or mometasone has a different safety profile from salmeterol in combination with fluticasone or budesonide. Five deaths of any cause were reported across all studies and no deaths from asthma; this information is insufficient to permit any firm conclusions about the relative risks of mortality on combination formoterol in comparison to combination salmeterol inhalers. Evidence on all-cause non-fatal serious adverse events indicates that there is probably little to no difference between formoterol/budesonide and salmeterol/fluticasone inhalers. However events for the other formoterol combination inhalers were too few to allow conclusions. Only 46 non-fatal serious adverse events were thought to be asthma related; this small number in addition to the absence of independent outcome assessment means that we have very low confidence for this outcome. We found no evidence of safety issues that would affect the choice between salmeterol and formoterol combination inhalers used for regular maintenance therapy by adults and children with asthma.
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Affiliation(s)
- Orlagh O'Shea
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Christopher J Cates
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
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Janjua S, Schmidt S, Ferrer M, Cates CJ. Inhaled steroids with and without regular formoterol for asthma: serious adverse events. Cochrane Database Syst Rev 2019; 9:CD006924. [PMID: 31553802 PMCID: PMC6760886 DOI: 10.1002/14651858.cd006924.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Epidemiological evidence has suggested a link between beta2-agonists and increases in asthma mortality. There has been much debate about whether regular (daily) long-acting beta2-agonists (LABA) are safe when used in combination with inhaled corticosteroids (ICS). This updated Cochrane Review includes results from two large trials that recruited 23,422 adolescents and adults mandated by the US Food and Drug Administration (FDA). OBJECTIVES To assess the risk of mortality and non-fatal serious adverse events (SAEs) in trials that randomly assign participants with chronic asthma to regular formoterol and inhaled corticosteroids versus the same dose of inhaled corticosteroid alone. SEARCH METHODS We identified randomised trials using the Cochrane Airways Group Specialised Register of trials. We checked websites of clinical trial registers for unpublished trial data as well as FDA submissions in relation to formoterol. The date of the most recent search was February 2019. SELECTION CRITERIA We included randomised clinical trials (RCTs) with a parallel design involving adults, children, or both with asthma of any severity who received regular formoterol and ICS (separate or combined) treatment versus the same dose of ICS for at least 12 weeks. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We obtained unpublished data on mortality and SAEs from the sponsors of the studies. We assessed our confidence in the evidence using GRADE recommendations. The primary outcomes were all-cause mortality and all-cause non-fatal serious adverse events. MAIN RESULTS We found 42 studies eligible for inclusion and included 39 studies in the analyses: 29 studies included 35,751 adults, and 10 studies included 4035 children and adolescents. Inhaled corticosteroids included beclomethasone (daily metered dosage 200 to 800 µg), budesonide (200 to 1600 µg), fluticasone (200 to 250 µg), and mometasone (200 to 800 µg). Formoterol metered dosage ranged from 12 to 48 µg daily. Fixed combination ICS was used in most of the studies. We judged the risk of selection bias, performance bias, and attrition bias as low, however most studies did not report independent assessment of causation of SAEs.DeathsSeventeen of 18,645 adults taking formoterol and ICS and 13 of 17,106 adults taking regular ICS died of any cause. The pooled Peto odds ratio (OR) was 1.25 (95% confidence interval (CI) 0.61 to 2.56, moderate-certainty evidence), which equated to one death occurring for every 1000 adults treated with ICS alone for 26 weeks; the corresponding risk amongst adults taking formoterol and ICS was also one death (95% CI 0 to 2 deaths). No deaths were reported in the trials on children and adolescents (4035 participants) (low-certainty evidence).In terms of asthma-related deaths, no children and adolescents died from asthma, but three of 12,777 adults in the formoterol and ICS treatment group died of asthma (both low-certainty evidence).Non-fatal serious adverse eventsA total of 401 adults experienced a non-fatal SAE of any cause on formoterol with ICS, compared to 369 adults who received regular ICS. The pooled Peto OR was 1.00 (95% CI 0.87 to 1.16, high-certainty evidence, 29 studies, 35,751 adults). For every 1000 adults treated with ICS alone for 26 weeks, 22 adults had an SAE; the corresponding risk for those on formoterol and ICS was also 22 adults (95% CI 19 to 25).Thirty of 2491 children and adolescents experienced an SAE of any cause when receiving formoterol with ICS, compared to 13 of 1544 children and adolescents receiving ICS alone. The pooled Peto OR was 1.33 (95% CI 0.71 to 2.49, moderate-certainty evidence, 10 studies, 4035 children and adolescents). For every 1000 children and adolescents treated with ICS alone for 12.5 weeks, 8 had an non-fatal SAE; the corresponding risk amongst those on formoterol and ICS was 11 children and adolescents (95% CI 6 to 21).Asthma-related serious adverse eventsNinety adults experienced an asthma-related non-fatal SAE with formoterol and ICS, compared to 102 with ICS alone. The pooled Peto OR was 0.86 (95% CI 0.64 to 1.14, moderate-certainty evidence, 28 studies, 35,158 adults). For every 1000 adults treated with ICS alone for 26 weeks, 6 adults had an asthma-related non-fatal SAE; the corresponding risk for those on formoterol and ICS was 5 adults (95% CI 4 to 7).Amongst children and adolescents, 9 experienced an asthma-related non-fatal SAE with formoterol and ICS, compared to 5 on ICS alone. The pooled Peto OR was 1.18 (95% CI 0.40 to 3.51, very low-certainty evidence, 10 studies, 4035 children and adolescents). For every 1000 children and adolescents treated with ICS alone for 12.5 weeks, 3 had an asthma-related non-fatal SAE; the corresponding risk on formoterol and ICS was 4 (95% CI 1 to 11). AUTHORS' CONCLUSIONS We did not find a difference in the risk of death (all-cause or asthma-related) in adults taking combined formoterol and ICS versus ICS alone (moderate- to low-certainty evidence). No deaths were reported in children and adolescents. The risk of dying when taking either treatment was very low, but we cannot be certain if there is a difference in mortality when taking additional formoterol to ICS (low-certainty evidence).We did not find a difference in the risk of non-fatal SAEs of any cause in adults (high-certainty evidence). A previous version of the review had shown a lower risk of asthma-related SAEs in adults taking combined formoterol and ICS; however, inclusion of new studies no longer shows a difference between treatments (moderate-certainty evidence).The reported number of children and adolescents with SAEs was small, so uncertainty remains in this age group.We included results from large studies mandated by the FDA. Clinical decisions and information provided to patients regarding regular use of formoterol and ICS need to take into account the balance between known symptomatic benefits of formoterol and ICS versus the remaining degree of uncertainty associated with its potential harmful effects.
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Affiliation(s)
- Sadia Janjua
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Stefanie Schmidt
- UroEvidence@Deutsche Gesellschaft für UrologieNestorstr. 8‐9 (1. Hof)BerlinGermany10709
| | - Montse Ferrer
- IMIM (Hospital del Mar Medical Research Institute)Health Services Research GroupC/ Doctor Aiguader, 88BarcelonaSpain08003
| | - Christopher J Cates
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
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George L, Brightling CE. Eosinophilic airway inflammation: role in asthma and chronic obstructive pulmonary disease. Ther Adv Chronic Dis 2016; 7:34-51. [PMID: 26770668 DOI: 10.1177/2040622315609251] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The chronic lung diseases, asthma and chronic obstructive pulmonary disease (COPD), are common affecting over 500 million people worldwide and causing substantial morbidity and mortality. Asthma is typically associated with Th2-mediated eosinophilic airway inflammation, in contrast to neutrophilic inflammation observed commonly in COPD. However, there is increasing evidence that the eosinophil might play an important role in 10-40% of patients with COPD. Consistently in both asthma and COPD a sputum eosinophilia is associated with a good response to corticosteroid therapy and tailored strategies aimed to normalize sputum eosinophils reduce exacerbation frequency and severity. Advances in our understanding of the multistep paradigm of eosinophil recruitment to the airway, and the consequence of eosinophilic inflammation, has led to the development of new therapies to target these molecular pathways. In this article we discuss the mechanisms of eosinophilic trafficking, the tools to assess eosinophilic airway inflammation in asthma and COPD during stable disease and exacerbations and review current and novel anti-eosinophilic treatments.
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Affiliation(s)
- Leena George
- Institute for Lung Health, NIHR Respiratory Biomedical Research Unit, Department of Infection, Immunity and Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Christopher E Brightling
- Institute for Lung Health, Clinical Science Wing, University Hospital of Leicester, Leicester LE3 9QP, UK
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Albertson TE, Schivo M, Gidwani N, Kenyon NJ, Sutter ME, Chan AL, Louie S. Pharmacotherapy of critical asthma syndrome: current and emerging therapies. Clin Rev Allergy Immunol 2015; 48:7-30. [PMID: 24178860 DOI: 10.1007/s12016-013-8393-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
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Affiliation(s)
- T E Albertson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA, 95817, USA,
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6
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Rank MA, Gionfriddo MR, Pongdee T, Volcheck GW, Li JT, Hagan CR, Erwin PJ, Hagan JB. Stepping down from inhaled corticosteroids with leukotriene inhibitors in asthma: a systematic review and meta-analysis. Allergy Asthma Proc 2015; 36:200-5. [PMID: 25976437 PMCID: PMC4405599 DOI: 10.2500/aap.2015.36.3839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The risks of using leukotriene receptor antagonists (LTRA) as part of a strategy for stepping down inhaled corticosteroid (ICS) are not well known. OBJECTIVE To estimate the risk of asthma exacerbation in individuals with stable asthma who start LTRA when stopping ICS or reducing ICS dose. METHODS We identified articles from a systematic review of English and non-English articles by using a number of data bases. We included randomized controlled trials with a stable asthma run-in period of 4 weeks or more and a follow-up period of at least 3 months. We included studies of individuals with stable asthma who stopped ICS and substituted LTRA (versus continuing ICS) and who reduced ICS while starting LTRA (versus placebo). RESULTS The search strategy identified 1132 potential articles, of which 52 were reviewed at the full-text level, and four met criteria for inclusion. The single article that met the inclusion criteria for substitution of LTRA for ICS as a step-down strategy found a statistically increased risk of treatment failure of 30.3% for substituting LTRA compared with 20.2% for continuing ICS. The three articles that met the inclusion criteria for comparing LTRA versus placebo in patients with stable asthma who reduce ICS found a modestly decreased risk ratio that favored LTRA of 0.57 (95% confidence interval, 0.36-0.90; I(2) = 0%) in studies that only included individuals >15 years old. CONCLUSION Only one study addressed the risk of substitution of LTRA for ICS in stable asthma, which limited any strong conclusions about this step-down strategy.
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Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona, USA
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7
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Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, Prasad KT, Yenge LB, Singh N, Behera D, Jindal SK, Gupta D, Balamugesh T, Bhalla A, Chaudhry D, Chhabra SK, Chokhani R, Chopra V, Dadhwal DS, D’Souza G, Garg M, Gaur SN, Gopal B, Ghoshal AG, Guleria R, Gupta KB, Haldar I, Jain S, Jain NK, Jain VK, Janmeja AK, Kant S, Kashyap S, Khilnani GC, Kishan J, Kumar R, Koul PA, Mahashur A, Mandal AK, Malhotra S, Mohammed S, Mohapatra PR, Patel D, Prasad R, Ray P, Samaria JK, Singh PS, Sawhney H, Shafiq N, Sharma N, Sidhu UPS, Singla R, Suri JC, Talwar D, Varma S. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015; 32:S3-S42. [PMID: 25948889 PMCID: PMC4405919 DOI: 10.4103/0970-2113.154517] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Venkata N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Lakshmikant B Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Thanagakunam Balamugesh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashish Bhalla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dhruva Chaudhry
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sunil K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ramesh Chokhani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Devendra S Dadhwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - George D’Souza
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Shailendra N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Bharat Gopal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Krishna B Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Indranil Haldar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sanjay Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vikram K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surender Kashyap
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai Kishan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok Mahashur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Amit K Mandal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Samir Malhotra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sabir Mohammed
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Pallab Ray
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Potsangbam Sarat Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Honey Sawhney
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nusrat Shafiq
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Updesh Pal S Sidhu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jagdish C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Subhash Varma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
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Kuhn H, Banthiya S, van Leyen K. Mammalian lipoxygenases and their biological relevance. Biochim Biophys Acta Mol Cell Biol Lipids 2014; 1851:308-30. [PMID: 25316652 DOI: 10.1016/j.bbalip.2014.10.002] [Citation(s) in RCA: 413] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 02/07/2023]
Abstract
Lipoxygenases (LOXs) form a heterogeneous class of lipid peroxidizing enzymes, which have been implicated not only in cell proliferation and differentiation but also in the pathogenesis of various diseases with major public health relevance. As other fatty acid dioxygenases LOXs oxidize polyunsaturated fatty acids to their corresponding hydroperoxy derivatives, which are further transformed to bioactive lipid mediators (eicosanoids and related substances). On the other hand, lipoxygenases are key players in the regulation of the cellular redox homeostasis, which is an important element in gene expression regulation. Although the first mammalian lipoxygenases were discovered 40 years ago and although the enzymes have been well characterized with respect to their structural and functional properties the biological roles of the different lipoxygenase isoforms are not completely understood. This review is aimed at summarizing the current knowledge on the physiological roles of different mammalian LOX-isoforms and their patho-physiological function in inflammatory, metabolic, hyperproliferative, neurodegenerative and infectious disorders. This article is part of a Special Issue entitled "Oxygenated metabolism of PUFA: analysis and biological relevance".
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Affiliation(s)
- Hartmut Kuhn
- Institute of Biochemistry, University Medicine Berlin - Charite, Chariteplatz 1, CCO-Building, Virchowweg 6, D-10117 Berlin, Germany.
| | - Swathi Banthiya
- Institute of Biochemistry, University Medicine Berlin - Charite, Chariteplatz 1, CCO-Building, Virchowweg 6, D-10117 Berlin, Germany
| | - Klaus van Leyen
- Neuroprotection Research Laboratory, Department of Radiology, Massachusetts Genrel Hospital and Harvard Medical School, Charlestown, MA, USA
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9
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Calapai G, Casciaro M, Miroddi M, Calapai F, Navarra M, Gangemi S. Montelukast-induced adverse drug reactions: a review of case reports in the literature. Pharmacology 2014; 94:60-70. [PMID: 25196099 DOI: 10.1159/000366164] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/27/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Montelukast, a leucotriene receptor antagonist, binds the cysteinyl leucotriene type 1 receptor. Montelukast is commonly prescribed to asthma patients as add-on therapy to inhaled corticosteroids. Several clinical trials emphasized that montelukast can be considered a safe drug. However, recent evidence reconsidered the benefit/risk ratio of the use of montelukast for both paediatric and adult patients. SUMMARY The present review analyzed the previous published case reports regarding montelukast-induced adverse drug reactions (ADRs). They included agitation, anxiety, depression, sleep disturbance, hallucinations, suicidal thinking and suicidality, tremor, dizziness, drowsiness, neuropathies and seizures. The immune system can be involved, in particular, cases of Churg-Strauss syndrome have been published. Furthermore, it can induce hypersensitivity reactions, including anaphylaxis and eosinophilic infiltration. In addition, hepatobiliary, pancreatic and uropoietic disorders have been observed. Some of these cases are characterized by severe prognosis (i.e. neurological deficit and fatal hepatotoxicity). Key Message: The use of montelukast can be burdened by several ADRs, of which physicians should be aware in their clinical practice. A better understanding of the mechanisms causing ADRs after using montelukast could help researchers and clinicians in defining a risk-reduction strategy aimed to lessen montelukast toxicity. More accurate epidemiological studies, in order to discover risk factors favouring montelukast-associated ADRs, are demanded.
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Affiliation(s)
- Gioacchino Calapai
- School and Division of Allergology and Clinical Immunology, University of Messina, Messina, Italy
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10
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Hon KLE, Leung TF, Leung AKC. Clinical effectiveness and safety of montelukast in asthma. What are the conclusions from clinical trials and meta-analyses? DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:839-50. [PMID: 25061277 PMCID: PMC4079631 DOI: 10.2147/dddt.s39100] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Asthma is a common childhood atopic disease associated with chronicity and impaired quality of life. As there is no cure for this disease, treatment relies on avoidance of triggers such as food and aeroallergens, the use of inhaled bronchodilators/corticosteroids and antiallergic or immunomodulating therapies. Inhaled corticosteroids (ICSs) and bronchodilators have been the mainstay. However, in Asia, myths and fallacies regarding Western medicine and corticosteroids are prevalent and lead to nonadherence to treatment. Also, use of traditional and proprietary herbal medicines is popular. In the past decades, a novel class of nonsteroidal immunomodulating montelukasts has become available. This article reviews the evidence for the effectiveness and clinical efficacy of these medications. A number of randomized and controlled trials have been performed over the years. The majority of studies confirm the usefulness of montelukast as monotherapy and add-on therapy to ICS in mild to moderate childhood asthma across all age groups. ICSs are generally superior to montelukasts for asthma management. However, montelukast has a place in the treatment of young children with viral-triggered wheezing diseases, exercise-induced asthma, and in children whose parents are steroid-phobic and find ICS unacceptable.
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Affiliation(s)
- Kam Lun Ellis Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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11
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Loymans RJB, Gemperli A, Cohen J, Rubinstein SM, Sterk PJ, Reddel HK, Jüni P, ter Riet G. Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis. BMJ 2014; 348:g3009. [PMID: 24919052 PMCID: PMC4019015 DOI: 10.1136/bmj.g3009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma. DESIGN Systematic review and network meta-analysis using Bayesian statistics. DATA SOURCES Cochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate. ELIGIBILITY CRITERIA TRIALS OF Adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome. RESULTS 64 trials with 59,622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting β agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting β agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy. CONCLUSIONS Strategies with combined inhaled corticosteroids and long acting β agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Armin Gemperli
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland Swiss Paraplegic Research, Nottwil, Switzerland
| | - Judith Cohen
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
| | - Sidney M Rubinstein
- Department of Health Sciences, Section Health Economics and Health Technology Assessment, VU University Amsterdam, Amsterdam, Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Peter Jüni
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Berne, Switzerland
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, PO box 22700, 1105 DE, Amsterdam, Netherlands
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12
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Abstract
A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.
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Affiliation(s)
- Andrea S Melani
- Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy.
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13
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Cates CJ, Jaeschke R, Schmidt S, Ferrer M. Regular treatment with formoterol and inhaled steroids for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2013:CD006924. [PMID: 23744625 DOI: 10.1002/14651858.cd006924.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Epidemiological evidence has suggested a link between beta2-agonists and increases in asthma mortality. Much debate has surrounded possible causal links for this association and whether regular (daily) long-acting beta2-agonists are safe when used alone or in conjunction with inhaled corticosteroids. This is an updated Cochrane Review. OBJECTIVES To assess the risk of fatal and non-fatal serious adverse events in people with chronic asthma given regular formoterol with inhaled corticosteroids versus the same dose of inhaled corticosteroids alone. SEARCH METHODS Trials were identified using the Cochrane Airways Group Specialised Register of trials. Web sites of clinical trial registers were checked for unpublished trial data; Food and Drug Administration (FDA) submissions in relation to formoterol were also checked. The date of the most recent search was August 2012. SELECTION CRITERIA Controlled clinical trials with a parallel design were included if they randomly allocated people of any age and severity of asthma to treatment with regular formoterol and inhaled corticosteroids for at least 12 weeks. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Unpublished data on mortality and serious adverse events were obtained from the sponsors. We assessed the quality of evidence using GRADE recommendations. MAIN RESULTS Following the 2012 update, we have included 20 studies on 10,578 adults and adolescents and seven studies on 2788 children and adolescents. We found data on all-cause fatal and non-fatal serious adverse events for all studies, and we judged the overall risk of bias to be low.Six deaths occurred in participants taking regular formoterol with inhaled corticosteroids, and one in a participant administered regular inhaled corticosteroids alone. The difference was not statistically significant (Peto odds ratio (OR) 3.56, 95% confidence interval (CI) 0.79 to 16.03, low-quality evidence). All deaths were reported in adults, and one was believed to be asthma-related.Non-fatal serious adverse events of any cause were very similar for each treatment in adults (Peto OR 0.98, 95% CI 0.76 to 1.27, moderate-quality evidence), and weak evidence suggested an increase in events in children on regular formoterol (Peto OR 1.62, 95% CI 0.80 to 3.28, moderate-quality evidence).In contrast with all-cause serious adverse events, the addition of new trial data means that asthma-related serious adverse events associated with formoterol are now significantly fewer in adults taking regular formoterol with inhaled corticosteroids (Peto OR 0.49, 95% CI 0.28 to 0.88, moderate-quality evidence). Although a greater number of asthma-related events were reported in children receiving regular formoterol, this finding was not statistically significant (Peto OR 1.49, 95% CI 0.48 to 4.61, low-quality evidence). AUTHORS' CONCLUSIONS From the evidence in this review, it is not possible to reassure people with asthma that regular use of inhaled corticosteroids with formoterol carries no risk of increasing mortality in comparison with use of inhaled corticosteroids alone. On the other hand, we have found no conclusive evidence of serious harm, and only one asthma-related death was registered during more than 4200 patient-years of observation with formoterol.In adults, no significant difference in all-cause non-fatal serious adverse events was noted with regular formoterol with inhaled corticosteroids, but a significant reduction in asthma-related serious adverse events was observed in comparison with inhaled corticosteroids alone.In children the number of events was too small, and consequently the results too imprecise, to allow determination of whether the increased risk of all-cause non-fatal serious adverse events found in a previous meta-analysis on regular formoterol alone is abolished by the additional use of inhaled corticosteroids.We await the results of large ongoing surveillance studies mandated by the Food and Drug Administration (FDA) for more information. Clinical decisions and information provided to patients regarding regular use of formoterol have to take into account the balance between known symptomatic benefits of formoterol and the degree of uncertainty associated with its potential harmful effects.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George's University of London, Cranmer Terrace, London, UK, SW17 0RE
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14
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Cates CJ, Karner C. Combination formoterol and budesonide as maintenance and reliever therapy versus current best practice (including inhaled steroid maintenance), for chronic asthma in adults and children. Cochrane Database Syst Rev 2013:CD007313. [PMID: 23633340 DOI: 10.1002/14651858.cd007313.pub3] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Traditionally inhaled treatment for asthma has used separate preventer and reliever therapies. The combination of formoterol and budesonide in one inhaler has made possible a single inhaler for both prevention and relief of symptoms (single inhaler therapy or SiT). OBJECTIVES To assess the efficacy and safety of budesonide and formoterol in a single inhaler for maintenance and reliever therapy in asthma compared with maintenance with inhaled corticosteroids (ICS) (alone or as part of current best practice) and any reliever therapy. SEARCH METHODS We searched the Cochrane Airways Group trials register in February 2013. SELECTION CRITERIA Parallel, randomised controlled trials of 12 weeks or longer in adults and children with chronic asthma. Studies had to assess the combination of formoterol and budesonide as SiT, against a control group that received inhaled steroids and a separate reliever inhaler. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 13 trials involving 13,152 adults and one of the trials also involved 224 children (which have been separately reported). All studies were sponsored by the manufacturer of the SiT inhaler. We considered the nine studies assessing SiT against best practice to be at a low risk of selection bias, but a high risk of detection bias as they were unblinded.In adults whose asthma was not well-controlled on ICS, the reduction in hospital admission with SiT did not reach statistical significance (Peto odds ratio (OR) 0.81; 95% confidence interval (CI) 0.45 to 1.44, eight trials, N = 8841, low quality evidence due to risk of detection bias in open studies and imprecision). The rates of hospital admission were low; for every 1000 people treated with current best practice six would experience a hospital admission over six months compared with between three and eight treated with SiT. The odds of experiencing exacerbations needing treatment with oral steroids were lower with SiT compared with control (OR 0.83; 95% CI 0.70 to 0.98, eight trials, N = 8841, moderate quality evidence due to risk of detection bias). For every 100 adults treated with current best practice over six months, seven required a course of oral steroids, whilst for SiT there would be six (95% CI 5 to 7). The small reduction in time to first severe exacerbation needing medical intervention was not statistically significant (hazard ratio (HR) 0.94; 95% CI 0.85 to 1.04, five trials, N = 7355). Most trials demonstrated a reduction in the mean total daily dose of ICS with SiT (mean reduction was based on self-reported data from patient diaries and ranged from 107 to 385 µg/day). Withdrawals due to adverse events were more common in people treated with SiT (OR 2.85; 95% CI 1.89 to 4.30, moderate quality evidence due to risk of detection bias).Three studies including 4209 adults compared SiT with higher dose budesonide maintenance and terbutaline for symptom relief. The studies were considered as low risk of bias. The run-in for these studies involved withdrawal of LABA, and patients were recruited who were symptomatic during run-in. The reduction in the odds of hospitalisation with SiT compared with higher dose ICS did not reach statistical significance (Peto OR; 0.56; 95% CI 0.28 to 1.09, moderate quality evidence due to imprecision). Fewer patients on SiT needed a course of oral corticosteroids (OR 0.54; 95% CI 0.45 to 0.64, high quality evidence). For every 100 adults treated with ICS over 11 months, 18 required a course of oral steroids, whilst for SiT there would be 11 (95% CI 9 to 12). Withdrawals due to adverse events were more common in people treated with SiT (OR 0.57; 95% CI 0.35 to 0.93, high quality evidence).One study included children (N = 224), in which SiT was compared with higher dose budesonide. There was a significant reduction in participants who needed an increase in their inhaled steroids with SiT, but there were only two hospitalisations for asthma and no separate data on courses of oral corticosteroids. Less inhaled and oral corticosteroids were used in the SiT group and the annual height gain was also 1 cm greater in the SiT group, (95% CI 0.3 cm to 1.7 cm).The results for fatal serious adverse events were too rare to rule out either treatment being harmful. There was no significant difference found in non-fatal serious adverse events for any of the comparisons. AUTHORS' CONCLUSIONS Single inhaler therapy has now been demonstrated to reduce exacerbations requiring oral corticosteroids against current best practice strategies and against a fixed higher dose of inhaled steroids. The strength of evidence that SiT reduces hospitalisation against these same treatments is weak. There were more discontinuations due to adverse events on SiT compared to current best practice, but no significant differences in serious adverse events. Our confidence in these conclusions is limited by the open-label design of the trials, and by the unknown adherence to treatment in the current best practice arms of the trials.Single inhaler therapy can reduce the risk of asthma exacerbations needing oral corticosteroids in comparison with fixed dose maintenance ICS and separate relief medication. The reduced odds of exacerbations with SiT compared with higher dose ICS should be viewed in the context of the possible impact of LABA withdrawal during study run-in. This may have made the study populations more likely to respond to SiT.Single inhaler therapy is not currently licensed for children under 18 years of age in the United Kingdom and there is currently very little research evidence for this approach in children or adolescents.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George’s, University of London, London, UK.
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15
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Raissy HH, Kelly HW, Harkins M, Szefler SJ. Inhaled corticosteroids in lung diseases. Am J Respir Crit Care Med 2013; 187:798-803. [PMID: 23370915 PMCID: PMC3707369 DOI: 10.1164/rccm.201210-1853pp] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 01/24/2013] [Indexed: 01/29/2023] Open
Abstract
Inhaled corticosteroids (ICSs) are used extensively in the treatment of asthma and chronic obstructive pulmonary disease (COPD) due to their broad antiinflammatory effects. They improve lung function, symptoms, and quality of life and reduce exacerbations in both conditions but do not alter the progression of disease. They decrease mortality in asthma but not COPD. The available ICSs vary in their therapeutic index and potency. Although ICSs are used in all age groups, younger and smaller children may be at a greater risk for adverse systemic effects because they can receive higher mg/kg doses of ICSs compared with older children. Most of the benefit from ICSs occurs in the low to medium dose range. Minimal additional improvement is seen with higher doses, although some patients may benefit from higher doses. Although ICSs are the preferred agents for managing persistent asthma in all ages, their benefit in COPD is more controversial. When used appropriately, ICSs have few adverse events at low to medium doses, but risk increases with high-dose ICSs. Although several new drugs are being developed and evaluated, it is unlikely that any of these new medications will replace ICSs as the preferred initial long-term controller therapy for asthma, but more effective initial controller therapy could be developed for COPD.
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Affiliation(s)
| | | | - Michelle Harkins
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Stanley J. Szefler
- Division of Pediatric Clinical Pharmacology and
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, Denver, Colorado
- Department of Pediatrics and
- Department of Pharmacology, University of Colorado School of Medicine, Denver, Colorado
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16
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Louie S, Zeki AA, Schivo M, Chan AL, Yoneda KY, Avdalovic M, Morrissey BM, Albertson TE. The asthma-chronic obstructive pulmonary disease overlap syndrome: pharmacotherapeutic considerations. Expert Rev Clin Pharmacol 2013; 6:197-219. [PMID: 23473596 PMCID: PMC7046086 DOI: 10.1586/ecp.13.2] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is a commonly encountered yet loosely defined clinical entity. ACOS accounts for approximately 15-25% of the obstructive airway diseases and patients experience worse outcomes compared with asthma or COPD alone. Patients with ACOS have the combined risk factors of smoking and atopy, are generally younger than patients with COPD and experience acute exacerbations with higher frequency and greater severity than lone COPD. Pharmacotherapeutic considerations require an integrated approach, first to identify the relevant clinical phenotype(s), then to determine the best available therapy. The authors discuss the array of existing and emerging classes of drugs that could benefit those with ACOS and share their therapeutic approach. A consensus international definition of ACOS is needed to design prospective, randomized clinical trials to evaluate specific drug interventions on important outcomes such as lung function, acute exacerbations, quality of life and mortality.
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Affiliation(s)
- Samuel Louie
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Amir A Zeki
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Michael Schivo
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Andrew L Chan
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Ken Y Yoneda
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Mark Avdalovic
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Brian M Morrissey
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
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17
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Cates CJ, Oleszczuk M, Stovold E, Wieland LS. Safety of regular formoterol or salmeterol in children with asthma: an overview of Cochrane reviews. Cochrane Database Syst Rev 2012; 10:CD010005. [PMID: 23076961 PMCID: PMC4022036 DOI: 10.1002/14651858.cd010005.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Two large surveillance studies in adults with asthma have found an increased risk of asthma-related mortality in those who took regular salmeterol as monotherapy in comparison to placebo or regular salbutamol. No similar sized surveillance studies have been carried out in children with asthma, and we remain uncertain about the comparative safety of regular combination therapy with either formoterol or salmeterol in children with asthma. OBJECTIVES We have used the paediatric trial results from Cochrane systematic reviews to assess the safety of regular formoterol or salmeterol, either as monotherapy or as combination therapy, in children with asthma. METHODS We included Cochrane reviews relating to the safety of regular formoterol and salmeterol from a search of the Cochrane Database of Systematic Reviews conducted in May 2012, and ran updated searches for each of the reviews. These were independently assessed. All the reviews were assessed for quality using the AMSTAR tool. We extracted the data relating to children from each review and from new trials found in the updated searches (including risks of bias, study characteristics, serious adverse event outcomes, and control arm event rates).The safety of regular formoterol and salmeterol were assessed directly from the paediatric trials in the Cochrane reviews of monotherapy and combination therapy with each product. Then monotherapy was indirectly compared to combination therapy by looking at the differences between the pooled trial results for monotherapy and the pooled results for combination therapy. The comparative safety of formoterol and salmeterol was assessed using direct evidence from trials that randomised children to each treatment; this was combined with the result of an indirect comparison of the combination therapy trials, which represents the difference between the pooled results of each product when randomised against inhaled corticosteroids alone. MAIN RESULTS We identified six high quality, up to date Cochrane reviews. Four of these related to the safety of regular formoterol or salmeterol (as monotherapy or combination therapy) and these included 19 studies in children. We added data from two recent studies on salmeterol combination therapy in 689 children which were published after the relevant Cochrane review had been completed, making a total of 21 trials on 7474 children (from four to 17 years of age). The two remaining reviews compared the safety of formoterol with salmeterol from trials randomising participants to one or other treatment, but the reviews only included a single trial in children in which there were 156 participants.Only one child died across all the trials, so impact on mortality could not be assessed.We found a statistically significant increase in the odds of suffering a non-fatal serious adverse event of any cause in children on formoterol monotherapy (Peto odds ratio (OR) 2.48; 95% confidence interval (CI) 1.27 to 4.83, I(2) = 0%, 5 trials, N = 1335, high quality) and smaller increases in odds which were not statistically significant for salmeterol monotherapy (Peto OR 1.30; 95% CI 0.82 to 2.05, I(2) = 17%, 5 trials, N = 1333, moderate quality), formoterol combination therapy (Peto OR 1.60; 95% CI 0.80 to 3.28, I(2) = 32%, 7 trials, N = 2788, moderate quality) and salmeterol combination therapy (Peto OR 1.20; 95% CI 0.37 to 2.91, I(2) = 0%, 5 trials, N = 1862, moderate quality).We compared the pooled results of the monotherapy and combination therapy trials. There was no significant difference between the pooled ORs of children with a serious adverse event (SAE) from long-acting beta(2)-agonist beta agonist (LABA) monotherapy (Peto OR 1.60; 95% CI 1.10 to 2.33, 10 trials, N = 2668) and combination trials (Peto OR 1.50; 95% CI 0.82 to 2.75, 12 trials, N = 4,650). However, there were fewer children with an SAE in the regular inhaled corticosteroid (ICS) control group (0.7%) than in the placebo control group (3.6%). As a result, there was an absolute increase of an additional 21 children (95% CI 4 to 45) suffering such an SAE of any cause for every 1000 children treated over six months with either regular formoterol or salmeterol monotherapy, whilst for combination therapy the increased risk was an additional three children (95% CI 1 fewer to 12 more) per 1000 over three months.We only found a single trial in 156 children comparing the safety of regular salmeterol to regular formoterol monotherapy, and even with the additional evidence from indirect comparisons between the combination formoterol and salmeterol trials, the CI around the effect on SAEs is too wide to tell whether there is a difference in the comparative safety of formoterol and salmeterol (OR 1.26; 95% CI 0.37 to 4.32). AUTHORS' CONCLUSIONS We do not know if regular combination therapy with formoterol or salmeterol in children alters the risk of dying from asthma.Regular combination therapy is likely to be less risky than monotherapy in children with asthma, but we cannot say that combination therapy is risk free. There are probably an additional three children per 1000 who suffer a non-fatal serious adverse event on combination therapy in comparison to ICS over three months. This is currently our best estimate of the risk of using LABA combination therapy in children and has to be balanced against the symptomatic benefit obtained for each child. We await the results of large on-going surveillance studies to further clarify the risks of combination therapy in children and adolescents with asthma.The relative safety of formoterol in comparison to salmeterol remains unclear, even when all currently available direct and indirect trial evidence is combined.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George’s, University of London, London, UK.
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Dumitru C, Chan SMH, Turcanu V. Role of leukotriene receptor antagonists in the management of pediatric asthma: an update. Paediatr Drugs 2012; 14:317-30. [PMID: 22897162 DOI: 10.2165/11599930-000000000-00000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
At present, the main indications for leukotriene receptor antagonists (LTRA) in pediatric asthma are as add-on therapy to inhaled corticosteroids (ICS) and as initial controller therapy in children with mild asthma, especially those who cannot or will not use ICS. LTRA are also useful for patients who have concomitant rhinitis, and patients with viral-induced wheeze and exercise-induced asthma. It should be noted that the benefits of LTRA therapy have been demonstrated in children as young as 6 months of age and recent clinical trials have further proven the benefits of LTRA in acute asthma exacerbations. However, considering the important pro-inflammatory effects that leukotrienes (LT) have in experimental models of asthma, it may seem surprising that LTRA treatment outcomes are not better and that in some clinical trials only a minority of patients could be classified as full responders. This could be explained by potential additional LT receptors that are not affected by LTRA. Such receptors could represent new therapeutic targets in asthma. Furthermore, progress in differentiating between asthma phenotypes that result from different pathogenic mechanisms, some of which may involve LT to a lesser degree, should lead to an improved, personalized use of LTRA for treating asthma.
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Affiliation(s)
- Catalina Dumitru
- Kings College London, Kings Health Partners, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Asthma, Allergy and Respiratory Science, Guys Hospital, London, UK
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Debelleix S. Les anti-leucotriènes dans la prise en charge de l’asthme selon l’âge. Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Epidemiological evidence has suggested a link between beta(2)-agonists and increases in asthma mortality. There has been much debate about possible causal links for this association, and whether regular (daily) long-acting beta(2)-agonists are safe. OBJECTIVES The aim of this review is to assess the risk of fatal and non-fatal serious adverse events in trials that randomised patients with chronic asthma to regular formoterol versus placebo or regular short-acting beta(2)-agonists. SEARCH METHODS We identified trials using the Cochrane Airways Group Specialised Register of trials. We checked websites of clinical trial registers for unpublished trial data and Food and Drug Administration (FDA) submissions in relation to formoterol. The date of the most recent search was January 2012. SELECTION CRITERIA We included controlled, parallel design clinical trials on patients of any age and severity of asthma if they randomised patients to treatment with regular formoterol and were of at least 12 weeks' duration. Concomitant use of inhaled corticosteroids was allowed, as long as this was not part of the randomised treatment regimen. DATA COLLECTION AND ANALYSIS Two authors independently selected trials for inclusion in the review. One author extracted outcome data and the second author checked them. We sought unpublished data on mortality and serious adverse events. MAIN RESULTS The review includes 22 studies (8032 participants) comparing regular formoterol to placebo and salbutamol. Non-fatal serious adverse event data could be obtained for all participants from published studies comparing formoterol and placebo but only 80% of those comparing formoterol with salbutamol or terbutaline.Three deaths occurred on regular formoterol and none on placebo; this difference was not statistically significant. It was not possible to assess disease-specific mortality in view of the small number of deaths. Non-fatal serious adverse events were significantly increased when regular formoterol was compared with placebo (Peto odds ratio (OR) 1.57; 95% CI 1.06 to 2.31). One extra serious adverse event occurred over 16 weeks for every 149 people treated with regular formoterol (95% CI 66 to 1407 people). The increase was larger in children than in adults, but the impact of age was not statistically significant. Data submitted to the FDA indicate that the increase in asthma-related serious adverse events remained significant in patients taking regular formoterol who were also on inhaled corticosteroids.No significant increase in fatal or non-fatal serious adverse events was found when regular formoterol was compared with regular salbutamol or terbutaline. AUTHORS' CONCLUSIONS In comparison with placebo, we have found an increased risk of serious adverse events with regular formoterol, and this does not appear to be abolished in patients taking inhaled corticosteroids. The effect on serious adverse events of regular formoterol in children was greater than the effect in adults, but the difference between age groups was not significant.Data on all-cause serious adverse events should be more fully reported in journal articles, and not combined with all severities of adverse events or limited to those events that are thought by the investigator to be drug-related.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George’s, University of London, London, UK.
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Yang D, Luo H, Wang J, Bunjhoo H, Xu Y, Xiong W. Comparison of inhaled corticosteroids and leukotriene receptor antagonists in adolescents and adults with mild to moderate asthma: a meta-analysis. CLINICAL RESPIRATORY JOURNAL 2012; 7:74-90. [PMID: 22364111 DOI: 10.1111/j.1752-699x.2012.00287.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) and oral leukotriene receptor antagonists (LTRA) are effective drugs used in the management of asthma as controller monotherapy in adolescents and adults, although there are debates as to which one is better. OBJECTIVES To thoroughly compare the efficacy and tolerability of ICS vs LTRA in adolescents and adults with mild to moderate asthma. METHODS Relative database were searched for the review. Randomized controlled trials of more than or equal to 4 weeks' treatment duration comparing ICS with LTRA were reviewed. RESULTS AND CONCLUSION Twenty-four trials with 6197 randomized adolescents and adults with mild to moderate asthma met the inclusion criteria with a minimum duration of 4 weeks' treatment. Significant differences favouring ICS were found in all indices of pulmonary function. Other significant benefits of ICS were shown in symptoms, nocturnal awakenings, rescue-medication use, symptom-free days and quality of life. As to each special symptom of adverse effects, ICS was similar to LTRA in the incidence of headache, nausea and throat discomfort, but significantly higher in the incidence of hoarseness and oral pharyngeal candidiasis. Concerning withdrawal because of adverse events potentially related to treatment, ICS was similar to LTRA but significantly superior to LTRA in decreasing the asthma exacerbations or attacks during the treatment period. These results show that ICS may be the better drug in terms of efficacy and tolerability, except hoarseness and oral pharyngeal candidiasis, and should thus have priority over LTRA in asthma monotherapy in adolescents and adults.
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Affiliation(s)
- Danlei Yang
- Department of Respiratory Diseases, Tongji Hospital, Key Lab of Pulmonary Diseases of Health Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Cates CJ, Lasserson TJ. Regular treatment with formoterol versus regular treatment with salmeterol for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2012; 3:CD007695. [PMID: 22419326 PMCID: PMC4015850 DOI: 10.1002/14651858.cd007695.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND An increase in serious adverse events with both regular formoterol and regular salmeterol in chronic asthma has been demonstrated in previous Cochrane reviews. OBJECTIVES We set out to compare the risks of mortality and non-fatal serious adverse events in trials which have randomised patients with chronic asthma to regular formoterol versus regular salmeterol. SEARCH METHODS We identified trials using the Cochrane Airways Group Specialised Register of trials. We checked manufacturers' websites of clinical trial registers for unpublished trial data and also checked Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol. The date of the most recent search was January 2012. SELECTION CRITERIA We included controlled, parallel-design clinical trials on patients of any age and with any severity of asthma if they randomised patients to treatment with regular formoterol versus regular salmeterol (without randomised inhaled corticosteroids), and were of at least 12 weeks' duration. DATA COLLECTION AND ANALYSIS Two authors independently selected trials for inclusion in the review and extracted outcome data. We sought unpublished data on mortality and serious adverse events from the sponsors and authors. MAIN RESULTS The review included four studies (involving 1116 adults and 156 children). All studies were open label and recruited patients who were already taking inhaled corticosteroids for their asthma, and all studies contributed data on serious adverse events. All studies compared formoterol 12 μg versus salmeterol 50 μg twice daily. The adult studies were all comparing Foradil Aerolizer with Serevent Diskus, and the children's study compared Oxis Turbohaler to Serevent Accuhaler. There was only one death in an adult (which was unrelated to asthma) and none in children, and there were no significant differences in non-fatal serious adverse events comparing formoterol to salmeterol in adults (Peto odds ratio (OR) 0.77; 95% confidence interval (CI) 0.46 to 1.28), or children (Peto OR 0.95; 95% CI 0.06 to 15.33). Over a six-month period, in studies involving adults that contributed to this analysis, the percentages with serious adverse events were 5.1% for formoterol and 6.4% for salmeterol; and over a three-month period the percentages of children with serious adverse events were 1.3% for formoterol and 1.3% for salmeterol. AUTHORS' CONCLUSIONS We identified four studies comparing regular formoterol to regular salmeterol (without randomised inhaled corticosteroids, but all participants were on regular background inhaled corticosteroids). The events were infrequent and consequently too few patients have been studied to allow any firm conclusions to be drawn about the relative safety of formoterol and salmeterol. Asthma-related serious adverse events were rare and there were no reported asthma-related deaths.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George’s University of London, London, UK
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Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, FitzGerald M, Leigh R, Watson W, Boulet LP. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012; 19:127-64. [PMID: 22536582 PMCID: PMC3373283 DOI: 10.1155/2012/635624] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and⁄or gaps in the previous guidelines. METHODS Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations. RESULTS The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified. CONCLUSIONS The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee's new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
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Chauhan BF, Ben Salah R, Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids in children with persistent asthma. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009585] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
PURPOSE OF REVIEW Guidelines suggest that asthma medication should be reduced once asthma control is sustained. Moderate-dose inhaled corticosteroids (ICS) can typically be reduced, but questions remain about the lowest effective ICS dose and the role of non-ICS controllers in treatment reduction. Long-acting beta agonist (LABA) safety concerns have created controversy about how to step down patients on ICS/LABA therapy. This review will focus on the current status of these issues. RECENT FINDINGS Intermittent ICS treatment, often in fixed combination with short-acting beta agonist, is an emerging strategy for control of mild asthma. Addition of leukotriene modifiers, LABAs, and omalizumab to ICS can allow for reduced ICS dosing. Doses of ICS that control symptoms may be inadequate to control exacerbations. Reducing ICS dose before discontinuing LABAs may be the more effective approach for patients on combination therapy. SUMMARY Use of non-ICS controllers allows for ICS dose reduction with superior outcomes. Tapering of ICS prior to LABA discontinuation may be the favored approach for patients on ICS/LABA therapy, but an understanding of long-term outcomes and further safety data are required. The lowest ICS dose that adequately controls both asthma impairment and risk remains to be determined.
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Weir NA, Levine SJ. Achieving symptom control in patients with moderate asthma. Clin Med Insights Circ Respir Pulm Med 2011; 6:1-11. [PMID: 22259262 PMCID: PMC3256747 DOI: 10.4137/ccrpm.s5100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta(2)-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV(1) to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta(2)-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma.
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Affiliation(s)
- Nargues A. Weir
- The Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
- The Laboratory of Asthma and Lung Inflammation, Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Stewart J. Levine
- The Laboratory of Asthma and Lung Inflammation, Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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Lasserson TJ, Ferrara G, Casali L. Combination fluticasone and salmeterol versus fixed dose combination budesonide and formoterol for chronic asthma in adults and children. Cochrane Database Syst Rev 2011:CD004106. [PMID: 22161385 DOI: 10.1002/14651858.cd004106.pub4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long-acting beta-agonists are a common second line treatment in people with asthma inadequately controlled with inhaled corticosteroids. Single device inhalers combine a long-acting beta-agonist with an inhaled steroid delivering both drugs as a maintenance treatment regimen. This updated review compares two fixed-dose options, fluticasone/salmeterol FP/SALand budesonide/formoterol, since this comparison represents a common therapeutic choice. OBJECTIVES To assess the relative effects of fluticasone/salmeterol and budesonide/formoterol in people with asthma. SEARCH METHODS We searched the Cochrane Airways Group register of trials with prespecified terms. We performed additional hand searching of manufacturers' web sites and online trial registries. Search results are current to June 2011. SELECTION CRITERIA We included randomised studies comparing fixed dose fluticasone/salmeterol and budesonide/formoterol in adults or children with a diagnosis of asthma. Treatment in the studies had to last for a minimum of 12 weeks. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion in the review. We combined continuous data outcomes with a mean difference (MD), and dichotomous data outcomes with an odds ratio (OR). We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS Five studies met the review entry criteria (5537 adults). Study populations entered the studies having previously been treated with inhaled steroids and had moderate or mild airway obstruction (mean FEV(1) predicted between 65% and 84% at baseline). Most of the studies assessed treatment over a period of six months. The studies were at a low risk of selection and performance/detection bias, although we could not determine whether missing data had an impact on the results. Availablility of outcome data was satisfactory.Primary outcomesThe odds ratio for exacerbations requiring oral steroids was lower with fluticasone/salmeterol but did not reach statistical significance (OR 0.89, 95% confidence interval (CI) 0.74 to 1.07, four studies, N = 4949). With an assumed risk with budesonide/formoterol of 106/1000 participants requiring oral steroids, treatment with fluticasone/salmeterol would lead to between 25 fewer and seven more people per 1000 experiencing a course of oral steroids. Although the odds of hospital admission was higher with fluticasone/salmeterol, this did not reach statistical significance (OR 1.29, 95% CI 0.68 to 2.47, four studies, 4879 participants). With an assumed risk in the budesonide/formoterol of 7/1000, between two fewer and 10 more people per 1000 would be hospitalised on fluticasone/salmeterol. The odds of a serious adverse event related to asthma was higher with fluticasone/salmeterol but did not differ significantly between treatments (OR 1.47, 95% CI 0.75 to 2.86, three studies, 4054 participants). With an assumed risk in the budesonide/formoterol of 7/1000, between two fewer and 13 more people per 1000 would experience a serious adverse event on fluticasone/salmeterol.Secondary outcomesLung function outcomes, symptoms, rescue medication, composite of exacerbations leading to either emergency department visit or hospital admission, withdrawals and adverse events did not differ statistically between treatments. Assessment of quality of life was limited to two studies, both of which gave results that did not reach statistical significance. One study reported one death out of 1000 participants on fluticasone/salmeterol and no deaths in a similar number of participants treated with budesonide/formoterol. No deaths were reported in the other studies. AUTHORS' CONCLUSIONS Statistical imprecision in the effect estimates for exacerbations and serious adverse events do not enable us to conclude that either therapy is superior. The uncertainty around the effect estimates justify further trials to provide more definitive conclusions; the overall quality of evidence based on GRADE recommendations for the three primary outcomes and withdrawals due to serious adverse events was moderate. We rated the quality of evidence for mortality to be low. Results for lung function outcomes showed that the drugs were sufficiently similar that further research is unlikely to change the effects. No trials were identified in the under-12s and research in this population is a high priority. Evaluation of quality of life is a priority for future research.
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Affiliation(s)
- Toby J Lasserson
- Cochrane Editorial Unit, The Cochrane Collaboration, 13 Cavendish Square, London, UK, W1G 0AN
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Cates CJ, Lasserson TJ. Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events. Cochrane Database Syst Rev 2010:CD007694. [PMID: 20091646 PMCID: PMC4015852 DOI: 10.1002/14651858.cd007694.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND An increase in serious adverse events with both regular formoterol and regular salmeterol in chronic asthma has been demonstrated in comparison with placebo in previous Cochrane reviews. This increase was significant in trials that did not randomise participants to an inhaled corticosteroid, but less certain in the smaller numbers of participants in trials that included an inhaled corticosteroid in the randomised treatment regimen. OBJECTIVES We set out to compare the risks of mortality and non-fatal serious adverse events in trials which have randomised patients with chronic asthma to regular formoterol versus regular salmeterol, when each are used with an inhaled corticosteroid as part of the randomised treatment. SEARCH STRATEGY Trials were identified using the Cochrane Airways Group Specialised Register of trials. Manufacturers' web sites of clinical trial registers were checked for unpublished trial data and Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol were also checked. The date of the most recent search was July 2009. SELECTION CRITERIA Controlled clinical trials with a parallel design, recruiting patients of any age and severity of asthma were included if they randomised patients to treatment with regular formoterol versus regular salmeterol (each with a randomised inhaled corticosteroid), and were of at least 12 weeks duration. DATA COLLECTION AND ANALYSIS Two authors independently selected trials for inclusion in the review and extracted outcome data. Unpublished data on mortality and serious adverse events were sought from the sponsors and authors. MAIN RESULTS Eight studies met the eligibility criteria of the review recruiting 6,163 adults and adolescents. There were seven studies (involving 5,935 adults and adolescents) comparing formoterol and budesonide to salmeterol and fluticasone. All but one study administered the products as a combined inhaler, and most used formoterol 50 mcg and budesonide 400 mcg twice daily versus salmeterol 50 mcg and fluticasone 250 mcg twice daily. There were two deaths overall (one on each combination) and neither were thought to be related to asthma.There was no significant difference between treatment groups for non-fatal serious adverse events, either all-cause (Peto OR 1.14; 95% CI 0.82 to 1.59, I(2) = 26%) or asthma-related (Peto OR 0.69; 95% CI 0.37 to 1.26, I(2) = 33%). Over 23 weeks the rates for all-cause serious adverse events were 2.6% on formoterol and budesonide and 2.3% on salmeterol and fluticasone, and for asthma-related serious adverse events, 0.6% and 0.8% respectively.There was one study (228 adults) comparing formoterol and beclomethasone to salmeterol and fluticasone, but there were no deaths or hospital admissions.No studies were found in children. AUTHORS' CONCLUSIONS The seven identified studies in adults did not show any significant difference in safety between formoterol and budesonide in comparison with salmeterol and fluticasone. Asthma-related serious adverse events were rare, and there were no reported asthma-related deaths. There was a single small study comparing formoterol and beclomethasone to salmeterol and fluticasone in adults, but no serious adverse events occurred in this study. No studies were found in children.Overall there is insufficient evidence to decide whether regular formoterol and budesonide or beclomethasone have equivalent or different safety profiles from salmeterol and fluticasone.
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Affiliation(s)
- Christopher J Cates
- Population Health Sciences and Education, St George’s University of London, London, UK
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