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Dhar R, Talwar D, Christopher DJ, Dumra H, Koul PA, Chhajed PN, Chowdhury SR, Arjun P, Guleria R. Expert opinion on diagnosis and management of Severe Asthma in low and middle income countries (LMIC) with focus on India. J Asthma 2024:1-13. [PMID: 38767570 DOI: 10.1080/02770903.2024.2349614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/25/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up. DATA SOURCES A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation. STUDY SELECTIONS The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review. RESULTS In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs. CONCLUSIONS Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients.
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Affiliation(s)
- Raja Dhar
- Department of Pulmonology, CK BIRLA Hospitals, Kolkata, India
| | | | | | - Harjit Dumra
- Sparsh Chest Disease Centre, Navrangpura, Ahmedabad, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Prashant N Chhajed
- Department of Lung Care and Sleep Center, Institute of Pulmonology, Medical Research and Development, Fortis Hiranandani Hospital, Vashi, Mumbai, India
- Department of Respiratory Medicine, Dr. Balabhai Nanavati Hospital and Lilavati Hospital, Mumbai, Maharashtra, India
| | | | - Padmanabhan Arjun
- Department of Respiratory Medicine, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Laitano R, Calzetta L, Matino M, Pistocchini E, Rogliani P. Asthma management with triple ICS/LABA/LAMA combination to reduce the risk of exacerbation: an umbrella review compliant with the PRIOR statement. Expert Opin Pharmacother 2024; 25:1071-1081. [PMID: 38864834 DOI: 10.1080/14656566.2024.2366991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/07/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION According to Global Initiative for Asthma (GINA) guidelines, long-acting muscarinic antagonists (LAMAs) should be considered as add-on therapy in patients with asthma that remains uncontrolled, despite treatment with medium-dose (MD) or high-dose (HD) inhaled corticosteroids (ICS)/long-acting β2-agonist (LABA) combinations. In patients ≥ 18 years, LAMA may be added in triple combination with an ICS and a LABA. To date, the precise efficacy of triple ICS/LABA/LAMA combination remains uncertain concerning the impact on exacerbation risk in patients with uncontrolled asthma. Therefore, an umbrella review was performed to systematically summarize available data on the effect of triple ICS/LABA/LAMA combination on the risk of asthma exacerbation. METHODS An umbrella review has been performed according to the PRIOR statement. RESULTS The overall results obtained from 5 systematic reviews and meta-analyses suggest that triple ICS/LABA/LAMA combination reduces the risk of asthma exacerbation. HD-ICS showed a greater effect particularly in reducing severe asthma exacerbation, especially in patients with evidence of type 2 inflammation biomarkers. CONCLUSIONS The findings of this umbrella review suggest an optimization of ICS dose in triple ICS/LABA/LAMA combination, based on the severity of exacerbation and type 2 biomarkers expression.
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Affiliation(s)
- Rossella Laitano
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Matteo Matino
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elena Pistocchini
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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3
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Al-Moamary MS, Alhaider SA, Allehebi R, Idrees MM, Zeitouni MO, Al Ghobain MO, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2024; 19:1-55. [PMID: 38444991 PMCID: PMC10911239 DOI: 10.4103/atm.atm_248_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/31/2023] [Indexed: 03/07/2024] Open
Abstract
The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed Saad Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyad Allehebi
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Respiratory Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah F. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Paediatrics, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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4
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van Zyl-Smit RN, Kerstjens HAM, Maspero J, Tanase AM, Lawrence D, Mezzi K, D'Andrea P, Chapman KR. Triple Therapy with Mometasone/Indacaterol/Glycopyrronium or Doubling the ICS/LABA Dose in GINA Step 4: IRIDIUM Analyses. Pulm Ther 2023; 9:395-409. [PMID: 37526856 PMCID: PMC10447675 DOI: 10.1007/s41030-023-00234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/23/2023] [Indexed: 08/02/2023] Open
Abstract
INTRODUCTION GINA guidelines recommend increasing the dose of inhaled corticosteroids (ICS) as a step-up option for patients with inadequately controlled asthma at GINA step 4 [inadequately controlled asthma on medium-dose ICS/long-acting beta-2 agonist (LABA)]. The aim of this study was to compare the efficacy and safety of long-acting muscarinic antagonists (LAMA) add-on to medium-dose ICS/LABA in patients at GINA 2022 step 4. METHODS This post hoc analysis of the IRIDIUM study evaluated the change from baseline in trough forced expiratory volume (FEV1 ) in patients receiving medium-dose MF/IND/GLY versus high-dose MF/IND and high-dose FLU/SAL at Week 26. Other outcomes included improvement in lung functions [peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory flow between 25% and 75% of the FVC (FEF)25-75%)], asthma control [Asthma Control Questionnaire (ACQ-7)], responder analysis (≥ 0.5 unit improvement in ACQ-7), and reduction in asthma exacerbations at Weeks 26 and 52. RESULTS A total of 1930 patients were included in this analysis. Medium-dose MF/IND/GLY improved trough FEV1 versus high-dose MF/IND (Δ 41 mL; 95% CI - 7-90) and high-dose FLU/SAL (Δ 88 mL; 95% CI 39-137) at Week 26 which were sustained until Week 52. Exacerbation rates were 16% lower with medium-dose MF/IND/GLY versus high-dose MF/IND for all (mild, moderate, and severe) exacerbations and 21-30% lower versus high-dose FLU/SAL for all (mild, moderate, and severe), moderate or severe, and severe exacerbations over 52 weeks. Further improvements in other lung functions were observed with medium-dose MF/IND/GLY. No new safety signals were identified. CONCLUSION Medium-dose MF/IND/GLY improved lung function and reduced asthma exacerbations compared to high-dose ICS/LABA and may be an undervalued option in patients at GINA 2022 step 4. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02571777.
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Affiliation(s)
- Richard N van Zyl-Smit
- Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Huib A M Kerstjens
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Jorge Maspero
- Allergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, Argentina
| | | | | | | | - Peter D'Andrea
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Kenneth R Chapman
- Division of Respiratory Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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5
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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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Niimi A, Fukunaga K, Taniguchi M, Nakamura Y, Tagaya E, Horiguchi T, Yokoyama A, Yamaguchi M, Nagata M. Executive summary: Japanese guidelines for adult asthma (JGL) 2021. Allergol Int 2023; 72:207-226. [PMID: 36959028 DOI: 10.1016/j.alit.2023.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/25/2023] Open
Abstract
Asthma is characterized by chronic airway inflammation, variable airway narrowing, and sensory nerve irritation, which manifest as wheezing, dyspnea, chest tightness, and cough. Longstanding asthma may result in airway remodeling and become intractable. Despite the increased prevalence of asthma in adults, asthma-associated deaths have decreased in Japan (0.94 per 100,000 people in 2020). The goals of asthma treatment include the control of symptoms and reduction of future risks. A functional partnership between physicians and patients is indispensable for achieving these goals. Long-term management with medications and the elimination of triggers and risk factors are fundamental to asthma treatment. Asthma is managed via four steps of pharmacotherapy ("controllers"), ranging from mild to intensive treatments, depending on disease severity; each step involves daily administration of an inhaled corticosteroid, which varies from low to high dosage. Long-acting β2 agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs. Allergen immunotherapy is a new option that is employed as a controller treatment. Further, as of 2021, anti-IgE antibody, anti-IL-5 and anti-IL-5 receptor α-chain antibodies, and anti-IL-4 receptor α-chain antibodies are available for the treatment of severe asthma. Bronchial thermoplasty can be performed for asthma treatment, and its long-term efficacy has been reported. Algorithms for their usage have been revised. Comorbidities, such as allergic rhinitis, chronic rhinosinusitis, chronic obstructive pulmonary disease, and aspirin-exacerbated respiratory disease, should also be considered during the treatment of chronic asthma. Depending on the severity of episodes, inhaled short-acting β2 agonists, systemic corticosteroids, short-acting muscarinic antagonists, oxygen therapy, and other approaches are used as needed ("relievers") during exacerbation.
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Affiliation(s)
- Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Koichi Fukunaga
- Pulmonary Division, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masami Taniguchi
- Center for Immunology and Allergology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yoichi Nakamura
- Medical Center for Allergic and Immune Diseases, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Etsuko Tagaya
- Department of Respiratory Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiko Horiguchi
- Department of Respiratory Medicine, Toyota Regional Medical Center, Toyota, Japan
| | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Masao Yamaguchi
- Division of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama, Japan; Allergy Center, Saitama Medical University Hospital, Saitama Medical University, Saitama, Japan
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7
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Paucigranulocytic Asthma: Potential Pathogenetic Mechanisms, Clinical Features and Therapeutic Management. J Pers Med 2022; 12:jpm12050850. [PMID: 35629272 PMCID: PMC9145917 DOI: 10.3390/jpm12050850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 12/13/2022] Open
Abstract
Asthma is a heterogeneous disease usually characterized by chronic airway inflammation, in which several phenotypes have been described, related to the age of onset, symptoms, inflammatory characteristics and treatment response. The identification of the inflammatory phenotype in asthma is very useful, since it allows for both the recognition of the asthmatic triggering factor as well as the optimization of treatment The paucigranulocytic phenotype of asthma (PGA) is characterized by sputum eosinophil levels <1−3% and sputum neutrophil levels < 60%. The precise characteristics and the pathobiology of PGA are not fully understood, and, in some cases, it seems to represent a previous eosinophilic phenotype with a good response to anti-inflammatory treatment. However, many patients with PGA remain uncontrolled and experience asthmatic symptoms and exacerbations, irrespective of the low grade of airway inflammation. This observation leads to the hypothesis that PGA might also be either a special phenotype driven by different kinds of cells, such as macrophages or mast cells, or a non-inflammatory phenotype with a low grade of eosinophilic inflammation. In this review, we aim to describe the special characteristics of PGA and the potential therapeutic interventions that could be offered to these patients.
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8
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Braido F, Tiotiu A, Guidos-Fogelbach G, Baiardini I, Cosini F, Correia de Sousa J, Bikov A, Novakova S, Labor M, Kaidashev I, Nedeva D, Kowal K, Mihaicuta S, Urrutia Pereira M, Solé D, Novakova P, Chong-Neto H, Vrzy L, Ansotegui IJ, Bernstein JA, Boulet LP, Canonica GW, Dubuske L, Nunes C, Ivancevich JC, Santus P, Rosario N, Emelyanov A, Steiropoulos P. Manifesto on inhaled triple therapy in asthma: an Interasma (Global Asthma Association - GAA) document. J Asthma 2021; 59:2402-2412. [PMID: 34936532 DOI: 10.1080/02770903.2021.2022160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The optimal use of drug combinations for the management of asthma is providing significant results. This has prompted INTERASMA (Global Asthma Association) to take a position on inhaled triple therapy in asthma. Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto, developed by Interasma scientific network (INES) members. The manifesto describes the evidence gathered to date and states, advocates, and proposes issues on Inhaled corticosteroid (ICS) plus Long-acting beta 2 agonist (LABA) and long-acting muscarinic antagonists (LAMA) with the aim of challenging assumptions, fostering commitment, and bringing about change.
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Affiliation(s)
- Fulvio Braido
- IRCCS, Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France.,EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control, University of Lorraine, Nancy, France
| | - Guillermo Guidos-Fogelbach
- Instituto Politécnico Nacional, E.N.M.H/S.E.P.I, Laboratorio de Bioquímica Estructural, Ciudad de México, México
| | - Ilaria Baiardini
- Department of Internal Medicine, University of Genoa, Genova, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Andras Bikov
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Sylvia Novakova
- Allergy Unit of Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
| | | | - Igor Kaidashev
- Ukrainian Medical Stomatological Academy, Poltava, Ukraine
| | | | - Krzysztof Kowal
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Stefan Mihaicuta
- Pulmonology Department, Cardio Prevent Foundation, University of Medicine and Pharmacy "Dr Victor Babes", Timisoara, Romania
| | - Marilyn Urrutia Pereira
- Federal University of Pampa - campus Uruguaiana, Pediatic Program of Asthma Prevention (PIPA), Pontifícia Universidade Católica do Rio Grande do Sul, Universidad Nacional de Córdoba
| | - Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, Sociedade Brasileira de Pediatria, Universidade Federal de São Paulo
| | | | - Herberto Chong-Neto
- Division of Allergy and Immunology, Department of Pediatrics, Federal University of Paraná, Curitiba, Brazil
| | | | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section University of Cincinnati, Cincinnati, OH, USA
| | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Lawrence Dubuske
- Division of Allergy and Immunology, Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Carlos Nunes
- Centro de ImmunoAlergologia de Algarve, Porto, Portugal
| | - Juan Carlos Ivancevich
- Immunology Department, Faculty of Medicine, del Salvador University, Buenos Aires, Argentina
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences, University of Milan, Division of Respiratory Diseases "L. Sacco" Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University named after I.I.Mechnikov, St-Petersburg, Russia
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, University General Hospital Dragana, Alexandroupolis, Greece
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9
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de Carvalho-Pinto RM, Cançado JED, Pizzichini MMM, Fiterman J, Rubin AS, Cerci A, Cruz ÁA, Fernandes ALG, Araujo AMS, Blanco DC, Cordeiro G, Caetano LSB, Rabahi MF, de Menezes MB, de Oliveira MA, Lima MA, Pitrez PM. 2021 Brazilian Thoracic Association recommendations for the management of severe asthma. J Bras Pneumol 2021; 47:e20210273. [PMID: 34932721 PMCID: PMC8836628 DOI: 10.36416/1806-3756/e20210273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/20/2022] Open
Abstract
Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.
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Affiliation(s)
- Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração − InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Jussara Fiterman
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS) Brasil
| | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre − UFCSPA − Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci
- . Universidade Estadual de Londrina − UEL − Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná − PUCPR − Londrina (PR) Brasil
| | - Álvaro Augusto Cruz
- . Universidade Federal da Bahia − UFBA − Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Ana Maria Silva Araujo
- . Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro − IDT/UFRJ − Rio de Janeiro (RJ) Brasil
| | - Daniela Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS), Brasil
| | - Gediel Cordeiro
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
- . Hospital Madre Teresa, Belo Horizonte (MG) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás − UFG − Goiânia (GO) Brasil
| | - Marcelo Bezerra de Menezes
- . Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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10
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de Llano LP, Naval E, Mejía N, Domínguez-Ortega J. Inhaled indacaterol/glycopyrronium/mometasone furoate fixed-dose combination in moderate-to-severe asthma. Expert Rev Respir Med 2021; 16:1-15. [PMID: 34783265 DOI: 10.1080/17476348.2021.2005585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fixed-dose long-acting beta2-agonist (LABA)/inhaled corticosteroid (ICS) combinations and add-on therapies as needed are the mainstay for maintenance therapy in asthma. However, more than 40% of patients have an inadequately controlled disease. The development of triple fixed-dose combinations consisting of long-acting muscarinic antagonist (LAMA)/LABA/ICS has paved the way for a new approach to reach therapeutic goals of an optimal control of symptoms and an effective prevention of future exacerbations. AREAS COVERED A search was conducted on PubMed (MEDLINE), using the MeSH terms [asthma] + [indacaterol] + [glycopyrronium] +[mometasone furoate] + [treatment], until October 2021. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Clinical studies with IND/MF/GLY (Enerzair Breezhaler) are summarized, and its place in current asthma therapy is examined. EXPERT OPINION Triple therapy has been shown to be an effective and safe therapeutic option for asthma patients who remain uncontrolled despite ICS/LABA combination. The recently approved single-inhaler indacaterol/glycopyrronium/mometasone fixed dose combination has demonstrated to significantly reduce exacerbations, improve FEV1, symptoms and quality of life compared to ICS/LABA, including, salmeterol/fluticasone combination. Moreover, once-daily dosing may improve adherence.
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Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte, Lugo, Spain
| | - Elsa Naval
- Pneumology Service, Hospital Universitario de la Ribera, Alzira, Valencia, Spain
| | - Natalia Mejía
- Medical Affairs Department. Novartis Farmacéutica, Barcelona, Spain
| | - Javier Domínguez-Ortega
- Allergy Department, Hospital La Paz Institute for Health Research, Madrid, Spain.,Respiratory Disease Network Biomedical Research Centre (CIBERES), Madrid, Spain
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11
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Hartman JE, Srikanthan K, Caneja C, Ten Hacken NHT, Kerstjens HAM, Shah PL, Slebos DJ. Bronchoscopic Targeted Lung Denervation in Patients with Severe Asthma: Preliminary Findings. Respiration 2021; 101:184-189. [PMID: 34515243 DOI: 10.1159/000518515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022] Open
Abstract
Treatment options for severe asthma are limited, particularly in those patients who do not meet criteria for biologicals. Targeted lung denervation (TLD) is the bronchoscopic ablation of the peribronchial vagal nerve trunks to reduce cholinergic stimulation of airway smooth muscle and submucosal glands. This report describes the experience of the first 2 asthma patients treated with TLD worldwide. The participants were 54 and 51 years of age, and both had severe asthma (GINA 5) (FEV1: 53% and 113% of predicted; AQLQ scores: 5.3 and 4.4). Both participants were treated with TLD in a single day-case procedure under general anaesthesia. Lung function, health status, and adverse event data were collected at baseline and 12 months after TLD. No treatment-related serious adverse events were reported up to 12 months. Cough symptoms improved in both participants, and 1 participant reported a marked reduction in rescue medication use at 6 months. There were no significant changes in spirometry, lung volumes, or health status. In conclusion, TLD was performed safely in both participants, but more evidence is needed to clarify safety and efficacy of TLD in severe asthma. Therefore, further investigation of the treatment in severe asthma patients would be useful.
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Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Karthi Srikanthan
- Royal Brompton Hospital, London, United Kingdom.,National Heart & Lung Institute, Imperial College, London, United Kingdom.,Chelsea & Westminster Hospital, London, United Kingdom
| | - Cielito Caneja
- Royal Brompton Hospital, London, United Kingdom.,Chelsea & Westminster Hospital, London, United Kingdom
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Pallav L Shah
- Royal Brompton Hospital, London, United Kingdom.,National Heart & Lung Institute, Imperial College, London, United Kingdom.,Chelsea & Westminster Hospital, London, United Kingdom
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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12
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Kerwin E, Dorinsky P, Patel M, Rossman K, Reisner C, Maes A, Darken P, Griffis D, Fjällbrant H. A randomized controlled trial of glycopyrrolate administered by metered dose inhaler in patients with uncontrolled asthma despite ICS/LABA treatment. J Asthma 2021; 59:1420-1432. [PMID: 34338132 DOI: 10.1080/02770903.2021.1938603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of three doses of glycopyrrolate metered dose inhaler (GP MDI) in patients with uncontrolled asthma despite treatment with inhaled corticosteroid/long-acting β2-agonists (ICS/LABA) with or without tiotropium, to characterize the benefit of triple therapy. METHOD This phase II/III, double-blind study randomized patients to 24 weeks' treatment with twice-daily GP MDI 36 µg, 18 µg, 9 µg, or placebo MDI (all delivered via Aerosphere inhalers), or once-daily open-label tiotropium 2.5 µg. Patients continued their own ICS/LABA regimen throughout the study. The primary endpoint was change from baseline in forced expiratory volume in 1 s (FEV1) area under the curve from 0 - 4 h (AUC0 - 4) at Week 24. Secondary endpoints included patient questionnaires to measure asthma control or symptoms. Safety was also assessed. RESULTS The primary analysis (modified intent-to-treat) population included 1066 patients. The primary study endpoint was not met (changes from baseline in FEV1 AUC0 - 4 at Week 24 were 294 mL, 284 mL, 308 mL, 240 mL, and 347 mL for GP MDI 36 µg, GP MDI 18 µg, GP MDI 9 µg, placebo, and open-label tiotropium, respectively). There were no significant differences between treatment and placebo in secondary endpoints at Week 24. Post-hoc analyses using post-bronchodilator FEV1 as the baseline measurement, or averaging values across multiple baseline visits, showed a dose-related response to GP MDI. The incidence of adverse events was low and similar across treatments. CONCLUSION Although this study did not meet its primary endpoint, post hoc analyses identified a dose-related response to GP MDI when alternative definitions of baseline FEV1 were used in the analyses.
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Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul Dorinsky
- BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Mehul Patel
- BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Kimberly Rossman
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Colin Reisner
- Formerly of BioPharmaceuticals R&D, AstraZeneca, Morristown, NJ, USA
| | - Andrea Maes
- Formerly of Biopharmaceuticals R&D, AstraZeneca, Wilmington, DE, USA
| | - Patrick Darken
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
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13
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Murphy RC, Pavord ID, Alam R, Altman MC. Management Strategies to Reduce Exacerbations in non-T2 Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2588-2597. [PMID: 34246435 DOI: 10.1016/j.jaip.2021.04.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
There have been considerable advances in our understanding of asthmatic airway inflammation, resulting in a paradigm shift of classifying individuals on the basis of either the presence or the absence of type 2 (T2) inflammatory markers. Several novel monoclonal antibody therapies targeting T2 cytokines have demonstrated significant clinical effects including reductions in acute exacerbations and improvements in asthma-related quality of life and lung function for individuals with T2-high asthma. However, there have been fewer advancements in developing therapies for those without evidence of T2 airway inflammation (so-called non-T2 asthma). Here, we review the heterogeneity of molecular mechanisms responsible for initiation and regulation of non-T2 inflammation and discuss both current and potential future therapeutic options for individuals with non-T2 asthma.
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Affiliation(s)
- Ryan C Murphy
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Wash; Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash.
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rafeul Alam
- Division of Allergy and Immunology, Department of Medicine, National Jewish Health and University of Colorado, Denver, Colo
| | - Matthew C Altman
- Center for Lung Biology, Department of Medicine, University of Washington, Seattle, Wash; Division of Allergy and Immunology, University of Washington, Seattle, Wash
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14
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Ora J, Calzetta L, Ritondo BL, Matera MG, Rogliani P. Current long-acting muscarinic antagonists for the treatment of asthma. Expert Opin Pharmacother 2021; 22:2343-2357. [PMID: 34219573 DOI: 10.1080/14656566.2021.1952182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The role of long-acting muscarinic antagonists (LAMAs) is well established in uncontrolled asthma, but not in milder stages. AREAS COVERED This review examines the main randomized controlled trials (RCTs) that have investigated LAMAs administered as monotherapy or in combination to asthmatic patients, according to the different phenotypes. It offers an overview of the role of LAMAs or their fixed dose combinations (FDCs) in the treatment across all the different stages of asthma. EXPERT OPINION Tiotropium is now widely recognized as treatment for moderate to severe uncontrolled asthma (step 4-5) in adults and children. The most recent new evidence is: a) in adults, three different LAMA/long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) FDCs have been recently approved, extending the treatment options for these patients; b) therapy with LAMAs does not depend on patient's Th2 status and justifies the indication regardless of patient's phenotyping; c) in the milder stages, the high variability of response to LAMAs and the lack of a good phenotyping of patients represents the main obstacle in prescribing LAMAs. A better characterization of parasympathetic tone activity could improve LAMAs prescription.
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Affiliation(s)
- Josuel Ora
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paola Rogliani
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy.,Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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15
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Kim LHY, Saleh C, Whalen-Browne A, O’Byrne PM, Chu DK. Triple vs Dual Inhaler Therapy and Asthma Outcomes in Moderate to Severe Asthma: A Systematic Review and Meta-analysis. JAMA 2021; 325:2466-2479. [PMID: 34009257 PMCID: PMC8135065 DOI: 10.1001/jama.2021.7872] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE The benefits and harms of adding long-acting muscarinic antagonists (LAMAs) to inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs) for moderate to severe asthma remain unclear. OBJECTIVE To systematically synthesize the outcomes and adverse events associated with triple therapy (ICS, LABA, and LAMA) vs dual therapy (ICS plus LABA) in children and adults with persistent uncontrolled asthma. DATA SOURCES MEDLINE, Embase, CENTRAL, ICTRP, FDA, and EMA databases from November 2017, to December 8, 2020, without language restriction. STUDY SELECTION Two investigators independently selected randomized clinical trials (RCTs) comparing triple vs dual therapy in patients with moderate to severe asthma. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analyses, including individual patient-level exacerbation data, were used. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess certainty (quality) of the evidence. MAIN OUTCOMES AND MEASURES Severe exacerbations, asthma control (measured using the Asthma Control Questionnaire [ACQ-7], a 7-item list with each item ranging from 0 [totally controlled] to 6 [severely uncontrolled]; minimal important difference, 0.5), quality of life (measured using the Asthma-related Quality of Life [AQLQ] tool; score range, 1 [severely impaired] to 7 [no impairment]; minimal important difference, 0.5), mortality, and adverse events. RESULTS Twenty RCTs using 3 LAMA types that enrolled 11 894 children and adults (mean age, 52 years [range, 9-71 years]; 57.7% female) were included. High-certainty evidence showed that triple therapy vs dual therapy was significantly associated with a reduction in severe exacerbation risk (9 trials [9932 patients]; 22.7% vs 27.4%; risk ratio, 0.83 [95% CI, 0.77 to 0.90]) and an improvement in asthma control (14 trials [11 230 patients]; standardized mean difference [SMD], -0.06 [95% CI, -0.10 to -0.02]; mean difference in ACQ-7 scale, -0.04 [95% CI, -0.07 to -0.01]). There were no significant differences in asthma-related quality of life (7 trials [5247 patients]; SMD, 0.05 [95% CI, -0.03 to 0.13]; mean difference in AQLQ score, 0.05 [95% CI, -0.03 to 0.13]; moderate-certainty evidence) or mortality (17 trials [11 595 patients]; 0.12% vs 0.12%; risk ratio, 0.96 [95% CI, 0.33 to 2.75]; high-certainty evidence) between dual and triple therapy. Triple therapy was significantly associated with increased dry mouth and dysphonia (10 trials [7395 patients]; 3.0% vs 1.8%; risk ratio, 1.65 [95% CI, 1.14 to 2.38]; high-certainty evidence), but treatment-related and serious adverse events were not significantly different between groups (moderate-certainty evidence). CONCLUSIONS AND RELEVANCE Among children (aged 6 to 18 years) and adults with moderate to severe asthma, triple therapy, compared with dual therapy, was significantly associated with fewer severe asthma exacerbations and modest improvements in asthma control without significant differences in quality of life or mortality.
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Affiliation(s)
- Lisa H. Y. Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carol Saleh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Paul M. O’Byrne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Derek K. Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St Joe’s Hamilton, Hamilton, Ontario, Canada
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16
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Kyriakopoulos C, Gogali A, Bartziokas K, Kostikas K. Identification and treatment of T2-low asthma in the era of biologics. ERJ Open Res 2021; 7:00309-2020. [PMID: 34109244 PMCID: PMC8181790 DOI: 10.1183/23120541.00309-2020] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022] Open
Abstract
Currently, and based on the development of relevant biologic therapies, T2-high is the most well-defined endotype of asthma. Although much progress has been made in elucidating T2-high inflammation pathways, no specific clinically applicable biomarkers for T2-low asthma have been identified. The therapeutic approach of T2-low asthma is a problem urgently needing resolution, firstly because these patients have poor response to steroids, and secondly because they are not candidates for the newer targeted biologic agents. Thus, there is an unmet need for the identification of biomarkers that can help the diagnosis and endotyping of T2-low asthma. Ongoing investigation is focusing on neutrophilic airway inflammation mediators as therapeutic targets, including interleukin (IL)-8, IL-17, IL-1, IL-6, IL-23 and tumour necrosis factor-α; molecules that target restoration of corticosteroid sensitivity, mainly mitogen-activated protein kinase inhibitors, tyrosine kinase inhibitors and phosphatidylinositol 3-kinase inhibitors; phosphodiesterase (PDE)3 inhibitors that act as bronchodilators and PDE4 inhibitors that have an anti-inflammatory effect; and airway smooth muscle mass attenuation therapies, mainly for patients with paucigranulocytic inflammation. This article aims to review the evidence for noneosinophilic inflammation being a target for therapy in asthma; discuss current and potential future therapeutic approaches, such as novel molecules and biologic agents; and assess clinical trials of licensed drugs in the treatment of T2-low asthma.
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Affiliation(s)
- Chris Kyriakopoulos
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
| | - Athena Gogali
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Konstantinos Kostikas
- Respiratory Medicine Dept, University of Ioannina School of Medicine, Ioannina, Greece
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17
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van den Berg MPM, Nijboer-Brinksma S, Bos IST, van den Berge M, Lamb D, van Faassen M, Kema IP, Gosens R, Kistemaker LEM. The novel TRPA1 antagonist BI01305834 inhibits ovalbumin-induced bronchoconstriction in guinea pigs. Respir Res 2021; 22:48. [PMID: 33557843 PMCID: PMC7871391 DOI: 10.1186/s12931-021-01638-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
Background Asthma is a chronic respiratory disease in which the nervous system plays a central role. Sensory nerve activation, amongst others via Transient Receptor Potential Ankyrin 1 (TRPA1) channels, contributes to asthma characteristics including cough, bronchoconstriction, mucus secretion, airway hyperresponsiveness (AHR) and inflammation. In the current study, we evaluated the efficacy of the novel TRPA1 antagonist BI01305834 against AHR and inflammation in guinea-pig models of asthma. Methods First, a pilot study was performed in a guinea-pig model of allergic asthma to find the optimal dose of BI01305834. Next, the effect of BI01305834 on (1) AHR to inhaled histamine after the early and late asthmatic reaction (EAR and LAR), (2) magnitude of EAR and LAR and (3) airway inflammation was assessed. Precision-cut lung slices and trachea strips were used to investigate the bronchoprotective and bronchodilating-effect of BI01305834. Statistical evaluation of differences of in vivo data was performed using a Mann–Whitney U test or One-way nonparametric Kruskal–Wallis ANOVA, for ex vivo data One- or Two-way ANOVA was used, all with Dunnett’s post-hoc test where appropriate. Results A dose of 1 mg/kg BI01305834 was selected based on AHR and exposure data in blood samples from the pilot study. In the subsequent study, 1 mg/kg BI01305834 inhibited AHR after the EAR, and the development of EAR and LAR elicited by ovalbumin in ovalbumin-sensitized guinea pigs. BI01305834 did not inhibit allergen-induced total and differential cells in the lavage fluid and interleukin-13 gene expression in lung homogenates. Furthermore, BI01305834 was able to inhibit allergen and histamine-induced airway narrowing in guinea-pig lung slices, without affecting histamine release, and reverse allergen-induced bronchoconstriction in guinea-pig trachea strips. Conclusions TRPA1 inhibition protects against AHR and the EAR and LAR in vivo and allergen and histamine-induced airway narrowing ex vivo, and reverses allergen-induced bronchoconstriction independently of inflammation. This effect was partially dependent upon histamine, suggesting a neuronal and possible non-neuronal role for TRPA1 in allergen-induced bronchoconstriction.
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Affiliation(s)
- Mariska P M van den Berg
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Susan Nijboer-Brinksma
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I Sophie T Bos
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten van den Berge
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - David Lamb
- Immunology + Respiratory, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Martijn van Faassen
- Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud Gosens
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Loes E M Kistemaker
- Department of Molecular Pharmacology, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands. .,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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18
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Abstract
Background: Severe asthma is a heterogeneous disease that consists of various phenotypes driven by different pathways. Associated with significant morbidity, an important negative impact on the quality of life of patients, and increased health care costs, severe asthma represents a challenge for the clinician. With the introduction of various antibodies that target type 2 inflammation (T2) pathways, severe asthma therapy is gradually moving to a personalized medicine approach. Objective: The purpose of this review was to emphasize the important role of personalized medicine in adult severe asthma management. Methods: An extensive research was conducted in medical literature data bases by applying terms such as "severe asthma" associated with "structured approach," "comorbidities," "biomarkers," "phenotypes/endotypes," and "biologic therapies." Results: The management of severe asthma starts with a structured approach to confirm the diagnosis, assess the adherence to medications and identify confounding factors and comorbidities. The definition of phenotypes or endotypes (phenotypes defined by mechanisms and identified through biomarkers) is an important step toward the use of personalized medicine in asthma. Severe allergic and nonallergic eosinophilic asthma are two defined T2 phenotypes for which there are efficacious targeted biologic therapies currently available. Non-T2 phenotype remains to be characterized, and less efficient target therapy exists. Conclusion: Despite important progress in applying personalized medicine to severe asthma, especially in T2 inflammatory phenotypes, future research is needed to find valid biomarkers predictive for the response to available biologic therapies to develop more effective therapies in non-T2 phenotype.
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Affiliation(s)
- Angelica Tiotiu
- From the Department of Pulmonology, University Hospital of Nancy, Nancy, France; and
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19
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Kaplan A, Chang KL. Tiotropium in asthma - perspectives for the primary care physician. Postgrad Med 2020; 133:552-564. [PMID: 32896185 DOI: 10.1080/00325481.2020.1816329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Asthma is a heterogeneous disease characterized by airway inflammation resulting from complex interactions between multiple hosts as well as environmental factors. As a chronic respiratory condition, asthma exerts a significant impact on patients and the healthcare system. Per the Global Initiative for Asthma (GINA), inhaled corticosteroids (ICS) with/without long-acting beta2-agonists (LABAs) should be used as the preferred controllers for the management of asthma. Despite a range of therapeutic options, many patients with asthma remain uncontrolled, resulting in an increased risk of hospitalization and emergency room visits and a worsened quality of life. Tiotropium (Spiriva®, Boehringer Ingelheim Pharmaceuticals, Inc; 1.25 µg, two puffs, once daily), delivered via the Respimat® inhaler (Boehringer Ingelheim Pharmaceuticals, Inc.), was the first long-acting muscarinic antagonist to be approved as an add-on maintenance treatment option for patients with asthma aged ≥6 years at GINA steps 4 and 5. By binding to the muscarinic receptors M1 and M3 in the bronchial airways, tiotropium antagonizes the action of acetylcholine, leading to smooth muscle relaxation and reduced mucus secretion.The efficacy and safety of tiotropium add-on to ICS±LABA maintenance treatment have been evaluated in randomized controlled trials (RCTs) involving patients with a range of asthma severities (mild, moderate, and severe) and across age groups (children, adolescents, and adults). Add-on tiotropium was found to be well tolerated and efficacious in all RCTs. Moreover, the findings from real-world studies complement results from RCTs, showing beneficial effects of tiotropium in reducing exacerbations, hospitalization, emergency room visits, and asthma worsening.In this review article, we discuss the pathophysiology of asthma and the role of tiotropium in the management of asthma from the perspective of a primary care physician.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ku-Lang Chang
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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Khurana S, Bush A, Holguin F. Management of severe asthma: summary of the European Respiratory Society/American Thoracic Society task force report. Breathe (Sheff) 2020; 16:200058. [PMID: 33304407 PMCID: PMC7714544 DOI: 10.1183/20734735.0058-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Educational aims This article is mainly intended for trainees and specialists who are interested in the management of severe asthma.
It aims to inform readers about the updated ERS/ATS recommendations for management of severe asthma, specifically on the topics of biologics, macrolides and long-acting muscarinic antagonists. It also provides guidance on utilisation of available biomarkers in selecting advanced therapies in severe asthma.
This article summarises the 2019 @EuroRespSoc/@ATScommunity Severe Asthma Task Force recommendations on the use of anti-IL-5 strategy, anti-IL-4/13 antibody, tiotropium and macrolides in severe asthma, and the role of biomarkers in directing therapyhttps://bit.ly/3braK43
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Affiliation(s)
- Sandhya Khurana
- University of Rochester School of Medicine and Dentistry, Pulmonary and Critical Care Medicine, Rochester, NY, USA
| | - Andrew Bush
- Dept of Paediatrics, National Heart & Lung Institute, Imperial College London, London, UK
| | - Fernando Holguin
- University of Colorado, Pulmonary Sciences and Critical Care Medicine, Denver, CO, USA
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Luz MI, Aguiar R, Morais-Almeida M. The reality of LAMAs for adult asthmatic patients. Expert Rev Respir Med 2020; 14:1087-1094. [PMID: 32687426 DOI: 10.1080/17476348.2020.1794828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The use of tiotropium is approved for the treatment of asthma. There are several studies completed or currently ongoing with the long-acting muscarinic antagonists (LAMAs) umeclidinium and glycopyrronium as an add-on asthma treatment. Adding a second bronchodilator with a different mechanism of action for the treatment of uncontrolled asthma may be a suitable therapeutic approach, although several issues still under discussion. AREAS COVERED The reality of LAMA plus long-acting beta-agonists (LABA) treatment for adult asthma. A systematic search was conducted on March 2020, and included 6 electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science and Google Scholar. EXPERT OPINION A growing body of evidence generated from several randomized clinical trials is supporting the use of LAMA in adulthood asthma always in association with inhaled corticosteroid (ICS). Currently, only tiotropium has been approved and included in the guidelines. Other LAMAs are under evaluation in clinical trials. Several clinical trials are supporting the use of a triple therapy (ICS/LABA/LAMA) in uncontrolled asthmatic patients under ICS/LABA.
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Affiliation(s)
- Maria Inês Luz
- Serviço de Pneumologia, Hospital Prof. Doutor Fernando Fonseca , Amadora, Portugal.,Centro de Alergia, Hospital CUF Descobertas , Lisboa, Portugal
| | - Rita Aguiar
- Centro de Alergia, Hospital CUF Descobertas , Lisboa, Portugal
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Kerwin E, Pascoe S, Bailes Z, Nathan R, Bernstein D, Dahl R, von Maltzahn R, Robbins K, Fowler A, Lee L. A phase IIb, randomised, parallel-group study: the efficacy, safety and tolerability of once-daily umeclidinium in patients with asthma receiving inhaled corticosteroids. Respir Res 2020; 21:148. [PMID: 32532275 PMCID: PMC7291639 DOI: 10.1186/s12931-020-01400-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/19/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients with asthma uncontrolled on inhaled corticosteroids may benefit from umeclidinium (UMEC), a long-acting muscarinic antagonist. METHODS This Phase IIb, double-blind study included patients with reversible, uncontrolled/partially-controlled asthma for ≥6 months, receiving ≥100 mcg/day fluticasone propionate (or equivalent) for ≥12 weeks. Following a 2-week run-in on open-label fluticasone furoate (FF) 100 mcg, patients were randomised (1:1:1) to receive UMEC 31.25 mcg, UMEC 62.5 mcg or placebo on top of FF 100 mcg once-daily for 24 weeks. As-needed salbutamol was provided. Primary and secondary endpoints were change from baseline in clinic trough forced expiratory volume in 1 s (FEV1) and clinic FEV1 3 h post-dose, respectively, at Week 24. Other endpoints included change from baseline in home daily spirometry (trough FEV1, evening FEV1, morning [pre-dose] and evening peak expiratory flow) over 24 weeks. Safety was assessed throughout the study. RESULTS The intent-to-treat population comprised 421 patients (UMEC 31.25 mcg: n =139, UMEC 62.5 mcg: n =139, placebo: n =143). UMEC 31.25 mcg and 62.5 mcg demonstrated significantly greater improvements from baseline in clinic trough FEV1 at Week 24 (difference [95% CI]: 0.176 L [0.092, 0.260; p<0.001] and 0.184 L [0.101, 0.268; p<0.001], respectively), clinic FEV1 3 h post-dose at Week 24 (0.190 L [0.100, 0.279; p<0.001] and 0.198 L [0.109, 0.287; p<0.001], respectively) and mean change from baseline in daily home spirometry over 24 weeks versus placebo. No new safety signals were identified. CONCLUSIONS UMEC is a highly effective bronchodilator that leads to improved lung function when administered as a single bronchodilator on top of FF in subjects with fully reversible, uncontrolled/partially-controlled moderate asthma. These data support a favourable benefit/risk profile for UMEC (31.25 mcg and 62.5 mcg). TRIAL REGISTRATION GSK study ID: 205832; Clinicaltrials.gov ID: NCT03012061.
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Affiliation(s)
- Edward Kerwin
- Crisor LLC Research, Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Zelie Bailes
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Robert Nathan
- Asthma & Allergy Associates, P.C. and Research Center, Colorado Springs, CO, USA
| | - David Bernstein
- Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Bernstein Clinical Research Center, Cincinnati, OH, USA
| | - Ronald Dahl
- GSK, 980 Great West Road, Brentford, Middlesex, UK
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Fixed-dose combination of indacaterol/glycopyrronium/mometasone furoate once-daily versus salmeterol/fluticasone twice-daily plus tiotropium once-daily in patients with uncontrolled asthma: A randomised, Phase IIIb, non-inferiority study (ARGON). Respir Med 2020; 170:106021. [PMID: 32843164 DOI: 10.1016/j.rmed.2020.106021] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/06/2020] [Accepted: 05/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The efficacy and safety of once-daily (o.d.) fixed-dose combination of indacaterol (IND), glycopyrronium (GLY) and mometasone furoate (MF) via Breezhaler® versus concurrent administration of salmeterol/fluticasone (SAL/FLU) twice-daily (b.i.d.) via Accuhaler®+Tiotropium (TIO) o.d. via Respimat® was evaluated in patients with uncontrolled asthma. METHODS Patients (aged ≥18 years), symptomatic (Asthma Control Questionnaire [ACQ]-7 ≥1.5) despite treatment with long-acting β2-agonist/inhaled corticosteroid medium- or high-dose, received IND/GLY/MF high- (150/50/160 μg) or medium-dose (150/50/80 μg) o.d. or SAL/FLU high-dose (50/500 μg) b.i.d.+Tio 5 μg o.d. for 24 weeks. The primary objective was to confirm the non-inferiority of either dose of IND/GLY/MF to SAL/FLU high dose + TIO in terms of Asthma Quality of Life Questionnaire (AQLQ). Additional endpoints: ACQ-7, lung function, health status (St George's Respiratory Questionnaire [SGRQ]), exacerbations, and safety after 24 weeks. RESULTS IND/GLY/MF high- and medium-dose met the primary endpoint, confirming non-inferiority to SAL/FLU high dose + TIO for AQLQ (least square mean treatment difference [Δ]: 0.073 and -0.038, respectively; both p < 0.001). IND/GLY/MF high-dose improved ACQ-7 (Δ: -0.124; p = 0.004), trough FEV1 (Δ: 96 mL; p < 0.001), peak expiratory flow (morning [Δ: 9.56 L/min; p = 0.005], evening [Δ: 9.15 L/min; p = 0.006]) and SGRQ (Δ: -2.00; p = 0.04) versus SAL/FLU high dose + TIO. Improvements in these endpoints were comparable for IND/GLY/MF medium-dose and SAL/FLU high dose + TIO. Adverse events were generally comparable across treatments. CONCLUSIONS IND/GLY/MF high- and medium-dose o.d. via a single inhaler were non-inferior to SAL/FLU high-dose b.i.d. + TIO o.d. via two inhalers for AQLQ. IND/GLY/MF high-dose o.d. improved lung function, asthma control and health status versus SAL/FLU high dose + TIO, while IND/GLY/MF medium-dose had comparable efficacy but at a corresponding lower steroid dose.
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Abstract
PURPOSE OF REVIEW The goal of this review is to discuss strategies to prevent asthma exacerbations in children, focusing on recent advances in knowledge and understanding. RECENT FINDINGS Asthma exacerbations are common, and their prevention is an important goal to avoid detrimental impacts such as loss of disease control and lung function and significant healthcare costs. A number of strategies have been studied as tools for prevention of asthma exacerbations. Daily inhaled corticosteroids (ICSs) are effective for many children with asthma. However, alternative strategies such as intermittent ICS therapy, antileukotrienes, and biologics have been studied as means to lessen corticosteroid exposure. Further, recent studies have examined add-on strategies for children not controlled with ICS alone. Finally, personalizing therapy with targeted approaches has provided significant benefit to those with moderate-severe disease. SUMMARY Recent research highlights many potentially effective treatment strategies to prevent asthma exacerbations in children. We have reviewed and summarized the data on treatment approaches to help provide a better understanding of the methods that can be utilized. An individualized approach with careful monitoring is essential to identify the most effective strategies to prevent asthma exacerbations in each child.
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Holguin F, Cardet JC, Chung KF, Diver S, Ferreira DS, Fitzpatrick A, Gaga M, Kellermeyer L, Khurana S, Knight S, McDonald VM, Morgan RL, Ortega VE, Rigau D, Subbarao P, Tonia T, Adcock IM, Bleecker ER, Brightling C, Boulet LP, Cabana M, Castro M, Chanez P, Custovic A, Djukanovic R, Frey U, Frankemölle B, Gibson P, Hamerlijnck D, Jarjour N, Konno S, Shen H, Vitary C, Bush A. Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2020; 55:13993003.00588-2019. [PMID: 31558662 DOI: 10.1183/13993003.00588-2019] [Citation(s) in RCA: 333] [Impact Index Per Article: 83.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/08/2019] [Indexed: 12/11/2022]
Abstract
This document provides clinical recommendations for the management of severe asthma. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the European Respiratory Society/American Thoracic Society Task Force's questions. The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of asthma experts, who made specific recommendations on six specific questions. After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made the following recommendations: 1) suggest using anti-interleukin (IL)-5 and anti-IL-5 receptor α for severe uncontrolled adult eosinophilic asthma phenotypes; 2) suggest using a blood eosinophil cut-point ≥150 μL-1 to guide anti-IL-5 initiation in adult patients with severe asthma; 3) suggest considering specific eosinophil (≥260 μL-1) and exhaled nitric oxide fraction (≥19.5 ppb) cut-offs to identify adolescents or adults with the greatest likelihood of response to anti-IgE therapy; 4) suggest using inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite Global Initiative for Asthma (GINA) step 4-5 or National Asthma Education and Prevention Program (NAEPP) step 5 therapies; 5) suggest a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on GINA step 5 or NAEPP step 5 therapies, irrespective of asthma phenotype; and 6) suggest using anti-IL-4/13 for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of blood eosinophil levels. These recommendations should be reconsidered as new evidence becomes available.
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Affiliation(s)
- Fernando Holguin
- Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA .,F. Holguin is ATS co-chair
| | | | - Kian Fan Chung
- Experimental Studies Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah Diver
- Respiratory Biomedical Unit, University of Leicester, Leicester, UK
| | - Diogenes S Ferreira
- Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anne Fitzpatrick
- Division of Pulmonology Allergy/Immunology, Cystic Fibrosis and Sleep, Emory University, Atlanta, GA, USA
| | - Mina Gaga
- Respiratory Medicine Dept and Asthma Centre, Athens Chest Hospital, Athens, Greece
| | | | - Sandhya Khurana
- Pulmonary Diseases and Critical Care, University of Rochester, Rochester, NY, USA
| | - Shandra Knight
- Biomedical Library, National Jewish Health, Denver, CO, USA
| | | | - Rebecca L Morgan
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Victor E Ortega
- Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ian M Adcock
- Molecular Cell Biology Group, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, AZ, USA
| | - Chris Brightling
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | - Michael Cabana
- Division of General Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, MO, USA
| | - Pascal Chanez
- Dept of Respiratory Diseases, University of Aix-Marseille, Marseille, France
| | - Adnan Custovic
- Paediatric Allergy, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Ratko Djukanovic
- Respiratory Biomedical Research, University of Southampton, Southampton, UK
| | - Urs Frey
- Dept of Pediatrics, University Children's Hospital, Basel, Switzerland
| | | | - Peter Gibson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | | | - Nizar Jarjour
- Division of Pulmonary and Critical Care, University of Wisconsin, Madison, WI, USA
| | - Satoshi Konno
- Dept of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Huahao Shen
- Dept of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Cathy Vitary
- Asthma Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andy Bush
- Dept of Paediatrics, Imperial College London, National Heart and Lung Institute, London, UK.,A. Bush is ERS co-chair
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Buhl R, FitzGerald JM, Meltzer EO, de la Hoz A, Sigmund R, Kerstjens HAM, Bleecker ER. Efficacy of once-daily tiotropium Respimat in adults with asthma at GINA Steps 2-5. Pulm Pharmacol Ther 2019; 60:101881. [PMID: 31874283 DOI: 10.1016/j.pupt.2019.101881] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 01/07/2023]
Abstract
Tiotropium Respimat is an efficacious add-on to maintenance treatment in patients with symptomatic asthma. Currently, the Global Initiative for Asthma (GINA) strategy recommends tiotropium for patients at Steps 4-5. To assess the clinical benefits of tiotropium Respimat across asthma severities, GINA Steps 2-5, a post hoc analysis of five double-blind trials (12-48-weeks; patients aged 18-75 years) investigated the effect of tiotropium Respimat, 5 μg or 2.5 μg, versus placebo, on peak forced expiratory volume in 1 s (FEV1) within 3 h post-dose (FEV1(0-3h)) response, and Asthma Control Questionnaire-7 (ACQ-7) responder rate. GINA step grouping was based on patients' background treatment regimen. Baseline characteristics of patients (N = 2926) were balanced between treatments. Tiotropium Respimat showed consistent improvements in lung function across GINA steps; placebo-corrected peak FEV1(0-3h) improvements after tiotropium Respimat 5 μg and 2.5 μg were: Step 2 (Week 8), 135 mL (95% confidence interval: 84, 187) and 155 mL (103, 206); Step 3 (Week 24), 187 mL (139, 235) and 235 mL (187, 283); Step 4 (Week 24), 111 mL (63, 159) and 181 mL (35, 326); Step 5 (Week 24; 5 μg only), 164 mL (5, 323). Asthma control improved with tiotropium Respimat versus placebo, showing statistical significance (nominal P value) with tiotropium Respimat 5 μg at Step 4 (odds ratio 1.36 [1.03, 1.78]). Safety profiles were similar between treatments. In conclusion, tiotropium Respimat add-on therapy improves lung function, and may improve asthma control, in adults across disease severities.
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Affiliation(s)
- Roland Buhl
- Johannes Gutenberg University Mainz, Mainz, Germany.
| | | | - Eli O Meltzer
- University of California, San Diego, La Jolla, CA, USA.
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany.
| | - Ralf Sigmund
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany.
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, And Groningen Research Institute for Asthma and COPD GRAIC, Groningen, the Netherlands.
| | - Eugene R Bleecker
- Genomics and Precision Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
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Murphy KR, Chipps BE. Tiotropium in children and adolescents with asthma. Ann Allergy Asthma Immunol 2019; 124:267-276.e3. [PMID: 31805357 DOI: 10.1016/j.anai.2019.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium-a long-acting muscarinic antagonist-as add-on therapy to an inhaled corticosteroid with or without a long-acting β2-agonist provides clinical benefit with a safety profile similar to placebo. OBJECTIVE To review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s). METHODS We searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events. RESULTS Overall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection. CONCLUSION Once-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.
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Affiliation(s)
- Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
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Averell CM, Laliberté F, Duh MS, Wu JW, Germain G, Faison S. Characterizing Real-World Use Of Tiotropium In Asthma In The USA. J Asthma Allergy 2019; 12:309-321. [PMID: 31632091 PMCID: PMC6789414 DOI: 10.2147/jaa.s216932] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background Tiotropium bromide (TIO) is a long-acting muscarinic antagonist recommended as an add-on therapy option for patients with uncontrolled asthma on inhaled corticosteroids (ICS) and long-acting β2-agonists (LABA). However, real-world data on TIO use in asthma remains limited. To identify unmet needs, this study explored the use of TIO in US patients with asthma. Methods This retrospective cohort study used IQVIATM Health Plan Claims Data (October 1, 2014─December 31, 2016). Patients with asthma diagnoses initiating TIO 1.25 or 2.5 mcg after September 16, 2015 (first dispensing on index date) with ≥6 and ≥3 months continuous enrollment pre- and post-index, respectively, were identified. Patients with COPD diagnoses were excluded. Baseline characteristics, healthcare resource utilization and costs, and treatment patterns before and following TIO initiation were described for TIO cohorts and subgroups classified by concomitant medications received during the 30-day period after initiation. Results The study included 766 TIO 1.25 mcg and 1055 TIO 2.5 mcg users. In the TIO 1.25 mcg cohort, 16% (126/766) used TIO monotherapy while 61% (465/766) used TIO+ICS/LABA± leukotriene receptor antagonists (triple therapy). In TIO 1.25 mcg monotherapy and triple therapy subgroups, 39% and 49% were treated by allergists/pulmonologists, 27% and 48% experienced a moderate/severe asthma exacerbation, and 50% and 68% used rescue oral corticosteroids during the baseline period, respectively. Following triple therapy initiation, 44% of patients discontinued ICS within 6 months. The TIO 2.5 mcg cohort demonstrated similar trends. Conclusion This study provided insights into real-world US use of TIO in asthma. Overall, 16–19% of patients received TIO monotherapy and had high baseline exacerbation rates, suggesting that additional ICS-containing medication may be beneficial. Patients initiating triple therapy were among the most severe, with high baseline exacerbation rates and rescue medication use, and had high post-treatment ICS discontinuation rates, suggesting unmet needs in this population.
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Affiliation(s)
- Carlyne M Averell
- US Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | | | | | - Sarai Faison
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
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Burden of Asthma and Role of 2.5 µg Tiotropium Respimat ® as an Add-On Therapy: A Systematic Review of Phase 2/3 Trials. Adv Ther 2019; 36:2587-2599. [PMID: 31435830 PMCID: PMC6822828 DOI: 10.1007/s12325-019-01062-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Indexed: 12/11/2022]
Abstract
Introduction Tiotropium, a long-acting muscarinic antagonist, is approved for maintenance treatment of asthma in patients at least 6 years of age in the USA. We systematically reviewed published evidence on the efficacy and safety of 2.5 µg tiotropium Respimat® add-on therapy to inhaled corticosteroid (ICS) with or without additional controller medication(s) in children, adolescents, and adults with asthma. Methods We searched PubMed from inception until October 3, 2018, for phase 2 and 3 randomized controlled trials (RCTs) evaluating the effects of 2.5 µg tiotropium Respimat® on lung function parameters in patients with asthma. We extracted adjusted mean differences for lung function data and adverse events (AEs) from relevant articles. Results Overall, 11 RCTs (three phase 2 and eight phase 3 studies) including 3244 patients (2.5 µg tiotropium Respimat®, n = 1642; placebo, n = 1602) met the predefined inclusion criteria. Once-daily 2.5 µg tiotropium Respimat® improved lung function parameters, including peak and trough forced expiratory volume in 1 s and peak and trough forced vital capacity, versus placebo. Overall, the safety profile of 2.5 µg tiotropium Respimat® was comparable to that of placebo, with the most commonly reported AEs being asthma worsening, reduction in peak expiratory rate, nasopharyngitis, and respiratory tract infections. Conclusion On the basis of the results of phase 2 and 3 studies, 2.5 µg tiotropium Respimat® as add-on to ICS therapy was safe and associated with consistent improvements in lung function in patients with asthma of varying severities across different age groups. Funding Development of the manuscript was funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). Electronic supplementary material The online version of this article (10.1007/s12325-019-01062-w) contains supplementary material, which is available to authorized users.
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Cazzola M, Puxeddu E, Matera MG, Rogliani P. A potential role of triple therapy for asthma patients. Expert Rev Respir Med 2019; 13:1079-1085. [PMID: 31422716 DOI: 10.1080/17476348.2019.1657408] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The use of LAMAs in asthma is now supported by pharmacological and clinical evidence, whereas the effectiveness of therapy with ICS/LABA/LAMA fixed dose combinations in patients with asthma still remains to be determined. Areas covered: The pharmacological rationale that explains why it is possible to use triple therapy in asthma and the results of clinical studies that have explored the effects of this therapy in asthmatics is critically examined. A systematic search was conducted on 10 August 2019, and included six electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science, and Google Scholar. Expert opinion: The real role of single inhaler triple therapy in asthma will be demonstrated when the various trials that are currently ongoing or are scheduled will be completed. We believe that it is appropriate to treat with triple therapy asthmatic patients who have smoked and remain symptomatic or suffer from frequent exacerbations despite initial inhaler therapy with ICS/LABA. However, we must establish when to step up or mainly step down triple therapy especially in patients who are well controlled, and what will be the cost of these combinations in the management of asthma.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Ermanno Puxeddu
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome , Italy
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Cheng WC, Liao WC, Wu BR, Chen CY, Shen MF, Chen WC, Hsia TC, Tu CY, Chen CH, Hsu WH. Clinical predictors of asthmatics in identifying subgroup requiring long-term tiotropium add-on therapy: a real-world study. J Thorac Dis 2019; 11:3785-3793. [PMID: 31656651 DOI: 10.21037/jtd.2019.09.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background According to several phase III studies, tiotropium [a long-acting muscarinic antagonist (LAMA)] is a well-tolerated add-on therapy to inhaled corticosteroids (ICS) for asthmatics with or without the addition of long-acting beta2-agonists (LABAs). However, real-world studies based on clinical phenotypes to predict the long-term need of tiotropium as an add-on therapy for asthmatics are limited. Methods This is a retrospective study conducted at a single medical center in Taiwan from July 2016 to July 2018. An asthma control test (ACT) is applied to uncontrolled asthmatics to evaluate the effectiveness of tiotropium as an add-on therapy. Asthmatic subgroups with different clinical phenotypes and needing long-term tiotropium as a maintenance treatment are identified. The effectiveness of tiotropium add-on therapy is defined as an improvement of ACT score ≥3 points 3 months after the treatment (vs. baseline), while the long-term requirement of tiotropium is defined as tiotropium dependency >1 year. Results The study analyzed a total of 160 uncontrolled asthmatics regardless of low- or medium-to-high-dose ICS plus LABA. One hundred and twelve patients responded well (ACT score increased ≥3 points) to tiotropium. These patients were further divided into two subgroups: one with tiotropium add-on therapy for ≥1 year due to patients' difficulties in stepping down from tiotropium; the other with tiotropium add-on therapy for <1 year due to successful step-down treatment according to Global Initiative for Asthma (GINA) score. All clinical characteristics of these two groups were collected and analyzed. Univariate and multivariate analyses showed that asthma-and-chronic obstructive pulmonary disease (COPD)-overlap (ACO), initial forced expiratory volume-one second (FEV1) % predicted <80%, or body mass index (BMI) >30 kg/m2 were predictors for asthmatics requiring long-term tiotropium add-on therapy. Conclusions Tiotropium add-on therapy is effective for uncontrolled asthmatics. Moreover, patients with ACO, initial FEV1% predicted <80%, or BMI >30 kg/m2 require long-term tiotropium add-on therapy for asthma control.
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Affiliation(s)
- Wen-Chien Cheng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,School of Medicine, China Medical University, Taichung.,Department of Internal Medicine, Hyperbaric Oxygen Therapy Center, China Medical University, Taichung
| | - Wei-Chih Liao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,Department of Internal Medicine, Hyperbaric Oxygen Therapy Center, China Medical University, Taichung.,Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Biing-Ru Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,School of Medicine, China Medical University, Taichung
| | - Chih-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,Department of Internal Medicine, Hyperbaric Oxygen Therapy Center, China Medical University, Taichung.,Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Meng-Fang Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung
| | - Wei-Chun Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,Department of Internal Medicine, Hyperbaric Oxygen Therapy Center, China Medical University, Taichung.,Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Te-Chun Hsia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,Department of Internal Medicine, Hyperbaric Oxygen Therapy Center, China Medical University, Taichung.,Department of Respiratory Therapy, China Medical University, Taichung
| | - Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,School of Medicine, China Medical University, Taichung.,Department of Life Science, National Chung Hsing University, Taichung
| | - Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung.,Graduate Institute of Clinical Medical Science, China Medical University, Taichung.,Taiwan Clinical Trial Consortium for Lung Diseases (TCoC), Taichung
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung
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Meng JF, Li H, Luo MJ, Li HB. Efficacy of tiotropium in treating patients with moderate-to-severe asthma: A meta-analysis and systematic review based on 14 randomized controlled trials. Medicine (Baltimore) 2019; 98:e16637. [PMID: 31415357 PMCID: PMC6831397 DOI: 10.1097/md.0000000000016637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/03/2019] [Accepted: 07/05/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The goal of the current meta-analysis and systematic review was to explore the efficacy of tiotropium in treating patients with moderate-to-severe asthma on the basis of qualified randomized controlled trials (RCTs). METHODS The following online electronic databases, such as Cochrane, PubMed, and Embase database were screened to identify qualified studies updated to January 2019 through the use of index words. Several literatures that were relevant to the present analysis were also included. To further analyze the main outcomes, we utilized the odds rations (OR), and mean difference (MD) along with its 95% confidence interval (95% CI). RESULTS A total of 14 RCTs with 4998 patients in the tiotropium group and 5074 patients in the control group were included in the present study. On the basis of the pooled results, tiotropium was significantly associated with improved morning PEF (SMD: 3.29, 95%CI: 2.03-4.55), evening PEF (SMD: 3.36, 95%CI: 2.24-4.48), peak FEV (SMD: 2.67, 95%CI: 1.47-3.88), and trough FEV (SMD: 1.90, 95%CI: 0.87-2.92) vs the control group. Nevertheless, no significant difference was observed in peak FVC (SMD: 0.77, 95%CI: -0.21-1.76), trough FVC (SMD: 0.67, 95%CI: -0.18-1.53), AE (RR: 0.98, 95%CI: 0.94-1.02) and serious AE (RR: 1.08, 95%CI: 0.77-1.52) between the 2 groups. CONCLUSIONS In this review, we summarized the significant effect of tiotropium for the treatment of moderate-to-severe asthma, mainly in increasing morning PEF, evening PEF, peak FEV and trough FEV based on high-quality RCTs. Nevertheless, no significant difference in peak FVC, trough FVC, AE and serious AE was found between the 2 groups. A close comparison of the 2 groups revealed that more high-quality larger-sample RCTs are needed to gather more strong evidence on the therapeutic efficacy and safety of tiotropium for clinical practice.
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Vogelberg C, Szefler SJ, Vrijlandt EJLE, Boner AL, Engel M, El Azzi G, Vulcu SD, Moroni-Zentgraf PM, Eickmeier O, Hamelmann EH. Tiotropium add-on therapy is safe and reduces seasonal worsening in paediatric asthma patients. Eur Respir J 2019; 53:13993003.01824-2018. [PMID: 31097514 PMCID: PMC6581158 DOI: 10.1183/13993003.01824-2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 03/19/2019] [Indexed: 11/05/2022]
Abstract
There remains an unmet need for effective, well-tolerated therapeutic options in paediatric patients with not fully controlled asthma, for whom safety is of paramount importance.Data were pooled from five randomised, double-blind, placebo-controlled studies evaluating tiotropium 5 or 2.5 µg versus placebo add-on therapy in patients with symptomatic asthma aged 1-17 years. Analysis included adverse events (AEs) and serious AEs (SAEs) reported throughout and for 30 days following treatment.Of 1691 patients treated, 1119 received tiotropium. Reporting of AEs was low and comparable across all groups: tiotropium 5 µg (51%), tiotropium 2.5 µg (51%) and placebo (54%). Reporting of drug-related AEs, those leading to discontinuation and SAEs was also low and balanced between treatment groups, irrespective of age, disease severity or sex. The number of AEs related to asthma symptoms and exacerbations was lower with tiotropium (5 µg) than with placebo, particularly during the seasonal peaks of these AEs.This comprehensive analysis of a large safety database allowed subgroup analyses that are often impractical with individual trials and provides further support for the safety of once-daily tiotropium Respimat add-on therapy in paediatric patients with symptomatic asthma.
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Affiliation(s)
- Christian Vogelberg
- Dept of Pediatric Pulmonology and Allergy, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Stanley J Szefler
- Children's Hospital of Colorado and the University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Elianne J L E Vrijlandt
- Dept of Pediatric Pulmonology and Pediatric Allergy, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Attilio L Boner
- UOC di Pediatria, Dipartimento di Scienze Chirurgiche Odontostomatologiche e Materno Infantili, Policlinico "G. Rossi", Verona, Italy
| | - Michael Engel
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Georges El Azzi
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | - Olaf Eickmeier
- Dept of Pediatric Allergology, Pulmonology and Cystic Fibrosis, University Children's Hospital, Goethe University, Frankfurt, Germany
| | - Eckard H Hamelmann
- Klinik für Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld and Allergy Center of the Ruhr University, Bochum, Germany
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Mansfield L, Bernstein JA. Tiotropium in asthma: From bench to bedside. Respir Med 2019; 154:47-55. [PMID: 31212121 DOI: 10.1016/j.rmed.2019.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/21/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Tiotropium is a long-acting muscarinic antagonist approved for maintenance treatment of asthma in children, adolescents, and adults in the United States, and recommended as add-on treatment for uncontrolled asthma despite treatment with inhaled corticosteroids and/or long-acting beta-2 agonists. This review traces the journey of tiotropium from its historical origins through early preclinical testing to human clinical trials and real-life studies. DATA SOURCES A search was performed in PubMed using search terms 'tiotropium' and 'asthma.' Relevant references cited in those articles were reviewed. STUDY SELECTIONS English language articles published from December 2008-December 2018 were screened. Articles evaluating the efficacy, cost-effectiveness, real-life evidence, and steroid-sparing effect of tiotropium with inadequately controlled asthma were included. RESULTS Anticholinergics have a long history of use in the treatment of obstructive airway diseases. Evidence indicates that tiotropium's mechanism of action consists of bronchodilation and diminished mucus secretion, with preclinical evidence suggesting an anti-inflammatory effect as well. Phase 2 and 3 clinical trials have demonstrated that tiotropium is efficacious and safe, resulting in significant improvements in lung function in adults, adolescents, and children across asthma severities. Emerging evidence suggests that add-on tiotropium might potentially enable reductions in inhaled corticosteroid dose in patients with uncontrolled asthma. Further, tiotropium is a cost-effective treatment option that is also effective in the clinical practice setting. CONCLUSIONS An increasing body of evidence indicates that tiotropium can play a significant role in the treatment of patients with uncontrolled asthma.
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Affiliation(s)
- Lyndon Mansfield
- Department of Pediatrics, Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Jonathan A Bernstein
- Department of Clinical Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Mokoka MC, McDonnell MJ, MacHale E, Cushen B, Boland F, Cormican S, Doherty C, Doyle F, Costello RW, Greene G. Inadequate assessment of adherence to maintenance medication leads to loss of power and increased costs in trials of severe asthma therapy: results from a systematic literature review and modelling study. Eur Respir J 2019; 53:13993003.02161-2018. [PMID: 30846467 DOI: 10.1183/13993003.02161-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/20/2019] [Indexed: 01/01/2023]
Abstract
Adherence to inhaled maintenance therapy in severe asthma is rarely adequately assessed, and its influence on trial outcomes is unknown. We systematically determined how adherence to maintenance therapy is assessed in clinical trials of "add-on" therapy for severe asthma. We model the improvement in trial power that could be achieved by accurately assessing adherence.A systematic search of six major databases identified randomised trials of add-on therapy for severe asthma. The relationship between measuring adherence and study outcomes was assessed. An estimate of potential improvements in statistical power and sample size was derived using digitally recorded adherence trial data.87 randomised controlled trials enrolling 22 173 participants were included. Adherence assessment was not reported in 67 trials (n=13 931, 63%). Studies that reported adherence used a range of self-report and subjective methods. None of the studies employed an objective assessment of adherence. Studies that reported adherence had a significantly reduced pooled variance in forced expiratory volume in 1 s (FEV1) compared to those that did not assess adherence: s2=0.144 L2 versus s2=0.168 L2, p<0.0001. Power to detect clinically relevant changes in FEV1 was significantly higher in trials that reported adherence assessment (mean power achieved 59% versus 49%). Modelling suggests that up to 50% of variance in FEV1 outcomes is attributable to undetected variations in adherence. Controlling for such variations could potentially halve the required sample size.Few trials of add-on therapy monitor adherence to maintenance inhaled therapy, resulting in a greater variance in trial outcomes and inadequate power for determining efficacy.
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Affiliation(s)
- Matshediso C Mokoka
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Elaine MacHale
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Breda Cushen
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Christina Doherty
- Beaumont Library, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Doyle
- Dept of Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard W Costello
- Dept of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Garrett Greene
- Clinical Research Centre, Smurfit Building, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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Buhl R, Hamelmann E. Future perspectives of anticholinergics for the treatment of asthma in adults and children. Ther Clin Risk Manag 2019; 15:473-485. [PMID: 30936709 PMCID: PMC6422409 DOI: 10.2147/tcrm.s180890] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite major advances in therapeutic interventions and the availability of detailed treatment guidelines, a high proportion of patients with symptomatic asthma remain uncontrolled. Asthma management is largely guided by the Global Initiative for Asthma (GINA) strategy and is based on a backbone of inhaled corticosteroid (ICS) therapy with the use of additional therapies to achieve disease control. Inhaled long-acting bronchodilators alone and in combination are the preferred add-on treatment options. Although long-acting muscarinic antagonists (LAMAs) are a relatively recent addition to disease management recommendations for asthma, tiotropium has been extensively studied in a large clinical trial program. In Europe and the United States, tiotropium is approved for patients aged ≥6 years and uncontrolled on medium- to high-dose ICS/long-acting β2-agonists at GINA Steps 4 and 5 with a history of exacerbations. Evidence supports the efficacy of tiotropium Respimat® in adults in terms of lung function and asthma control, with a safety profile comparable with that of placebo across a range of asthma severities. Similarly, clinical trials in patients aged 1-17 years have shown improvements in lung function and trends toward improved asthma control. Furthermore, its efficacy makes tiotropium relatively easy to incorporate into routine clinical practice, irrespective of allergic status and without the need for patient phenotyping. Tiotropium is a cost-effective treatment that may offer an important alternative to other, more expensive add-on therapies. This review discusses the potential future position of LAMAs in clinical practice by considering the continuously evolving evidence. Prominence is given to tiotropium, the only LAMA supported by a structured clinical trial program in asthma to date, while also considering other recommended treatment options for patients with uncontrolled asthma. The importance of effective patient/caregiver-clinician communication and shared decision-making in enhancing treatment adherence is also highlighted.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Johannes Gutenberg University Hospital Mainz, Mainz, Germany,
| | - Eckard Hamelmann
- Children's Center Bethel, Evangelic Hospital Bethel, Department of Pediatrics, Bielefeld, Germany
- University Children's Hospital, Allergy Center Ruhr, Ruhr University Bochum, Bochum, Germany
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Nanda A, Baptist AP, Divekar R, Parikh N, Seggev JS, Yusin JS, Nyenhuis SM. Asthma in the older adult. J Asthma 2019; 57:241-252. [PMID: 30656998 DOI: 10.1080/02770903.2019.1565828] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: The older adult population is increasing worldwide, and a significant percentage has asthma. This review will discuss the challenges to diagnosis and management of asthma in older adults. Data Sources: PubMed was searched for multiple terms in various combinations, including asthma, older adult, elderly, comorbid conditions, asthma diagnosis, asthma treatment, biologics and medication side effects, and adverse events. From the search, the data sources that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Study Selections: Study selections that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Results: Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital. Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting β-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Conclusions: The diagnosis and management of asthma in older adults has certain challenges, but if the clinician is aware of them, the morbidity and mortality of this condition can be improved in this growing population.
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Affiliation(s)
- Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, TX, USA.,Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alan P Baptist
- Division of Allergy and Immunology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Rohit Divekar
- Division of Allergy and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Neil Parikh
- Capital Allergy and Respiratory Disease Center, Sacramento, CA, USA
| | - Joram S Seggev
- Department of Internal Medicine, Roseman University College of Medicine, Las Vegas, NV, USA
| | - Joseph S Yusin
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sharmilee M Nyenhuis
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL, USA
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Lin J, Wan H, Kang J, Ma Q, Chen P, Jin M, Wang H, Liu S, Hao Q, Lin Y, Su L, Hu N. Add-on Tiotropium in Chinese Patients With Moderate Asthma: A Pooled Subgroup Analysis of MezzoTinA-Asthma 1 and 2. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2019; 11:519-528. [PMID: 31172720 PMCID: PMC6557774 DOI: 10.4168/aair.2019.11.4.519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/19/2019] [Accepted: 03/07/2019] [Indexed: 01/26/2023]
Abstract
Purpose Asthma affects approximately 30 million patients in China; however, tiotropium data for Chinese patients is limited. This study aimed to assess the efficacy and safety of tiotropium in Chinese patients with moderate symptomatic asthma. Methods A post hoc subgroup analysis was conducted on 430 Chinese patients pooled from two 24-week, replicate phase 3 trials (NCT01172808 and NCT01172821), in which they received once-daily tiotropium 2.5 µg (Tio R2.5) or 5 µg (Tio R5) (n = 106 or 109, respectively), twice-daily salmeterol 50 µg (Sal 50) (n = 110), or placebo (n = 105), while maintaining inhaled corticosteroids (ICS). The co-primary endpoints assessed in week 24 were forced expiratory volume in 1 second (FEV1) peak0–3h response, trough FEV1 response, and responder rate as assessed using the Asthma Control Questionnaire (ACQ). Results For both FEV1 peak0–3h responses and trough FEV1 responses, the mean treatment differences were greater for Tio R2.5, Tio R5, and Sal 50 compared with placebo at 0.249 L, 0.234 L, and 0.284 L, and 0.172 L, 0.180 L, and 0.164 L, respectively (P< 0.001). The ACQ responder rate in placebo, Tio R2.5, Tio R5, and Sal 50 was 58.7%, 62.3%, 59.3%, and 69.1%, respectively. Furthermore, 11 (2.6%) of 430 patients had serious adverse events (Tio R5, n = 4; Tio R2.5, n = 1; Sal 50, n = 1; and placebo, n = 5). Conclusions Once-daily tiotropium, as add-on to medium-dose ICS, was effective and well tolerated for Chinese patients with moderate symptomatic asthma, consistent with the main analysis.
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Affiliation(s)
- Jiangtao Lin
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - Huanying Wan
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Kang
- Department of Pulmonary Diseases, the First Hospital of China Medical University, Shenyang, China
| | - Qianli Ma
- Department of Pulmonary Diseases, Xinqiao Hospital, Chongqing, China
| | - Ping Chen
- Department of Pulmonary Diseases, the Second Xiangya Hospital of Central South University, Changsha, China
| | - Meiling Jin
- Department of Pulmonary Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Haoyan Wang
- Department of Pulmonary Diseases, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Shuang Liu
- Department of Pulmonary and Critical Care Medicine, Capital Medical University Affiliated Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qinglin Hao
- Department of Pulmonary Diseases, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yong Lin
- Department of Pulmonary Diseases, Nanjing Chest Hospital, Nanjing, China
| | - Lin Su
- Boehringer Ingelheim, Shanghai, China
| | - Na Hu
- Boehringer Ingelheim, Shanghai, China
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Chen S, Golam S, Myers J, Bly C, Smolen H, Xu X. Systematic literature review of the clinical, humanistic, and economic burden associated with asthma uncontrolled by GINA Steps 4 or 5 treatment. Curr Med Res Opin 2018; 34:2075-2088. [PMID: 30047292 DOI: 10.1080/03007995.2018.1505352] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study sought to characterize the epidemiologic, clinical, humanistic, and economic burden of patients with asthma uncontrolled by GINA Steps 4 or 5 treatment (severe, uncontrolled asthma [SUA]). METHODS A systematic literature review adhering to PRISMA guidelines was performed. Relevant publications were searched for in MEDLINE and EMBASE from January 2004 to September 2016 and in a conference proceedings database from January 2012 to October 2016. Studies were screened using the Population, Intervention, Comparator, Outcomes, Study Design, and Time (PICOS-T) framework. Studies of SUA with observational (prospective and retrospective), randomized, or nonrandomized study designs; adult patient populations; sample sizes ≥20 patients; epidemiologic or clinical outcomes, patient-reported outcomes (PROs), or economic outcomes were included. For our analysis, SUA was defined as inadequate control of asthma, despite the use of medium- to high-dosage inhaled corticosteroids and at least one additional treatment. RESULTS A total of 195 articles reporting unique study populations were included. Prevalence of SUA was as great as 87.4% for patients with severe asthma, although values varied depending on the criteria used to define asthma control. Compared with patients with severe asthma who were controlled, patients with SUA experienced more symptoms, night-time awakenings, rescue medication use, and worse PROs. SUA-associated costs were 3-times greater than costs for patients with severe, controlled disease. CONCLUSION Despite the availability of approved asthma treatments, this literature analysis confirms that SUA poses a substantial epidemiologic, clinical, humanistic, and economic burden. Published data are limited for certain aspects of SUA, highlighting a need for further research.
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Affiliation(s)
| | | | - Julie Myers
- c Medical Decision Modeling Inc. , Indianapolis , IN, USA
| | - Chris Bly
- c Medical Decision Modeling Inc. , Indianapolis , IN, USA
| | - Harry Smolen
- c Medical Decision Modeling Inc. , Indianapolis , IN, USA
| | - Xiao Xu
- a AstraZeneca , Gaithersburg , MD, USA
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Lin J, Yang D, Huang M, Zhang Y, Chen P, Cai S, Liu C, Wu C, Yin K, Wang C, Zhou X, Su N. Chinese expert consensus on diagnosis and management of severe asthma. J Thorac Dis 2018; 10:7020-7044. [PMID: 30746249 PMCID: PMC6344700 DOI: 10.21037/jtd.2018.11.135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/25/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Jiangtao Lin
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Dong Yang
- Department of Respiratory Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Mao Huang
- Department of Respiratory Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yongming Zhang
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ping Chen
- Department of Respiratory Medicine, General Hospital of Shenyang Military Region, Shenyang 110015, China
| | - Shaoxi Cai
- Department of Respiratory Medicine, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China
| | - Chuntao Liu
- Department of Respiratory Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Changgui Wu
- Department of Respiratory Medicine, Xijing Hospital of Fourth Military Medical University, Xi’an 710032, China
| | - Kaisheng Yin
- Department of Respiratory Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Changzheng Wang
- Department of Respiratory Medicine, Xinqiao Hospital of Third Military Medical University, Chongqing 400037, China
| | - Xin Zhou
- Department of Respiratory Medicine, First People’s Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Nan Su
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
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Hoshino M, Akitsu K, Ohtawa J. Comparison between montelukast and tiotropium as add-on therapy to inhaled corticosteroids plus a long-acting β 2-agonist in for patients with asthma. J Asthma 2018; 56:995-1003. [PMID: 30212239 DOI: 10.1080/02770903.2018.1514047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objective: Asthma often remains uncontrolled despite treatment with inhaled corticosteroids (ICS) alone or with ICS plus a long-acting β2-agonist (LABA). The recommended alternative is the addition of either montelukast or tiotropium. The aim of this study was to compare the effects of montelukast and tiotropium on airway inflammation and remodeling in persistent asthma. Methods: Eighty-seven patients with asthma were treated with budesonide and formoterol (640/18 μg); then, the patients were randomly allocated to three groups to receive oral montelukast (10 mg/day), inhaled tiotropium (5 μg/day), or no add-on to the maintenance therapy for 48 weeks. Fractional exhaled nitric oxide (FeNO) and pulmonary function were measured, and quantitative computed tomography was performed. Results: Compared to the maintenance therapy, add-on montelukast significantly decreased FeNO (p < 0.05) and improved airflow obstruction (p < 0.05), whereas airway dimensions remained unchanged. Changes in FeNO were significantly correlated with changes in FEV1 (r = -0.71, p < 0.001). In contrast, the addition of tiotropium significantly decreased airway wall area corrected for body surface area (WA/BSA) (p < 0.05), decreased wall thickness (T/√BSA) (p < 0.05) and improved airflow obstruction (p < 0.05) with no change in FeNO. Changes in WA/BSA and T/√BSA were significantly correlated with the change in percentage predicted FEV1 (r = -0.84, p < 0.001 and r = -0.59, p < 0.01, respectively). Conclusions:Adding either montelukast or tiotropium to ICS/LABA may provide additive benefits with respect to the pulmonary function and airway inflammation or remodeling in patients with asthma.
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Affiliation(s)
- Makoto Hoshino
- a Division of Clinical Allergy, Department of Internal Medicine, Atami Hospital, International University of Health and Welfare , Atami , Japan
| | - Kenta Akitsu
- b Department of Radiology, Atami Hospital, International University of Health and Welfare , Atami , Japan
| | - Junichi Ohtawa
- b Department of Radiology, Atami Hospital, International University of Health and Welfare , Atami , Japan
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Busse WW, Maspero JF, Rabe KF, Papi A, Wenzel SE, Ford LB, Pavord ID, Zhang B, Staudinger H, Pirozzi G, Amin N, Akinlade B, Eckert L, Chao J, Graham NMH, Teper A. Liberty Asthma QUEST: Phase 3 Randomized, Double-Blind, Placebo-Controlled, Parallel-Group Study to Evaluate Dupilumab Efficacy/Safety in Patients with Uncontrolled, Moderate-to-Severe Asthma. Adv Ther 2018; 35:737-748. [PMID: 29725983 PMCID: PMC5960488 DOI: 10.1007/s12325-018-0702-4] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Indexed: 11/07/2022]
Abstract
Introduction Dupilumab, a fully human anti-IL-4Rα monoclonal antibody, inhibits signaling of both interleukin (IL)-4 and IL-13, which are key drivers of type 2-mediated inflammation. Dupilumab is approved in the EU, USA, and other countries for the treatment of adults with inadequately controlled moderate-to-severe atopic dermatitis. Following positive phase 2 results in asthma, the phase 3 Liberty Asthma QUEST trial was initiated to provide further evidence for dupilumab efficacy and safety in patients with uncontrolled, moderate-to-severe asthma. Methods Liberty Asthma QUEST is a phase 3, multinational, multicenter, randomized, double-blind, placebo-controlled, parallel-group trial (NCT02414854) in patients with persistent asthma who are receiving continuous treatment with inhaled corticosteroids (ICS) plus one or two other asthma controller medicines. A total of 1902 patients (aged ≥ 12 years) were randomized in a 2:2:1:1 ratio to receive 52 weeks of add-on therapy with subcutaneously administered dupilumab 200 or 300 mg every 2 weeks or matched placebo. The study consisted of a 4 ± 1-week screening period, 52-week randomized treatment period, and 12-week post-treatment follow-up period. All patients continued to receive their prescribed ICS plus up to two additional controller medications. The primary efficacy endpoints were annualized rate of severe exacerbation events during the 52-week treatment period and absolute change from baseline in pre-bronchodilator FEV1 at week 12. Conclusion Uncontrolled asthma patients with persistent symptoms represent a population of significant unmet need, for whom new treatments are required. Patients with severe asthma are at high risk of asthma exacerbations, and face an accelerated decline in lung function and impaired quality of life. QUEST examines the efficacy of dupilumab in this at-risk patient population; it is the largest placebo-controlled study in uncontrolled, moderate-to-severe asthma with a biologic agent to date, and the only phase 3 study of a biologic therapy of asthma that enrolled patients irrespective of baseline type 2 inflammatory biomarker levels. Funding Sanofi and Regeneron Pharmaceuticals, Inc. Clinical Trials.gov Identifier NCT02414854.
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Kerwin E, Wachtel A, Sher L, Nyberg J, Darken P, Siddiqui S, Duncan EA, Reisner C, Dorinsky P. Efficacy, safety, and dose response of glycopyrronium administered by metered dose inhaler using co-suspension delivery technology in subjects with intermittent or mild-to-moderate persistent asthma: A randomized controlled trial. Respir Med 2018; 139:39-47. [PMID: 29858000 DOI: 10.1016/j.rmed.2018.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This randomized, double-blind, placebo-controlled, cross-over, Phase II dose-ranging study investigated the efficacy and safety of GP MDI (glycopyrronium administered by metered dose inhaler formulated using co-suspension delivery technology) compared with an open-label active comparator, salmeterol dry powder inhaler (SAL DPI), in subjects with intermittent or mild-to-moderate persistent asthma. METHODS Subjects were randomized to receive five of seven treatments (GP MDI 28.8, 14.4, 7.2, 3.6, and 1.9 μg, placebo MDI, and SAL DPI 50 μg), each for a 14-day period. The primary endpoint was peak change from baseline in forced expiratory volume in 1 s (FEV1) on Day 15. Secondary endpoints included additional lung function parameters and symptoms (Asthma Control Questionnaire-5). Safety was monitored throughout. RESULTS Of 248 subjects randomized, 211 completed the study. All doses of GP MDI resulted in significant improvements in the primary endpoint compared with placebo MDI in a dose-ordered fashion (range 85-155 mL, p < .0001), without appreciable differences between the two highest doses of GP MDI (28.8 and 14.4 μg) and SAL DPI 50 μg. Improvements in secondary lung function endpoints and symptoms were generally dose-ordered, with GP MDI 28.8 μg showing the greatest improvements. Similar results were observed when endpoints were analyzed based on subjects' background use of inhaled corticosteroids (yes/no). All GP MDI doses were well tolerated with no evidence of a dose-related effect on adverse events. CONCLUSIONS The results of this study suggest that GP MDI could offer an important treatment option for maintenance therapy of asthma, and warrants further investigation in Phase III clinical trials.
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Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA.
| | - Andrew Wachtel
- Southern California Institute for Respiratory Diseases, Los Angeles, CA, USA
| | - Lawrence Sher
- Peninsula Research Associates, Rolling Hills Estates, CA, USA
| | - Jack Nyberg
- Pearl - a member of the AstraZeneca Group, Morristown, NJ, USA
| | - Patrick Darken
- Pearl - a member of the AstraZeneca Group, Morristown, NJ, USA
| | | | | | - Colin Reisner
- Pearl - a member of the AstraZeneca Group, Morristown, NJ, USA; AstraZeneca, Gaithersburg, MD, USA
| | - Paul Dorinsky
- Pearl - a member of the AstraZeneca Group, Durham, NC, USA
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Drake MG, Lebold KM, Roth-Carter QR, Pincus AB, Blum ED, Proskocil BJ, Jacoby DB, Fryer AD, Nie Z. Eosinophil and airway nerve interactions in asthma. J Leukoc Biol 2018; 104:61-67. [PMID: 29633324 DOI: 10.1002/jlb.3mr1117-426r] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 12/19/2022] Open
Abstract
Airway eosinophils are increased in asthma and are especially abundant around airway nerves. Nerves control bronchoconstiction and in asthma, airway hyperreactivity (where airways contract excessively to inhaled stimuli) develops when eosinophils alter both parasympathetic and sensory nerve function. Eosinophils release major basic protein, which is an antagonist of inhibitory M2 muscarinic receptors on parasympathetic nerves. Loss of M2 receptor inhibition potentiates parasympathetic nerve-mediated bronchoconstriction. Eosinophils also increase sensory nerve responsiveness by lowering neurons' activation threshold, stimulating nerve growth, and altering neuropeptide expression. Since sensory nerves activate parasympathetic nerves via a central neuronal reflex, eosinophils' effects on both sensory and parasympathetic nerves potentiate bronchoconstriction. This review explores recent insights into mechanisms and effects of eosinophil and airway nerve interactions in asthma.
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Affiliation(s)
- Matthew G Drake
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Katherine M Lebold
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Quinn R Roth-Carter
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Alexandra B Pincus
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Emily D Blum
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Becky J Proskocil
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - David B Jacoby
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Allison D Fryer
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Zhenying Nie
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Abstract
PURPOSE OF REVIEW Current guidelines recommend a stepwise approach for pharmacological therapy aimed to achieve and maintain asthma control. Despite these recommendations, at least 50% of patients continue to be uncontrolled with risk of asthma exacerbations that can often be serious and are associated with deterioration of quality of life. In recent years, the interest in anticholinergic bronchodilators, which have been primarily used in the treatment of chronic obstructive pulmonary disease, has increased patients with uncontrolled asthma. This review analyzes the mechanisms for the proposed clinical use of anticholinergic bronchodilators as an adjunctive therapy in asthma. RECENT FINDINGS Based on existing and recent evidence, the use of anticholinergic bronchodilators, particularly long-acting muscarinic antagonists (LAMAs), plays an important role as add-on therapy in patients uncontrolled on existing therapies. In particular, the use of anticholinergics in asthma may have a role in patients intolerant to long-acting β2 agonist, in patients with certain pharmacogenetic profiles and in those patients with asthma symptoms mostly at night. SUMMARY Data from clinical trials and from real-life confirm the safety and efficacy of LAMAs, especially tiotropium, in patients who remain uncontrolled despite the use of inhaled corticosteroid therapy.
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Abstract
PURPOSE OF REVIEW Asthma is a heterogeneous disease not only on a clinical but also on a mechanistic level. For a long time, the molecular mechanisms of asthma were considered to be driven by type 2 helper T cells (Th2) and eosinophilic airway inflammation; however, extensive research has revealed that T2-low subtypes that differ from the dominant T2 paradigm are also common. RECENT FINDINGS Research into asthma pathways has led to the recognition that some asthma phenotypes show absence of T2 inflammation or alternate between T2 and non-T2 responses. Moreover, numerous immune response modifiers that block key-molecules such as interleukin (IL)-5, IL-13, and immunoglobulin E (IgE) have been identified. Along the way, these studies pointed that T2-low inflammation may also be responsible for lack of responsiveness to current treatment regimes. SUMMARY Asthma pathogenesis is characterized by two major endotypes, a T2-high featuring increased eosinophilic airway inflammation, and a T2-low endotype presenting with either neutrophilic or paucigranulocytic airway inflammation and showing greater resistance to steroids. This clearly presents an unmet therapeutic challenge. A precise definition and characterization of the mechanisms that drive this T2-low inflammatory response in each patient phenotype is necessary to help identify novel drug targets and design more effective and targeted treatments.
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Zervas E, Samitas K, Papaioannou AI, Bakakos P, Loukides S, Gaga M. An algorithmic approach for the treatment of severe uncontrolled asthma. ERJ Open Res 2018. [PMID: 29531957 PMCID: PMC5838355 DOI: 10.1183/23120541.00125-2017] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
A small subgroup of patients with asthma suffers from severe disease that is either partially controlled or uncontrolled despite intensive, guideline-based treatment. These patients have significantly impaired quality of life and although they constitute <5% of all asthma patients, they are responsible for more than half of asthma-related healthcare costs. Here, we review a definition for severe asthma and present all therapeutic options currently available for these severe asthma patients. Moreover, we suggest a specific algorithmic treatment approach for the management of severe, difficult-to-treat asthma based on specific phenotype characteristics and biomarkers. The diagnosis and management of severe asthma requires specialised experience, time and effort to comprehend the needs and expectations of each individual patient and incorporate those as well as his/her specific phenotype characteristics into the management planning. Although some new treatment options are currently available for these patients, there is still a need for further research into severe asthma and yet more treatment options. Stepwise approach for the treatment of severe asthmahttp://ow.ly/rLPl30i0TyZ
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Affiliation(s)
- Eleftherios Zervas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Konstantinos Samitas
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | | | - Petros Bakakos
- 1st Respiratory Medicine Dept, Athens Chest Hospital "Sotiria", University of Athens, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Dept, Attikon Hospital, University of Athens, Athens, Greece
| | - Mina Gaga
- 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
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Zhang L, Huang G, Jin L, Han S. Therapeutic Effects of a Long-Acting Cholinergic Receptor Blocker, Tiotropium Bromide, on Asthma. Med Sci Monit 2018; 24:944-950. [PMID: 29446377 PMCID: PMC5822933 DOI: 10.12659/msm.907950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to evaluate the therapeutic effects of tiotropium bromide on asthma. Material/Methods A total of 160 patients with moderate persistent asthma were randomly divided into 4 groups (n=40): the 3 control groups were given fluticasone propionate aerosol (group A), salmeterol-fluticasone propionate inhalant (group B), and tiotropium bromide inhalation powder combined with salmeterol-fluticasone propionate inhalant (group C), respectively, and the experimental group received tiotropium bromide inhalation powder combined with fluticasone propionate aerosol (group D) and salbutamol was used to relieve symptoms when necessary. Results After 8 weeks of treatment, the pulmonary function of group D, which was significantly better than those of group A (P<0.05), was similar to those of groups B and C (P>0.05). Group D had significantly better asthma control test scores and nighttime symptom scores than in group A (P<0.05), without significant differences from those of group B or group C (P>0.05). The number of times salbutamol was used to alleviate symptoms was significantly different (P<0.05) between group D and group A (P<0.05), as well as between group C and group D (P<0.05). Groups D and B had similar results (P>0.05). IL-13 levels in induced sputum had significant differences (P<0.05). The levels in group D, which were higher than those of groups A and B (P<0.05), were similar to those of group C (P>0.05). Conclusions Tiotropium bromide combined with fluticasone propionate improved the respiratory function and quality of life, and is a new therapy for moderate, persistent asthma.
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Affiliation(s)
- Li Zhang
- Department of Respiratory Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China (mainland)
| | - Guangyin Huang
- Department of Respiratory Medicine, Jurong Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China (mainland)
| | - Long Jin
- Department of Respiratory Medicine, Jurong Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China (mainland)
| | - Shuhua Han
- Department of Respiratory Medicine, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China (mainland)
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Fukumitsu K, Kanemitsu Y, Asano T, Takeda N, Ichikawa H, Yap JMG, Fukuda S, Uemura T, Takakuwa O, Ohkubo H, Maeno K, Ito Y, Oguri T, Nakamura A, Takemura M, Niimi A. Tiotropium Attenuates Refractory Cough and Capsaicin Cough Reflex Sensitivity in Patients with Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1613-1620.e2. [PMID: 29408386 DOI: 10.1016/j.jaip.2018.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Asthmatic cough is often refractory to standard treatments such as inhaled corticosteroids (ICS) and long-acting β2 agonists (LABA). Tiotropium may modulate cough reflex sensitivity of acute viral cough, but its efficacy in asthmatic cough remains unknown. OBJECTIVE To evaluate whether tiotropium improves cough and cough reflex sensitivity in patients with asthma refractory to ICS/LABA. METHODS Seventeen consecutive patients with asthma with chronic cough despite the use of ICS/LABA (13 women; 43.4 ± 19.0 years; average ICS dose, 651 ± 189 μg/d; fluticasone equivalent) were additionally treated with tiotropium (5 μg/d) for 4 to 8 weeks to examine its effects on pulmonary function and capsaicin cough reflex sensitivity (cough thresholds C2 and C5). Cough severity, cough-specific quality of life, and asthma control were also evaluated using cough visual analog scales (VASs), the Japanese version of Leicester Cough Questionnaire (J-LCQ), and Asthma Control Test (ACT), respectively. Patients with an improved cough VAS score of 15 mm or more were considered responders to tiotropium. RESULTS Tiotropium significantly improved cough VAS, J-LCQ, and ACT scores, but not FEV1. Changes in cough VAS score correlated with those in C2 (r = -0.58; P = .03), C5 (r = -0.58; P = .03), and ACT scores (r = -0.62; P = .02), but not in FEV1 in the overall patients. When analyses were confined to the 11 responders, tiotropium significantly improved capsaicin cough reflex sensitivity within the subgroup (C2: P = .01 and C5: P = .02) and versus the nonresponders (C2: P = .004 and C5: P = .02). CONCLUSION Tiotropium may alleviate asthmatic cough refractory to ICS/LABA by modulating cough reflex sensitivity but not through bronchodilation.
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Affiliation(s)
- Kensuke Fukumitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan.
| | - Takamitsu Asano
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Norihisa Takeda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Hiroya Ichikawa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Jennifer Maries Go Yap
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Satoshi Fukuda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Takehiro Uemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Osamu Takakuwa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Hirotsugu Ohkubo
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Ken Maeno
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Yutaka Ito
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Tetsuya Oguri
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Atsushi Nakamura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Masaya Takemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
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