1
|
Visser CD, Faay MRA, Özdemir A, Guchelaar HJ, Teichert M. Short-acting β 2-agonists (SABA) overuse in asthma and patients' perceptions for this behavior. Respir Med 2024; 231:107723. [PMID: 38936636 DOI: 10.1016/j.rmed.2024.107723] [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: 04/14/2024] [Revised: 06/04/2024] [Accepted: 06/24/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Short-acting β2-agonists (SABA) overuse is associated with poor asthma control. The Global Initiative for Asthma (GINA) 2019-updated strategy report has therefore taken a paradigm shift in reliever therapy recommendations. OBJECTIVES (I) To investigate the status of SABA overuse and medication dispensing patters in asthma in the Netherlands (II) validate dispensing data for SABA overuse identification and (III) understand patients' perspectives towards this SABA-taking behavior to inform future improvement strategies. METHODS An annually repeated cross-sectional study was conducted from 2017 to 2021 using pharmacy dispensing data in a real-world setting, including asthma patients aged 18-45 with ≥1 inhaler. A following qualitative study was performed in identified SABA overusing patients with a questionnaire and semi-structured interviews, supported by theoretical frameworks. RESULTS Dispensing data was available from 87 % of all community pharmacies (n = 1994) in 2017 and 95 % (n = 2005) in 2021. SABA overuse prevalence was constant for the five study-years with 20.6 % (±0.5 %). Increased ICS-formoterol and decreased SABA dispenses were observed in starters of inhalation therapy in 2021. 53 asthma patients completed the questionnaire of whom 43 patients confirmed SABA overuse, generating a positive predictive value of 81 %. Key behavioral drivers covered 7 themes regarding capability (knowledge; skills; memory, attention and decision process) motivation (emotion; beliefs about-capabilities; consequences) and opportunity (environmental context). CONCLUSION SABA overuse remains in one-fifth of asthma patients across the Netherlands, requiring careful attention from healthcare professionals. Dispensing data is a valid measure for SABA overuse in a clinical setting, facilitating patient selection. To meet patients' varied supporting needs, integration of tailored behavioral interventions is essential.
Collapse
Affiliation(s)
- Claire D Visser
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maaike R A Faay
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ayşe Özdemir
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; Royal Dutch Pharmacists Association (KNMP), The Hague, the Netherlands
| |
Collapse
|
2
|
Hung CT, Liu DC, Chou KT, Kao YH. Trends in polypharmacy among U.S. adults with asthma, 2001-2020. J Asthma 2024:1-11. [PMID: 39120956 DOI: 10.1080/02770903.2024.2391446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/22/2024] [Accepted: 08/08/2024] [Indexed: 08/11/2024]
Abstract
OBJECTIVE This study aimed to evaluate trends in polypharmacy prevalence among adults with asthma in the United States. METHODS Data from the 2001-2020 National Health and Nutrition Examination Survey were used to estimate the weighted prevalence of polypharmacy. Joinpoint regression analysis was conducted to evaluate trends in polypharmacy. Trends were first evaluated overall and then stratified by asthma severity and asthma control. A multivariable logistic regression model was used to identify factors associated with polypharmacy. RESULTS From 2001 to 2020, a stable trend in polypharmacy among U.S. adults with asthma was observed (average annual percent change [AAPC]=1.02, p=0.71). Trends across different asthma severity were stable (mild asthma: AAPC=2.93, p=0.20; moderate asthma: AAPC=-2.22, p=0.35; severe asthma: AAPC=0.45, p=0.82). Trends in adults with good asthma control and those with poor control stayed constant (good control: AAPC=0.82, p=0.68; poor control: AAPC=-1.22, p=0.82). Several factors, including older age, females, Non-Hispanic Black, health insurance coverage, family income, number of healthcare visits, former smokers, multi-morbidities, asthma severity, and asthma control, were associated with polypharmacy. CONCLUSIONS Polypharmacy prevalence has remained constant among U.S. adults with asthma over the past two decades. Despite a stable overall trend, disparities in polypharmacy prevalence persist across different asthma severity and control status, underscoring the need for tailored medication management to improve asthma care.
Collapse
Affiliation(s)
- Chun-Tse Hung
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Ding-Cheng Liu
- School of Pharmacy and Pharmaceutical Science, Department of Regulatory and Quality Sciences, University of Southern California, USA
| | - Kuan-Ting Chou
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsiu Kao
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
3
|
Chen W, Puttock EJ, Schatz M, Crawford W, Vollmer WM, Xie F, Xu S, Lustigova E, Zeiger RS. Risk Factors for Acute Asthma Exacerbations in Adults With Mild Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00549-X. [PMID: 38821437 DOI: 10.1016/j.jaip.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/07/2024] [Accepted: 05/22/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Although individuals with mild asthma account for 30% to 40% of acute asthma exacerbations (AAEs), relatively little attention has been paid to risk factors for AAEs in this population. OBJECTIVE To identify risk factors associated with AAEs in patients with mild asthma. METHODS This was a retrospective cohort study. We used administrative data from a large managed care organization to identify 199,010 adults aged 18 to 85 years who met study criteria for mild asthma between 2013 and 2018. An asthma-coded qualifying visit (index visit) was identified for each patient. We then used information at the index visit or from the year before the index visit to measure potential risk factors for AAEs in the subsequent year. An AAE was defined as either an asthma-coded hospitalization or emergency department visit, or an asthma-related systemic corticosteroid administration (intramuscular or intravenous) or oral corticosteroid dispensing. Poisson regression models with robust SEs were used to estimate the adjusted risk ratios for future AAEs. RESULTS In the study cohort, mean age was 44 years and 64% were female; 6.5% had AAEs within 1 year after the index visit. In multivariate models, age, sex, race, ethnicity, smoking status, body mass index, prior acute asthma care, and a variety of comorbidities and other clinical characteristics were significant predictors for future AAE risk. CONCLUSION Population-based disease management strategies for asthma should be expanded to include people with mild asthma in addition to those with moderate to severe disease.
Collapse
Affiliation(s)
- Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif.
| | - Eric J Puttock
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| | - William Crawford
- Department of Allergy, Kaiser Permanente Southern California, Harbor City, Calif
| | | | - Fagen Xie
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Eva Lustigova
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| |
Collapse
|
4
|
Liptzin DR. Primatene mist: Does it have a place in treating croup? Ann Allergy Asthma Immunol 2024; 132:662. [PMID: 38702105 DOI: 10.1016/j.anai.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Deborah R Liptzin
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington.
| |
Collapse
|
5
|
Suh DI, Johnston SL. The Wiser Strategy of Using Beta-Agonists in Asthma: Mechanisms and Rationales. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2024; 16:217-234. [PMID: 38910281 PMCID: PMC11199159 DOI: 10.4168/aair.2024.16.3.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 05/26/2024] [Accepted: 05/29/2024] [Indexed: 06/25/2024]
Abstract
Concerns regarding the safety of beta-2 agonists have led to revisions of the major asthma guidelines to better address these issues. Although these updates allow for a combination of previous and current strategies, they may confuse clinical practitioners. Beta-2 agonists are vital for alleviating asthma symptoms by relaxing smooth muscles; however, they also pose significant risks by inducing pro-inflammatory mediators both in vitro and in vivo. In addition to the risks of overuse and symptom masking, the use of beta-agonists alone at therapeutic doses can worsen airway inflammation and enhance virus-induced inflammation during asthma exacerbation. Inhaled corticosteroids (ICS) can effectively prevent these adverse effects. With new insights into the mechanisms of these adverse events, reserving short-acting beta-agonists for acute symptom relief during exacerbations and only for those who are already on ICS or oral steroids represents a careful approach to using beta-agonists with least adverse effects in patients with asthma. However, a major drawback of this approach is the potential non-compliance with ICS, leading to beta-agonist use without the necessary counteraction by ICS. An optimal strategy, both during and outside exacerbations, would integrate beta-agonists into an anti-inflammatory regimen that includes ICS, ideally combined with the same inhaler to ensure their concurrent use where finances allow. This would maintain the beneficial effects of beta-agonists, such as bronchodilation, while preventing the adverse effects from the induction of inflammatory mediators. This method is aligned with diverse clinical settings, maximizes the safe use of beta-agonists, and supports a comprehensive guideline-compliant management strategy.
Collapse
Affiliation(s)
- Dong In Suh
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | | |
Collapse
|
6
|
Kaplan C, Christophides AH, Kranidis AM, Saint-Fleur AL, Kier C. All shook up: how the COVID-19 pandemic rocked pediatric asthma care. Curr Opin Pediatr 2024; 36:237-243. [PMID: 38299973 DOI: 10.1097/mop.0000000000001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW Asthma management is a crucial aspect of public health. The landscape of asthma management underwent significant change in the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. These changes greatly affected existing patients, individuals suffering with undiagnosed illness, providers, and the healthcare system as a whole. RECENT FINDINGS Providers had to navigate through the potential risk of exposure while weighing the benefit of office visits for patients. This promoted the rapid uptake of telemedicine and virtual outreach, as well as modifications to acute management and controller therapies. Telehealth allowed for the remote monitoring of these patient populations, increased compliance with home-based self-management, and an emphasis on patient education. Furthermore, the pandemic underscored the importance of proactive asthma management as many individuals were left untreated or undiagnosed for various reasons. It is evident that the SARS-CoV-2 pandemic reshaped the landscape of various components of the healthcare system, including asthma management, necessitating innovative approaches to monitoring and patient education. SUMMARY Understanding the lessons learned from this time period is crucial for enhancing the resilience of our health system in the wake of future challenges that may be posed against our system.
Collapse
Affiliation(s)
| | - Alexa H Christophides
- Department of Anesthesiology, Stony Brook Children's Hospital, Stony Brook, New York
| | | | - Ashley L Saint-Fleur
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
7
|
Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:870-879. [PMID: 38237858 PMCID: PMC10999356 DOI: 10.1016/j.jaip.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/14/2023] [Accepted: 01/01/2024] [Indexed: 02/05/2024]
Abstract
The Global Initiative for Asthma (GINA) recommends that short-acting β2-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)-formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.
Collapse
Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, Mo.
| | - Richard Beasley
- Medical Research Institute of New Zealand Victoria University of Wellington, Wellington, New Zealand
| |
Collapse
|
8
|
Arora NS, Zhou S, Baptist AP. Regulatory and Insurance Challenges Must Be Overcome in the United States to Meet Global Standards for Asthma Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:624-626. [PMID: 38458699 DOI: 10.1016/j.jaip.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 03/10/2024]
Affiliation(s)
- Nonie S Arora
- Division of Rheumatology, Allergy, and Immunology, University of North Carolina, Chapel Hill, NC.
| | | | - Alan P Baptist
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, Mich
| |
Collapse
|
9
|
Zaeh SE, Eakin MN, Chupp G. Implementing Antiinflammatory Reliever Strategies in Asthma: The Evolving Paradigm of Asthma Management. Chest 2024; 165:250-252. [PMID: 38336438 DOI: 10.1016/j.chest.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 02/12/2024] Open
Affiliation(s)
- Sandra E Zaeh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT.
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Geoffrey Chupp
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
10
|
Kotkowski CB, Brown AW. Stepping up by stepping down. J Cyst Fibros 2024; 23:5-7. [PMID: 38129256 DOI: 10.1016/j.jcf.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023]
Affiliation(s)
| | - A Whitney Brown
- Cystic Fibrosis Foundation, Bethesda, MD, United States; Inova Fairfax Advanced Lung Disease and Lung Transplant Program, Falls Church, VA, United States.
| |
Collapse
|
11
|
Jeppesen JS, Jessen S, Thomassen M, Backer V, Bangsbo J, Hostrup M. Inhaled beta 2 -agonist, formoterol, enhances intense exercise performance, and sprint ability in elite cyclists. Scand J Med Sci Sports 2024; 34:e14500. [PMID: 37880916 DOI: 10.1111/sms.14500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE Many athletes use long-acting beta2 -agonist formoterol in treatment of asthma. However, studies in non-athlete cohorts demonstrate that inhaled formoterol can enhance sprint performance calling into question whether its use in competitive sports should be restricted. We investigated whether formoterol at upper recommended inhaled doses (54 μg) would enhance sprint ability and intense exercise performance in elite cyclists. METHODS Twenty-one male cyclists (V̇O2max : 70.4 ± 4.3 mL × min-1 × kg-1 , mean ± SD) completed two 6-s all-out sprints followed by 4-min all-out cycling after inhaling either 54 μg formoterol or placebo. We also assessed cyclists' leg muscle mass by dual-energy X-ray absorptiometry and muscle fiber type distribution of vastus lateralis biopsies. RESULTS Peak and mean power output during the 6-s sprint was 32 W (95% CI, 19-44 W, p < 0.001) and 36 W (95% CI, 24-48 W, p < 0.001) higher with formoterol than placebo, corresponding to an enhancing effect of around 3%. Power output during 4-min all-out cycling was 9 W (95% CI, 2-16 W, p = 0.01) greater with formoterol than placebo, corresponding to an enhancing effect of 2.3%. Performance changes in response to formoterol were unrelated to cyclists' VO2max and leg lean mass, whereas muscle fiber Type I distribution correlated with change in sprinting peak power in response to formoterol (r2 = 0.314, p = 0.012). CONCLUSION Our findings demonstrate that an inhaled one-off dose of 54 μg formoterol has a performance-enhancing potential on sprint ability and short intense performance in elite male cyclists, which is irrespective of training status but partly related to muscle fiber type distribution for sprint ability.
Collapse
Affiliation(s)
- Jan S Jeppesen
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Søren Jessen
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Martin Thomassen
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Backer
- Department of Otorhinolaryngology, Head and Neck Surgery, and Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Jens Bangsbo
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Morten Hostrup
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
12
|
Murphy VE, Gibson PG, Schatz M. Managing Asthma During Pregnancy and the Postpartum Period. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3585-3594. [PMID: 37482082 DOI: 10.1016/j.jaip.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
Asthma is one of the most common chronic diseases in pregnancy and is associated with adverse perinatal outcomes. Asthma symptoms worsen in approximately 40% of women, and exacerbations requiring medical intervention occur in at least 20% of women. Factors associated with exacerbation and worsening asthma include multiparity, obesity, Black race, exacerbations before pregnancy, and poor asthma control. Exacerbations are associated with further increased risks for poor perinatal outcomes, including low birth weight, preterm birth, and small for gestational age (SGA) status, as well as an increase in the development of asthma in early childhood. Common medications used for asthma, including short-acting β-agonists and inhaled corticosteroids, are considered safe to use in pregnancy. Whereas guidelines generally suggest traditional step therapy for managing asthma in pregnancy, there are alternative models of care and management approaches that may be effective in pregnancy, but require more research. These include single-inhaler maintenance and reliever therapy, treatment adjustment with FeNO, treatable traits personalized medicine approaches, and telemedicine. Little is known about changes to asthma in the postpartum period. However, low adherence to medication and the potential effects of postpartum depression on asthma exacerbation risk warrant further research.
Collapse
Affiliation(s)
- Vanessa E Murphy
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia; Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia.
| | - Peter G Gibson
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia; Asthma and Breathing Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
| |
Collapse
|
13
|
Yuan F, Yang Y, Liu L, Zhou P, Zhu Y, Chai Y, Chen K, Tang W, Huang Q, Zhang C. Research progress on the mechanism of astragaloside IV in the treatment of asthma. Heliyon 2023; 9:e22149. [PMID: 38045181 PMCID: PMC10692808 DOI: 10.1016/j.heliyon.2023.e22149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/05/2023] Open
Abstract
Asthma is a common chronic respiratory disease, and its treatment is a core problem and challenge in clinical practice. Glucocorticoids (GCs) are the first-line therapy for the treatment of asthma. Local and systemic adverse reactions caused by GCs create obstacles to the treatment of asthma. Therefore, the research target is to find a new, safe, and effective therapeutic medicine at present. Natural products are an important source for treating asthma with low cost and low toxicity. Astragaloside IV (AS-IV) is an active ingredient of traditional Chinese medicine Astragalus mongholicus Bunge. Previous studies have indicated that AS-IV plays a therapeutic role in the treatment of asthma by inhibiting airway inflammation and remodeling the airway, and by regulating immunity and neuroendocrine function (Fig. 1) . It has a variety of biological characteristics such as multi-target intervention, high safety, and good curative effect. This article reviews the specific mechanism of AS-IV for the treatment of asthma to provide references for subsequent research.
Collapse
Affiliation(s)
- Fanyi Yuan
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yang Yang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Liu
- Department of Pharmacy, Hospital of Chengdu university of Traditional Chinese Medicine, Chengdu, China
| | - Pengcheng Zhou
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yi Zhu
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yilu Chai
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Keling Chen
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wenjun Tang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qingsong Huang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Chuantao Zhang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| |
Collapse
|
14
|
Krings JG, Sekhar TC, Chen V, Blake KV, Sumino K, James AS, Clover AK, Lenze EJ, Brownson RC, Castro M. Beginning to Address an Implementation Gap in Asthma: Clinicians' Views of Prescribing Reliever Budesonide-Formoterol Inhalers and SMART in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2767-2777. [PMID: 37245736 DOI: 10.1016/j.jaip.2023.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored. OBJECTIVE To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States. METHODS Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation. RESULTS Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making. CONCLUSIONS Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.
Collapse
Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo.
| | - Tejas C Sekhar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Vanessa Chen
- Brown School of Social Work and Public Health, Washington University in St Louis, St Louis, Mo
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Fla
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Aimee S James
- Occupational Therapy and Surgery (Public Health Sciences), Washington University in St Louis School of Medicine, St Louis, Mo
| | - Amber K Clover
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Ross C Brownson
- Prevention Research Center, Brown School, Washington University in St Louis, St Louis, Mo
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Kansas, Kansas City, Kan
| |
Collapse
|
15
|
Hatter L, Eathorne A, Hills T, Bruce P, Houghton C, Weatherall M, Beasley R. Patterns of Asthma Medication Use in New Zealand After Publication of National Asthma Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2757-2764.e5. [PMID: 37178765 DOI: 10.1016/j.jaip.2023.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In June 2020, the New Zealand (NZ) adolescent and adult asthma guidelines recommended budesonide/formoterol, taken as maintenance and/or reliever therapy, as the preferred therapeutic approach. OBJECTIVE To investigate whether these recommendations were associated with changes in clinical practice indicated by asthma medication use trends. METHODS NZ national dispensing data for inhaler medications from January 2010 to December 2021 were reviewed. Monthly "dispensings" of inhaled budesonide/formoterol, inhaled corticosteroid (ICS), other ICS/long-acting β2-agonists (LABA), and inhaled short-acting β2-agonists (SABA), for the 12+ age group, were displayed graphically with piecewise regression used to produce plots of rates by time with a July 1, 2020, break point. The number of dispensings in the last 6 months that data were available (July-December 2021) was compared with the corresponding period, July-December 2019. RESULTS Budesonide/formoterol dispensing increased markedly after July 1, 2020 (regression coefficient 41.1 inhalers dispensed/100,000 population per month [95% confidence interval (CI): 36.3-45.6, P < .0001]; 64.7% increase in the number of dispensings between July-December 2019 and July-December 2021), in contrast to "other ICS/LABA" (regression coefficient: -15.9 [95% CI: -22.2 to -9.6, P < .0001]; -1.7% decrease) and SABA (regression coefficient: -14.7 [95% CI: -29.7 to 0.3, P = .055]; -10.6% decrease), respectively. CONCLUSION In NZ, a progressive increase in budesonide/formoterol dispensing, accompanied by a reduction in SABA and "other ICS/LABA" dispensing, occurred after publication of the 2020 NZ asthma guidelines. While acknowledging the limitations in the interpretation of temporal associations, these findings suggest that the transition to ICS/formoterol reliever-based therapy can be achieved if recommended and promoted as the preferred therapeutic approach in national guidelines.
Collapse
Affiliation(s)
- Lee Hatter
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tom Hills
- Medical Research Institute of New Zealand, 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
| | - Mark Weatherall
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand; School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand.
| |
Collapse
|
16
|
Warman KL, Silver EJ. Get SMART: Teaching Pediatric Residents the 2020 Focused Asthma Updates' Recommendations for Symptom-Based Medication Increases. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2023; 19:11320. [PMID: 37441565 PMCID: PMC10333455 DOI: 10.15766/mep_2374-8265.11320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 03/15/2023] [Indexed: 07/15/2023]
Abstract
Introduction The 2020 Focused Asthma Updates introduced a paradigm shift in the treatment of asthma that includes symptom-based adjustments to outpatient asthma treatment that vary by age and severity. The length and complexity of the updates have made them challenging to adopt. Methods We implemented an educational session among pediatric residents to increase their familiarity with, comprehension of, and plans to adopt two evidence-based recommendations introduced in the 2020 Updates for symptom-based therapy. Facilitators led groups of four to six pediatric residents in cased-based discussions during a 30-minute, ambulatory care-based session. One week prior, participants and facilitators received synopses of the 2007 Guidelines for the Diagnosis and Management of Asthma and the 2020 Updates. Facilitators also received a guide and scripts explaining new concepts, providing supporting data, and highlighting learning objectives. Retrospective pre/post surveys assessed participants' familiarity with, comprehension of, and planned adoption of recommendations for intermittent steroids and single maintenance and reliever therapy (SMART) before and after the conference. The surveys also assessed prior exposure to the 2020 Updates and reflections on the educational session. Results There were 26 participants. Ratings of familiarity, comprehension, and adoption plans regarding the recommendations significantly improved (ps < .001, Wilcoxon signed rank test). The case-based approach was well received, and the material was deemed relevant. Discussion This educational session significantly increased pediatric residents' familiarity with, comprehension of, and plans to adopt two new evidence-based treatments. Dissemination of this educational session may improve outpatient asthma management.
Collapse
Affiliation(s)
- Karen L. Warman
- Associate Professor, Division of Academic General Pediatrics, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
| | - Ellen Johnson Silver
- Professor, Division of Academic General Pediatrics, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
| |
Collapse
|
17
|
Reddel HK, Brusselle G, Lamarca R, Gustafson P, Anderson GP, Jorup C. Safety and Effectiveness of As-Needed Formoterol in Asthma Patients Taking Inhaled Corticosteroid (ICS)-Formoterol or ICS-Salmeterol Maintenance Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2104-2114.e3. [PMID: 37054881 DOI: 10.1016/j.jaip.2023.03.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND As-needed low-dose inhaled corticosteroid (ICS)-formoterol reliever is recommended in patients with asthma prescribed maintenance ICS-formoterol. Clinicians often ask whether ICS-formoterol reliever can be used with other maintenance ICS-long-acting β2-agonists. OBJECTIVE To evaluate the safety and effectiveness of as-needed formoterol in patients taking maintenance ICS-formoterol or ICS-salmeterol from the RELIEF study. METHODS RELIEF (SD-037-0699) was a 6-month, open-label study that randomized 18,124 patients with asthma to as-needed formoterol 4.5 μg or salbutamol 200 μg on top of maintenance therapy. This post hoc analysis included patients on maintenance ICS-formoterol or ICS-salmeterol (n = 5436). The primary safety outcome was a composite of serious adverse events (SAEs) and/or adverse events leading to discontinuation (DAEs); the primary effectiveness outcome was time-to-first exacerbation. RESULTS For both maintenance groups and both relievers, similar numbers of patients had ≥1 SAE and/or DAE. In patients taking maintenance ICS-salmeterol, but not ICS-formoterol, significantly more non-asthma-related and nonserious DAEs occurred with as-needed formoterol versus as-needed salbutamol (P = .0066 and P = .0034, respectively). In patients taking maintenance ICS-formoterol, there was a significantly lower risk in time-to-first exacerbation with as-needed formoterol versus as-needed salbutamol (hazard ratio [HR]: 0.82, 95% confidence interval [CI]: 0.70, 0.95; P = .007). In patients taking ICS-salmeterol maintenance, time-to-first exacerbation was not significantly different between treatment arms (HR: 0.95, 95% CI: 0.84, 1.06; P = .35). CONCLUSIONS As-needed formoterol significantly reduced exacerbation risk compared with as-needed salbutamol when added to maintenance ICS-formoterol, but not to maintenance ICS-salmeterol. More DAEs were seen with ICS-salmeterol maintenance therapy plus as-needed formoterol. Further research is needed to assess whether this is relevant to as-needed combination ICS-formoterol.
Collapse
Affiliation(s)
- Helen Kathryn Reddel
- The Woolcock Institute of Medical Research, The University of Sydney, and Macquarie University, Sydney, Australia.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Rosa Lamarca
- BioPharmaceuticals R&D, Late-Stage Development, Respiratory & Immunology, AstraZeneca, Barcelona, Spain
| | - Per Gustafson
- BioPharmaceuticals Medical, Respiratory & Immunology, AstraZeneca, Gothenburg, Sweden
| | - Gary P Anderson
- Lung Health Research Centre, Department of Biochemistry and Pharmacology, University of Melbourne, Melbourne, VIC, Australia
| | - Carin Jorup
- BioPharmaceuticals R&D, Late-Stage Development, Respiratory & Immunology, AstraZeneca, Gothenburg, Sweden
| |
Collapse
|
18
|
Mohan A, Lugogo NL. Mild asthma: Lessons learned and remaining questions. Respir Med 2023:107326. [PMID: 37328016 DOI: 10.1016/j.rmed.2023.107326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/19/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
Patients living with mild disease represent the largest proportion of asthma patients. There are significant challenges in proposing a definition that would best describe these patients, while also accurately identifying at-risk individuals. Current literature suggests considerable inflammatory and clinical heterogeneity within this group. Research has shown that these patients are at risk of poor control, exacerbations, lung function decline, and death. Despite conflicting data on its prevalence, eosinophilic inflammation appears to be a predictor of poorer outcomes in mild asthma. There is an immediate need to better understand phenotypic clusters in mild asthma. It is also important to understand factors that influence disease progression and remission, as it is evident that both vary in mild asthma. Guided by robust literature that supports inhaled corticosteroid-based strategies over short-acting beta-agonist (SABA) reliant regimens, the management of these patients has evolved considerably. Unfortunately, SABA use remains high in clinical practice despite strong advocacy from the Global Initiative for Asthma. Future mild asthma research should explore the role of biomarkers, develop prediction tools based on composite risk scores, and explore targeted therapies at least for at-risk individuals.
Collapse
Affiliation(s)
- Arjun Mohan
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Njira L Lugogo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
19
|
Carr TF, Fajt ML, Kraft M, Phipatanakul W, Szefler SJ, Zeki AA, Peden DB, White SR. Treating asthma in the time of COVID. J Allergy Clin Immunol 2023; 151:809-817. [PMID: 36528110 PMCID: PMC9749385 DOI: 10.1016/j.jaci.2022.12.800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-Prone Asthma clinical trials network is actively assessing novel treatments for severe asthma during the coronavirus disease (COVID-19) pandemic and has needed to adapt to various clinical dilemmas posed by the COVID-19 pandemic. Pharmacologic interactions between established asthma therapies and novel drug interventions for COVID-19 infection, including antivirals, biologics, and vaccines, have emerged as a critical and unanticipated issue in the clinical care of asthma. In particular, impaired metabolism of some long-acting beta-2 agonists by the cytochrome P4503A4 enzyme in the setting of antiviral treatment using ritonavir-boosted nirmatrelvir (NVM/r, brand name Paxlovid) may increase risk for adverse cardiovascular events. Although available data have documented the potential for such interactions, these issues are largely unappreciated by clinicians who treat asthma, or those dispensing COVID-19 interventions in patients who happen to have asthma. Because these drug-drug interactions have not previously been relevant to patient care, clinicians have had no guidance on management strategies to reduce potentially serious interactions between treatments for asthma and COVID-19. The Precision Interventions for Severe and/or Exacerbation-Prone Asthma network considered the available literature and product information, and herein share our considerations and plans for treating asthma within the context of these novel COVID-19-related therapies.
Collapse
Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh
| | - Monica Kraft
- Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, Boston
| | - Stanley J Szefler
- The University of Colorado School of Medicine and Children's Hospital Colorado, Department of Pediatrics, The Breathing Institute, Aurora
| | - Amir A Zeki
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, UC Davis Lung Center, Sacramento
| | - David B Peden
- Division of Allergy and Immunology, Department of Pediatrics, University of North Carolina, Chapel Hill
| | - Steven R White
- Department of Medicine, the University of Chicago, Chicago.
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Couillard S, Petousi N, Smigiel KS, Molfino NA. Toward a Predict and Prevent Approach in Obstructive Airway Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:704-712. [PMID: 36682536 DOI: 10.1016/j.jaip.2023.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
Asthma and chronic obstructive pulmonary disease are currently diagnosed and treated after the demonstration of variable airflow limitation and symptoms. Under this framework, undiagnosed and unchecked airway inflammation is associated with recurrent acute attacks, airway remodeling, airflow limitation, adverse effects of corticosteroids, and impaired quality of life, ultimately leading to the collection of side effects termed "people remodeling." This one-size-fits-all damage control approach aims to control symptoms and treat exacerbations rather than modify the underlying disease process. The advent of highly effective therapies targeting proximal drivers of airway inflammation calls for a paradigm shift; upstream-acting therapies offer potential to alter the disease course and achieve clinical remission. We propose moving away from downstream firefighting and toward a "predict and prevent" model, measuring inflammation and providing anti-inflammatory therapy early, without waiting for further clinical deterioration. Much in the same way that high blood pressure and cholesterol are used to predict and prevent heart attacks, in asthma, elevated blood eosinophils and/or exhaled nitric oxide can be used to predict and prevent asthma attacks. We also advocate moving research further upstream by identifying patients with subclinical airway inflammation or disease who may be at risk of progressing to airflow limitation and associated morbidities and intervening early to prevent them. In summary, we call for a predict and prevent approach in obstructive airway disease.
Collapse
Affiliation(s)
- Simon Couillard
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nayia Petousi
- Respiratory Medicine Unit and NIHR Oxford Respiratory BRC, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | |
Collapse
|
23
|
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
| | | |
Collapse
|
24
|
Levy ML, Bacharier LB, Bateman E, Boulet LP, Brightling C, Buhl R, Brusselle G, Cruz AA, Drazen JM, Duijts L, Fleming L, Inoue H, Ko FWS, Krishnan JA, Mortimer K, Pitrez PM, Sheikh A, Yorgancıoğlu A, Reddel HK. Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Prim Care Respir Med 2023; 33:7. [PMID: 36754956 PMCID: PMC9907191 DOI: 10.1038/s41533-023-00330-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention and management worldwide. GINA develops and publishes evidence-based, annually updated resources for clinicians. GINA guidance is adopted by national asthma guidelines in many countries, adapted to fit local healthcare systems, practices, and resource availability. GINA is independent of industry, funded by the sale and licensing of its materials. This review summarizes key practical guidance for primary care from the 2022 GINA strategy report. It provides guidance on confirming the diagnosis of asthma using spirometry or peak expiratory flow. GINA recommends that all adults, adolescents and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, either taken regularly, or (for adults and adolescents with "mild" asthma) as combination ICS-formoterol taken as needed for symptom relief. For patients with moderate-severe asthma, the preferred regimen is maintenance-and-reliever therapy (MART) with ICS-formoterol. Asthma treatment is not "one size fits all"; GINA recommends individualized assessment, adjustment, and review of treatment. As many patients with difficult-to-treat or severe asthma are not referred early for specialist review, we provide updated guidance for primary care on diagnosis, further investigation, optimization and treatment of severe asthma across secondary and tertiary care. While the GINA strategy has global relevance, we recognize that there are special considerations for its adoption in low- and middle-income countries, particularly the current poor access to inhaled medications.
Collapse
Affiliation(s)
| | - Leonard B. Bacharier
- grid.412807.80000 0004 1936 9916Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Eric Bateman
- grid.7836.a0000 0004 1937 1151Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Louis-Philippe Boulet
- grid.23856.3a0000 0004 1936 8390Québec Heart and Lung Institute, Université Laval, Québec City, QC Canada
| | - Chris Brightling
- grid.9918.90000 0004 1936 8411Institute for Lung Health, Leicester NIHR BRC, University of Leicester, Leicester, UK
| | - Roland Buhl
- grid.410607.4Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | - Guy Brusselle
- grid.410566.00000 0004 0626 3303Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium ,grid.5645.2000000040459992XDepartments of Epidemiology and Respiratory Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alvaro A. Cruz
- grid.8399.b0000 0004 0372 8259ProAR Foundation and Federal University of Bahia, Salvador, Bahia Brazil
| | - Jeffrey M. Drazen
- grid.38142.3c000000041936754XBrigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA USA
| | - Liesbeth Duijts
- grid.5645.2000000040459992XDivisions of Respiratory Medicine and Allergology and Neonatology, Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Louise Fleming
- grid.7445.20000 0001 2113 8111National Heart and Lung Institute, Imperial College, London, UK
| | - Hiromasa Inoue
- grid.258333.c0000 0001 1167 1801Department of Pulmonary Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Fanny W. S. Ko
- grid.10784.3a0000 0004 1937 0482Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jerry A. Krishnan
- grid.185648.60000 0001 2175 0319Breathe Chicago Center, University of Illinois Chicago, Chicago, IL USA
| | - Kevin Mortimer
- grid.513149.bLiverpool University Hospitals NHS Foundation Trust, Liverpool, UK ,grid.5335.00000000121885934University of Cambridge, Cambridge, UK ,grid.16463.360000 0001 0723 4123Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Paulo M. Pitrez
- grid.415169.e0000 0001 2198 9354Hospital Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | - Aziz Sheikh
- grid.4305.20000 0004 1936 7988Department of Primary Care Research & Development, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Arzu Yorgancıoğlu
- grid.411688.20000 0004 0595 6052Department of Pulmonology, Celal Bayar University, Manisa, Turkey
| | - Helen K. Reddel
- grid.1013.30000 0004 1936 834XThe Woolcock Institute of Medical Research and The University of Sydney, Sydney, NSW Australia
| |
Collapse
|
25
|
de Las Vecillas L, Quirce S. Landscape of short-acting beta-agonists (SABA) overuse in Europe. Clin Exp Allergy 2023; 53:132-144. [PMID: 36468654 DOI: 10.1111/cea.14250] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/20/2022] [Accepted: 10/12/2022] [Indexed: 12/11/2022]
Abstract
This review article provides an overview of short-acting beta-agonist (SABA) use and prescribing trends in Europe, summarizing updated data on the results from the industry-funded SABINA program (SABA use IN asthma) and other studies on this matter. SABA use continues to increase worldwide. Overuse has been defined as ≥3 canisters/year. Almost a third of European patients with asthma, at all severity levels, overuse SABA. Guidelines recommend close monitoring of patients who overuse SABA and avoiding over-reliance on SABA monotherapy. SABA overuse is associated with increased risk of asthma exacerbations and mortality, increased use of health services and negative physical and mental health outcomes. Reliance on SABA monotherapy can be unsafe and therefore it is necessary to change asthma treatment approaches and policies. Changes in physician and patient behaviours towards SABA use are required to ensure that patients with asthma are not over-reliant on SABA monotherapy. Notwithstanding, the limitations of the studies on the use of SABA should be considered, taking into account that the prescription/purchase of medication canisters does not always represent the actual use of the medication and that associations between SABA overuse and poor asthma outcomes may not be directly causal. National health systems and asthma guidelines must align asthma management with global recommendations and adjust them to local needs.
Collapse
Affiliation(s)
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
| |
Collapse
|
26
|
Nanda A, Siles R, Park H, Louisias M, Ariue B, Castillo M, Anand MP, Nguyen AP, Jean T, Lopez M, Altisheh R, Pappalardo AA. Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee. J Allergy Clin Immunol 2023; 151:869-880. [PMID: 36720288 DOI: 10.1016/j.jaci.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 01/29/2023]
Abstract
The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.
Collapse
Affiliation(s)
- Anil Nanda
- Asthma and Allergy Center, Lewisville-Flower Mound; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Roxana Siles
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Henna Park
- Department of Pediatrics, University of Illinois Hospital, Chicago
| | - Margee Louisias
- Department of Medicine, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Cleveland; Department of Immunology, Boston Children's Hospital, Boston; Harvard Medical School, Boston
| | - Barbara Ariue
- Department of Pediatrics, Division of Allergy/Immunology, Loma Linda Children's Hospital, Loma Linda
| | - Maria Castillo
- Department of Medical Education at Driscoll Children's Hospital, Corpus Christi
| | - Mahesh Padukudru Anand
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysore
| | - Anh P Nguyen
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, School of Medicine, University of California Davis, Sacramento
| | - Tiffany Jean
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Michael Lopez
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Roula Altisheh
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Andrea A Pappalardo
- Department of Pediatrics, Department of Medicine, University of Illinois at Chicago, Chicago
| |
Collapse
|
27
|
Hollenbach JP, Collins MS, Wasser C, Fedele D. Implementation of standardized asthma management programs in outpatient settings. Ann Allergy Asthma Immunol 2023; 130:571-576. [PMID: 36702245 DOI: 10.1016/j.anai.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW This article reviews new approaches, facilitators, barriers, and opportunities to increasing adoption of standardized asthma management programs in the outpatient care setting. RECENT FINDINGS Primary care clinicians providing asthma care in the outpatient setting are challenged by the complexity of guidelines and want standardization of tools that are easy to use and that can be integrated within their practice's workflow. Programs that integrate clinical decision support tools within a practice's electronic health record and provide support from specialists may enhance uptake of asthma management programs in the outpatient setting and reduce asthma morbidity. Lack of an implementation science framework, consideration for organizational context, and clinician buy-in are recently recognized barriers to adoption of asthma programs and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly, and may not be capable of wide dissemination because of the EHR interoperability problem. CONCLUSION Programs that simplify the guidelines, integrate clinical decision support within the EHR, and ground their approach with an implementation science framework may improve the quality of asthma care provided in the outpatient setting.
Collapse
Affiliation(s)
- Jessica P Hollenbach
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut.
| | - Melanie Sue Collins
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut; Division of Pediatric Pulmonary and Sleep Medicine, Connecticut Children's Medical Center, Hartford, Connecticut; Central Connecticut Cystic Fibrosis Center, Hartford, Connecticut
| | - Caleb Wasser
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, Florida
| |
Collapse
|
28
|
Casanova S, Ahmed E, Bourdin A. Definition, Phenotyping of Severe Asthma, Including Cluster Analysis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1426:239-252. [PMID: 37464124 DOI: 10.1007/978-3-031-32259-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Asthma is defined as severe when it is uncontrolled despite the high intensity of treatment, or that loses control when a therapeutic step down is tried.These patients, for years, have been "uniformly" treated with massive doses of inhaled and oral corticosteroids regardless of their inflammatory state.Initially, asthma was considered of genesis "exclusively allergic." Subsequently, thanks to the development of noninvasive tools and of human monoclonal antibodies targeting interleukin 5, a pathogenetic role has been given to eosinophils. Management of steroids based on sputum eosinophil counts has been suggested according to clinical phenotypes identified through cluster analysis.The algorithms obtained from the cluster analysis have proved later to be poorly predictive of the inflammatory phenotype and difficult to apply in clinical practice.In the new era of precision medicine, the greatest challenge is finding clinical or biological elements predictive of response to therapies such as biologics. Cluster analyses performed on omics data or on cohorts of patients treated with biologics are more promising in this sense.In this article, starting from the current definition of severe asthma, we review the phenotypes proposed over time to date, showing the difficulty underlying the process of "phenotyping" due to the scarcity of available biomarkers.
Collapse
Affiliation(s)
- Serena Casanova
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Engi Ahmed
- Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, INSERM, Montpellier, France
| | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, INSERM, Montpellier, France
| |
Collapse
|
29
|
Ioniuc I, Miron I, Lupu VV, Starcea IM, Azoicai A, Alexoae M, Adam Raileanu A, Dragan F, Lupu A. Challenges in the Pharmacotherapeutic Management of Pediatric Asthma. Pharmaceuticals (Basel) 2022; 15:1581. [PMID: 36559032 PMCID: PMC9785161 DOI: 10.3390/ph15121581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Bronchial asthma is one of the most common chronic conditions in pediatric practice, with increasing prevalence hampered by poor socioeconomic impacts, leading to major public health issues. Considered as a complex heterogeneous syndrome, not a single disease, the management of the disease is a real challenge, impacting medical staff, patients and caregivers. Over the decades, a significant number of diagnostic and treatment regimen have been developed to achieve good standards, sustaining balanced control of the disease. This paper attempts a review on the establishment of new trends in the management of bronchial asthma in the pediatric age group.
Collapse
Affiliation(s)
- Ileana Ioniuc
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ingrith Miron
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Alice Azoicai
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Monica Alexoae
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Anca Adam Raileanu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Felicia Dragan
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Ancuta Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| |
Collapse
|
30
|
Skoner DP, Golant AK, Norton AE, Stukus DR. Is This Medication Safe for My Child? How to Discuss Safety of Commonly Used Medications With Parents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3064-3072. [PMID: 35963511 DOI: 10.1016/j.jaip.2022.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
All drugs have potential side effects, but thoughtful use can maximize benefits while minimizing risks. Children should not be considered just small adults regarding drug safety because their growth and development are discordant with their ability to sense and self-report drug side effects. Detecting side effects requires vigilance and education from prescribers to parents, who are tasked with monitoring their child over time. A drug's safety profile is published in the package label after pivotal trials are conducted in relatively small and sometimes narrow segments of the population during the U.S. Food and Drug Administration approval process. Drug safety profiles can change as data from postmarketing reports and long-term monitoring during phase IV trials emerge. As such, prescribers are obligated to maintain current understanding of any changes to drug labels. Discussing potential side effects, monitoring, and when to report concerns can be a time-consuming process during patient encounters. This review offers current information regarding potential side effects of some of the most commonly used medications for allergic conditions, asthma, and atopic dermatitis. This information and discussion will hopefully assist clinicians in their conversations with parents, including advice surrounding prescribing medication to minimize adverse effects, parental monitoring, and documentation.
Collapse
Affiliation(s)
- David P Skoner
- Section of Allergy and Immunology, West Virginia University Children's Hospital, Morgantown, WVa
| | - Alexandra K Golant
- Department of Dermatology and Laboratory of Inflammatory Skin Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio.
| |
Collapse
|
31
|
Bognanni A, Chu DK, Rank MA, Bernstein J, Ellis AK, Golden D, Greenhawt M, Hagan JB, Horner CC, Ledford DK, Lieberman J, Luong AU, Marks LA, Orlandi RR, Samant SA, Shaker M, Soler ZM, Stevens WW, Stukus DR, Wang J, Peters AT. Topical corticosteroids for chronic rhinosinusitis with nasal polyposis: GRADE systematic review and network meta-analysis. J Allergy Clin Immunol 2022; 150:1447-1459. [PMID: 35970310 DOI: 10.1016/j.jaci.2022.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/07/2022] [Accepted: 07/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyposis (CRSwNP) is associated with a significant disease burden. The optimal use of and administration route for intranasal corticosteroids (INCS) when managing CRSwNP are unclear. OBJECTIVE We systematically synthesized the evidence addressing INCS for CRSwNP. METHODS We searched studies archived in Medline, Embase, and Central from database inception until September 1, 2021, for randomized controlled trials comparing INCS using any delivery method to placebo or other INCS administration types. Paired reviewers screened records, abstracted data, and rated risk of bias (CLARITY revision of Cochrane Risk of Bias version 1 tool) independently and in duplicate. We synthesized the evidence for each outcome using random effects network meta-analyses. We critically appraised the evidence following the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) approach. RESULTS We analyzed 61 randomized controlled trials (7176 participants, 8 interventions). Sinusitis-related quality of life might improve with INCS rinse (mean difference [MD] -6.83, 95% confidence interval [CI] -11.94 to -1.71) and exhalation delivery system (EDS) (MD -7.86, 95% CI -14.64 to -1.08) compared to placebo (both low certainty evidence). Nasal obstruction symptoms are likely improved when receiving INCS via stent/dressing (MD -0.31, 95% CI -0.54 to -0.08), spray (MD -0.51, 95% CI -0.61 to -0.41), and EDS (MD -0.35, 95% CI -0.51 to -0.18) (all moderate to high certainty) compared to placebo. We found no important differences in adverse effects among interventions (moderate certainty for INCS spray, very low to low certainty for others). CONCLUSIONS Multiple delivery forms of INCS are viable therapeutic options for CRSwNP, resulting in improvement of patient-important outcomes. INCS via stent, spray, and EDS appear to be beneficial across the widest range of considered outcomes.
Collapse
Affiliation(s)
- Antonio Bognanni
- Evidence in Allergy Group, Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Derek K Chu
- Evidence in Allergy Group, Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Ariz.
| | | | - Anne K Ellis
- Department of Medicine, Division of Allergy & Immunology, Queen's University, Kingston, Canada
| | - David Golden
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew Greenhawt
- Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colo
| | | | - Caroline C Horner
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis K Ledford
- Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Jay Lieberman
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tenn
| | - Amber U Luong
- McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Tex
| | | | | | | | - Marcus Shaker
- Dartmouth Geisel School of Medicine and the Dartmouth Hitchcock Medical Center, Section of Allergy, Lebanon, NH.
| | | | - Whitney W Stevens
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anju T Peters
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| |
Collapse
|
32
|
Brattsand R, Selroos O. May a different kinetic mode explain the high efficacy/safety profile of inhaled budesonide? Pulm Pharmacol Ther 2022; 77:102167. [PMID: 36180011 DOI: 10.1016/j.pupt.2022.102167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022]
Abstract
The claimed functional basis for ICSs in asthma and COPD is airway selectivity, attained by inhaling a potent, lipophilic compound with long local dissolution/absorption time. The development has been empirically based, resulting in five widely used ICSs. Among them, budesonide (BUD) deviates by being less lipophilic, leading to a more rapid systemic uptake with plasma peaks with some systemic anti-inflammatory activity. By this, BUD fits less well into the current pharmacological dogma of optimal ICS profile. In this review we compared the physicochemical, pharmacological and clinical properties of BUD, fluticasone propionate (FP) and fluticasone furoate (FF), representing different levels of lipophilicity, airway and systemic kinetics, focusing on their long-acting β2-agonist (LABA) combinations, in line with current GINA and GOLD recommendations. We are aware of the differences between formoterol (FORM) and the not rapid acting LABAs such as e.g. salmeterol and vilanterol but our comparisons are based on currently available combination products. A beclomethasone dipropionate (BDP)/FORM combination is also commented upon. Based on clinical comparisons in asthma and COPD, we conclude that the BUD/formoterol (BUD/FORM) combination is as effective and safe as the FP and FF combinations, and is in some cases even better as it can be used as "maintenance plus reliever therapy" (MART) in asthma and as maintenance in COPD. This is difficult to explain by current views of required ICS's/LABAs pharmacokinetic profiles. We propose that BUD achieves its efficacy by a combination of airway and systemic activity. The airway activity is dominating. The systemic activity contributes by plasma peaks, which are high enough for supportive anti-inflammatory actions at the blood and bone marrow levels but not sufficiently long to trigger a similar level of systemic adverse effects. This may be due to BUD's capacity to exploit a systemic differentiation mechanism as programmed for cortisol's various actions. This differentiation prospect can be reached only for an ICS with short plasma half-life. Here we present an alternative mode for an ICS to reach combined efficacy and safety, based on a poorly investigated and exploited physiological mechanism. A preference of this mode is broader versatility, due to that its straighter dose-response should allow a better adaptation to disease fluctuations, and that its rapid activity enables use as "anti-inflammatory reliever".
Collapse
Affiliation(s)
- Ralph Brattsand
- Experimental Pharmacology, Budera Company, Kristinehamn, Sweden.
| | | |
Collapse
|
33
|
Allergies Don't Take a Vacation. Ann Allergy Asthma Immunol 2022; 130:419-421. [PMID: 36115634 DOI: 10.1016/j.anai.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/21/2022]
|
34
|
Imam SF, Zafar S, Oppenheimer J. SMART in treatment of asthma exacerbations. Ann Allergy Asthma Immunol 2022; 129:703-708. [PMID: 35914659 DOI: 10.1016/j.anai.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness and practicality of SMART (single maintenance and reliever therapy) in the treatment of asthma exacerbation. DATA SOURCES PubMed, MEDLINE, Cochrane, and Clinical Trial databases using the keywords SMART therapy, maintenance and reliever therapy, and budesonide and formoterol. STUDY SELECTION Articles were selected based on their relevance and applicability to this topic. RESULTS Multiple studies have evaluated the efficacy of SMART in reducing asthma exacerbations in comparison to standard inhaled corticosteroid (ICS) maintenance and short-acting beta-agonist (SABA) rescue therapy. Most of the randomized trials demonstrated a reduction in asthma exacerbation with open-label studies revealing similar effectiveness in reducing asthma exacerbation. Previously, concerns have been raised regarding the administration of increased doses of long-acting beta-agonist that may potentially mask symptoms and delay appropriate medical attention. However, studies have not demonstrated an increase in morbidity or mortality. The primary concern regarding many of these trials is that they have been sponsored by pharmaceutical companies. CONCLUSION Although not all studies demonstrated the effectiveness of SMART, the majority revealed a significant reduction in asthma exacerbation frequency and severity.
Collapse
Affiliation(s)
- Syed Fahmeed Imam
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School.
| | - Saira Zafar
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School
| | - John Oppenheimer
- Division of Allergy/Immunology, Rheumatology, & Pulmonology, Department of Medicine, Rutgers New Jersey Medical School
| |
Collapse
|
35
|
Schatz M, Zeiger RS. Asthma Guidance: Options for Individualized Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:S39-S40. [PMID: 34949333 DOI: 10.1016/j.jaip.2021.10.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| |
Collapse
|