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Arslan B, Çetin GP, Yilmaz İ. The Role of Long-Acting Antimuscarinic Agents in the Treatment of Asthma. J Aerosol Med Pulm Drug Deliv 2023; 36:189-209. [PMID: 37428619 DOI: 10.1089/jamp.2022.0059] [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] [Indexed: 07/12/2023] Open
Abstract
The journey of using anticholinergics in the treatment of asthma started with anticholinergic-containing plants such as Datura stramonium and Atropa belladonna, followed by ipratropium bromide and continued with tiotropium, glycopyrronium, and umeclidinium. Although antimuscarinics were used in the maintenance treatment of asthma over a century ago, after a long time (since 2014), it has been recommended to be used as an add-on long-acting antimuscarinic agent (LAMA) therapy in the maintenance treatment of asthma. The airway tone controlled by the vagus nerve is increased in asthma. Allergens, toxins, or viruses cause airway inflammation and inflammation-related epithelial damage, increased sensory nerve stimulation, ganglionic and postganglionic acetylcholine (ACh) release by inflammatory mediators, intensification of ACh signaling at M1 and M3 muscarinic ACh receptors (mAChRs), and dysfunction of M2 mAChR. Optimal anticholinergic drug for asthma should effectively block M3 and M1 receptors, but have minimal effect on M2 receptors. Tiotropium, umeclidinium, and glycopyrronium are anticholinergic agents with this feature. Tiotropium has been used in a separate inhaler as an add-on treatment to inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA), and glycopyrronium and umeclidinium have been used in a single inhaler as a combination of ICS/LABA/LAMA in asthma in recent years. Guidelines recommend this regimen as an optimization step for patients with severe asthma before initiating any biologic or systemic corticosteroid therapy. In this review, the history of antimuscarinic agents, their effectiveness and safety in line with randomized controlled trials, and real-life studies in asthma treatment will be discussed according to the current data.
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Affiliation(s)
- Bahar Arslan
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - Gülden Paçacı Çetin
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
| | - İnsu Yilmaz
- Division of Immunology and Allergy, Department of Chest Diseases, Erciyes University School of Medicine, Kayseri, Turkey
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Umeda A, Shimada H, Yamane T, Mochizuki T, Inoue Y, Tsushima K, Miyagawa K, Mochida A, Takeda H, Okada Y, Masaki K, Matsusaka M, Fukunaga K. Real-world effects of once-daily inhaled steroid (fluticasone furoate) combined with long-acting beta-2 agonist (vilanterol) and long-acting muscarinic antagonist (umeclidinium) on lung function tests of asthma patients in Japan. Front Physiol 2023; 14:1131949. [PMID: 37179838 PMCID: PMC10170765 DOI: 10.3389/fphys.2023.1131949] [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: 12/26/2022] [Accepted: 04/03/2023] [Indexed: 05/15/2023] Open
Abstract
Background: The Japanese drug use system allowed the once-daily use of inhaled corticosteroid fluticasone furoate (FF) combined with a long-acting beta-2 agonist vilanterol (VI) and a long-acting muscarinic antagonist umeclidinium (UMEC) against asthma on 18 February 2021. We investigated the real-world effects of these drugs (FF/UMEC/VI) mainly on lung function tests. Methods: This was an open-label, uncontrolled, within-group time-series (before-after) study. Prior asthma treatment (inhaled corticosteroid with/without a long-acting beta-2 agonist with/without a long-acting muscarinic antagonist) was switched to FF/UMEC/VI 200/62.5/25 μg. Subjects were evaluated by lung function tests prior to, and 1-2 months after, initiation of FF/UMEC/VI 200/62.5/25 μg. Patients were asked questions regarding the asthma control test and preference for drugs. Results: Overall, 114 asthma outpatients (97% Japanese) were enrolled from February 2021 to April 2022: 104 subjects completed the study. Forced expiratory volume in 1 s, peak flow, and asthma control test score of FF/UMEC/VI 200/62.5/25 μg-treated subjects were significantly increased (p < 0.001, p < 0.001, and p < 0.01, respectively). In contrast with FF/VI 200/25 μg, instantaneous flow at 25% of the forced vital capacity and expiratory reserve volume were significantly increased by FF/UMEC/VI 200/62.5/25 μg (p < 0.01, p < 0.05, respectively). Sixty-six percent of subjects declared they wanted to continue FF/UMEC/VI 200/62.5/25 μg in the future. Adverse effects, mainly local, were seen in 30% of patients, but no serious adverse effects were seen. Conclusion: Once-daily FF/UMEC/VI 200/62.5/25 μg was effective against asthma without serious adverse events. This is the first report that demonstrated FF/UMEC/VI dilated peripheral airways using lung function tests. This evidence on drug effects may improve our understanding of pulmonary physiology and the pathophysiology of asthma.
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Affiliation(s)
- Akira Umeda
- Department of General Medicine, School of Medicine, International University of Health and Welfare (IUHW), IUHW Shioya Hospital, Yaita, Japan
- Department of Respiratory Medicine, IUHW Shioya Hospital, Yaita, Japan
- *Correspondence: Akira Umeda,
| | - Hisato Shimada
- Department of Respiratory Medicine, IUHW Shioya Hospital, Yaita, Japan
| | - Tateki Yamane
- Department of Digestive Organ, IUHW Shioya Hospital, Yaita, Japan
| | | | - Yasushi Inoue
- Respiratory Diseases Center, IUHW Mita Hospital, Tokyo, Japan
| | - Kenji Tsushima
- Department of Pulmonary Medicine, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Kazuya Miyagawa
- Department of Pharmacology, School of Pharmacy, International University of Health and Welfare, Otawara, Japan
| | - Atsumi Mochida
- Department of Pharmacology, School of Pharmacy, International University of Health and Welfare, Otawara, Japan
| | - Hiroshi Takeda
- Department of Pharmacology, School of Pharmacy at Fukuoka, International University of Health and Welfare, Fukuoka, Japan
| | - Yasumasa Okada
- Department of Internal Medicine, National Hospital Organization Murayama Medical Center, Musashimurayama, Japan
| | - Katsunori Masaki
- Division of Pulmonary Medicine, Department of Medicine, Keio University, Tokyo, Japan
| | - Masako Matsusaka
- Division of Pulmonary Medicine, Department of Medicine, Keio University, Tokyo, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University, Tokyo, Japan
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Matera MG, Rinaldi B, Belardo C, Calzetta L, Cazzola M. Pharmacokinetic considerations surrounding triple therapy for uncontrolled asthma. Expert Opin Drug Metab Toxicol 2023; 19:345-355. [PMID: 37376964 DOI: 10.1080/17425255.2023.2230130] [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] [Received: 12/28/2022] [Revised: 04/12/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION Solid pharmacological rationale and clinical evidence support the use of a combination of an inhaled corticosteroid (ICS), a long-acting β2-agonist, and a long-acting muscarinic antagonist in severe asthma, which clinically results in increased lung function, improved symptoms, and decreased exacerbation rates. AREAS COVERED We examined the pharmacokinetic issues associated with triple therapy for uncontrolled asthma. We considered the pharmacokinetic characteristics of the three drug classes, the role of inhalers in influencing their pharmacokinetic behavior, and the impact of severe asthma on the pharmacokinetics of inhaled drugs. EXPERT OPINION The pharmacokinetics of ICSs and bronchodilators are not affected to a great extent by severe asthma, according to a detailed review of the currently accessible literature. Compared to healthy people, patients with severe asthma show only minor variations in a few pharmacokinetic characteristics, which are unlikely to have therapeutic significance and do not require particular attention. However, the difficulty of obtaining pharmacokinetic profiles of the three drugs included in a triple therapy suggests that the clinical response should be followed over time, which can be considered a good surrogate indicator of whether the drugs have reached sufficient concentrations in the lung to exert a valid pharmacological action.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Carmela Belardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome 'Tor Vergata', Rome, Italy
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Casale TB, Foggs MB, Balkissoon RC. Optimizing asthma management: Role of long-acting muscarinic antagonists. J Allergy Clin Immunol 2022; 150:557-568. [PMID: 35933228 DOI: 10.1016/j.jaci.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Patients with asthma who are suboptimally responsive to inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs) are frequently exposed to oral corticosteroids and high-dose ICS, which can lead to significant side effects. Long-acting muscarinic antagonists (LAMAs) have demonstrated efficacy and safety in a subset of these patients. This review summarizes the results of key studies using LAMAs in patients with asthma aged 12 years or older. LAMA as an add-on treatment improved lung function and asthma control in patients with uncontrolled asthma across studies. The efficacy of LAMAs as an add-on to ICS was superior to that of placebo and ICS dose escalation and comparable with that of LABAs. LAMA plus ICS plus LABA provided modest improvements in bronchodilation and increased the time to first severe exacerbation versus ICS plus LABA. Single-inhaler triple therapy was associated with decreased health care resource utilization and improved cost-effectiveness versus multiple inhalers. LAMAs were generally well tolerated; asthma exacerbations, bronchitis, and nasopharyngitis were common adverse events with LAMA in combination with ICS alone or ICS plus LABA. Thus, the overall evidence presented in this review supports the use of add-on LAMA treatment as a reasonable option in patients with asthma uncontrolled with ICS plus LABA or ICS alone.
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Affiliation(s)
- Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla.
| | | | - Ronald C Balkissoon
- Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, Colo
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Ora J, Calzetta L, Ritondo BL, Matera MG, Rogliani P. Current long-acting muscarinic antagonists for the treatment of asthma. Expert Opin Pharmacother 2021; 22:2343-2357. [PMID: 34219573 DOI: 10.1080/14656566.2021.1952182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The role of long-acting muscarinic antagonists (LAMAs) is well established in uncontrolled asthma, but not in milder stages. AREAS COVERED This review examines the main randomized controlled trials (RCTs) that have investigated LAMAs administered as monotherapy or in combination to asthmatic patients, according to the different phenotypes. It offers an overview of the role of LAMAs or their fixed dose combinations (FDCs) in the treatment across all the different stages of asthma. EXPERT OPINION Tiotropium is now widely recognized as treatment for moderate to severe uncontrolled asthma (step 4-5) in adults and children. The most recent new evidence is: a) in adults, three different LAMA/long-acting β2-agonist (LABA)/inhaled corticosteroid (ICS) FDCs have been recently approved, extending the treatment options for these patients; b) therapy with LAMAs does not depend on patient's Th2 status and justifies the indication regardless of patient's phenotyping; c) in the milder stages, the high variability of response to LAMAs and the lack of a good phenotyping of patients represents the main obstacle in prescribing LAMAs. A better characterization of parasympathetic tone activity could improve LAMAs prescription.
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Affiliation(s)
- Josuel Ora
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paola Rogliani
- Respiratory Medicine Unit, University Hospital "Tor Vergata", Rome, Italy.,Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Hozawa S, Ohbayashi H, Tsuchiya M, Hara Y, Lee LA, Nakayama T, Tamaoki J, Fowler A, Nishi T. Safety of Once-Daily Single-Inhaler Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol in Japanese Patients with Asthma: A Long-Term (52-Week) Phase III Open-Label Study. J Asthma Allergy 2021; 14:809-819. [PMID: 34262299 PMCID: PMC8275015 DOI: 10.2147/jaa.s305918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The pivotal CAPTAIN study reported a favorable safety profile with once-daily inhaled corticosteroid/long-acting muscarinic antagonist/long-acting β2-agonist (ICS/LAMA/LABA) triple combination of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) in patients with inadequately controlled asthma, some of whom were Japanese. Here, we evaluate the long-term (52 weeks) safety of FF/UMEC/VI in Japanese patients with asthma. Patients and Methods This was a Phase III, 52-week, multicenter, non-comparator, non-randomized, open-label study (NCT03184987) in Japanese adults receiving maintenance therapy with ICS/LABA, with or without LAMA. At enrollment, patients were allocated to either FF/UMEC/VI 100/62.5/25mcg (Group 1) or 200/62.5/25mcg (Group 2). Patients in Group 1 could have their treatment stepped up to 200/62.5/25mcg at Week 24 if their Asthma Control Questionnaire (ACQ)-7 score was >0.75. The primary endpoint was the incidence of adverse events (AEs) and serious AEs (SAEs). Secondary endpoints included vital signs, electrocardiogram measurements, and clinical laboratory tests (biochemistry, hematology, urinalysis). Efficacy was assessed as "other" endpoints. Results A total of 111 Japanese patients were included in the intention-to-treat (ITT) population. Overall, 77 (69%) patients reported ≥1 AE (Group 1: n=30 [64%]; step-up group: n=7 [78%]; Group 2: n=40 [73%]). SAEs were reported for 1 (2.1%) and 2 (3.6%) patients in Groups 1 and 2, respectively. All SAEs were considered unrelated to study treatment. One AE and one SAE led to study withdrawal: oropharyngeal discomfort (Group 1); eosinophilic granulomatosis with polyangiitis (Group 2). No new safety concerns were identified throughout the 52-week treatment period. Conclusion In this uncontrolled open-label study, no new safety concerns were observed with long-term (52 weeks) treatment with once-daily FF/UMEC/VI among 111 Japanese patients with asthma.
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Affiliation(s)
| | | | - Michiko Tsuchiya
- Department of Respiratory Medicine, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
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7
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Beier J, Watz H, Diamant Z, Hohlfeld JM, Singh D, Pinot P, Jones I, Tillmann HC. Lung function improvements following inhaled indacaterol/glycopyrronium/mometasone furoate are independent of dosing time in asthma patients: a randomised trial. ERJ Open Res 2021; 7:00425-2020. [PMID: 33898609 PMCID: PMC8053816 DOI: 10.1183/23120541.00425-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/14/2020] [Indexed: 01/12/2023] Open
Abstract
Once-daily asthma treatment should prevent night-time deterioration, irrespective of the time of dosing. IND/GLY/MF, a fixed-dose combination of inhaled indacaterol acetate (IND, long-acting β2-agonist (LABA)), glycopyrronium bromide (GLY, long-acting muscarinic antagonist) and mometasone furoate (MF, inhaled corticosteroid (ICS)) delivered by Breezhaler, is indicated in adult asthma patients inadequately controlled on LABA/ICS. A randomised, double-blind, placebo-controlled, three-period, crossover, phase II study was performed to investigate the bronchodilator effect of IND/GLY/MF (150/50/80 μg) dosed morning and evening versus placebo in patients with mild-moderate asthma. The primary end-point was weighted mean forced expiratory volume in 1 s (FEV1) over 24 h following 14 days of IND/GLY/MF dosed a.m. and p.m. versus placebo. Secondary end-points included the effect of dosing time on peak expiratory flow (PEF) and safety/tolerability. Of 37 randomised patients (age 18–72 years; 21 male, 16 female) 34 completed all three treatment periods. At screening, median (range) pre-bronchodilator FEV1 was 75.8% (60–96%). Patients were using stable low- (83.8%) or medium-dose (16.2%) ICS. Morning and evening dosing of IND/GLY/MF improved FEV1 (area under the curve from 0 to 24 h) by 610 mL (90% CI 538–681 mL) and 615 mL (90% CI 544–687 mL), respectively, versus placebo. Mean PEF over 14 days increased by 70.7 L·min−1 (90% CI 60.5–80.9 L·min−1) following a.m. dosing, and by 59.7 L·min−1 (90% CI 49.5–69.9 L·min−1) following p.m. dosing of IND/GLY/MF versus placebo. IND/GLY/MF demonstrated a safety profile comparable with placebo. Once-daily inhaled IND/GLY/MF was well tolerated and provided sustained lung function improvements over 24 h, irrespective of a.m. or p.m. dosing, in patients with mild–moderate asthma. This randomised study found single-inhaler indacaterol/glycopyrronium/mometasone furoate improved respiratory parameters FEV1 and PEF in asthma patients, and showed similar efficacy when taken once daily in the morning or eveninghttps://bit.ly/3fH0I1K
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Affiliation(s)
- Jutta Beier
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Zuzana Diamant
- Dept of Respiratory Medicine and Allergology, Institute for Clinical Science, Skåne University Hospital, Lund, Sweden.,Dept of Microbiology, Immunology and Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium.,Dept of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre and QPS-NL, Groningen, The Netherlands
| | - Jens M Hohlfeld
- German Center for Lung Research (BREATH), Hannover, Germany.,Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Dave Singh
- University of Manchester, Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Pascale Pinot
- Novartis Institutes for Biomedical Research, Basel, Switzerland
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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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Matera MG, Belardo C, Rinaldi M, Rinaldi B, Cazzola M. Emerging muscarinic receptor antagonists for the treatment of asthma. Expert Opin Emerg Drugs 2020; 25:123-130. [PMID: 32312134 DOI: 10.1080/14728214.2020.1758059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The increased acetylcholine signaling in asthma pathophysiology offers the rationale for the use of LAMAs in the treatment of asthmatic patients. Tiotropium is still the only LAMA approved for use in asthma but there is a real interest in developing novel LAMAs for the treatment of asthma, or at least to extend this indication to other LAMAs already on the market. AREAS COVERED We examined and discussed trials and research that have studied or are evaluating the role of LAMAs already on the market in asthma and possible novel muscarinic acetylcholine receptor antagonists. EXPERT OPINION Glycopyrronium and umeclidinium will soon be included in the GINA strategy with the same current indications of tiotropium. It is likely that the choice of the LAMA will be influenced not so much by its pharmacological profile as by the type of triple therapy chosen. It is extremely difficult to identify a new LAMA that is more effective than tiotropium, but is it plausible that new technologies that will allow delivering the drug in a more targeted way and with a lower risk of adverse effects may represent the real progress in the use of LAMAs in asthma in the coming years.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Carmela Belardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Michele Rinaldi
- Multidisciplnary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli" , Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata" , Rome, Italy
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Matera MG, Rinaldi B, Berardo C, Rinaldi M, Cazzola M. A review of the pharmacokinetics of M 3 muscarinic receptor antagonists used for the treatment of asthma. Expert Opin Drug Metab Toxicol 2020; 16:143-148. [PMID: 31958237 DOI: 10.1080/17425255.2020.1716730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: There is solid evidence that in patients with poorly controlled severe asthma despite the use of ICS and LABA, the addition of LAMAs, such as tiotropium, significantly increases the time to the first severe exacerbation and provides a modest but sustained bronchodilation. However, only a very limited number of pharmacokinetic studies with these agents have been performed in asthmatic patients.Areas covered: The pharmacokinetic profile of inhaled tiotropium, umeclidinium and glycopyrronium in healthy volunteers and that of inhaled tiotropium and umeclidinium in asthmatic patients have been reviewed.Expert opinion: In asthmatic patients, LAMAs are rapidly absorbed into the systemic compartment and demonstrate bi-exponential elimination (rapidly declining plasma concentrations followed by slow apparent terminal elimination). Apparently, the severity of asthma does not change the pharmacokinetics of LAMAs. The limited information available is focused on the plasma pharmacokinetic profile of these drugs and, consequently, although suitable for establishing a systemic safety profile, it does not tell us much about possible therapeutic efficacy of LAMAs in asthmatics because quantification of systemic plasma values is neither at the airways, which are their site of action nor representative of their transport to this site.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Barbara Rinaldi
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carmela Berardo
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Michele Rinaldi
- Multidisciplnary Department of Medical-Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Holguin F, Cardet JC, Chung KF, Diver S, Ferreira DS, Fitzpatrick A, Gaga M, Kellermeyer L, Khurana S, Knight S, McDonald VM, Morgan RL, Ortega VE, Rigau D, Subbarao P, Tonia T, Adcock IM, Bleecker ER, Brightling C, Boulet LP, Cabana M, Castro M, Chanez P, Custovic A, Djukanovic R, Frey U, Frankemölle B, Gibson P, Hamerlijnck D, Jarjour N, Konno S, Shen H, Vitary C, Bush A. Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2020; 55:13993003.00588-2019. [PMID: 31558662 DOI: 10.1183/13993003.00588-2019] [Citation(s) in RCA: 315] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/08/2019] [Indexed: 12/11/2022]
Abstract
This document provides clinical recommendations for the management of severe asthma. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the European Respiratory Society/American Thoracic Society Task Force's questions. The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of asthma experts, who made specific recommendations on six specific questions. After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made the following recommendations: 1) suggest using anti-interleukin (IL)-5 and anti-IL-5 receptor α for severe uncontrolled adult eosinophilic asthma phenotypes; 2) suggest using a blood eosinophil cut-point ≥150 μL-1 to guide anti-IL-5 initiation in adult patients with severe asthma; 3) suggest considering specific eosinophil (≥260 μL-1) and exhaled nitric oxide fraction (≥19.5 ppb) cut-offs to identify adolescents or adults with the greatest likelihood of response to anti-IgE therapy; 4) suggest using inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite Global Initiative for Asthma (GINA) step 4-5 or National Asthma Education and Prevention Program (NAEPP) step 5 therapies; 5) suggest a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on GINA step 5 or NAEPP step 5 therapies, irrespective of asthma phenotype; and 6) suggest using anti-IL-4/13 for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of blood eosinophil levels. These recommendations should be reconsidered as new evidence becomes available.
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Affiliation(s)
- Fernando Holguin
- Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA .,F. Holguin is ATS co-chair
| | | | - Kian Fan Chung
- Experimental Studies Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah Diver
- Respiratory Biomedical Unit, University of Leicester, Leicester, UK
| | - Diogenes S Ferreira
- Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anne Fitzpatrick
- Division of Pulmonology Allergy/Immunology, Cystic Fibrosis and Sleep, Emory University, Atlanta, GA, USA
| | - Mina Gaga
- Respiratory Medicine Dept and Asthma Centre, Athens Chest Hospital, Athens, Greece
| | | | - Sandhya Khurana
- Pulmonary Diseases and Critical Care, University of Rochester, Rochester, NY, USA
| | - Shandra Knight
- Biomedical Library, National Jewish Health, Denver, CO, USA
| | | | - Rebecca L Morgan
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Victor E Ortega
- Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ian M Adcock
- Molecular Cell Biology Group, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, AZ, USA
| | - Chris Brightling
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | - Michael Cabana
- Division of General Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, MO, USA
| | - Pascal Chanez
- Dept of Respiratory Diseases, University of Aix-Marseille, Marseille, France
| | - Adnan Custovic
- Paediatric Allergy, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Ratko Djukanovic
- Respiratory Biomedical Research, University of Southampton, Southampton, UK
| | - Urs Frey
- Dept of Pediatrics, University Children's Hospital, Basel, Switzerland
| | | | - Peter Gibson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | | | - Nizar Jarjour
- Division of Pulmonary and Critical Care, University of Wisconsin, Madison, WI, USA
| | - Satoshi Konno
- Dept of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Huahao Shen
- Dept of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Cathy Vitary
- Asthma Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andy Bush
- Dept of Paediatrics, Imperial College London, National Heart and Lung Institute, London, UK.,A. Bush is ERS co-chair
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Abstract
PURPOSE OF REVIEW The precision medicine concept is both appealing and challenging. We review here the recent findings in the endotype-driven approach for major allergic diseases. RECENT FINDINGS Stratified medicine for different allergic diseases can identify patients who are more likely to benefit or experience an adverse reaction in response to a given therapy and anticipate their long-term outcome and vital risk. In addition, this approach potentially facilitates drug development and prevention strategies. SUMMARY The endotype-driven approach in allergic diseases has tremendous potential, but there are notable barriers in reaching the new world of precision medicine. Multidimensional endotyping integrating visible properties with multiple biomarkers is recommended for both type 2 and nontype 2 allergic diseases to provide evidence that a certain pathway is the key driver for a given patient. Significant healthcare system changes are required to achieve the expected targets.
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13
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Buhl R, Hamelmann E. Future perspectives of anticholinergics for the treatment of asthma in adults and children. Ther Clin Risk Manag 2019; 15:473-485. [PMID: 30936709 PMCID: PMC6422409 DOI: 10.2147/tcrm.s180890] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite major advances in therapeutic interventions and the availability of detailed treatment guidelines, a high proportion of patients with symptomatic asthma remain uncontrolled. Asthma management is largely guided by the Global Initiative for Asthma (GINA) strategy and is based on a backbone of inhaled corticosteroid (ICS) therapy with the use of additional therapies to achieve disease control. Inhaled long-acting bronchodilators alone and in combination are the preferred add-on treatment options. Although long-acting muscarinic antagonists (LAMAs) are a relatively recent addition to disease management recommendations for asthma, tiotropium has been extensively studied in a large clinical trial program. In Europe and the United States, tiotropium is approved for patients aged ≥6 years and uncontrolled on medium- to high-dose ICS/long-acting β2-agonists at GINA Steps 4 and 5 with a history of exacerbations. Evidence supports the efficacy of tiotropium Respimat® in adults in terms of lung function and asthma control, with a safety profile comparable with that of placebo across a range of asthma severities. Similarly, clinical trials in patients aged 1-17 years have shown improvements in lung function and trends toward improved asthma control. Furthermore, its efficacy makes tiotropium relatively easy to incorporate into routine clinical practice, irrespective of allergic status and without the need for patient phenotyping. Tiotropium is a cost-effective treatment that may offer an important alternative to other, more expensive add-on therapies. This review discusses the potential future position of LAMAs in clinical practice by considering the continuously evolving evidence. Prominence is given to tiotropium, the only LAMA supported by a structured clinical trial program in asthma to date, while also considering other recommended treatment options for patients with uncontrolled asthma. The importance of effective patient/caregiver-clinician communication and shared decision-making in enhancing treatment adherence is also highlighted.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Johannes Gutenberg University Hospital Mainz, Mainz, Germany,
| | - Eckard Hamelmann
- Children's Center Bethel, Evangelic Hospital Bethel, Department of Pediatrics, Bielefeld, Germany
- University Children's Hospital, Allergy Center Ruhr, Ruhr University Bochum, Bochum, Germany
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14
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Goldstein S. Clinical efficacy and safety of anticholinergic therapies in pediatric patients. Ther Clin Risk Manag 2019; 15:437-449. [PMID: 30936706 PMCID: PMC6422407 DOI: 10.2147/tcrm.s161362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The burden of uncontrolled asthma in children and adolescents is high. Treatment options for pediatric patients (aged under 18 years) with asthma are largely influenced by the Global Initiative for Asthma recommendations. Algorithms for adolescents (12-18 years) and adults are identical, but recommendations for children aged under 6 years and 6-11 years differ. Although the goals of treatment for pediatric patients with asthma are similar to those for adults, relatively few new therapies have been approved for this patient population within the last decade. Designing clinical trials involving children presents several challenges, notably that children are often less able to perform lung function tests, and traditional endpoints used in clinical trials with adults, such as forced expiratory volume in 1 second, asthma exacerbations and questionnaires, have limitations associated with their use in children. There are also ethical considerations related to the performance of longer placebo-controlled exacerbation trials. This review considers additional clinical endpoints to those traditionally reported, including forced expiratory flow at 25%-75% of forced vital capacity, which may help shed light on which treatments are most effective for use in pediatric patients with asthma. The pros and cons of specific and potentially clinically relevant endpoints are considered, along with device considerations and patient preferences that may enhance adherence and quality of life. Recent advances in the management of children and adolescents, including the US Food and Drug Administration and European Medicines Agency approval of tiotropium in patients with asthma aged 6 years and over, are also discussed.
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Affiliation(s)
- Stanley Goldstein
- Allergy and Asthma Care of Long Island, Rockville Centre, New York, NY, USA,
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15
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Gosens R, Gross N. The mode of action of anticholinergics in asthma. Eur Respir J 2018; 52:13993003.01247-2017. [PMID: 30115613 PMCID: PMC6340638 DOI: 10.1183/13993003.01247-2017] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 08/09/2018] [Indexed: 01/25/2023]
Abstract
Acetylcholine binds to muscarinic receptors to play a key role in the pathophysiology of asthma, leading to bronchoconstriction, increased mucus secretion, inflammation and airway remodelling. Anticholinergics are muscarinic receptor antagonists that are used in the treatment of chronic obstructive pulmonary disease and asthma. Recent in vivo and in vitro data have increased our understanding of how acetylcholine contributes to the disease manifestations of asthma, as well as elucidating the mechanism of action of anticholinergics. This review assesses the latest literature on acetylcholine in asthma pathophysiology, with a closer look at its role in airway inflammation and remodelling. New insights into the mechanism of action of anticholinergics, their effects on airway remodelling, and a review of the efficacy and safety of long-acting anticholinergics in asthma treatment will also be covered, including a summary of the latest clinical trial data. Pre-clinical data suggest that anticholinergics can reduce acetylcholine-induced airway inflammation and remodellinghttp://ow.ly/xqAQ30loP8F
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Affiliation(s)
| | - Nicholas Gross
- University Medical Research LLC, St Francis Hospital, Hartford, CT, USA
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16
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Abstract
PURPOSE OF REVIEW Current guidelines recommend a stepwise approach for pharmacological therapy aimed to achieve and maintain asthma control. Despite these recommendations, at least 50% of patients continue to be uncontrolled with risk of asthma exacerbations that can often be serious and are associated with deterioration of quality of life. In recent years, the interest in anticholinergic bronchodilators, which have been primarily used in the treatment of chronic obstructive pulmonary disease, has increased patients with uncontrolled asthma. This review analyzes the mechanisms for the proposed clinical use of anticholinergic bronchodilators as an adjunctive therapy in asthma. RECENT FINDINGS Based on existing and recent evidence, the use of anticholinergic bronchodilators, particularly long-acting muscarinic antagonists (LAMAs), plays an important role as add-on therapy in patients uncontrolled on existing therapies. In particular, the use of anticholinergics in asthma may have a role in patients intolerant to long-acting β2 agonist, in patients with certain pharmacogenetic profiles and in those patients with asthma symptoms mostly at night. SUMMARY Data from clinical trials and from real-life confirm the safety and efficacy of LAMAs, especially tiotropium, in patients who remain uncontrolled despite the use of inhaled corticosteroid therapy.
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Abstract
Parasympathetic activity is increased in patients with chronic obstructive pulmonary disease (COPD) and asthma and appears to be the major reversible component of airway obstruction. Therefore, treatment with muscarinic receptor antagonists is an effective bronchodilator therapy in COPD and also in asthmatic patients. In recent years, the accumulating evidence that the cholinergic system controls not only contraction by airway smooth muscle but also the functions of inflammatory cells and airway epithelial cells has suggested that muscarinic receptor antagonists could exert other effects that may be of clinical relevance when we must treat a patient suffering from COPD or asthma. There are currently six muscarinic receptor antagonists licenced for use in the treatment of COPD, the short-acting muscarinic receptor antagonists (SAMAs) ipratropium bromide and oxitropium bromide and the long-acting muscarinic receptor antagonists (LAMAs) aclidinium bromide, tiotropium bromide, glycopyrronium bromide and umeclidinium bromide. Concerns have been raised about possible associations of muscarinic receptor antagonists with cardiovascular safety, but the most advanced compounds seem to have an improved safety profile. Further beneficial effects of SAMAs and LAMAs are seen when added to existing treatments, including LABAs, inhaled corticosteroids and phosphodiesterase 4 inhibitors. The importance of tiotropium bromide in the maintenance treatment of COPD, and likely in asthma, has spurred further research to identify new LAMAs. There are a number of molecules that are being identified, but only few have reached the clinical development.
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Yehia AM, Monir HH. An Umeclidinium membrane sensor; Two-step optimization strategy for improved responses. Talanta 2017; 172:61-67. [DOI: 10.1016/j.talanta.2017.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 11/25/2022]
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19
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Yang S, Lee L, Pascoe S. Population Pharmacokinetics Modeling of Inhaled Umeclidinium for Adult Patients with Asthma. Eur J Drug Metab Pharmacokinet 2017; 42:79-88. [PMID: 27026339 DOI: 10.1007/s13318-016-0331-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Umeclidinium (UMEC; a long-acting anti-muscarinic) in combination with fluticasone furoate (an inhaled corticosteroid) is in development for asthma treatment. This secondary analysis aimed to develop a population pharmacokinetic model characterizing UMEC in adults with asthma, and evaluated the impact of covariates on pharmacokinetic parameters. METHODS Plasma concentration data from study NCT01641692 (assessing once-daily UMEC 15.6, 31.25, 62.5, 125, and 250 mcg, twice daily UMEC 15.6 and 31.25 mcg, and placebo) were analyzed using non-linear mixed-effect modeling in NONMEM®. Full likelihood, including observed data and data below the quantification limit (treated as censored), was maximized. Study endpoints were population pharmacokinetics (including apparent inhaled clearance [CL/F] and apparent distribution volume in the central compartment [V c/F]) and derived pharmacokinetic parameters (area under the concentration-time curve [AUC] and maximum concentration [C max] at steady-state). RESULTS In total, 128 patients provided 3757 data points. The pharmacokinetics of UMEC were best described using a two-compartment model with intravenous bolus input, due to fast absorption following inhalation. CL/F was 257 L/h and V c/F was 804 L. Creatinine clearance was a significant covariate for CL/F, as were age and body weight for V c/F. AUC and C max increased with increasing UMEC dose (once-daily 15.6-250 mcg: AUC0-24 median: 64.7-863 pg h/mL; C max median: 10.6-256 pg/mL). CONCLUSION The final population pharmacokinetic model adequately described the data, demonstrating minimal creatinine clearance, age, and body weight effects on overall plasma UMEC pharmacokinetics and systemic exposure.
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Affiliation(s)
- Shuying Yang
- GSK, Respiratory Medicines Development Centre, Stockley Park, Middlesex, UK.
- Clinical Pharmacology, Modelling and Simulation, R&D Projects Clinical Platforms and Sciences, GSK, Stockley Park West, 1-3 Iron Bridge Road, Uxbridge, Middlesex, UB11 1BT, UK.
| | - Laurie Lee
- GSK, Respiratory Medicines Development Centre, Stevenage, UK
| | - Steven Pascoe
- GSK, Respiratory Medicines Development Center, Research Triangle Park, NC, 27709-3398, USA
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20
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Lee L, Kerwin E, Collison K, Nelsen L, Wu W, Yang S, Pascoe S. The effect of umeclidinium on lung function and symptoms in patients with fixed airflow obstruction and reversibility to salbutamol: A randomised, 3-phase study. Respir Med 2017; 131:148-157. [PMID: 28947022 DOI: 10.1016/j.rmed.2017.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/07/2017] [Accepted: 08/11/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The long-acting muscarinic antagonist, umeclidinium (UMEC), combined with the inhaled corticosteroid, fluticasone furoate (FF), improves lung function in symptomatic patients with asthma. We assessed FF/UMEC in patients with a primary diagnosis of asthma or chronic obstructive pulmonary disease (COPD), but physiological characteristics of both (fixed airflow obstruction and reversibility to salbutamol). METHODS This double-blind, parallel-arm, 3-phase study randomised 338 patients (1:1:1:1:2:2) to FF 100 mcg alone or combined with UMEC (15.6, 62.5, 125, or 250 mcg) or vilanterol 25 mcg (Phase A, 4 weeks). Primary endpoint: change from baseline in clinic trough forced expiratory volume in 1 s (FEV1) (end of Phase A). Secondary endpoints: morning peak expiratory flow (PEF), rescue medication use and Evaluating Respiratory Symptoms in COPD (E-RS™: COPD) scores. Safety was assessed. RESULTS In the intent-to-treat population, the increase in trough FEV1 over FF was significant for FF/UMEC 62.5 (0.140 L [p = 0.019]) and 125 mcg (0.120 L [p = 0.039]), with similar changes for patients with a primary diagnosis of asthma or COPD. Changes from baseline in morning PEF and E-RS total score were greater for all FF/UMEC doses vs FF (p ≤ 0.05). Change from baseline in rescue medication use was statistically or clinically significant for all FF/UMEC doses vs FF. The incidence of on-treatment adverse events was 15%-32% (Phase A), with no dose-related effects. CONCLUSIONS FF/UMEC 62.5 mcg produced clinically meaningful improvements in FEV1, morning PEF, E-RS total score and rescue medication use. FF/UMEC may benefit patients with features of both asthma and COPD. CLINICALTRIALS.GOV: NCT02164539; GSK: 200699.
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Affiliation(s)
- Laurie Lee
- GSK, Gunnels Wood Rd, Stevenage, Hertfordshire SG1 2NY, UK.
| | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, PC, 3860 Crater Lake Ave, Medford, OR 97504, USA
| | | | - Linda Nelsen
- GSK, 1250 S Collegeville Rd, Collegeville, PA 19426, USA
| | - Wei Wu
- Biostatistics, PAREXEL International, 2520 Meridian Pkwy #200, Durham, NC 27713, USA
| | - Shuying Yang
- GSK, Stockley Park West, Uxbridge, Middlesex UB11 1BT, UK
| | - Steven Pascoe
- GSK, 5 Moore Dr, Research Triangle Park, NC 27709, USA
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Ferrando M, Bagnasco D, Braido F, Baiardini I, Passalacqua G, Puggioni F, Varricchi G, Canonica GW. Umeclidinium for the treatment of uncontrolled asthma. Expert Opin Investig Drugs 2017; 26:761-766. [PMID: 28406326 DOI: 10.1080/13543784.2017.1319472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Smooth muscle cell contraction in the airways is the principal therapeutic target in asthmatic subjects and its insufficient treatment is often a cause of uncontrolled disease. For this reason, research has focused on targeting smooth muscle activity with anticholinergic agents, including umeclidinium. Areas covered: This review highlights the potential application of umeclidinium, a long acting muscarinic antagonist, as a novel therapeutic approach for patients with severe uncontrolled asthma, despite maximal therapy. Expert opinion: Umeclidinium, similarly to tiotropium, which has been recently included in guidelines, may act by contrasting cholinergic activation in airways, preventing or at least reducing smooth muscle cells contraction and the consequent bronchoconstriction. This is similar to what occurs in chronic obstructive pulmonary disease, for which umeclidinium has been regularly approved. However, available data is not sufficient and further studies are needed before regulatory approval can be sought, since only phase II clinical trials have been conducted at present. Both quality of life and objectifiable clinical data and parameters must be assessed, including lung function improvements, reduction of exacerbations and reduction of as required medications.
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Affiliation(s)
- Matteo Ferrando
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Diego Bagnasco
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Fulvio Braido
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Ilaria Baiardini
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Giovanni Passalacqua
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Francesca Puggioni
- b Personalized Medicine Clinic Asthma and Allergy, Humanitas Clinical and Research Center, Department of Biomedical Science , Humanitas University , Rozzano (Milan) , Italy
| | - Gilda Varricchi
- c Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI) , University of Naples Federico II , Naples , Italy
| | - Giorgio Walter Canonica
- a Allergy and Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy.,b Personalized Medicine Clinic Asthma and Allergy, Humanitas Clinical and Research Center, Department of Biomedical Science , Humanitas University , Rozzano (Milan) , Italy
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Long-Acting Muscarinic Antagonists for Difficult-to-Treat Asthma: Emerging Evidence and Future Directions. Drugs 2017; 76:999-1013. [PMID: 27289376 DOI: 10.1007/s40265-016-0599-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Asthma is a complex disease where many patients remain symptomatic despite guideline-directed therapy. This suggests an unmet need for alternative treatment approaches. Understanding the physiological role of muscarinic receptors and the parasympathetic nervous system in the respiratory tract will provide a foundation of alternative therapeutics in asthma. Currently, several long-acting muscarinic antagonists (LAMAs) are on the market for the treatment of respiratory diseases. Many studies have shown the effectiveness of tiotropium, a LAMA, as add-on therapy in uncontrolled asthma. These studies led to FDA approval for tiotropium use in asthma. In this review, we discuss how the neurotransmitter acetylcholine itself contributes to inflammation, bronchoconstriction, and remodeling in asthma. We further describe the current clinical studies evaluating LAMAs in adult and adolescent patients with asthma, providing a comprehensive review of the current known physiological benefits of LAMAs in respiratory disease.
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23
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Cazzola M, Ora J, Rogliani P, Matera MG. Role of muscarinic antagonists in asthma therapy. Expert Rev Respir Med 2017; 11:239-253. [PMID: 28140686 DOI: 10.1080/17476348.2017.1289844] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Higher parasympathetic tone has been reported in asthmatics. In general, cholinergic contractile tone is increased by airway inflammation associated with asthma. Nevertheless, the role of muscarinic antagonists for the treatment of asthma has not yet been clearly defined. Areas covered: The use of SAMAs and LAMAs in asthma has been examined and discussed according with the published evidence. Particular attention has been given to the large Phase III clinical trial program designed to evaluate the efficacy and safety of tiotropium respimat added to standard treatment in adults, adolescents and children with persistent asthma across the spectrum of asthma severity. Expert commentary: The current evidence is that in patients with poorly controlled severe asthma despite the use of ICS and LABA, the addition of tiotropium significantly increases the time to the first severe exacerbation and provides a modest but sustained bronchodilation. Identical results should be produced using other LAMAs. In any case, the documentation that, at least in animal or in vitro models, LAMAs show significant anti-inflammatory and anti-proliferative capacities and are able to inhibit airway remodeling induced by allergens makes a strong presumption that the use of LAMAs in asthma may go beyond the simple bronchodilator effect.
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Affiliation(s)
- Mario Cazzola
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Josuel Ora
- b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Paola Rogliani
- a Chair of Respiratory Medicine, Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy.,b Division of Respiratory Medicine, Department of Internal Medicine , University Hospital Tor Vergata , Rome , Italy
| | - Maria Gabriella Matera
- c Chair of Pharmacology, Department of Experimental Medicine , Second University of Naples , Naples , Italy
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Thomson NC. New and developing non-adrenoreceptor small molecule drugs for the treatment of asthma. Expert Opin Pharmacother 2017; 18:283-293. [PMID: 28099820 DOI: 10.1080/14656566.2017.1284794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) alone or in combination with an inhaled long-acting beta2-agonist (LABA) are the preferred long-term treatment for adults and adolescents with symptomatic asthma. Additional drugs include leukotriene-receptor antagonists, slow-release theophylline and the long-acting muscarinic antagonist (LAMA) tiotropium (approved in 2015). There is a need for more effective therapies, as many patients continue to have poorly controlled asthma. Areas covered: New and developing long-acting non-adrenoreceptor synthetic drugs for the treatment of symptomatic chronic asthma despite treatment with an ICS alone or combined with a LABA. Data was reviewed from studies published up until November 2016. Expert opinion: Tiotropium improves lung function and has a modest effect in reducing exacerbations when added to ICS alone or ICS and LABA. The LAMAs umeclidinium and glycopyrronium are under development in fixed dose combination with ICS and LABA. Novel small molecule drugs, such as CRTH2 receptor antagonists, PDE4 inhibitors, protein kinase inhibitors and nonsteroidal glucocorticoid receptor agonists and 'off-label' use of licensed drugs, such as macrolides and statins are under investigation for asthma, although their effectiveness in clinical practice is not established. To better achieve the goal of developing effective novel small molecule drugs for asthma will require greater understanding of mechanisms of disease and the different phenotypes and endotypes of asthma.
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Affiliation(s)
- Neil C Thomson
- a Institute of Infection, Immunity & Inflammation , University of Glasgow , Glasgow , UK
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25
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Thomson NC. New and developing non-adrenoreceptor small molecule drugs for the treatment of asthma. Expert Opin Pharmacother 2017. [DOI: 10.10.1080/14656566.2017.1284794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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Aalbers R, Park HS. Positioning of Long-Acting Muscarinic Antagonists in the Management of Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:386-393. [PMID: 28677351 PMCID: PMC5500692 DOI: 10.4168/aair.2017.9.5.386] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/09/2017] [Indexed: 01/13/2023]
Abstract
Despite a range of efficacious therapies for asthma, including inhaled corticosteroids (ICS) and long-acting β2-agonists (LABA), a significant proportion of patients have poor asthma control and retain a risk of future worsening of their symptoms. Long-acting muscarinic antagonist (LAMA) bronchodilators offer a well-tolerated, efficacious, and cost-effective add-on to a patient's treatment. Of the LAMAs currently under investigation or available for the treatment of asthma, evidence from a comprehensive clinical trial program in adults and children shows that once-daily treatment with tiotropium provides benefits for patients with uncontrolled asthma despite the use of ICS and LABAs. Tiotropium is included in the Global Initiative for Asthma (GINA) strategy document as an add-on therapy option for patients at Step 4 or 5 with a history of asthma exacerbations. Tiotropium Respimat® has demonstrated safety and efficacy in patients with a range of disease severities, ages, and phenotypes. This review describes the evidence for the use of LAMA as add-on therapy for patients with asthma who remain uncontrolled despite the use of ICS and LABA treatments.
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Affiliation(s)
- René Aalbers
- Department of Pulmonology, Martini Hospital, Groningen, The Netherlands
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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Busse WW, Dahl R, Jenkins C, Cruz AA. Long-acting muscarinic antagonists: a potential add-on therapy in the treatment of asthma? Eur Respir Rev 2016; 25:54-64. [PMID: 26929422 DOI: 10.1183/16000617.0052-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory disorder of the airways that is a major global burden on both individuals and healthcare systems. Despite guideline-directed treatment, a significant proportion of patients with asthma do not achieve control. This review focuses on the potential use of long-acting anticholinergics as bronchodilators in the treatment of asthma, with results published from clinical trials of glycopyrrolate, umeclidinium and tiotropium. The tiotropium clinical trial programme is the most advanced, with data available from a number of phase II and III studies of tiotropium as an add-on to inhaled corticosteroid maintenance therapy, with or without a long-acting β2-agonist, in patients across asthma severities. Recent studies using the Respimat Soft Mist inhaler have identified 5 µg once daily as the preferred dosing regimen, which has shown promising results in adults, adolescents and children with asthma. Tiotropium Respimat has recently been incorporated into the Global Initiative for Asthma 2015 treatment strategy as a recommended alternative therapy at steps 4 and 5 in adult patients with a history of exacerbations. The increasing availability of evidence from ongoing and future clinical trials will be beneficial in determining where long-acting anticholinergic agents fit in future treatment guidelines across a variety of patient populations and disease severities.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Dahl
- Allergy Centre, Odense University Hospital, Odense, Denmark
| | | | - Alvaro A Cruz
- ProAR - Universidade Federal da Bahia, Bahia, Brazil
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Albertson TE, Chenoweth JA, Adams JY, Sutter ME. Muscarinic antagonists in early stage clinical development for the treatment of asthma. Expert Opin Investig Drugs 2016; 26:35-49. [PMID: 27927039 DOI: 10.1080/13543784.2017.1264388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Parasympathetic neurons utilize the neurotransmitter acetylcholine to modulate and constrict airway smooth muscles at the muscarinic acetylcholine receptor. Inhaled agents that antagonize the muscarinic (M) acetylcholine receptor, particularly airway M3 receptors, have increasing data supporting use in persistent asthma. Areas covered: Use of inhaled long-acting muscarinic antagonists (LAMA) in asthma is explored. The LAMA tiotropium is approved for maintenance in symptomatic asthma patients despite the use of inhaled corticosteroids (ICS), leukotriene receptor antagonists (LTRA) and/or long-acting beta2 agonists (LABA). LAMA agents currently approved for chronic obstructive pulmonary disease (COPD) include tiotropium, glycopyrrolate/glycopyrronium, umeclidinium and aclidinium. These agents are reviewed for their pharmacological differences and clinical trials in asthma. Expert opinion: Current guidelines place inhaled LAMAs as adjunctive maintenance therapy in symptomatic asthma not controlled by an ICS and/or a LTRA. LAMA agents will play an increasing role in moderate to severe symptomatic asthma patients. Additional LAMA agents are likely to seek a maintenance indication perhaps as a combined inhaler with an ICS or with an ICS and a LABA. These fixed-dose combination inhalers are being tested in COPD and asthma patients. Once-a-day dosing of inhaled LAMA agents in severe asthma patients will likely become the future standard.
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Affiliation(s)
- Timothy E Albertson
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA.,b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - James A Chenoweth
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
| | - Jason Y Adams
- a Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine , School of Medicine, U.C. Davis , Sacramento , CA , USA
| | - Mark E Sutter
- b Department of Emergency Medicine , School of Medicine U. C. Davis , Sacramento , CA , USA.,c Department of Medicine , Veterans Administration Northern California Health Care System , Mather , CA , USA
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Hansen S, Hoffmann-Petersen B, Sverrild A, Bräuner EV, Lykkegaard J, Bodtger U, Agertoft L, Korshøj L, Backer V. The Danish National Database for Asthma: establishing clinical quality indicators. Eur Clin Respir J 2016; 3:33903. [PMID: 27834178 PMCID: PMC5103671 DOI: 10.3402/ecrj.v3.33903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 12/12/2022] Open
Abstract
Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.
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Affiliation(s)
- Susanne Hansen
- Research Centre for Prevention and Health, Rigshospitalet Glostrup Hospital, Glostrup, Denmark
| | | | - Asger Sverrild
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | - Elvira V Bräuner
- Research Centre for Prevention and Health, Rigshospitalet Glostrup Hospital, Glostrup, Denmark
- Department of Occupational and Environmental Medicine, Bispebjerg - Frederiksberg Hospital, Copenhagen, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Uffe Bodtger
- Department of Respiratory Medicine, Naestved Hospital, Region Zealand, Denmark
- Department of Respiratory Medicine, Zealand University Hospital Roskilde, Region Zealand, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lone Agertoft
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | | | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark;
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Halpin DMG. Tiotropium in asthma: what is the evidence and how does it fit in? World Allergy Organ J 2016; 9:29. [PMID: 27679681 PMCID: PMC5022240 DOI: 10.1186/s40413-016-0119-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022] Open
Abstract
Despite current therapeutic approaches asthma remains uncontrolled in a significant proportion of patients. Short-acting anticholinergic bronchodilators have a very long history of use in asthma, and recent data confirms the importance of acetylcholine as both a bronchoconstrictor and as a regulator of inflammation and remodeling in the lungs. Data from a comprehensive clinical trial programme, as well as use in primary care, show the efficacy and safety of tiotropium in adults with mild to moderate asthma when it is added to ICS and in severe asthma when it is added to high doses of ICS plus LABA, as well as in adolescents. Tiotropium is cost effective and its benefits are not restricted to particular phenotypes, making it a useful addition to the therapeutic options recommended by the Global Initiative for Asthma (GINA) for people with poorly controlled asthma at steps 4 & 5.
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Vogelberg C. Tiotropium in the add-on treatment of asthma in adults: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10:525-533. [PMID: 27612491 PMCID: PMC5933593 DOI: 10.1177/1753465816662571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease, and its treatment is frequently
challenging despite detailed national and international guidelines. While basic
anti-inflammatory therapy usually consists of inhaled corticosteroids in doses
adapted to the asthma severity, add-on treatment with bronchodilators is
essential in more severe asthma. Only recently, the long-acting anticholinergic
tiotropium was introduced into the GINA guidelines. This review reports on the
studies that have been performed with tiotropium in adult asthmatic patients.
Following early proof-of-concept studies, several studies with tiotropium as an
add-on therapy to inhaled corticosteroids (ICS), with or without a long-acting
beta agonist (LABA), demonstrated convincing clinical benefit for patients.
Important lung function parameters and quality of life scores significantly
improved shortly after onset of the add-on therapy with tiotropium, and some
studies even demonstrated non-inferiority against salmeterol. All studies
reported an excellent safety profile of tiotropium. The still growing body of
tiotropium studies, both in adults and children, will help to identify the
position of tiotropium in future asthma guidelines and might also indicate which
patients benefit most from an add-on therapy with tiotropium.
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Affiliation(s)
- Christian Vogelberg
- University Hospital Carl Gustav Carus, Department of Pediatric Pulmonology and Allergology, Fetscherstr. 74, 01307 Dresden, Germany
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McIvor RA. Emerging therapeutic options for the treatment of patients with symptomatic asthma. Ann Allergy Asthma Immunol 2015; 115:265-271.e5. [PMID: 26254973 DOI: 10.1016/j.anai.2015.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/25/2015] [Accepted: 07/13/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Asthma is a chronic inflammatory disorder of the airways with increasing worldwide prevalence. Despite treatment according to guidelines, a considerable proportion of patients with asthma remain symptomatic. Different potential therapeutic options for the treatment of these patients are currently in development and undergoing clinical trials, and it is important to regularly review their status. DATA SOURCES A search of ClinicalTrials.gov was performed and supported by a PubMed literature search and restricted to the previous 10 years to ensure currency of data. The results were manually filtered to identify relevant articles. STUDY SELECTIONS Emerging therapies that are currently in phase 2 and 3 development include anti-interleukin agents (benralizumab, reslizumab, dupilumab, brodalumab, lebrikizumab, and mepolizumab), a chemoattractant receptor-homologous molecule expressed on a T-helper type 2 lymphocyte antagonist (OC000459), a phosphodiesterase-4 inhibitor (roflumilast), and long-acting muscarinic antagonists (glycopyrronium bromide, umeclidinium bromide, and tiotropium bromide). RESULTS The clinical trial program of the long-acting muscarinic antagonist tiotropium is currently the most advanced, with data available from different phase 2 and 3 studies. Results demonstrate that it is an efficacious add-on to at least inhaled corticosteroid maintenance therapy across severities of symptomatic asthma. CONCLUSION The results of ongoing and future studies will help to determine whether these emerging therapeutic options will help address the unmet need for improvement in asthma management.
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Affiliation(s)
- R Andrew McIvor
- McMaster University, Firestone Institute for Respiratory Health, Hamilton, Ontario, Canada.
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Yang S, Goyal N, Beerahee M, Trivedi R, Lee L, Pascoe S. Dose-response modelling of umeclidinium and fluticasone furoate/umeclidinium in asthma. Eur J Clin Pharmacol 2015; 71:1051-8. [PMID: 26174114 DOI: 10.1007/s00228-015-1894-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/23/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE In two dose-ranging crossover studies, the long-acting muscarinic antagonist umeclidinium (UMEC) was assessed as monotherapy in patients with asthma not treated with inhaled corticosteroids (ICS) (NCT01641692 [study 1]) and combined with the ICS fluticasone furoate (FF) in patients with asthma symptomatic on ICS (NCT01573624 [study 2]). The present study aimed to further characterise the UMEC dose-response relationship with change from baseline trough forced expiratory volume in one second (FEV1) (day 15). METHODS A model-based approach using non-linear mixed-effects analyses was used to assess data from studies 1 and 2. RESULTS Within the Study 1 dose range, no significant dose-response was demonstrated. In study 2, the slope-intercept on log-dose model showed a mild dose-response, with a 10 % probability of a 0.075-L FEV1 improvement with FF/UMEC 100/250 mcg; period 1 data (with an absent carryover effect) indicated an 88 % probability of a 0.075-L FEV1 improvement. CONCLUSION The model-based approach in study 2 identified FF/UMEC doses warranting further investigation.
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Affiliation(s)
- Shuying Yang
- Clinical Pharmacology, Modelling and Simulation, R&D Projects Clinical Platforms and Sciences, GlaxoSmithKline, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex, UB11 1BT, UK,
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Hoy HM, O'Keefe LC. Practical guidance on the recognition of uncontrolled asthma and its management. J Am Assoc Nurse Pract 2015; 27:466-75. [PMID: 26119777 DOI: 10.1002/2327-6924.12284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 05/12/2015] [Indexed: 12/30/2022]
Abstract
PURPOSE To highlight the significance of asthma in primary care and offer a practitioner-friendly interpretation of the asthma guidelines for the busy provider, while introducing new treatment options currently in clinical trials, such as the once-daily long-acting anticholinergic bronchodilator tiotropium Respimat. DATA SOURCES Articles with relevant adult data published between 2004 and 2015 were identified via PubMed. Additional references were obtained by reviewing bibliographies from selected articles. CONCLUSIONS In the United States, uncontrolled or symptomatic asthma is common, with rates of 46%-78% in primary care. Uncontrolled asthma has a substantial impact on patients' quality of life and represents a significant healthcare burden. Nurse practitioners can improve patients' asthma control through education, monitoring, assessment, and treatment. Although asthma management guidelines are readily available, the authors recognize that nurse practitioners see patients with multiple comorbidities, all of which have treatment guidelines of their own. IMPLICATIONS FOR PRACTICE Nurse practitioners have a compelling opportunity as frontline caregivers and patient educators to recognize and assess uncontrolled asthma, along with determining the steps necessary to help patients gain and maintain symptom control.
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Affiliation(s)
- Haley M Hoy
- College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama
| | - Louise C O'Keefe
- College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama
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Lee LA, Yang S, Kerwin E, Trivedi R, Edwards LD, Pascoe S. The effect of fluticasone furoate/umeclidinium in adult patients with asthma: a randomized, dose-ranging study. Respir Med 2014; 109:54-62. [PMID: 25452139 DOI: 10.1016/j.rmed.2014.09.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/12/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We evaluated the dose-response of umeclidinium (UMEC; a long-acting muscarinic antagonist) combined with fluticasone furoate (FF; an inhaled corticosteroid [ICS]) in patients with asthma. METHODS In a double-blind, three-period crossover study, 421 subjects (symptomatic on ICS), were randomized to a sequence of three of seven treatments: FF 100 mcg alone, FF 100 mcg combined with UMEC (15.6, 31.25, 62.5, 125, or 250 mcg), or vilanterol 25 mcg (a long-acting β-agonist), inhaled once-daily for 14 days (12-14-day washout). Trough forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), and safety were assessed. RESULTS Period baseline was a significant covariate, indicating a potential carryover effect between treatment periods. Across all treatment periods, trough FEV1 improved with FF/UMEC 125 and 250 versus FF (treatment difference 0.055 L [both doses]; p = 0.018). FF/UMEC increased morning (15.9-22.9 L/min) and evening (16.2-28.8 L/min) PEF versus FF. As intended assessments were confounded, post hoc Period 1 data analyses were performed, demonstrating significant increases in trough FEV1 with FF/UMEC 31.25, 62.5, and 250 versus FF. Trough FEV1 improvements with FF/UMEC were greater in subjects with fixed (0.095-0.304 L) versus non-fixed (-0.084 to 0.041 L) obstruction. The incidence of on-treatment adverse events was 13-25% across groups. No treatment-related effects on laboratory parameters were reported. CONCLUSION FF/UMEC may be a viable treatment for patients with asthma symptomatic on ICS; benefit may be most prominent in those with fixed obstruction. The carryover effect suggests future UMEC studies should use an alternative design. ClinicalTrials.gov: NCT01573624.
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Affiliation(s)
- Laurie A Lee
- Respiratory Medicines Development Center, GlaxoSmithKline, Research Triangle Park, NC, 27709-3398, USA.
| | - Shuying Yang
- Clinical Pharmacology Modelling and Simulation, RD Projects Clinical Platforms & Sciences, GlaxoSmithKline, Uxbridge, Middlesex, UB11 1BT, UK
| | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, PC, Medford, OR, 97504, USA
| | - Roopa Trivedi
- Respiratory Medicines Development Center, GlaxoSmithKline, Research Triangle Park, NC, 27709-3398, USA
| | - Lisa D Edwards
- Respiratory Medicines Development Center, GlaxoSmithKline, Research Triangle Park, NC, 27709-3398, USA
| | - Steven Pascoe
- Respiratory Medicines Development Center, GlaxoSmithKline, Research Triangle Park, NC, 27709-3398, USA
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