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Drummond D, Mazenq J, Lezmi G, Cros P, Coutier L, Desse B, Divaret-Chauveau A, Dubus JC, Girodet PO, Kiefer S, Llerena C, Pouessel G, Troussier F, Werner A, Schweitzer C, Lejeune S, Giovannini-Chami L. [Therapeutic management and adjustment of long-term treatment]. Rev Mal Respir 2024:S0761-8425(24)00244-4. [PMID: 39181752 DOI: 10.1016/j.rmr.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
- D Drummond
- Service de pneumologie et d'allergologie pédiatrique, hôpital Necker, AP-HP, université Paris Cité, Paris, France
| | - J Mazenq
- Service de pneumologie pédiatrique, hôpital la Timone, AP-HM, université Aix-Marseille, Marseille, France
| | - G Lezmi
- Service de pneumologie et d'allergologie pédiatrique, hôpital Necker, AP-HP, université Paris Cité, Paris, France
| | - P Cros
- Service de pédiatrie, CHU Morvan, Brest, France
| | - L Coutier
- Unité Inserm U1028, CNRS, UMR 5292, université de Lyon 1, Lyon, France; Service de pneumologie pédiatrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, Bron, France
| | - B Desse
- Service de pédiatrie-néonatalogie, CH de Grasse, Grasse, France
| | - A Divaret-Chauveau
- Service de médecine infantile et explorations fonctionnelles pédiatriques, DeVAH EA 3450, hôpital d'enfants, faculté de médecine de Nancy, CHRU de Nancy, université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - J-C Dubus
- Service de pneumologie pédiatrique, hôpital la Timone, AP-HM, université Aix-Marseille, Marseille, France
| | - P-O Girodet
- CIC1401, service de pharmacologie médicale, CHU de Bordeaux, université de Bordeaux, Bordeaux, France
| | - S Kiefer
- Service de médecine infantile et explorations fonctionnelles pédiatriques, DeVAH EA 3450, hôpital d'enfants, faculté de médecine de Nancy, CHRU de Nancy, université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - C Llerena
- UTEP 38, hôpital Couple-Enfant, CHU de Grenoble Alpes, Grenoble, France
| | - G Pouessel
- ULR 2694 : METRICS, université de Lille, Lille, France; Service de pédiatrie, CH de Roubaix, Roubaix, France; Univ. Lille, Service de pneumologie et d'allergologie pédiatrique, hôpital Jeanne de Flandre, CHU de Lille, F-59000 Lille, France
| | - F Troussier
- Service de pédiatrie, CHU d'Angers, Angers, France
| | - A Werner
- Pôle pédiatrique, Association française de pédiatrie ambulatoire (AFPA) Ancenis Saint-Géreon, Villeneuve-lès-Avignon, France
| | - C Schweitzer
- Service de médecine infantile et explorations fonctionnelles pédiatriques, DeVAH EA 3450, hôpital d'enfants, faculté de médecine de Nancy, CHRU de Nancy, université de Lorraine, Vandœuvre-Lès-Nancy, France
| | - S Lejeune
- Univ. Lille, Service de pneumologie et d'allergologie pédiatrique, hôpital Jeanne de Flandre, CHU de Lille, F-59000 Lille, France..
| | - L Giovannini-Chami
- Service de pneumologie et d'allergologie pédiatrique, hôpitaux pédiatriques de Nice CHU-Lenval, université Côte d'Azur, Nice, France
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2
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Licari A, Manti S, Mastellone F, Miraglia Del Giudice M, Marseglia GL, Tosca MA. Critical reappraisal of short-acting bronchodilators for pediatric respiratory diseases. Ital J Pediatr 2024; 50:104. [PMID: 38783314 PMCID: PMC11112862 DOI: 10.1186/s13052-024-01675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Short-acting bronchodilators are a class of medications commonly used to treat asthma, chronic obstructive pulmonary disease, and other respiratory conditions. The use of these medications has evolved over time as we have gained a better understanding of their effectiveness and safety in the pediatric population. This comprehensive review synthesizes the current understanding of short-acting β2-agonists and short-acting anticholinergics in children. It addresses indications, contraindications, safety considerations, and highlights areas where further research is needed to guide the most effective use of short-acting bronchodilators.
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Affiliation(s)
- Amelia Licari
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pediatric Unit, University of Pavia, Pavia, Italy.
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Sara Manti
- Department of Human Pathology of Adult and Childhood Gaetano Barresi, Pediatric Unit, University of Messina, Messina, Italy
| | - Francesco Mastellone
- Department of Life Sciences and Public Health, Post-Graduate School of Pediatrics, Policlinico Gemelli Universitary Foundation IRCCS, Catholic University of Sacre Hearth, Rome, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gian Luigi Marseglia
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pediatric Unit, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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3
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Bush A, Randerath W, Roche N. As needed ICS/formoterol: not all of Europe is equal. Eur Respir J 2024; 63:2400408. [PMID: 38806204 DOI: 10.1183/13993003.00408-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/15/2024] [Indexed: 05/30/2024]
Affiliation(s)
- Andrew Bush
- National Heart and Lung Institute, Imperial College, and Imperial Centre for Paediatrics and Child Health, London, UK
- Royal Brompton Hospital, London, UK
| | - Winifried Randerath
- Bethanien Hospital, Solingen, Germany
- Institute of Pneumology, University of Cologne, Cologne, Germany
| | - Nicolas Roche
- Pneumologie, Hôpital Cochin, Paris, France
- Département Médico-Universitaire THOROS (Thorax ORL Sommeil), AP-HP, Centre Université Paris Cité, UMR 1016, Institut Cochin, Paris, France
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Barry T, Holliday M, Sparks J, Biggs R, Colman A, Lamb R, Oldfield K, Shortt N, Kerse K, Martindale J, Eathorne A, Walton M, Black B, Harwood M, Bruce P, Semprini R, Bush A, Fleming L, Byrnes CA, McNamara D, Hatter L, Dalziel SR, Weatherall M, Beasley R. START CARE: a protocol for a randomised controlled trial of step-wise budesonide-formoterol reliever-based treatment in children. ERJ Open Res 2024; 10:00897-2023. [PMID: 38590934 PMCID: PMC11000271 DOI: 10.1183/23120541.00897-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/12/2024] [Indexed: 04/10/2024] Open
Abstract
Background Asthma is the most common chronic childhood respiratory condition globally. Inhaled corticosteroid (ICS)-formoterol reliever-based regimens reduce the risk of asthma exacerbations compared with conventional short-acting β2-agonist (SABA) reliever-based regimens in adults and adolescents. The current limited evidence for anti-inflammatory reliever therapy in children means it is unknown whether these findings are also applicable to children. High-quality randomised controlled trials (RCTs) are needed. Objective The study aim is to determine the efficacy and safety of budesonide-formoterol reliever alone or maintenance and reliever therapy (MART) compared with standard therapy: budesonide or budesonide-formoterol maintenance, both with terbutaline reliever, in children aged 5 to 11 years with mild, moderate and severe asthma. Methods A 52-week, multicentre, open-label, parallel group, phase III, two-sided superiority RCT will recruit 400 children aged 5 to 11 years with asthma. Participants will be randomised 1:1 to either budesonide-formoterol 100/6 µg Turbuhaler reliever alone or MART; or budesonide or budesonide-formoterol Turbuhaler maintenance, with terbutaline Turbuhaler reliever. The primary outcome is moderate and severe asthma exacerbations as rate per participant per year. Secondary outcomes are asthma control, lung function, exhaled nitric oxide and treatment step change. Assessment of Turbuhaler technique and cost-effectiveness analysis are also planned. Conclusion This will be the first RCT to compare the efficacy and safety of a step-wise budesonide-formoterol reliever alone or MART regimen with conventional inhaled ICS or ICS-long-acting β-agonist maintenance plus SABA reliever in children. The results will provide a much-needed evidence base for the treatment of asthma in children.
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Affiliation(s)
- Tasmin Barry
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Jenny Sparks
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rowan Biggs
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Atalie Colman
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rebekah Lamb
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Karen Oldfield
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nick Shortt
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kyley Kerse
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - John Martindale
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Michaela Walton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bianca Black
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Matire Harwood
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ruth Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Andrew Bush
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Louise Fleming
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Catherine A. Byrnes
- Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Starship Children's Health, Te Toka Tumai, Auckland, New Zealand
| | - David McNamara
- Starship Children's Health, Te Toka Tumai, Auckland, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
| | - Stuart R. Dalziel
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Starship Children's Health, Te Toka Tumai, Auckland, New Zealand
| | - Mark Weatherall
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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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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6
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Papi A, Ferreira DS, Agache I, Baraldi E, Beasley R, Brusselle G, Coleman C, Gaga M, Gotera Rivera CM, Melén E, Pavord ID, Peñate Gómez D, Schuermans D, Spanevello A, Tonia T, Schleich F. European Respiratory Society short guidelines for the use of as-needed ICS/formoterol in mild asthma. Eur Respir J 2023; 62:2300047. [PMID: 37678955 DOI: 10.1183/13993003.00047-2023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
Recent clinical trials of as-needed fixed-dose combination of inhaled corticosteroid (ICS)/formoterol have provided new evidence that may warrant a reconsideration of current practice. A Task Force was set up by the European Respiratory Society to provide evidence-based recommendations on the use of as-needed ICS/formoterol as treatment for mild asthma. The Task Force defined two questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The Task Force utilised the outcomes to develop recommendations for a pragmatic guideline for everyday clinical practice. The Task Force suggests that adults with mild asthma use as-needed ICS/formoterol instead of regular ICS maintenance treatment plus as-needed short-acting β2-antagonist (SABA) and that adolescents with mild asthma use either as-needed ICS/formoterol or ICS maintenance treatment plus as-needed SABA (conditional recommendation; low certainty of evidence). The recommendation for adults places a relatively higher value on the reduction of systemic corticosteroid use and the outcomes related to exacerbations, and a relatively lower value on the small differences in asthma control. Either treatment option is suggested for adolescent patients as the balance is very close and data more limited. The Task Force recommends that adult and adolescent patients with mild asthma use as-needed ICS/formoterol instead of as-needed SABA (strong recommendation; low certainty of evidence). This recommendation is based on the benefit of as-needed ICS/formoterol in mild asthma on several outcomes and the risks related to as-needed SABA in the absence of anti-inflammatory treatment. The implementation of this recommendation is hampered in countries (including European Union countries) where as-needed ICS/formoterol is not approved for mild asthma.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
- A. Papi and D.S. Ferreira contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
| | - Diogenes S Ferreira
- Private Practice, Allergy and Immunology, Belo Horizonte, Brazil
- A. Papi and D.S. Ferreira contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Eugenio Baraldi
- Department of Women's and Children's Health, University of Padova, Institute of Pediatric Research "Città della Speranza", Padova, Italy
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Mina Gaga
- Athens Chest Hospital, Athens, Greece
| | | | - Erik Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sachsska Children's Hospital, Stockholm, Sweden
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Daniel Schuermans
- Respiratory Division, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Department of Medicine and Cardiopulmonary Rehabilitation, Tradate Institute, Tradate, Italy
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- T. Tonia and F. Schleich contributed equally to this work
| | - Florence Schleich
- Respiratory Medicine, CHU Liege, Liege, Belgium
- GIGA-I3, University of Liege, Liege, Belgium
- T. Tonia and F. Schleich contributed equally to this work
- A. Papi, D.S. Ferreira and F. Schleich are Task Force co-chairs
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Larenas-Linnemann D, Romeo J, Ariue B, Oppenheimer J. American College of Allergy, Asthma and Immunology members' preferred steps 1 to 3 asthma maintenance and reliever therapy and incomplete insurance coverage indicated as main practice hurdle. Ann Allergy Asthma Immunol 2023; 131:451-457. [PMID: 37328056 DOI: 10.1016/j.anai.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND New asthma guidelines (GINA, 2022; NAEPP EPR-4, 2020) include considerable changes in treatment recommendations, specifically regarding anti-inflammatory rescue and Single MAintenance and Reliever Therapy (SMART). OBJECTIVE To explore American College of Allergy, Asthma and Immunology members' preferred treatment and perceived hurdles. METHODS A survey (SurveyMonkey) regarding steps 1 to 3 asthma therapy was e-mailed to American College of Allergy, Asthma and Immunology members. RESULTS The allergists completed 147 surveys (46% with >20 years of experience; 98% from United States; 29% academic, 75% [also] private practice). In addition, 69% follow the National Asthma Education and Prevention Program and 81% the Global Initiative for Asthma recommendations. Of 147 allergists, 117 (80%) indicated correctly what SMART strategy is; 21%/36%/50%/39% would use SMART in step 3 treatment of a below 5-year-old/5- to 11-year-old/12- to 65-year-old/above 65-year-old patient, respectively. In this group, 11% to 14% incorrectly chose inhaled corticosteroid (ICS) plus salmeterol and 9% ICS plus vilanterol for SMART. In a 4-year-old needing step 1 therapy (N = 129), 55% of the respondents would add anti-inflammatory therapy; for step 2 treatment, most would prescribe ICS 100 to 200 µg budesonide equivalent daily; in step 3, 49% would prescribe ICS plus long-acting beta-agonist (LABA). In a 7-year-old needing step 1 treatment (N = 134), 40% would prescribe only short-acting beta-agonist; in step 3, 45% would institute SMART strategy, but only 8 of 135 (6%) chose very-low dose ICS plus formoterol (as recommended in Global Initiative for Asthma); most (39%) use low-dose ICS plus formoterol. As for rescue therapy, 59% is now instituting some form of anti-inflammatory rescue. Finally, in a 25-year-old patient (N = 144): in step 1, 39% would prescribe exclusively short-acting beta-agonist; in step 2, 4% only anti-inflammatory rescue and the rest prescribes ICS maintenance; one-third begins SMART strategy at step 2 and 50% in step 3. Major hurdles for prescribing one's preferred strategy included incomplete insurance coverage, insurance not approving more than one canister of ICS-formoterol per month, and cost. CONCLUSION Asthma therapy varies among physicians, with respondents suggesting underutilization of the recommended anti-inflammatory rescue and SMART therapy. A major hurdle is lack of insurance coverage of medication in line with the guidelines.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Centro de Excelencia en Asma y Alergia, Mexico City, Mexico.
| | - Jonathan Romeo
- Allergy Partners of the Triangle, Raleigh, North Carolina
| | - Barbara Ariue
- Division of Allergy/Immunology, Department of Pediatrics, Loma Linda Children's Hospital, Loma Linda, California
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8
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Warraich S, Bush A, Levy ML, Fleming L. Regular (up to 10 puffs 4-hourly) inhaled salbutamol should be prescribed at discharge after an asthma attack: myth or maxim? Breathe (Sheff) 2023; 19:230054. [PMID: 37830102 PMCID: PMC10567074 DOI: 10.1183/20734735.0054-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/08/2023] [Indexed: 10/14/2023] Open
Abstract
Over the past 20 years, the concept of asthma weaning plans on discharge after an attack has crept into common practice, although the precise origin of these plans is unclear. High use of short-acting β2-agonists (SABAs) may result in tolerance to their bronchodilator effects, thus diminishing their efficacy, particularly when they are most needed at the time of an acute attack. Furthermore, key warning signs of a deterioration in asthma control may be masked and the weaning plan may encourage the over-use and over-reliance on SABAs. Side-effects from over-use may also occur, including lactic acidosis, downregulation of the β2-adrenoreceptor, increased allergen response and pro-inflammatory effects. The need for asthma education at discharge, a personal asthma action plan and vigilance about prescribing and ensuring adherence to maintenance therapy are definitely important. However, the current authors conclude that the benefit of prescribing regular salbutamol (up to 10 puffs every 4 h) at discharge after an acute asthma attack is a myth, and a very dangerous one.
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Affiliation(s)
- Sara Warraich
- Department of Respiratory Paediatrics, Addenbrookes Hospital, Cambridge, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Andrew Bush
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Louise Fleming
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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9
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Castagnoli R, Brambilla I, Giovannini M, Marseglia GL, Licari A. New approaches in childhood asthma treatment. Curr Opin Allergy Clin Immunol 2023; 23:319-326. [PMID: 37357774 PMCID: PMC10317303 DOI: 10.1097/aci.0000000000000922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the most recent advances in asthma management, focusing on novel approaches to pediatric asthma. RECENT FINDINGS In recent years, the therapeutic tools for pediatric asthma have expanded significantly for both the nonsevere and severe forms. The use of anti-inflammatory treatment, even for the mildest cases, and the withdrawal of symptomatic bronchodilation as monotherapy have been included in the most recent guidelines. Also, different biological therapies have revolutionized the therapeutical approach for severe uncontrolled asthma in children and adolescents. SUMMARY With the expanding landscape of novel therapeutic approaches for pediatric asthma, further evidence is needed to help clinicians choose the best option for patients, particularly those with severe asthma. The identification of novel predictive biomarkers may also help pediatricians in selecting children and adolescents for innovative therapies.
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Affiliation(s)
- Riccardo Castagnoli
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Ilaria Brambilla
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
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10
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Bigoni T, Alfano F, Baraldi F, Contoli M, Papi A. Evaluating as-needed inhaled corticosteroid strategies in asthma: expanding the benefits to mild asthma. Expert Rev Respir Med 2023; 17:623-634. [PMID: 37578053 DOI: 10.1080/17476348.2023.2247973] [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: 10/27/2022] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Adherence to regular anti-inflammatory treatment is commonly low, and short-acting β2 agonist (SABA) overuse is common in patients with asthma, leading to an increased risk of asthma-related adverse events. AREAS COVERED Given the pivotal role of inflammation in asthma, multiple as-needed inhaled corticosteroid (ICS)-containing therapies have been developed, leading to a reduction in asthma exacerbations and improvement in symptom control. Currently, as-needed ICS/formoterol is one of the most commonly available formulations; however, other combinations such as ICS/SABA have been shown to be superior to as-needed SABA alone. Therefore, we performed a comprehensive review of the available scientific literature to enhance the advantages and disadvantages of each combination in clinical practice. EXPERT OPINION The future direction we foresee in asthma management consists in abandoning as-needed short-acting bronchodilators in favor of as-needed ICS-containing therapies. Each patient is unique and differs from others; consequently, a single option will not fit everyone. Patients' and physicians' awareness of this perspective can be reached through the development of multiple therapeutic options suitable for each condition that can be found in 'real life'.
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Affiliation(s)
- Tommaso Bigoni
- Respiratory Unit, Department of Translational Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Franco Alfano
- Respiratory Unit, Department of Translational Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Federico Baraldi
- Respiratory Unit, Department of Translational Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Marco Contoli
- Respiratory Unit, Department of Translational Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Alberto Papi
- Respiratory Unit, Department of Translational Medicine, Sant'Anna University Hospital, Ferrara, Italy
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11
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Castagnoli R, Brambilla I, Giudice MMD, Marseglia GL, Licari A. Applying the new guidelines to asthma management in children. Curr Opin Allergy Clin Immunol 2023; 23:132-136. [PMID: 36637070 DOI: 10.1097/aci.0000000000000892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW This review aims to provide paediatricians with novel concepts from scientific evidence applicable to treating children with asthma. The latest guideline updates on paediatric asthma are discussed here, with a focus on the 2022 update of the GINA document. RECENT FINDINGS Mild asthma remains to be an important challenge for the paediatrician, and the introduction of new evidence-based treatment strategies, particularly those symptom-driven, could have a significant impact on the paediatric population. The identification of predictive biomarkers, the definition of biological treatment response, the possible duration of these therapies in this age group, as well as their potential action on airway remodelling are desirable in the short term. As the number of available biological treatment options expands, paediatricians should be supported by further evidence in decision-making. SUMMARY There is an urgent need to implement at multiple levels the latest therapeutic strategies proposed for asthma at all severities.
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Affiliation(s)
- Riccardo Castagnoli
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Ilaria Brambilla
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, University of Campania 'Luigi Vanvitelli', Napoli, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia
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12
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Cardet JC, Papi A, Reddel HK. "As-Needed" Inhaled Corticosteroids for Patients With Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:726-734. [PMID: 36702246 PMCID: PMC10006338 DOI: 10.1016/j.jaip.2023.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/25/2023]
Abstract
Prevention of severe asthma exacerbations is a primary management goal for asthma across the severity spectrum. Inhaled corticosteroids (ICSs) decrease the risk of asthma exacerbations, but patient adherence to ICS-containing medications as a daily maintenance therapy is poor, and many patients overuse short-acting beta2-agonist relievers; both are associated with increased risk of severe exacerbations and death. Airway inflammation also varies over time, influenced by exposures such as viral infections and allergen. As-needed ICS strategies, in which patients receive ICSs (or additional ICSs, if already taking controller therapy) whenever they take their reliever inhaler, empower patients to adjust their ICS intake in response to symptom fluctuation. These strategies can improve asthma morbidity outcomes, particularly by reducing severe exacerbations and reducing the risk of adverse effects of oral corticosteroids. In this review, the evidence for combination ICS-formoterol in a single inhaler, ICS and short-acting beta2-agonists in separate inhalers, and combination ICS-albuterol in a single inhaler is presented, along with practical considerations, evidence gaps, and implications for clinical practice for each strategy, presented by level of asthma severity and age group. Improving access to such strategies on a global scale is imperative to improve asthma outcomes and achieve equity across populations.
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Affiliation(s)
- Juan Carlos Cardet
- Division of Allergy and Immunology, Internal Medicine Department, Morsani College of Medicine, University of South Florida, Tampa, Fla.
| | - Alberto Papi
- Respiratory Medicine, CEMICEF, University of Ferrara, Ferrara, Italy
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
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13
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Beasley R, Bruce P, Houghton C, Hatter L. The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:762-772.e1. [PMID: 36639054 DOI: 10.1016/j.jaip.2023.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta2-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades. In this commentary, we review the rationale for combination ICS/formoterol therapy, the evidence on which this recommendation has been made, the limitations in the evidence, the practical issues relevant to the implementation of ICS/formoterol reliever-based regimens in clinical practice, and the emerging evidence for the efficacy and safety of combination ICS/salbutamol reliever therapy regimens.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; Capital and Coast District Health Board, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand.
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Claire Houghton
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; Victoria University of Wellington, Wellington, New Zealand
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14
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Krings JG, Gerald JK, Blake KV, Krishnan JA, Reddel HK, Bacharier LB, Dixon AE, Sumino K, Gerald LB, Brownson RC, Persell SD, Clemens CJ, Hiller KM, Castro M, Martinez FD. A Call for the United States to Accelerate the Implementation of Reliever Combination Inhaled Corticosteroid-Formoterol Inhalers in Asthma. Am J Respir Crit Care Med 2023; 207:390-405. [PMID: 36538711 PMCID: PMC9940146 DOI: 10.1164/rccm.202209-1729pp] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- James G. Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Joe K. Gerald
- Department of Community Environment and Policy, Mel and Enid Zuckerman College of Public Health
- Asthma & Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Kathryn V. Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children’s Health, Jacksonville, Florida
| | | | - Helen K. Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Leonard B. Bacharier
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne E. Dixon
- Division of Pulmonary Critical Care, Department of Medicine, University of Vermont, Burlington, Vermont
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Lynn B. Gerald
- Population Health Sciences Program, University of Illinois Chicago, Chicago, Illinois
| | - Ross C. Brownson
- Department of Surgery, School of Medicine, and
- Prevention Research Center, Brown School, Washington University in Saint Louis, St. Louis, Missouri
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, and
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Katherine M. Hiller
- Department of Emergency Medicine, School of Medicine, Indiana University, Bloomington, Indiana; and
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Kansas, Kansas City, Kansas
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15
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Dy T, Hamilton WJ, Kramer CB, Apter A, Krishnan JA, Stout JW, Teach SJ, Federman A, Elder J, Bryant-Stephens T, Bruhl RJ, Jackson S, Sumino K. Stakeholder engagement in eight comparative effectiveness trials in African Americans and Latinos with asthma. RESEARCH INVOLVEMENT AND ENGAGEMENT 2022; 8:63. [PMID: 36434672 PMCID: PMC9694541 DOI: 10.1186/s40900-022-00399-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The effects of stakeholder engagement, particularly in comparative effectiveness trials, have not been widely reported. In 2014, eight comparative effectiveness studies targeting African Americans and Hispanics/Latinos with uncontrolled asthma were funded by the Patient-Centered Outcomes Research Institute (PCORI) as part of its Addressing Disparities Program. Awardees were required to meaningfully involve patients and other stakeholders. Using specific examples, we describe how these stakeholders substantially changed the research protocols and in other ways participated meaningfully as full partners in the development and conduct of the eight studies. METHODS Using the method content analysis of cases, we identified themes regarding the types of stakeholders, methods of engagement, input from the stakeholders, changes made to the research protocols and processes, and perceived benefits and challenges of the engagement process. We used summaries from meetings of the eight teams, results from an engagement survey, and the final research reports as our data source to obtain detailed information. The descriptive data were assessed by multiple reviewers using inductive and deductive qualitative methods and discussed in the context of engagement literature. RESULTS Stakeholders participated in the planning, conduct, and dissemination phases of all eight asthma studies. All the studies included clinicians and community representatives as stakeholders. Other stakeholders included patients with asthma, their caregivers, advocacy organizations, and health-system representatives. Engagement was primarily by participation in advisory boards, although six of the eight studies (75%) also utilized focus groups and one-on-one interviews. Difficulty finding a time and location to meet was the most reported challenge to engagement, noted by four of the eight teams (50%). Other reported challenges and barriers to engagement included recruitment of stakeholders, varying levels of enthusiasm among stakeholders, controlling power dynamics, and ensuring that stakeholder involvement was reflected and had true influence on the project. CONCLUSION Engagement-driven modifications led to specific changes in study design and conduct that were felt to have increased enrollment and the general level of trust and support of the targeted communities. The level of interaction described, between investigators and stakeholders in each study and between investigator-stakeholder groups, is-we believe-unprecedented and may provide useful guidance for other studies seeking to improve the effectiveness of community-driven research.
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Affiliation(s)
- Tiffany Dy
- Division of Allergy and Immunology, Department of Internal Medicine, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, CB 8122, St. Louis, MO, 63110, USA.
| | - Winifred J Hamilton
- Environmental Health Service, Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Andrea Apter
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois Chicago and Population Health Sciences Program, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - James W Stout
- Department of Pediatrics and Health Services, University of Washington, Seattle, WA, USA
| | - Stephen J Teach
- Division of Emergency Medicine and the Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Alex Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Elder
- Institute for Behavioral and Community Health, School of Public Health, San Diego State University, San Diego, CA, USA
| | - Tyra Bryant-Stephens
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca J Bruhl
- Environmental Health Service, Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Shawni Jackson
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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16
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Rodriguez-Martinez CE, Sossa-Briceño MP, Garcia-Marcos L. Use of inhaled corticosteroids on an intermittent or as-needed basis in pediatric asthma: a systematic review of the literature. J Asthma 2022; 59:2189-2200. [PMID: 34806537 DOI: 10.1080/02770903.2021.2008430] [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: 07/05/2021] [Revised: 10/16/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To summarize the principal findings of all available studies that have evaluated the use of inhaled corticosteroids (ICS) on an intermittent or as-needed basis as an add-on therapy to short-acting β2-agonists (SABAs) or fast-acting β2-agonists (FABAs) in pediatric asthmatic patients. Studies could either include or omit the use of ICS during stable periods of the disease. DATA SOURCES Electronic databases MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Database of Systematic Reviews from inception to February 2021. STUDY SELECTIONS Relevant articles in the literature published by February 2021. RESULTS Of 294 references identified, 14 studies were included. The use of ICS on an intermittent or as-needed basis (as an add-on therapy to SABAs) has been shown to be more effective than treatment with SABA alone and to be similarly or less effective compared to regular daily ICS administration. Furthermore, strategies involving increasing the dose of ICS only when needed (as an add-on therapy to formoterol, a FABA) and keeping it low during stable stages of the disease (i.e. single maintenance and reliever therapy, SMART) have been shown to be similarly or more effective than comparators. CONCLUSION The use of ICS on an intermittent or as-needed basis as an add-on therapy to SABAs or FABAs, with or without ICS use during stable periods of the disease in pediatric asthmatic patients, encompasses several effective treatment strategies.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Luis Garcia-Marcos
- Pediatric Allergy and Pulmonology Units, "Virgen de la Arrixaca" University Children's Hospital, University of Murcia and IMIB Bioresearch Institute, ARADyAL Allergy Network Spain, Murcia, Spain
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17
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Mortimer K, Reddel HK, Pitrez PM, Bateman ED. Asthma management in low and middle income countries: case for change. Eur Respir J 2022; 60:2103179. [PMID: 35210321 PMCID: PMC9474897 DOI: 10.1183/13993003.03179-2021] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/07/2022] [Indexed: 11/05/2022]
Abstract
Asthma is the most common noncommunicable disease in children, and among the most common in adults. The great majority of people with asthma live in low and middle income countries (LMICs), which have disproportionately high asthma-related morbidity and mortality. Essential inhaled medications, particularly those containing inhaled corticosteroids (ICS), are often unavailable or unaffordable, and this explains much of the global burden of preventable asthma morbidity and mortality. Guidelines developed for LMICs are generally based on the outdated assumption that patients with asthma symptoms <1-3 times per week do not need (or benefit from) ICS. Even when ICS are prescribed, many patients manage their asthma with oral or inhaled short-acting β2-agonists (SABA) alone, owing to issues of availability and affordability. A single ICS-formoterol inhaler-based approach to asthma management for all severities of asthma, from mild to severe, starting at diagnosis, might overcome SABA overuse/over-reliance and reduce the burden of symptoms and severe exacerbations. However, ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. There is a pressing need for pragmatic clinical trial evidence of the feasibility and cost-effectiveness of this and other strategies to improve asthma care in these countries. The global health inequality in asthma care that deprives so many children, adolescents and adults of healthy lives and puts them at increased risk of death, despite the availability of highly effective therapeutic approaches, is unacceptable. A World Health Assembly Resolution on universal access to affordable and effective asthma care is needed to focus attention and investment on addressing this need.
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Affiliation(s)
- Kevin Mortimer
- Dept of Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Dept of Medicine, University of Cambridge, Cambridge, UK
| | - Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia
| | - Paulo M Pitrez
- Pediatric Respiratory Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Eric D Bateman
- Division of Pulmonology, Dept of Medicine, University of Cape Town, Cape Town, South Africa
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18
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Rodríguez-Martínez CE, Sossa-Briceño MP, Buendia JA. As-Needed Use of Short-Acting β 2-Agonists Alone Versus As-Needed Use of Short-Acting β 2-Agonists Plus Inhaled Corticosteroids in Pediatric Patients With Mild Intermittent (Step 1) Asthma: A Cost-Effectiveness Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1562-1568. [PMID: 35259534 DOI: 10.1016/j.jaip.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although the efficacy of the as-needed use of short-acting β2-agonists (SABAs) plus inhaled corticosteroids (ICS) for treating children with mild intermittent asthma has been demonstrated, evidence of its cost-effectiveness is scarce. OBJECTIVES The aim of the present study was to compare the cost-effectiveness of the as-needed use of SABAs alone versus the as-needed use of SABAs plus ICS in children 5 to 11 years old with mild intermittent (step 1) asthma but suffering from an exacerbation of asthma symptoms. METHODS A decision-analysis model was adapted. Effectiveness parameters were obtained from a randomized clinical trial. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national health care system in Colombia. The main outcome of the model was a first course of prednisone for an asthma exacerbation (AE). RESULTS Compared with the use of SABAs alone, the as-needed use of SABAs plus ICS was associated with lower overall treatment costs (US$17.99 vs US$27.94 mean cost per patient) and a higher probability of a lack of a requirement for a first course of prednisone (0.6500 vs 0.5100), thus showing dominance. CONCLUSIONS In Colombia, compared with the use of albuterol alone, the use of beclomethasone dipropionate added to albuterol as needed for symptom relief is cost-effective in children 5 to 11 years old with mild intermittent (step 1) asthma, because it involves a higher probability of a lack of a requirement for prednisone for AE at lower total treatment costs.
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Affiliation(s)
- Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia; Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia.
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Jefferson Antonio Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
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Bryant-Stephens T. Breaking the Skin Color Barriers for Asthma Medications - It's Not Black, Brown, or White. N Engl J Med 2022; 386:1574-1575. [PMID: 35443113 DOI: 10.1056/nejme2201666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tyra Bryant-Stephens
- From the Community Asthma Prevention Program, Center for Health Equity, Children's Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia
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20
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Duijts L, Fleming LJ, Bacharier LB, Pitrez PM, Reddel HK. Reply to Baraldi and Piacentini: Global Initiative for Asthma 2021: Asthma in Preschool Children and Short-Acting β 2-Agonist-Only Treatment. Am J Respir Crit Care Med 2022; 205:972-973. [PMID: 35202561 PMCID: PMC9838630 DOI: 10.1164/rccm.202112-2788le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Liesbeth Duijts
- Erasmus MC, University Medical Center RotterdamRotterdam, the Netherlands
| | - Louise J. Fleming
- National Heart and Lung Institute, Imperial College LondonLondon, United Kingdom
| | | | | | - Helen K. Reddel
- The Woolcock Institute of Medical ResearchSydney, New South Wales, Australia,The University of SydneySydney, New South Wales, Australia,Corresponding author (e-mail: )
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21
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Park HJ, Huh JY, Lee JS, Lee JS, Oh YM, Lee SW. Comparative efficacy of inhalers in mild-to-moderate asthma: systematic review and network meta-analysis. Sci Rep 2022; 12:5949. [PMID: 35396495 PMCID: PMC8993836 DOI: 10.1038/s41598-022-09941-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/24/2022] [Indexed: 12/03/2022] Open
Abstract
The comparative effectiveness of different inhaler therapies in mild-to-moderate asthma remains unclear. To assess this, we performed a systematic review and network meta-analysis of randomized controlled trials on the use of inhalers for mild-to-moderate asthma by searching PubMed, Cochrane, and Embase. A total of 29 trials including 43,515 patients and 12 types of inhaler therapies were included. For the prevention of severe and moderate-to-severe exacerbations, inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) as maintenance and reliever (SMART) showed the highest rank for effectiveness. As-needed ICS/LABA or short-acting β2-agonist (SABA) was similar to low-dose ICS and superior to as-needed SABA or LABA for the prevention of severe and moderate-severe exacerbations. As for lung function (FEV1), low-dose ICS/LABA had the highest rank; as-needed ICS/LABA was inferior to regular low-dose ICS but superior to placebo. Higher-dose ICS had a superior effect on the Asthma Control Questionnaire (ACQ) scores, and as-needed ICS/LABA and as-needed SABA or LABA had lower ranks in p-rankogram than did the regular use of low-dose ICS. As-needed ICS with LABA or SABA was more effective than a similar dose of regular ICS for preventing exacerbation in mild-to-moderate asthma. As-needed ICS showed some weakness in improving lung function and controlling asthma symptoms.
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Affiliation(s)
- Hyung Jun Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jin-Young Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Clinical Research Center, Asan Medical Center, Seoul, South Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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22
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Jat KR, Gupta A. Recent Advances in Long-Term Management of Asthma. Indian J Pediatr 2022; 89:378-386. [PMID: 35050462 DOI: 10.1007/s12098-021-04060-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Abstract
Asthma is one of the most common chronic diseases of childhood with significant morbidity. Management of asthma has evolved from inhaled corticosteroids to personalized therapy in recent years. This article summarizes the recent advances in the management of asthma. The severity of asthma is assessed retrospectively by the level of treatment required to control asthma symptoms.Recently, there has been an emphasis on not to use short-acting beta-2 agonist (SABA) alone, even for intermittent or mild asthma. Single maintenance and reliever therapy (MART) is increasingly being recommended. Asthma therapy should be personalized based on phenotype (clinical presentations) and endotypes (distinct mechanistic pathways) of asthma and by a continuous cycle of assessment of asthma control and risk assessment, treatment, and reviewing the response in children on treatment. Various add-on therapy like tiotropium and biological monoclonal antibodies have been approved for use in a subset of children with severe asthma. Before considering biologicals, it is vital to have a proper diagnosis, good compliance and inhaler technique, and treatment of comorbidities.
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Affiliation(s)
- Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King's College Hospital, King's College, London, UK
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma Strategy 2021. Executive Summary and Rationale for Key Changes. Arch Bronconeumol 2022; 58:35-51. [DOI: 10.1016/j.arbres.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022]
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Larenas-Linnemann D, Navarrete-Rodríguez EM, Luna-Pech JA, Benítez R, Cano-Salas MC, Del Rio-Navarro BE, García-Ramírez U, Gochicoa L, López-Estrada EC, Ortega-Martell JA, Salas Hernández J. An independent in-depth analysis proposing adjusted Global Initiative on Asthma (GINA) Step 1-2 treatment suggestions. Clin Exp Allergy 2021; 52:493-511. [PMID: 34904293 DOI: 10.1111/cea.14079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/27/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022]
Abstract
The Global initiative on asthma (GINA) strategy included major changes for the treatment of mild asthma in the 2020 version, that are even taken to a next level in 2021, leaving a preferred track with only rescue therapy with inhaled corticosteroid and formoterol (ICS-FORM) for step 1-2 in 12+ years-old. It has been questioned how solid the evidence behind these recommendations is. We decided to independently conduct an in-depth analysis of published evidence based on a comprehensive evaluation of original articles and related appendices and publications, including quality of evidence and risk-of-bias per article. We first defined the major asthma treatment goals and proceeded to review how these were met in publications referenced in the main asthma guidelines. For patients with GINA 2021 Step 1 characteristics the analysis supports GINA's decision to avoid SABA monotherapy and to prefer ICS-FORM rescue with as alternative ICS rescue every time a SABA is used for ≥12 years, even though evidence is extrapolated from step 2 patients. For 6-11 year-olds we propose to consider ICS-FORM rescue as an alternative, as its use has been approved in this age-group, be it not as rescue-medication. For patients with GINA 2021 Step 2 characteristics our proposal slightly differs from GINA 2021. We propose to continue avoiding the separate use of SABA, using ICS rescue whenever a fast-acting bronchodilator is taken (even with ICS maintenance). Also, the superiority of ICS-FORM rescue over classical step 2 treatment is not uniform and year-long experience is lacking. Consequently for now, both treatment options seem equal: ICS-FORM rescue or ICS maintenance with SABA (+ICS) rescue. For 6-11 year-olds ICS rescue every time a SABA is used has the advantage of lower total ICS dose; as alternative we suggest ICS-FORM rescue. The best treatment option depends on patient characteristics and treatment goals. Recommendations should be reviewed as soon as new evidence becomes available.
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Affiliation(s)
- D Larenas-Linnemann
- Médica Sur Fundación y Hospital, Centro de Excelencia en Asma y Alergia, Ciudad de México, México
| | - E M Navarrete-Rodríguez
- Hospital Infantil de México Federico Gómez, Servicio de Alegia e Inmunología Clínica, Ciudad de México, México
| | - J A Luna-Pech
- Universidad de Guadalajara, Departamento de Disciplinas Filosóficas Metodológicas e Instrumentales, Jalisco, México
| | - R Benítez
- Instituto nacional de enfermedades respiratorias "Ismael Cosío Villegas", Jefe del departamento de fisiología respiratoria, Ciudad de México, México
| | - M C Cano-Salas
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Departamento de Formación de Posgrado, Ciudad de México, México
| | - B E Del Rio-Navarro
- Hospital Infantil de México Federico Gómez, Servicio de Alegia e Inmunología Clínica, Ciudad de México, México
| | - U García-Ramírez
- CMN del Bajío, Departamento de Alergia e Inmunología Clínica, León, Guanajuato, México
| | - L Gochicoa
- Instituto nacional de enfermedades respiratorias "Ismael Cosío Villegas", Jefe del departamento de fisiología respiratoria, Ciudad de México, México
| | - E C López-Estrada
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Ciudad de México, México
| | - J A Ortega-Martell
- Universidad Autónoma del Estado de Hidalgo, Instituto de Ciencias para la Salud. Facultad de Medicina. Departamento de Inmunología. Estado de Hidalgo, México
| | - Jorge Salas Hernández
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Dirección General, Ciudad de México, México
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Hatter L, Bruce P, Holliday M, Anderson AJ, Braithwaite I, Corin A, Eathorne A, Grimes A, Harwood M, Hills T, Kearns C, Kerse K, Martindale J, Montgomery B, Riggs L, Sheahan D, Shortt N, Zazulia K, Weatherall M, McNamara D, Byrnes CA, Bush A, Dalziel SR, Beasley R. The Children's Anti-inflammatory Reliever (CARE) study: a protocol for a randomised controlled trial of budesonide-formoterol as sole reliever therapy in children with mild asthma. ERJ Open Res 2021; 7:00271-2021. [PMID: 34853785 PMCID: PMC8628747 DOI: 10.1183/23120541.00271-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Asthma is the most common chronic disease in children, many of whom are managed solely with a short-acting β2-agonist (SABA). In adults, the evidence that budesonide-formoterol as sole reliever therapy markedly reduces the risk of severe exacerbations compared with SABA alone has contributed to the Global Initiative for Asthma recommending against SABA monotherapy in this population. The current lack of evidence in children means it is unknown whether these findings are also relevant to this demographic. High-quality randomised controlled trials (RCTs) are needed. Objective The aim of this study is to determine the efficacy and safety of as-needed budesonide-formoterol therapy compared with as-needed salbutamol in children aged 5 to 15 years with mild asthma, who only use a SABA. Methods A 52-week, open-label, parallel group, phase III RCT will recruit 380 children aged 5 to 15 years with mild asthma. Participants will be randomised 1:1 to either budesonide-formoterol (Symbicort Rapihaler®) 50/3 µg, two actuations as needed, or salbutamol (Ventolin®) 100 µg, two actuations as needed. The primary outcome is asthma attacks as rate per participant per year. Secondary outcomes assess asthma control, lung function, exhaled nitric oxide and treatment step change. A cost-effectiveness analysis is also planned. Conclusion This is the first RCT to assess the safety and efficacy of as-needed budesonide-formoterol in children with mild asthma. The results will provide a much-needed evidence base for the treatment of mild asthma in children. This protocol describes the first randomised controlled trial to investigate the efficacy and safety of budesonide/formoterol as sole reliever therapy for children with mild asthma, providing urgently needed evidence in this populationhttps://bit.ly/35v0R3Z
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Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | | | | | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Arthur Grimes
- Motu Economic and Public Policy Research, Wellington, New Zealand
| | - Matire Harwood
- Dept of General Practice and Primary Healthcare, University of Auckland, Auckland, New Zealand
| | - Thomas Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ciléin Kearns
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kyley Kerse
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - John Martindale
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Lynn Riggs
- Motu Economic and Public Policy Research, Wellington, New Zealand
| | | | - Nick Shortt
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Katja Zazulia
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Weatherall
- Dept of Medicine, University of Otago, Wellington, New Zealand
| | - David McNamara
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Catherine A Byrnes
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Dept of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Stuart R Dalziel
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Dept of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand.,School of Biological Sciences, Victoria University Wellington, Wellington, New Zealand
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26
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Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S1-S18. [PMID: 34718211 DOI: 10.1016/j.jaip.2021.10.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Eur Respir J 2021; 59:13993003.02730-2021. [PMID: 34667060 PMCID: PMC8719459 DOI: 10.1183/13993003.02730-2021] [Citation(s) in RCA: 235] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes.GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as- needed combination ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA.Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4.Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia.
| | - Leonard B Bacharier
- Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric D Bateman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Guy G Brusselle
- Ghent University Hospital, Ghent, Belgium and Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Liesbeth Duijts
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong
| | - Jerry A Krishnan
- Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, USA
| | | | - Jiangtao Lin
- China-Japan Friendship Hospital, Peking University, Beijing, China
| | | | | | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, United Kingdom
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28
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Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming LJ, Inoue H, Ko FW, Krishnan JA, Levy ML, Lin J, Mortimer K, Pitrez PM, Sheikh A, Yorgancioglu AA, Boulet LP. Global Initiative for Asthma (GINA) Strategy 2021 - Executive Summary and Rationale for Key Changes. Am J Respir Crit Care Med 2021; 205:17-35. [PMID: 34658302 PMCID: PMC8865583 DOI: 10.1164/rccm.202109-2205pp] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults/adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as-needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS formoterol (maintenance-and-reliever therapy, MART) in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting beta2-agonist (LABA) (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age-groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment and review remain essential to optimize asthma outcomes.
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Affiliation(s)
- Helen K Reddel
- The University of Sydney, 4334, Woolcock Institute of Medical Research,, Sydney, New South Wales, Australia;
| | - Leonard B Bacharier
- Vanderbilt University Medical Center, 12328, Monroe Carell Jr Children's Hospital , Nashville, Tennessee, United States
| | - Eric D Bateman
- University of Cape Town Department of Medicine, 71984, Observatory, Western Cape, South Africa
| | - Christopher E Brightling
- NIHR Leicester Biomedical Research Centre, 573772, Leicester, United Kingdom of Great Britain and Northern Ireland
| | - Guy G Brusselle
- University Hospital Ghent, 60200, Ghent, Belgium and Erasmus MC University Medical Center, Rotterdam, Belgium
| | - Roland Buhl
- Mainz University Hospital, Pulmonary Department, Mainz, Germany
| | - Alvaro A Cruz
- Universidade Federal da Bahia, 28111, ProAR-Center of Excellence in Asthma, Salvador, Brazil
| | - Liesbeth Duijts
- Erasmus MC, 6993, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeffrey M Drazen
- Brigham and Woman's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - J Mark FitzGerald
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Louise J Fleming
- Imperial College London, 4615, London, United Kingdom of Great Britain and Northern Ireland
| | | | - Fanny W Ko
- The Chinese University of Hong Kong, 26451, Hong Kong, Hong Kong
| | - Jerry A Krishnan
- University of Illinois at Chicago, 14681, Breathe Chicago Center, Chicago, Illinois, United States
| | - Mark L Levy
- Locum GP, London, United Kingdom of Great Britain and Northern Ireland
| | - Jiangtao Lin
- Peking University, 12465, China-Japan Friendship Hospital, Beijing, China
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, 9655, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Paulo M Pitrez
- Hospital Moinhos de Vento, 156417, Porto Alegre, Rio Grande do Sul, Brazil
| | - Aziz Sheikh
- The University of Edinburgh, 3124, Usher Institute, Edinburgh, United Kingdom of Great Britain and Northern Ireland
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Mohan A, Ludwig A, Brehm C, Lugogo N, Sumino K, Hanania NA. Revisiting Mild Asthma: Current Knowledge and Future Needs. Chest 2021; 161:26-39. [PMID: 34543667 DOI: 10.1016/j.chest.2021.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/22/2021] [Accepted: 09/09/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common chronic airways disease with significant impact on patients, caregivers, and the health-care system. Although most research and novel interventions mainly have focused on patients with uncontrolled severe asthma, most patients with asthma have mild disease. Epidemiologic studies suggest that many patients with mild asthma report frequent exacerbations of the disease and uncontrolled symptoms. However, despite its impact, mild asthma does not have either a uniformly agreed on definition for or a consensus on its clinical and pathophysiologic progression. More recently, the approach to treatment of patients with mild asthma has undergone significant changes primarily based on emerging evidence that airway inflammation in this population is important. This led to clinical research studies that explored the efficacy of as-needed inhaled corticosteroids along with the rescue medications that traditionally have been the mainstay of treatment. Despite some advancement in the field in recent years, many controversies and unmet needs remain. In this review, we examine the current understanding of the pathophysiologic features and management of mild asthma. In addition, we outline unmet needs for future research. We conclude that mild asthma contributes significantly to the morbidity and mortality of asthma and should be the focus of future research.
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Affiliation(s)
- Arjun Mohan
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA.
| | - Amy Ludwig
- Department of Internal Medicine and Pediatrics, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caryn Brehm
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, MO
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX
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Jackson DJ, Bacharier LB. Inhaled corticosteroids for the prevention of asthma exacerbations. Ann Allergy Asthma Immunol 2021; 127:524-529. [PMID: 34400314 DOI: 10.1016/j.anai.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 07/27/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To provide an overview of the risk factors and mechanisms underlying asthma exacerbations and the role of inhaled corticosteroids (ICSs) in preventing exacerbations. DATA SOURCES Queries for asthma exacerbations and ICSs were conducted using PubMed, searching for primary articles and reviews. STUDY SELECTIONS Studies written in English, with a focus on well-designed randomized controlled clinical trials. RESULTS Asthma exacerbations remain a major source of morbidity, with future exacerbations most likely among patients with previous exacerbations and among those with peripheral blood eosinophilia. Exacerbations are often triggered by viral respiratory tract infections, but recent evidence supports nonviral triggers as well. In terms of exacerbation prevention, several approaches to ICS therapy have been found to be effective, including intermittent high-dose ICS without use of background controller in preschool children with recurrent episodic wheezing, intermittent high-dose ICS without use of background controller in adults with mild asthma, and as-needed ICS dosing whenever rescue treatment is needed among children, adolescents, and adults with mild asthma not receiving daily controller therapy. CONCLUSION ICSs are highly effective in preventing exacerbations of asthma. Multiple dosing strategies have been found to reduce exacerbation risk, allowing for a personalization of approaches based on individual patient phenotypes and preferences.
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Affiliation(s)
- Daniel J Jackson
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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31
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Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, Richardson R, Webb P, O'Boyle E, Hinks TS. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database Syst Rev 2021; 5:CD013518. [PMID: 33945639 PMCID: PMC8096360 DOI: 10.1002/14651858.cd013518.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Asthma affects 350 million people worldwide including 45% to 70% with mild disease. Treatment is mainly with inhalers containing beta₂-agonists, typically taken as required to relieve bronchospasm, and inhaled corticosteroids (ICS) as regular preventive therapy. Poor adherence to regular therapy is common and increases the risk of exacerbations, morbidity and mortality. Fixed-dose combination inhalers containing both a steroid and a fast-acting beta₂-agonist (FABA) in the same device simplify inhalers regimens and ensure symptomatic relief is accompanied by preventative therapy. Their use is established in moderate asthma, but they may also have potential utility in mild asthma. OBJECTIVES To evaluate the efficacy and safety of single combined (fast-onset beta₂-agonist plus an inhaled corticosteroid (ICS)) inhaler only used as needed in people with mild asthma. SEARCH METHODS We searched the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, ClinicalTrials.gov and the World Health Organization (WHO) trials portal. We contacted trial authors for further information and requested details regarding the possibility of unpublished trials. The most recent search was conducted on 19 March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over trials with at least one week washout period. We included studies of a single fixed-dose FABA/ICS inhaler used as required compared with no treatment, placebo, short-acting beta agonist (SABA) as required, regular ICS with SABA as required, regular fixed-dose combination ICS/long-acting beta agonist (LABA), or regular fixed-dose combination ICS/FABA with as required ICS/FABA. We planned to include cluster-randomised trials if the data had been or could be adjusted for clustering. We excluded trials shorter than 12 weeks. We included full texts, abstracts and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We analysed dichotomous data as odds ratios (OR) or rate ratios (RR) and continuous data as mean difference (MD). We reported 95% confidence intervals (CIs). We used Cochrane's standard methodological procedures of meta-analysis. We applied the GRADE approach to summarise results and to assess the overall certainty of evidence. Primary outcomes were exacerbations requiring systemic steroids, hospital admissions/emergency department or urgent care visits for asthma, and measures of asthma control. MAIN RESULTS We included six studies of which five contributed results to the meta-analyses. All five used budesonide 200 μg and formoterol 6 μg in a dry powder formulation as the combination inhaler. Comparator fast-acting bronchodilators included terbutaline and formoterol. Two studies included children aged 12+ and adults; two studies were open-label. A total of 9657 participants were included, with a mean age of 36 to 43 years. 2.3% to 11% were current smokers. FABA / ICS as required versus FABA as required Compared with as-required FABA alone, as-required FABA/ICS reduced exacerbations requiring systemic steroids (OR 0.45, 95% CI 0.34 to 0.60, 2 RCTs, 2997 participants, high-certainty evidence), equivalent to 109 people out of 1000 in the FABA alone group experiencing an exacerbation requiring systemic steroids, compared to 52 (95% CI 40 to 68) out of 1000 in the FABA/ICS as-required group. FABA/ICS as required may also reduce the odds of an asthma-related hospital admission or emergency department or urgent care visit (OR 0.35, 95% CI 0.20 to 0.60, 2 RCTs, 2997 participants, low-certainty evidence). Compared with as-required FABA alone, any changes in asthma control or spirometry, though favouring as-required FABA/ICS, were small and less than the minimal clinically-important differences. We did not find evidence of differences in asthma-associated quality of life or mortality. For other secondary outcomes FABA/ICS as required was associated with reductions in fractional exhaled nitric oxide, probably reduces the odds of an adverse event (OR 0.82, 95% CI 0.71 to 0.95, 2 RCTs, 3002 participants, moderate-certainty evidence) and may reduce total systemic steroid dose (MD -9.90, 95% CI -19.38 to -0.42, 1 RCT, 443 participants, low-certainty evidence), and with an increase in the daily inhaled steroid dose (MD 77 μg beclomethasone equiv./day, 95% CI 69 to 84, 2 RCTs, 2554 participants, moderate-certainty evidence). FABA/ICS as required versus regular ICS plus FABA as required There may be little or no difference in the number of people with asthma exacerbations requiring systemic steroid with FABA/ICS as required compared with regular ICS (OR 0.79, 95% CI 0.59 to 1.07, 4 RCTs, 8065 participants, low-certainty evidence), equivalent to 81 people out of 1000 in the regular ICS plus FABA group experiencing an exacerbation requiring systemic steroids, compared to 65 (95% CI 49 to 86) out of 1000 FABA/ICS as required group. The odds of an asthma-related hospital admission or emergency department or urgent care visit may be reduced in those taking FABA/ICS as required (OR 0.63, 95% CI 0.44 to 0.91, 4 RCTs, 8065 participants, low-certainty evidence). Compared with regular ICS, any changes in asthma control, spirometry, peak flow rates (PFR), or asthma-associated quality of life, though favouring regular ICS, were small and less than the minimal clinically important differences (MCID). Adverse events, serious adverse events, total systemic corticosteroid dose and mortality were similar between groups, although deaths were rare, so confidence intervals for this analysis were wide. We found moderate-certainty evidence from four trials involving 7180 participants that FABA/ICS as required was likely associated with less average daily exposure to inhaled corticosteroids than those on regular ICS (MD -154.51 μg/day, 95% CI -207.94 to -101.09). AUTHORS' CONCLUSIONS We found FABA/ICS as required is clinically effective in adults and adolescents with mild asthma. Their use instead of FABA as required alone reduced exacerbations, hospital admissions or unscheduled healthcare visits and exposure to systemic corticosteroids and probably reduces adverse events. FABA/ICS as required is as effective as regular ICS and reduced asthma-related hospital admissions or unscheduled healthcare visits, and average exposure to ICS, and is unlikely to be associated with an increase in adverse events. Further research is needed to explore use of FABA/ICS as required in children under 12 years of age, use of other FABA/ICS preparations, and long-term outcomes beyond 52 weeks.
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Affiliation(s)
| | - Sally Turner
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Sanjay Ramakrishnan
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Anastasia Fries
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matthew Gowell
- New College, University of Oxford Medical School, Oxford, UK
| | | | | | - Philip Webb
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Emily O'Boyle
- New College, University of Oxford Medical School, Oxford, UK
| | - Timothy Sc Hinks
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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32
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Reddel HK, O'Byrne PM, FitzGerald JM, Barnes PJ, Zheng J, Ivanov S, Lamarca R, Puu M, Alagappan VKT, Bateman ED. Efficacy and Safety of As-Needed Budesonide-Formoterol in Adolescents with Mild Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3069-3077.e6. [PMID: 33895362 DOI: 10.1016/j.jaip.2021.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medication adherence is challenging for adolescents. In mild asthma, as-needed budesonide-formoterol (BUD-FORM) reduces severe exacerbations compared with as-needed short-acting beta2-agonists, similar to the reduction with maintenance budesonide. OBJECTIVE This post hoc pooled analysis of Symbicort Given as-needed in Mild Asthma (SYGMA) 1 and 2 assessed the efficacy and safety of as-needed BUD-FORM in adolescents. METHODS SYGMA 1 and 2 were 52-week, double-blind studies (NCT022149199; NCT02224157) in patients 12 years or older with mild asthma. Patients were randomized to twice-daily placebo + as-needed BUD-FORM 200/6 μg, twice-daily BUD 200 μg + as-needed terbutaline (BUD maintenance), or twice-daily placebo + as-needed terbutaline 0.5 mg (SYGMA 1 only). Annualized severe exacerbation rates, maintenance treatment adherence, and safety (including change in height) were compared between treatment groups in adolescents (aged ≥12 to <18 years). RESULTS Severe exacerbation rate was similar with as-needed BUD-FORM and BUD maintenance (pooled analysis: 0.08 vs 0.07/y; P = .634), and was significantly lower with as-needed BUD-FORM versus as-needed terbutaline (SYGMA 1: 0.04 vs 0.17/y; P = .005). Median adherence was 73% in SYGMA 1 and 51% in SYGMA 2. Change in height from baseline in adolescents aged ≥12 years to <14 years was significantly greater with as-needed BUD-FORM (4.8 cm) versus BUD maintenance (3.9 cm) (pooled: P < .046), and was similar between as-needed BUD-FORM (4.5 cm) and as-needed terbutaline (4.1 cm) (SYGMA 1: P = .500). No new or unexpected safety concerns were identified. CONCLUSIONS In adolescents with mild asthma, as-needed BUD-FORM was superior to as-needed terbutaline for severe exacerbation reduction, with similar efficacy to BUD maintenance. As-needed BUD-FORM provides an alternative treatment option for adolescents with mild asthma, without needing daily treatment.
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Affiliation(s)
- Helen K Reddel
- The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.
| | - Paul M O'Byrne
- Firestone Institute for Respiratory Health, St Joseph's Healthcare and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - J Mark FitzGerald
- The Centre for Lung Health, Vancouver Coastal Health Research Institute and the University of British Columbia, Vancouver, BC, Canada
| | - Peter J Barnes
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Jinping Zheng
- State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | | | | | | | | | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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33
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O'Byrne PM, Reddel HK, Beasley R. The management of mild asthma. Eur Respir J 2021; 57:13993003.03051-2020. [PMID: 33093120 DOI: 10.1183/13993003.03051-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/08/2020] [Indexed: 12/28/2022]
Abstract
Inhaled corticosteroids (ICSs) have been recommended as a maintenance treatment, either alone or together with long-acting inhaled β2-agonists, for all asthma patients. Short-acting β2-agonists (SABAs) are rapid-onset bronchodilators, which provide symptom relief, but have no anti-inflammatory properties, yet are the most widely used as-needed reliever treatment for asthma and often the only treatment prescribed. Asthma patients can find adhering to daily preventative medication with ICS difficult and will often revert to using as-needed SABA as their only treatment, increasing their risk of exacerbations. The purpose of this review is to evaluate the efficacy of reliever medications that contain ICS compared with SABA as reliever, or with maintenance ICS and SABA as reliever, in mild asthma patients.Nine studies were identified that have evaluated the use of ICS as a component of an as-needed reliever in patients with mild asthma. Four of the most recent studies compared the combination of ICS/formoterol to SABA as reliever.ICS-containing reliever medication was superior to SABA as reliever alone, and was equivalent to maintenance ICS and SABA as reliever, particularly in reducing risks of severe asthma exacerbations, in studies which compared these reliever options.SABAs should not be used as a reliever without ICS. The concern about patients with mild asthma not being adherent to maintenance ICS supports a recommendation that ICS/formoterol should be considered as a treatment option instead of maintenance ICS, to avoid the risk of patients reverting to SABA alone.
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Affiliation(s)
- Paul M O'Byrne
- Firestone Institute for Respiratory Health, St Joseph's Hospital and Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
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34
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Ertoy Karagol HI, Bakirtas A. New Perspectives in the Management of Mild to Moderate Asthma in Children. J Asthma Allergy 2021; 14:293-299. [PMID: 33833531 PMCID: PMC8020053 DOI: 10.2147/jaa.s255218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/06/2021] [Indexed: 12/24/2022] Open
Abstract
Mild to moderate asthma makes up the greatest proportion of all asthma severities in childhood. Children who are treated with steps 1–2 are defined as having mild asthma and step 3 as having moderate asthma, according to the guidelines. Although many studies focused on the management of severe asthma over the last decade, there have also been important changes and improvements in the management of mild to moderate asthma. In this article, new perspectives in the management of children with mild to moderate asthma will be reviewed and compared according to the two major guidelines.
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Affiliation(s)
| | - Arzu Bakirtas
- Department of Pediatric Allergy and Asthma, Gazi University School of Medicine, Ankara, Turkey
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35
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Sumino K. Reply. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2121-2122. [PMID: 32499042 DOI: 10.1016/j.jaip.2020.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kaharu Sumino
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, Mo.
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36
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Lipworth B, Chan R, RuiWen Kuo C. Optimal asthma control in African American children with asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2121. [PMID: 32499041 DOI: 10.1016/j.jaip.2020.01.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom.
| | - Rory Chan
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Chris RuiWen Kuo
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
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37
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Hatter L, Bruce P, Braithwaite I, Holliday M, Fingleton J, Weatherall M, Beasley R. ICS-formoterol reliever versus ICS and short-acting β 2-agonist reliever in asthma: a systematic review and meta-analysis. ERJ Open Res 2021; 7:00701-2020. [PMID: 33532465 PMCID: PMC7836558 DOI: 10.1183/23120541.00701-2020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022] Open
Abstract
Background The Global Initiative for Asthma recommends as-needed inhaled corticosteroid (ICS)-formoterol as an alternative to maintenance ICS plus short-acting β2-agonist (SABA) reliever at step 2 of its stepwise treatment algorithm. Our aim was to assess the efficacy and safety of these two treatment regimens, with a focus on prevention of severe exacerbation. Methods We performed a systematic review and meta-analysis of all randomised controlled trials (RCTs) comparing as-needed ICS-formoterol with maintenance ICS plus SABA. MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrials.gov were searched from database inception to 12 December 2019. The primary outcome was time to first severe exacerbation. RCTs were excluded if they used as-needed budesonide-formoterol as part of a maintenance and reliever regimen, or did not report on severe exacerbations. The review is registered with PROSPERO (identifier number CRD42020154680). Results Four RCTs (n=8065 participants) were included in the analysis. As-needed ICS-formoterol was associated with a prolonged time to first severe exacerbation (hazard ratio 0.85, 95% CI 0.73–1.00; p=0.048) and reduced daily ICS dose (mean difference −177.3 μg, 95% CI −182.2–−172.4 μg). Asthma symptom control was worse in the as-needed group (Asthma Control Questionnaire-5 mean difference 0.12, 95% CI 0.09–0.14), although this did not meet the minimal clinically important difference of 0.50 units. There was no significant difference in serious adverse events (OR 1.07, 95% CI 0.84–1.36). Conclusion As-needed ICS-formoterol offers a therapeutic alternative to maintenance low-dose ICS plus SABA in asthma and may be the preferred option when prevention of severe exacerbation is the primary aim of treatment. As-needed low-dose ICS-formoterol prolongs time to first severe asthma exacerbation compared to maintenance ICS/SABA reliever and represents an alternative for patients, particularly when severe exacerbation prevention is the primary treatment aimhttps://bit.ly/3mpHVKc
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Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pepa Bruce
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Mark Holliday
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - James Fingleton
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
| | - Mark Weatherall
- Capital and Coast District Health Board, Wellington, New Zealand.,Dept of Medicine, University of Otago, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Capital and Coast District Health Board, Wellington, New Zealand
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38
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Al-Moamary MS, Alhaider SA, Alangari AA, Idrees MM, Zeitouni MO, Al Ghobain MO, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2021 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2021; 16:4-56. [PMID: 33680125 PMCID: PMC7908897 DOI: 10.4103/atm.atm_697_20] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 11/04/2022] Open
Abstract
The Saudi Initiative for Asthma 2021 (SINA-2021) is the fifth version of asthma guidelines for the diagnosis and management of asthma for adults and children, which is 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 less than 5 years. SINA guidelines have focused more on personalized approaches reflecting 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. 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 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 Centre, Riyadh, Saudi Arabia
| | - Abdullah A. Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Respiratory Division, Department of Medicine, 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 Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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39
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Ochoa Sangrador C, Díaz de Atauri ÁG, Martínez Rubio MV. Are inhaled corticosteroids effective in asthma exacerbations? Evidentia praxis. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.anpede.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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40
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Papi A, Blasi F, Canonica GW, Morandi L, Richeldi L, Rossi A. Treatment strategies for asthma: reshaping the concept of asthma management. Allergy Asthma Clin Immunol 2020; 16:75. [PMID: 32944030 PMCID: PMC7491342 DOI: 10.1186/s13223-020-00472-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/05/2020] [Indexed: 11/19/2022] Open
Abstract
Asthma is a common chronic disease characterized by episodic or persistent respiratory symptoms and airflow limitation. Asthma treatment is based on a stepwise and control-based approach that involves an iterative cycle of assessment, adjustment of the treatment and review of the response aimed to minimize symptom burden and risk of exacerbations. Anti-inflammatory treatment is the mainstay of asthma management. In this review we will discuss the rationale and barriers to the treatment of asthma that may result in poor outcomes. The benefits of currently available treatments and the possible strategies to overcome the barriers that limit the achievement of asthma control in real-life conditions and how these led to the GINA 2019 guidelines for asthma treatment and prevention will also be discussed.
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Affiliation(s)
- Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Respiratory Unit, Emergency Department, University Hospital S. Anna, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Francesco Blasi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University & Istituto Clinico Humanitas, Milan, Italy
| | - Luca Morandi
- Section of Cardiorespiratory and Internal Medicine, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Respiratory Unit, Emergency Department, University Hospital S. Anna, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Luca Richeldi
- Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Andrea Rossi
- Respiratory Section, Department of Medicine, University of Verona, Verona, Italy
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41
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Bender BG. Is It Time to Admit Defeat on Patient Adherence? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:186-187. [PMID: 31950901 DOI: 10.1016/j.jaip.2019.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Bruce G Bender
- Division of Behavioral Health, Department of Pediatrics, National Jewish Health, Denver, Colo.
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42
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Ochoa Sangrador C, Gimeno Díaz de Atauri Á, Martínez Rubio MV. [Are inhaled corticosteroids effective in asthma exacerbations? Evidentia praxis]. An Pediatr (Barc) 2020; 94:54.e1-54.e6. [PMID: 32712029 DOI: 10.1016/j.anpedi.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 11/24/2022] Open
Abstract
A clinical scenario is presented, from which a structured clinical question arises: In asthmatic children or adolescents with exacerbation symptoms, does the use of inhaled corticosteroids (newly instituted or base dose increased) reduce the risk of exacerbations that require systemic steroids and/or hospitalization? To answer it, we carried out a bibliographic search, with selection, evaluation and graduation of the evidence, following GRADE criteria. We did not find sufficient evidence to consider intermittent inhaled steroids as an alternative to maintenance inhaled steroids to avoid exacerbations that require the use of systemic steroids. The use of a combination of inhaled steroids with formoterol, as a rescue treatment at the onset of symptoms, is only effective when used by patients with this maintenance treatment, compared to those who only have inhaled steroids and rescue with beta2-agonists of short action; when patients already take maintenance combined therapy, combined rescue does not reduce the risk. In patients with asthma attacks attended in the emergency department, inhaled steroids compared to placebo reduce the risk of admission, but not when compared to systemic corticosteroids.
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Affiliation(s)
- Carlos Ochoa Sangrador
- Servicio de Pediatría, Hospital Virgen de la Concha, Zamora, España; Comité de Pediatría Basada en la Evidencia de la Asociación Española de Pediatría y de la Asociación Española de Pediatría de Atención Primaria, Madrid, España.
| | - Álvaro Gimeno Díaz de Atauri
- Comité de Pediatría Basada en la Evidencia de la Asociación Española de Pediatría y de la Asociación Española de Pediatría de Atención Primaria, Madrid, España; Servicio de Pediatría, Hospital 12 de Octubre, Madrid, España
| | - María Victoria Martínez Rubio
- Comité de Pediatría Basada en la Evidencia de la Asociación Española de Pediatría y de la Asociación Española de Pediatría de Atención Primaria, Madrid, España; Centro de Salud Los Fresnos, Torrejón de Ardoz, Madrid, España
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43
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Raherison C, Deschildre A, Garcia G, Girodet PO, Taillé C, Chenivesse C, Devouassoux G, Molimard M, Didier A. [Management of mild asthma in 2019-2020: What about new international therapeutic proposals (GINA 2019)?]. Rev Mal Respir 2020; 37:427-432. [PMID: 32331830 DOI: 10.1016/j.rmr.2020.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- C Raherison
- Service des maladies respiratoires, pôle cardiothoracique, CHU de Haut-Lévèque, Bordeaux, France.
| | - A Deschildre
- Service de pneumologie et allergologie pédiatriques, CHRU de Lille, hôpital Jeanne de Flandre, Lille, France
| | - G Garcia
- Service de pneumologie, université Paris-Sud, université Paris-Saclay, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - P-O Girodet
- Inserm CIC1401, CHU de Bordeaux, université de Bordeaux, Bordeaux, France
| | - C Taillé
- Groupe hospitalier universitaire, service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, Nord-université de Paris, hôpital Bichat, AP-HP, Paris, France
| | - C Chenivesse
- Service de pneumologie et immuno-allergologie, CHU de Lille, Institut Pasteur Lille, université de Lille, Lille, France
| | - G Devouassoux
- EA7426, service de pneumologie, université Claude Bernard Lyon 1, hospices civils de Lyon, hôpital de la Croix Rousse, Lyon, France
| | - M Molimard
- Inserm-U1219 pharmaco-épidémiologie, université de Bordeaux, Bordeaux, France
| | - A Didier
- Pôle des voies respiratoires, CHU de Toulouse, hôpital Larrey, 31059 Toulouse, France; Inserm U1043, CNRS UMR 5282, centre de physiopathologie Toulouse Purpan, université Toulouse III, Toulouse, France
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44
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Reddel HK. Response: The most fundamental change in asthma management in 30 years? Eur Respir J 2019; 54:54/5/1901860. [PMID: 31754074 DOI: 10.1183/13993003.01860-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, Glebe, Australia
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