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Pfeffer PE, Rupani H, De Simoni A. Bringing the treatable traits approach to primary care asthma management. FRONTIERS IN ALLERGY 2023; 4:1240375. [PMID: 37799134 PMCID: PMC10548136 DOI: 10.3389/falgy.2023.1240375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Asthma continues to be a major cause of illness with a significant mortality, despite its increasing range of treatments. Adoption of a treatable traits approach in specialist centres has led to improvements in control of asthma and reduced exacerbations in patients with severe asthma. However, most patients with this illness, particularly those with mild-to-moderate asthma, are cared for in primary care according to guidelines that emphasise the use of pharmacotherapeutic ladders uniformly implemented across all patients. These pharmacotherapeutic ladders are more consistent with a "one-size-fits-all" approach than the treatable traits approach. This can be harmful, especially in patients whose symptoms and airway inflammation are discordant, and extra-pulmonary treatable traits are often overlooked. Primary care has extensive experience in patient-centred holistic care, and many aspects of the treatable traits approach could be rapidly implemented in primary care. Blood eosinophil counts, as a biomarker of the treatable trait of eosinophilia, are already included in routine haematology tests and could be used in primary care to guide titration of inhaled corticosteroids. Similarly, poor inhaler adherence could be further assessed and managed in primary care. However, further research is needed to guide how some treatable traits could feasibly be assessed and/or managed in primary care, for example, how to best manage patients in primary care, who are likely suffering from breathing pattern disorders and extra-pulmonary treatable traits, with frequent use of their reliever inhaler in the absence of raised T2 biomarkers. Implementation of the treatable traits approach across the disease severity spectrum will improve the quality of life of patients with asthma but will take time and research to embed across care settings.
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Affiliation(s)
- Paul E. Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Hitasha Rupani
- Department of Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Anna De Simoni
- Wolfson Institute of Population Health and Asthma UK Centre for Applied Research, Queen Mary University of London, London, United Kingdom
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Casale TB, Foggs MB, Balkissoon RC. Optimizing asthma management: Role of long-acting muscarinic antagonists. J Allergy Clin Immunol 2022; 150:557-568. [PMID: 35933228 DOI: 10.1016/j.jaci.2022.06.015] [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: 10/27/2021] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Patients with asthma who are suboptimally responsive to inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs) are frequently exposed to oral corticosteroids and high-dose ICS, which can lead to significant side effects. Long-acting muscarinic antagonists (LAMAs) have demonstrated efficacy and safety in a subset of these patients. This review summarizes the results of key studies using LAMAs in patients with asthma aged 12 years or older. LAMA as an add-on treatment improved lung function and asthma control in patients with uncontrolled asthma across studies. The efficacy of LAMAs as an add-on to ICS was superior to that of placebo and ICS dose escalation and comparable with that of LABAs. LAMA plus ICS plus LABA provided modest improvements in bronchodilation and increased the time to first severe exacerbation versus ICS plus LABA. Single-inhaler triple therapy was associated with decreased health care resource utilization and improved cost-effectiveness versus multiple inhalers. LAMAs were generally well tolerated; asthma exacerbations, bronchitis, and nasopharyngitis were common adverse events with LAMA in combination with ICS alone or ICS plus LABA. Thus, the overall evidence presented in this review supports the use of add-on LAMA treatment as a reasonable option in patients with asthma uncontrolled with ICS plus LABA or ICS alone.
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Affiliation(s)
- Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla.
| | | | - Ronald C Balkissoon
- Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, Colo
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Agusti A, Fabbri L, Lahousse L, Singh D, Papi A. Single inhaler triple therapy (SITT) in asthma: Systematic review and practice implications. Allergy 2022; 77:1105-1113. [PMID: 34478578 PMCID: PMC9290056 DOI: 10.1111/all.15076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
A significant number of patients with asthma remain uncontrolled despite treatment with inhaled corticosteroids (ICS) and long-acting β2 adrenergic bronchodilators (LABA). The addition of long-acting antimuscarinic agents (LAMA) can improve the management of asthma in these patients. Recently, three novel triple therapy (ICS/LABA/LAMA) formulations in a single-inhaler device (SITT) have been investigated in patients with uncontrolled asthma despite ICS/LABA treatment. Here, we review systematically the evidence available to date in relation to SITT in patients with uncontrolled asthma despite ICS-LABA treatment and conclude that SITT is a safe and effective therapeutic alternative in these patients. We also discuss how to position this new therapeutic alternative in their practical clinical management as well as the opportunities and challenges that it may generate for patients, physicians, and payers.
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Affiliation(s)
- Alvar Agusti
- Respiratory Institute IDIBAPS CIBERES Hospital ClinicUniv. Barcelona Barcelona Spain
| | - Leonardo Fabbri
- Section of Respiratory Medicine Department of Morphology, Surgery and Experimental Medicine University of Ferrara Ferrara Italy
| | - Lies Lahousse
- Department of Bioanalysis Ghent University Ghent Belgium
| | - Dave Singh
- Medicines Evaluation Unit University of ManchesterManchester University NHS Foundation Trust Manchester UK
| | - Alberto Papi
- Emergency Department, Respiratory Medicine University of FerraraUniversity Hospital S. Anna Ferrara Italy
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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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