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Laitano R, Calzetta L, Matino M, Pistocchini E, Rogliani P. Asthma management with triple ICS/LABA/LAMA combination to reduce the risk of exacerbation: an umbrella review compliant with the PRIOR statement. Expert Opin Pharmacother 2024; 25:1071-1081. [PMID: 38864834 DOI: 10.1080/14656566.2024.2366991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/07/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION According to Global Initiative for Asthma (GINA) guidelines, long-acting muscarinic antagonists (LAMAs) should be considered as add-on therapy in patients with asthma that remains uncontrolled, despite treatment with medium-dose (MD) or high-dose (HD) inhaled corticosteroids (ICS)/long-acting β2-agonist (LABA) combinations. In patients ≥ 18 years, LAMA may be added in triple combination with an ICS and a LABA. To date, the precise efficacy of triple ICS/LABA/LAMA combination remains uncertain concerning the impact on exacerbation risk in patients with uncontrolled asthma. Therefore, an umbrella review was performed to systematically summarize available data on the effect of triple ICS/LABA/LAMA combination on the risk of asthma exacerbation. METHODS An umbrella review has been performed according to the PRIOR statement. RESULTS The overall results obtained from 5 systematic reviews and meta-analyses suggest that triple ICS/LABA/LAMA combination reduces the risk of asthma exacerbation. HD-ICS showed a greater effect particularly in reducing severe asthma exacerbation, especially in patients with evidence of type 2 inflammation biomarkers. CONCLUSIONS The findings of this umbrella review suggest an optimization of ICS dose in triple ICS/LABA/LAMA combination, based on the severity of exacerbation and type 2 biomarkers expression.
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Affiliation(s)
- Rossella Laitano
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Matteo Matino
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elena Pistocchini
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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Oppenheimer J, Kerstjens HA, Boulet LP, Hanania NA, Kerwin E, Moore A, Nathan RA, Peachey G, Pizzichini E, Slade D, Zarankaite A, Pavord ID. Characterization of Moderate and Severe Asthma Exacerbations in the CAPTAIN Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00533-6. [PMID: 38777124 DOI: 10.1016/j.jaip.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/23/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Limited data exist on the relative impact of moderate and severe exacerbations on asthma control and impairment. OBJECTIVE To explore data from the CAPTAIN trial to evaluate the relationship between first moderate or severe exacerbation and changes in lung function, symptoms, physical activity limitation scores, and short-acting β2-agonist (SABA) usage to determine the clinical relevance of moderate events. METHODS CAPTAIN was a phase IIIA 24- to 52-week, multicenter, international, randomized controlled trial evaluating efficacy and safety of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) versus FF/VI in patients with uncontrolled asthma on inhaled corticosteroid/long-acting β2-agonist. Outcomes reported include first postrandomization exacerbation event by severity (wk 1-52), frequency and duration of moderate and severe exacerbations, and time course of changes over ± 14-day peri-exacerbation period for lung function, symptoms, limitations, and SABA use. RESULTS Of the intent-to-treat population (n = 2,436), 550 patients (23%) continued to 52 weeks. There were 529 moderate and 546 severe exacerbations. Lung function changes were similar, but symptom, physical activity limitation scores, and SABA use were higher, for severe versus moderate exacerbations. Lung function decline preceded increases in symptom, physical activity limitation scores, and SABA use, irrespective of exacerbation severity. Lung function variables, limitation scores, and SABA use returned to pre-exacerbation baseline after approximately 8 to 12 days for both exacerbation severities. CONCLUSIONS Whereas severe events were associated with greater impact on symptoms, physical activity limitations, and SABA use, onset and time to resolution were generally similar for moderate and severe events. Both exacerbation severities represent clinically important deteriorations comprising clinical and functional changes.
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Affiliation(s)
| | - Huib A Kerstjens
- Faculty of Medical Sciences, University of Groningen and University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Edward Kerwin
- Altitude Clinical Consulting and Clinical Research Institute, Medford, OR
| | - Alison Moore
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Robert A Nathan
- Asthma & Allergy Associates, PC, and Research Center, Colorado Springs, Colo
| | - Guy Peachey
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Emilio Pizzichini
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK; Department of Clinical Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil
| | | | - Agne Zarankaite
- Global Medical Affairs, General Medicines, GSK, Brentford, Middlesex, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory National Institute for Health & Care Research Biomedical Research Centres, Oxford, UK.
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Canonica GW, Varricchi G, Paoletti G, Heffler E, Virchow JC. Advancing precision medicine in asthma: Evolution of treatment outcomes. J Allergy Clin Immunol 2023; 152:835-840. [PMID: 37531979 DOI: 10.1016/j.jaci.2023.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/04/2023]
Abstract
The article discusses the historical evolution of asthma treatment and highlights recent advancements in personalized medicine, specifically the use of biologics in severe asthma therapy and its potential combination with allergen immunotherapy (AIT). One of the major breakthroughs of biologics is their potential effect on airway remodeling, a crucial aspect of asthma chronicity. The article introduces the concept of disease-modifying antiasthmatic drugs, which aim to modify the course of asthma and possibly modulate or prevent airway remodeling. Furthermore, the critical importance of patient-centered outcome measures to evaluate the efficacy and effectiveness of asthma treatments is emphasized, with the innovative concept of asthma remission introduced as a potential outcome. Recent studies suggest that AIT can be used as an additional therapy to biologic agents for the treatment of allergic asthma. The combination of these treatments has been shown to induce improved clinical outcomes. However, AIT is actually not recommended for use in patients with severe asthma, but encouraging results from studies investigating the combined use of AIT and biologics indicate a novel approach to exploring these treatment modalities. In conclusion, the introduction of biologics and AIT has changed the scenario of respiratory allergy treatment, from a "one size fits all" approach to embracing "individual treatments."
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Asthma & Allergy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy.
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy; Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy; World Allergy Organization (WAO) Center of Excellence, Naples, Italy; Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Giovanni Paoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Asthma & Allergy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Asthma & Allergy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
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Ciółkowski J, Hydzik P, Rachel M, Mazurek-Durlak Z, Skalska-Izdebska R, Mazurek H. Childhood asthma treatment based on indirect hyperresponsiveness test: Randomized controlled trial. Pediatr Pulmonol 2023; 58:2583-2591. [PMID: 37341585 DOI: 10.1002/ppul.26556] [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: 11/24/2022] [Revised: 05/02/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE The purpose of this study was to assess the usefulness of indirect airway hyperresponsiveness (AHR) test using hypertonic saline in determining the dose of inhaled corticosteroids (ICS) to maintain asthma control in children. METHODS A group of 104 patients (7-15 years) with mild-moderate atopic asthma were monitored for their asthma control and treatment for 1 year. Patients were randomly assigned to a symptom-only monitored group and a group with therapy changes based on the symptoms and severity of AHR. Spirometry, exhaled nitric oxide, and blood eosinophils (BEos) were assessed on enrollment and every 3 months thereafter. RESULTS During the study period, the number of mild exacerbations was lower in the AHR group (44 vs. 85; the absolute rate per patient 0.83 vs. 1.67; relative rate 0.49, 95% confidence interval: 0.346-0.717 (p < 0.001)]. Mean changes from baseline in clinical (except asthma control test), inflammatory, and lung function parameters were similar between groups. Baseline BEos correlated with AHR and was a risk factor for recurrent exacerbation in all patients. There was no significant difference in the final ICS dose between AHR and symptoms group: 287 (SD 255) vs. 243 (158) p = 0.092. CONCLUSIONS Adding an indirect AHR test to clinical monitoring of childhood asthma reduced the number of mild exacerbations, with similar current clinical control and final ICS dose as in the symptom-monitored group. The hypertonic saline test appears to be a simple, cheap, and safe tool for monitoring the treatment of mild-to-moderate asthma in children.
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Affiliation(s)
- Janusz Ciółkowski
- Allergology Outpatient Clinic, The Regional Public Hospital in Lesko, Lesko, Poland
| | - Paweł Hydzik
- Department of Quantitative Methods in the Faculty of Management, Rzeszów University of Technology, Rzeszów, Poland
| | - Marta Rachel
- Institute of Medical Sciences, College of Medical Science, Rzeszów University, Rzeszów, Poland
| | | | - Renata Skalska-Izdebska
- Allergology Outpatient Clinic, The Regional Public Hospital in Lesko, Lesko, Poland
- Institute of Medical Sciences, College of Medical Science, Rzeszów University, Rzeszów, Poland
| | - Henryk Mazurek
- Department of Pneumonology and Cystic Fibrosis, National Research Institute of Tuberculosis and Lung Disorders, Rabka-Zdrój, Poland
- Institute of Health, State University of Applied Sciences in Nowy Sącz, Nowy Sącz, Poland
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Shen YL, Hsieh YA, Huang YM, Peng YH, Chen LI, Dai FC, Lin YS, Huang CW. Assessing the prognostic value of respiratory oscillometry in patients with difficult-to-treat asthma. Sci Rep 2023; 13:2457. [PMID: 36774404 PMCID: PMC9922248 DOI: 10.1038/s41598-023-29672-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/08/2023] [Indexed: 02/13/2023] Open
Abstract
Respiratory oscillometry is widely explored in asthma management; however, there is currently no consensus on its routine work-up in patients with difficult-to-treat asthma. We conducted a retrospective, cross-sectional study involving patients with difficult-to-treat asthma at Asia University Hospital between January 2017 and October 2020. We aimed to correlate clinical significance of respiratory oscillometry and asthma treatment outcomes including symptoms control and exacerbation in patients with difficult-to-treat asthma. Among the 69 patients enrolled in the study, a total of 26.1% of the patients experienced at least one severe or two moderate exacerbations. Patients with ACT < 20 presented a higher prevalence of higher frequency-dependent resistance (FDR; the difference in resistance at 5 Hz and 20 Hz) and frequency of resonance (Fres) than those with ACT ≥ 20. In the multivariable analysis, comorbidities, COPD or allergic rhinitis, and FDR were independent factors in increasing the odds ratio in poorly controlled asthma. (FDR ≥ 0.10 vs. < 0.10, adjusted ORR = 5.05, P = 0.037) There was a higher proportion of frequent exacerbations in patients with higher FDR (FDR ≥ 0.10 vs. < 0.10 = 30.0%:20.7%), but IOS parameters failed to predict frequent exacerbations on further analysis. FDR may be a potential clinical parameter for predicting symptom control in patients with difficult-to-treat asthma.
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Affiliation(s)
- Yi-Luen Shen
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC
| | - Yi-An Hsieh
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC
| | - Yu-Ming Huang
- Department of Respiratory Therapy, Asia University Hospital, Taichung, Taiwan, ROC
| | - Yi-Hao Peng
- Department of Respiratory Therapy, Asia University Hospital, Taichung, Taiwan, ROC
| | - Ling-I Chen
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC
| | - Fang-Chuan Dai
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC
| | - Yu-Sheng Lin
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC
| | - Chien-Wen Huang
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, No. 222, Fuxin Rd., Wufeng Dist., Taichung City, 41354, Taiwan, ROC.
- Department of Medical Laboratory Science and Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan, ROC.
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de Gabory L, Amet S, Le Maux A, Meunier JP, Chartier A, Chenivesse C. Cross-sectional study to describe allergic rhinitis flare-ups and associated airways phenotype in house dust mite sensitization. PLoS One 2023; 18:e0283246. [PMID: 36952530 PMCID: PMC10035855 DOI: 10.1371/journal.pone.0283246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 03/05/2023] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVES To quantify and describe flare-ups of house dust mite allergic rhinitis (HDM-AR) which had occurred during the last 12 months in a population of adults and children candidate for Allergen ImmunoTherapy (AIT). Next, to identify associated clinical features. MATERIALS AND METHODS This was an observational, multicenter, cross-sectional study that included patients aged ≥ 5 years with HDM-AR eligible for AIT and without prior AIT for at least 12 months. Flare-ups were all period with impairment of quality of life (QoL) and requiring a change in their usual treatment. Data were collected using medical records and patient questionnaires. Variables associated with the occurrence of ≥ 2 AR flare-ups were identified. RESULTS 1,701 patients were included (average age: 23 years, 51.5% males, 30.4% children, 17.7% adolescents and 51.9% adults). Severe and persistent AR affected 70.9% of them and 53.7% showed polysensitization. Asthma was associated with AR in 34.4% and was well-controlled in 58.5%. The occurrence of at least one AR flare-up in the year was reported by 77.7%, with an annual rate in the whole population of 2.6 ± 3.9 and a duration of 14.1 ± 17.1 days. Deeply or moderately AR-related degraded QoL was experienced by 39.5% and 64.6%, respectively. The occurrence of ≥ 2 AR flare-ups was reported by 54.5% and was associated with polysensitization, AR intermittence and severity. CONCLUSION AR flare-ups are frequent and impair QoL in HDM-allergic patients, suggesting that it could be considered as therapeutic targets.
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Affiliation(s)
- Ludovic de Gabory
- Otorhinolaryngology Department, Hôpital Pellegrin, University Hospital of Bordeaux, Bordeaux, France
| | - Sabine Amet
- Direction Médicale, Allergologisk Laboratorium København Société par Actions Simplifiées (ALK SAS), La Défense, France
| | - Annelore Le Maux
- Direction Médicale, Allergologisk Laboratorium København Société par Actions Simplifiées (ALK SAS), La Défense, France
| | | | - Antoine Chartier
- Direction Médicale, Allergologisk Laboratorium København Société par Actions Simplifiées (ALK SAS), La Défense, France
| | - Cécile Chenivesse
- Service de Pneumologie et Immuno-Allergologie, CHU de Lille, Univ. Lille, CNRS, Inserm, Institut Pasteur de Lille U1019 - UMR 9017 - CIIL - Center for Infection and Immunity of Lille, CRISALIS / F-CRIN INSERM Network, Lille, France
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Xude Z, Shaojie F, Beibei G, Jingjing L, Donghua X, Fengxia L. LncRNAs ENST00000499459 and TCONS_00004989 enhance asthma progression in children with house dust mite-induced allergic asthma. Allergy Asthma Clin Immunol 2022; 18:101. [PMID: 36463267 PMCID: PMC9719245 DOI: 10.1186/s13223-022-00742-7] [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: 07/11/2022] [Accepted: 11/16/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Long non-coding RNAs (lncRNAs) have been extensively reported to play critical roles in the pathogenesis of various disease, especially in cancer. However, little is known about the role of lncRNAs in the pathogenesis of pediatric allergic asthma. METHODS High-throughput sequencing analysis was performed to identify differentially expressed mRNAs and lncRNAs in peripheral blood mononuclear cells (PBMCs) from 3 children with allergic asthma and 3 matched healthy controls. Bioinformatics analysis was used to select candidate lncRNAs and mRNAs that may be involved in the pathogenesis of asthma. Candidate lncRNAs were validated in a larger size of asthma patients and healthy controls. Finally, lncRNAs and molecular pathways associated with the pathogenesis of allergic asthma were identified by competing endogenous RNA (ceRNA) analysis. RESULTS Five differentially expressed lncRNAs were identified after high-throughput sequencing and verified by real-time PCR. LncRNAs ENST0000631797, TCONS_00004989 and ENST00000499459 were verified to be differentially expressed in allergic asthma. Besides, ENST00000499459/DIXDC1 axis was identified to play a crucial role in allergic asthma after comprehensive ceRNA network analysis. CONCLUSION ENST00000499459 and TCONS_00004989 are potential biomarkers for house dust mite-induced allergic asthma.
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Affiliation(s)
- Zhang Xude
- Department of Allergy, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
| | - Feng Shaojie
- Department of Allergy, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
| | - Guo Beibei
- Department of Allergy, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
| | - Liu Jingjing
- Department of Allergy, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
| | - Xu Donghua
- The First Clinical Medicine College, Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China ,Department of Rheumatology, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
| | - Liu Fengxia
- Department of Allergy, The First Affiliated Hospital of Weifang Medical University/Weifang People’s Hospital, Weifang, People’s Republic of China
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Tabberer M, Wells JR, Chandler D, Abetz-Webb L, Zhang S, Meeraus W, Fowler A, Slade D. Patient experience of moderate asthma attacks: qualitative research in the USA and Germany. J Patient Rep Outcomes 2022; 6:117. [DOI: 10.1186/s41687-022-00506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/05/2022] [Indexed: 11/24/2022] Open
Abstract
Abstract
Background
There is limited information available on the impact of moderate asthma exacerbations, often called “asthma attacks” (i.e., those not requiring hospitalisation or treatment with systemic corticosteroids) on patients’ lives. This multi-country qualitative study explored the patient experience of these events.
Methods
Semi-structured concept elicitation interviews were conducted in the USA and Germany with adult patients with asthma who had experienced a moderate asthma exacerbation in the prior 30 days. Physicians with experience in managing patients with asthma were also interviewed. Interviews explored patients’ experience of symptoms and impact of moderate exacerbations and associated exacerbation triggers and treatment patterns. Physicians were also asked about their interpretation of a clinical definition and treatment of a moderate exacerbation.
Results
Twenty-eight patient (n = 20 in the USA, n = 8 in Germany) and six physician (n = 3 in the USA, n = 3 in Germany) interviews were conducted. During their moderate exacerbation, all patients reported experiencing shortness of breath, which many considered to be severe and the most bothersome symptom. Wheezing was also reported by all patients and considered severe by two thirds of patients. Most patients also reported coughing and chest tightness. All or almost all patients reported that moderate exacerbation caused fatigue/tiredness and impacted their physical functioning, emotional functioning, activities of daily living and work/school life. Most patients reported using rescue or maintenance inhalers to alleviate symptoms of the exacerbation. Conceptual saturation (i.e., the point at which no new concepts are likely to emerge with continued data collection) was achieved. Findings were used to develop a patient-focused conceptual model of the experience of moderate asthma exacerbations, outlining concepts related to triggers, symptoms, impact, and treatment from the patient perspective. Physician data was consistent with patient reports and complemented the conceptual model.
Conclusions
Findings from concept elicitation interviews highlight the increased frequency, duration and severity of asthma symptoms and increased rescue medication use during moderate asthma exacerbations compared with the typical daily asthma experience, which have a substantial impact on patients’ lives.
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Orlovic M, Magni T, Lukyanov V, Guerra I, Madoni A. Cost-effectiveness of single-inhaler extrafine beclometasone dipropionate/formoterol fumarate/glycopyrronium in patients with uncontrolled asthma in England. Respir Med 2022; 201:106934. [PMID: 35872377 DOI: 10.1016/j.rmed.2022.106934] [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: 03/14/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND In patients with asthma that is uncontrolled by a medium- or high-dose inhaled corticosteroid (ICS) plus long-acting β2-agonist (LABA), a maintenance therapy option is the addition of a long-acting muscarinic agonist, either via multiple inhalers, or single-inhaler triple therapy (SITT). One SITT is the extrafine formulation of beclometasone dipropionate/formoterol fumarate/glycopyrronium (BDP/FF/G). We used data from two 52-week clinical trials (TRIMARAN and TRIGGER), both conducted in adults with asthma uncontrolled by ICS/LABA, to investigate the cost-effectiveness of BDP/FF/G. METHODS A Markov cohort state transition model (focusing on exacerbations) was used to investigate the cost-effectiveness of medium- or high-dose BDP/FF/G vs medium- or high-dose BDP/FF, and high-dose BDP/FF/G vs high-dose BDP/FF + tiotropium. The model analysed cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER), and was developed from the England National Health Service perspective (2020 costs). Uncertainty of the inputs was estimated using one-way and probabilistic sensitivity analyses. RESULTS Both medium- and high-dose BDP/FF/G were cost-effective vs BDP/FF, with ICERs of £12,224 and £15,587 per QALY gained. High-dose BDP/FF/G was dominant vs BDP/FF + tiotropium, as it was both cheaper and gained QALYs. Sensitivity analyses were consistent with the base model: medium- and high-dose BDP/FF/G had 94.3% and 88.3% likelihoods to be cost-effective vs BDP/FF; high-dose BDP/FF/G had 100% likelihood to be a dominant strategy vs BDP/FF + tiotropium. CONCLUSIONS Both medium- and high-dose BDP/FF/G were cost-effective vs medium- and high-dose BDP/FF in adults with asthma that was uncontrolled by ICS/LABA. In addition, high-dose BDP/FF/G was a dominating strategy to high-dose BDP/FF + tiotropium. CLINICALTRIALS GOV: NCT02676076 and NCT02676089.
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Affiliation(s)
| | | | | | - Ines Guerra
- IQVIA Solutions BV, Amsterdam, the Netherlands.
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Papi A, Singh D, Virchow JC, Canonica GW, Vele A, Georges G. Normalisation of airflow limitation in asthma: Post-hoc analyses of TRIMARAN and TRIGGER. Clin Transl Allergy 2022; 12:e12145. [PMID: 35450196 PMCID: PMC9014197 DOI: 10.1002/clt2.12145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background In asthma, persistent airflow limitation (PAL) is associated with poorer control, lung function decline and exacerbations. Using post‐hoc analyses we evaluated: the relationship between post‐salbutamol PAL at screening, airflow limitation (AL) during 52 weeks treatment with extrafine beclometasone dipropionate/formoterol fumarate/glycopyrronium (BDP/FF/G) versus BDP/FF and the risk of moderate/severe asthma exacerbations. Methods TRIMARAN and TRIGGER were double‐blind studies comparing BDP/FF/G with BDP/FF (TRIMARAN medium‐dose ICS; TRIGGER high‐dose) in adults with uncontrolled asthma. Patients were subgrouped according to post‐salbutamol PAL status at screening, and AL over the 52‐week treatment period. Results Most patients with post‐salbutamol PAL at screening had AL at all on‐treatment visits (TRIMARAN 62.8%; TRIGGER 66.8%). A significantly higher proportion of patients had normalised airflow on ≥1 follow‐up visit when receiving BDP/FF/G than BDP/FF (TRIMARAN 44.1 vs. 33.1% [p = 0.003]; TRIGGER 40.1 vs. 26.0% [p < 0.001]). In patients with post‐salbutamol PAL at screening and normalised AL at ≥1 follow‐up visit, exacerbation rates were 15% (p = 0.105) and 19% (p = 0.039) lower in TRIMARAN and TRIGGER versus those with AL on all visits. There was a trend to lower exacerbation rates in patients receiving BDP/FF/G than BDP/FF, particularly in patients in whom AL was normalised. Conclusion In these analyses, AL in asthma was associated with an increased exacerbation incidence. Inhaled triple therapy with extrafine BDP/FF/G was more likely to normalise airflow, and was associated with a trend to a lower exacerbation rate than BDP/FF, particularly in the subgroup of patients in whom treatment was associated with airflow normalisation. ClinicalTrials.gov: TRIMARAN, NCT02676076; TRIGGER, NCT02676089.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit University of Ferrara, University Hospital S. Anna Ferrara Italy
| | - Dave Singh
- Medicines Evaluation Unit The University of Manchester, Manchester University NHS Foundation Trust Manchester UK
| | - J Christian Virchow
- Departments for Pneumology/Internal Intensive Care Medicine Center for Internal Medicine, University Medicine Rostock Rostock Germany
| | - G Walter Canonica
- Center of Personalized Medicine: Asthma and Allergy Humanitas University and Research Hospital IRCCS Milan Italy
| | - Andrea Vele
- Global Clinical Development Chiesi Farmaceutici SpA Parma Italy
| | - George Georges
- Global Clinical Development Chiesi Farmaceutici SpA Parma Italy
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Kumar J, Kumar P, Goyal JP, Thakur C, Choudhary P, Meena J, Charan J, Singh K, Gupta A. Vitamin D supplementation in childhood asthma: a systematic review and meta-analysis of randomised controlled trials. ERJ Open Res 2021; 8:00662-2021. [PMID: 35141325 PMCID: PMC8819253 DOI: 10.1183/23120541.00662-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background There is conflicting evidence for vitamin D supplementation in childhood asthma. We aimed to systematically synthesise the evidence on the efficacy and safety of vitamin D supplementation in childhood asthma. Methods We searched electronic databases (Medline, Embase and Web of Science) and a register (CENTRAL) for randomised controlled trials (RCTs) published until 30 September 2021. RCTs enrolling asthmatic children (1–18 years old) and comparing vitamin D against placebo/routine care were included if they met at least one of the endpoints of interest (asthma attacks, emergency visits or hospitalisation). We used the Risk of Bias 2 tool for risk of bias assessment. Random-effects meta-analysis with RevMan 5.3 software was performed. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the level of certainty of the evidence. Results 18 RCTs (1579 participants) were included. The pooled meta-analysis did not find a significant effect of vitamin D supplementation on asthma attacks requiring rescue systemic corticosteroids (six studies with 445 participants; risk ratio (RR) 1.13, 95% CI 0.86–1.48; I2=0%) (moderate-certainty evidence). In addition, there was no significant difference in the proportion of children with asthma attacks of any severity (11 trials with 1132 participants; RR 0.84, 95% CI 0.65–1.09; I2=58%) (very low-certainty evidence). Vitamin D does not reduce the need for emergency visits (three studies with 361 participants; RR 0.97, 95% CI 0.89–1.07; I2=0%) and hospitalisation (RR: 1.38, 95% CI 0.52–3.66; I2=0%) (low-certainty evidence). Conclusion Very low- to moderate-certainty evidence suggests that vitamin D supplementation might not have any protective effect in childhood asthma. Very low to moderate certainty evidence suggests that adjuvant vitamin D supplementation might not have any protective effect in childhood asthma. Therefore, routine vitamin D supplementation in asthmatic children should be avoided.https://bit.ly/3xQVitV
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12
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Nakamura Y, Hozawa S, Sagara H, Ohbayashi H, Lee LA, Crawford J, Tamaoki J, Nishi T, Fowler A. Efficacy and safety of once-daily, single-inhaler fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol in Japanese patients with inadequately controlled asthma: the CAPTAIN study. Curr Med Res Opin 2021; 37:1657-1665. [PMID: 34162298 DOI: 10.1080/03007995.2021.1944849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE In CAPTAIN, a double-blind, parallel-group, Phase IIIA study, fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) improved lung function, symptoms and asthma control versus FF/VI in patients with inadequately controlled asthma. Here, we report efficacy and safety from a Japanese cohort in CAPTAIN. METHODS Adults with inadequately controlled asthma despite inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) were randomized (1:1:1:1:1:1) to once-daily FF/VI (100/25 mcg or 200/25 mcg) or FF/UMEC/VI (100/31.25/25 mcg, 100/62.5/25 mcg, 200/31.25/25 mcg, or 200/62.5/25 mcg) for ≥24 weeks. Endpoints included change from baseline in clinic trough FEV1 (primary), annualized rate of moderate/severe asthma exacerbations (key secondary), clinic FEV1 3 h post-dose, and Asthma Control Questionnaire (ACQ)-7, St George's Respiratory Questionnaire (SGRQ) (all Week 24), Evaluating Respiratory Symptoms (E-RS): Asthma total scores (Weeks 21-24) (all secondary). Adverse events and adverse events of special interest were monitored. Clinical trials.gov registry no: NCT02924688. RESULTS Overall, 229 of 2436 patients in the intention-to-treat (ITT) population were from Japan. In this cohort, change from baseline in trough FEV1 for FF/UMEC/VI 100/62.5/25 mcg versus FF/VI 100/25 mcg was 105 mL (95% confidence interval -5, 216) and 69 mL (-42, 179) for 200/62.5/25 mcg versus 200/25 mcg. These observations were supported by clinic FEV1 at 3 h post-dose. Moderate/severe exacerbation incidence was low and similar across pooled treatment groups (FF/VI, FF/UMEC 31.25 mcg/VI, FF/UMEC 62.5 mcg/VI). All pooled groups demonstrated clinically important improvements from baseline in ACQ-7, SGRQ and E-RS: Asthma total scores. Safety profiles were consistent with the overall ITT population, with no new safety concerns. CONCLUSION FF/UMEC/VI is an effective option with a favorable risk-benefit profile in Japanese patients with uncontrolled moderate or severe asthma on ICS/LABA.
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Affiliation(s)
- Yoichi Nakamura
- Medical Center for Allergic and Immune Diseases, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
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13
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Averell CM, Laliberté F, Germain G, Duh MS, Lima R, Mahendran M, Slade DJ. Symptom control in patients with asthma using inhaled corticosteroids/long-acting β 2-agonists (fluticasone furoate/vilanterol or budesonide/formoterol) in the US: a retrospective matched cohort study. J Asthma 2021; 59:1805-1818. [PMID: 34375568 DOI: 10.1080/02770903.2021.1963767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: Treatment with fluticasone furoate/vilanterol (FF/VI), an inhaled corticosteroid/long-acting β2-agonist therapy, reduces the risk of severe asthma exacerbations and improves lung function and symptom control in patients with asthma. However, real-world data remain limited among asthma patients in the United States (US).Methods: This retrospective cohort study propensity score (PS) matched adult asthma patients initiating once-daily FF/VI 100/25 mcg with patients initiating twice-daily budesonide/formoterol (B/F) 160/4.5 mcg using a US claims database (01/01/2015-12/31/2018). Asthma control was measured by the mean number of short-acting β2-agonist (SABA) canisters dispensed per patient-year (PPY) during follow-up. Time to first, and rates of, overall and severe asthma exacerbations were also measured.Results: After PS matching, 18531 patients receiving FF/VI were matched to 18531 patients receiving B/F. Mean SABA canisters dispensed PPY was significantly lower for FF/VI compared with B/F users (FF/VI: 1.47, B/F: 1.64; p < 0.001). FF/VI use resulted in 13% significantly lower risk of having an overall asthma-related exacerbation and 22% lower risk of a severe exacerbation versus B/F use (overall exacerbation hazard ratio [HR] [95% confidence interval (CI)]: 0.87 [0.82-0.92], p < 0.001; severe exacerbation HR: 0.78 [0.63-0.97], p = 0.027). Asthma-related exacerbation rates per 100 patient-days were also significantly lower for the FF/VI compared with B/F group (overall: 0.0475 vs. 0.0558, p < 0.001; severe 0.0026 vs. 0.0033, p = 0.020).Conclusions: In real-world practice, initiation of once-daily FF/VI 100/25 mcg in adults with asthma was associated with lower use of SABA and fewer asthma-related exacerbations, which may indicate better asthma control, when compared with use of twice-daily B/F 160/4.5 mcg.
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Affiliation(s)
- Carlyne M Averell
- US Value, Evidence and Outcomes, GlaxoSmithKline plc, Research Triangle Park, NC, United States
| | - François Laliberté
- Health Economics and Outcomes Research; Groupe d'analyses, Ltée, Montréal, QC, Canada
| | - Guillaume Germain
- Health Economics and Outcomes Research; Groupe d'analyses, Ltée, Montréal, QC, Canada
| | - Mei Sheng Duh
- Health Economics and Outcomes Research, Analysis Group, Inc, Boston, MA, United States
| | - Robson Lima
- US Medical Affairs, GlaxoSmithKline plc, Research Triangle Park, NC, United States
| | - Malena Mahendran
- Health Economics and Outcomes Research; Groupe d'analyses, Ltée, Montréal, QC, Canada
| | - David J Slade
- Clinical Sciences, GlaxoSmithKline plc, Research Triangle Park, NC, United States
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Rogliani P, Ritondo BL, Calzetta L. Triple therapy in uncontrolled asthma: a network meta-analysis of Phase III studies. Eur Respir J 2021; 58:13993003.04233-2020. [PMID: 33509960 DOI: 10.1183/13993003.04233-2020] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/13/2021] [Indexed: 11/05/2022]
Abstract
Conflicting evidence is currently available concerning the impact on asthma exacerbation of triple inhaled corticosteroid (ICS), long-acting β2-adrenoceptor agonist (LABA), and long-acting muscarinic receptor antagonist (LAMA) fixed-dose combination (FDC). Since meta-analyses allow settling controversies of apparently inconsistent results, we performed a network meta-analysis of Phase III randomised controlled trials including 9535 patients to assess the effect of ICS/LABA/LAMA combinations in uncontrolled asthma. Triple combination therapies with an ICS administered at high dose (HD) were more effective (p<0.05) than medium dose (MD) ICS/LABA/LAMA FDC and both MD and HD ICS/LABA FDCs against moderate to severe exacerbation (relative risk [RR] from 0.61 to 0.80) and increasing trough forced expiratory volume in the 1st second (mL from +33 to +114). Triple combination therapies including HD ICS were superior (p<0.05) than MD ICS/LABA/LAMA FDC in preventing severe exacerbation (RR from 0.46 to 0.65), but not with respect to moderate exacerbation (p>0.05). Triple combination therapies were equally effective on asthma control, with no safety concerns. This quantitative synthesis suggests that ICS/LABA/LAMA FDCs are effective and safe in uncontrolled asthma, and that the dose of ICS in the combination represents the discriminating factor to treat patients with a history of moderate or severe exacerbation.
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Affiliation(s)
- Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Beatrice Ludovica Ritondo
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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15
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Papi A, Virchow JC, Singh D, Kots M, Vele A, Georges G, Canonica GW. Extrafine triple therapy and asthma exacerbation seasonality: TRIMARAN and TRIGGER post hoc analyses. J Allergy Clin Immunol 2021; 148:262-265.e2. [PMID: 33485959 DOI: 10.1016/j.jaci.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous studies have shown seasonal variation in asthma exacerbations, peaking over the winter months. A single-inhaler triple therapy containing extrafine formulations of the inhaled corticosteroid (ICS) beclomethasone dipropionate (BDP), long-acting β2-agonist formoterol fumarate (FF), and long-acting muscarinic antagonist glycopyrronium (G) is in development for asthma. OBJECTIVE We sought to evaluate whether calendar season impacted the relative effect of BDP/FF/G versus BDP/FF on moderate and severe asthma exacerbations. METHODS TRIMARAN and TRIGGER were double-blind 52-week studies comparing BDP/FF/G with BDP/FF (TRIMARAN medium-dose ICS; TRIGGER high-dose) in adults with uncontrolled asthma (Asthma Control Questionnaire-7 score ≥1.5), prebronchodilator FEV1 less than 80% predicted, history of 1 or more asthma exacerbation, who had been receiving ICS/long-acting β2-agonist for at least 4 weeks before entry. Moderate and severe asthma exacerbations were captured throughout each study. In these post hoc analyses, the annual moderate and severe exacerbation rate was calculated for each month, with rate ratios determined from events grouped by season. RESULTS In patients who received BDP/FF alone, there was a marked seasonal effect on the occurrence of asthma exacerbations, with the rate highest in the winter months. However, the addition of the long-acting muscarinic antagonist component to BDP/FF reduced this seasonal variation, especially during the winter, such that the relative effect of BDP/FF/G versus BDP/FF was greatest in the winter (significant 20.3% reduction [P = .0008]). Reductions in the other seasons ranged between 8.6% and 12.0%. CONCLUSIONS These post hoc analyses indicate that inhaled triple therapy with extrafine BDP/FF/G reduces seasonal peaks in moderate and severe exacerbations, and confirm the overall utility of adding long-acting muscarinic antagonist to ICS/long-acting β2-agonist in the management of asthma.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S. Anna, Ferrara, Italy.
| | - Johann Christian Virchow
- Universitätsmedizin Rostock, Zentrum für Innere Medizin, Abteilung für Pneumologie, Rostock, Germany
| | - Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Giorgio Walter Canonica
- Humanitas University and Research Hospital IRCCS, Center of Personalized Medicine: Asthma and Allergy, Milan, Italy
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16
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Briggs A, Nasser S, Hammerby E, Buchs S, Virchow JC. The impact of moderate and severe asthma exacerbations on quality of life: a post hoc analysis of randomised controlled trial data. J Patient Rep Outcomes 2021; 5:6. [PMID: 33438083 PMCID: PMC7803866 DOI: 10.1186/s41687-020-00274-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This paper reports the duration of moderate and severe exacerbations in patients with house dust mite induced allergic asthma and the impact on patients' quality of life. METHODS Post-hoc analyses were conducted using data collected during a phase III multi-national trial (MT-04) that investigated time to moderate or severe asthma exacerbation among 485 patients during withdrawal from inhaled corticosteroids. Patient diaries were analysed to ascertain duration of exacerbations. The impact on patients' quality of life was measured by calculating utilities for five health states using the EuroQol-5 Dimension (EQ-5D-3L) and Asthma Quality of Life Questionnaire (AQL-5D). A regression analysis predicted the disutility of moving from 'well controlled asthma' to the other four health states: 'partially controlled asthma', 'uncontrolled asthma', 'moderate exacerbation' and 'severe exacerbation'. RESULTS Two hundred four patients experienced exacerbations. Moderate and severe exacerbations involved statistically significant reductions in lung function compared to the constant peak expiratory flow observed for patients without exacerbations. Lung function decline occurred for 28 days, decreasing approximately 14 days before an exacerbation followed by a return to baseline over 14 days. Asthma symptoms, the use of short-acting β2-agonists, and frequency of nocturnal awakening all increased, starting 10-14 days before an exacerbation, and returned to baseline within 10-28 days following exacerbations. Compared to 'well controlled asthma', the disutility of having a 'moderate exacerbation' ranged from - 0.0834 to - 0.0921 (EQ-5D-3L) and from - 0.114 to - 0.121 (AQL-5D); and of having a 'severe exacerbation' from - 0.115 to - 0.163 (EQ-5D-3L) and from - 0.153 to - 0.217 (AQL-5D), depending on the length of the observation period. CONCLUSIONS The impact of moderate and severe exacerbations in house dust mite induced allergic asthma extends 14 days before and 28 days after the peak exacerbation event. The impact of exacerbations on patients' health-related quality of life (HRQoL) continues long after their occurrence.
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Affiliation(s)
- Andrew Briggs
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, England
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England
| | - Eva Hammerby
- ALK-Abello A/S, Bøge Allé 1, DK-2970, Hørsholm, Denmark.
| | - Sarah Buchs
- ALK-Abello A/S, Bøge Allé 1, DK-2970, Hørsholm, Denmark
| | - J Christian Virchow
- Department of Pulmonology/Intensive Care Medicine, University of Rostock, Rostock, Germany
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Tosca MA, Licari A, Pistorio A, Marseglia GL, Ciprandi G. ControL'Asma Project: new insights. Pediatr Allergy Immunol 2020; 31 Suppl 26:23-25. [PMID: 33236422 DOI: 10.1111/pai.13353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
The Italian Society of Paediatric Allergy and Immunology has developed the project "ControL'Asma," a nationwide study involved ten third-level pediatric allergy clinics across Italy. The first findings of the "ControL'Asma" project showed that asthma was more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled, and partly controlled asthma affected about the half of subjects, and the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.
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Affiliation(s)
| | - Amelia Licari
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Angela Pistorio
- Epidemiology, Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genoa, Italy
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Schleich FN, Malinovschi A, Chevremont A, Seidel L, Louis R. Risk factors associated with frequent exacerbations in asthma. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Singh D, Virchow JC, Canonica GW, Vele A, Kots M, Georges G, Papi A. Determinants of response to inhaled extrafine triple therapy in asthma: analyses of TRIMARAN and TRIGGER. Respir Res 2020; 21:285. [PMID: 33121501 PMCID: PMC7597025 DOI: 10.1186/s12931-020-01558-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/23/2020] [Indexed: 01/10/2023] Open
Abstract
Background A number of single-inhaler triple therapies are being developed for asthma, including the extrafine formulation of beclometasone dipropionate (BDP), formoterol fumarate (FF), and glycopyrronium (G). Given asthma is a heterogenous disease, we investigated whether the clinical response to the addition of the long-acting muscarinic antagonist component within inhaled triple therapy was impacted by a range of clinical characteristics. Methods These were pre-specified and post-hoc sub-group analyses of TRIMARAN and TRIGGER, which were double-blind, 52-week studies comparing medium-strength (100/6/10 µg; TRIMARAN) and high-strength (200/6/10 µg; TRIGGER) BDP/FF/G with the respective BDP/FF strengths in adults with uncontrolled asthma and a history of ≥ 1 exacerbation. Co-primary endpoints were pre-dose forced expiratory volume in 1 s (FEV1) at Week 26 and the rate of moderate-to-severe exacerbations over 52 weeks. Key secondary endpoints: peak FEV1 at Week 26 and average morning peak expiratory flow over the first 26 weeks in each study, and severe exacerbation rate over 52 weeks (pooled data). Results Baseline clinical characteristics (pre-specified analyses) had no consistent effect on the lung function improvements with BDP/FF/G. For the exacerbation endpoints, sub-groups with higher reversibility gained greatest relative benefit from BDP/FF/G versus BDP/FF. In post-hoc analyses with patients sub-grouped by screening blood eosinophil values, in TRIMARAN the greatest relative effect of BDP/FF/G versus BDP/FF on the lung function endpoints was in the ≤ 300 cells/µL group; in TRIGGER, eosinophil levels did not markedly influence the relative efficacy of BDP/FF/G versus BDP/FF. Eosinophil levels did not influence relative efficacy on moderate-to-severe or severe exacerbations. Conclusion Overall, the relative efficacy of extrafine BDP/FF/G versus BDP/FF was not influenced by a range of clinical characteristics. However, some patient sub-groups gained additional benefit from BDP/FF/G for certain endpoints. In particular, for exacerbations the relative efficacy of BDP/FF/G was greater in more reversible patients. Trial registration ClinicalTrials.gov: TRIMARAN, NCT02676076 (registered February 8, 2016, https://clinicaltrials.gov/ct2/show/NCT02676076?term=NCT02676076&draw=2&rank=1,); TRIGGER, NCT02676089 (registered February 8, 2016, https://clinicaltrials.gov/ct2/show/NCT02676089?term=NCT02676089&draw=2&rank=1)
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Johann Christian Virchow
- Zentrum Für Innere Medizin, Abteilung Für Pneumologie, Universitätsmedizin Rostock, Rostock, Germany
| | - Giorgio Walter Canonica
- Center of Personalized Medicine: Asthma and Allergy, Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Alberto Papi
- Respiratory Medicine Unit, University of Ferrara, University Hospital S.Anna, Ferrara, Italy
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20
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Canonica GW, Blasi F, Paggiaro P, Senna G, Passalacqua G, Spanevello A, Aliberti S, Bagnasco D, Bonavia M, Bonini M, Brussino L, Bucca C, Caiaffa MF, Calabrese C, Camiciottoli G, Caminati M, Carpagnano GE, Caruso C, Centanni S, Conte ME, Corsico AG, Cosmi L, Costantino MT, Crimi N, D’Alò S, D'Amato M, Del Giacco S, Farsi A, Favero E, Foschino Barbaro MP, Guarnieri G, Guida G, Latorre M, Lo Cicero S, Lombardi C, Macchia L, Mazza F, Menzella F, Milanese M, Montagni M, Montuschi P, Nucera E, Parente R, Patella V, Pelaia G, Pini L, Puggioni F, Ricciardi L, Ricciardolo FL, Richeldi L, Ridolo E, Rolla G, Santus P, Scichilone N, Spadaro G, Vianello A, Viviano V, Yacoub MR, Zappa MC, Heffler E. Oral CorticoSteroid sparing with biologics in severe asthma: A remark of the Severe Asthma Network in Italy ( SANI). World Allergy Organ J 2020; 13:100464. [PMID: 32999699 PMCID: PMC7509464 DOI: 10.1016/j.waojou.2020.100464] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022] Open
Abstract
According to the data derived from several national and international registries, including SANI (Severe Asthma Network Italy), and considering the strong impact that frequent or regular use of oral corticosteroid has on quality of life (QoL) of severe asthmatics, as well as on the costs for managing corticosteroid-related diseases, oral corticosteroid sparing up to withdrawal should be considered a primary outcome in the management of severe asthma. New biologics have clearly demonstrated that this effect is possible, with concomitant reduction in the rate of exacerbations and in symptom control. Then, there is no reason for using so frequently oral corticosteroid before having explored all alternatives currently available for a large part of severe asthmatics.
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Key Words
- Biologics
- CRSwNP, chronic rhinosinusitis with nasal polyposis
- EMA, European Medicines Agency
- FDA, Food & Drug Administration
- FEV1, forced expiratory volume in the 1st second
- GINA, Global Initiative for Asthma
- GRADE, Grading of Recommendations Assessment, Development and Evaluation
- ISAR, International Severe Asthma Registry
- OCSs, Oral CorticoSteroids
- Oral corticosteroids
- RW, Real World
- Real-life
- Registr
- SA, severe asthma
- SANI, Severe Asthma Network in Italy
- SARP, Severe Asthma Research Program
- SHARP, Severe Heterogeneous Asthma Research collaboration, Patient-centred
- Severe asthma
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Affiliation(s)
- Giorgio Walter Canonica
- Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Francesco Blasi
- Respiratory Unit and Adult Cystic Fibrosis Center, And Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Italy
| | - Gianenrico Senna
- Department of Medicine, Allergy Unit Asthma Center, University of Verona, Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Italy
| | | | - Stefano Aliberti
- Respiratory Unit and Adult Cystic Fibrosis Center, And Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Italy
| | | | - Matteo Bonini
- Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Italy
| | - Luisa Brussino
- Allergy and Clinical Immunology, University of Turin & AO Mauriziano, Turin, Italy
- Respiratory Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Caterina Bucca
- Allergy and Clinical Immunology, University of Turin & AO Mauriziano, Turin, Italy
- Respiratory Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Maria F. Caiaffa
- Department of Medical Sciences and Surgery, School and Chair of Allergology and Clinical Immunology, University of Foggia, Italy
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gianna Camiciottoli
- Deptartment of Experimental and Clinical Biomedical Sciences “Mario Serio”, Respiratory Unit, Careggi University Hospital, Florence, Italy
| | - Marco Caminati
- Department of Medicine, Allergy Unit Asthma Center, University of Verona, Italy
| | - Giovanna E. Carpagnano
- Respiratory Medicine Section, Policlinico of Bari, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Cristiano Caruso
- Allergy Unit, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
| | - Stefano Centanni
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Maria E. Conte
- Respiratory Unit, Presidio Ospedaliero of Pordenone, Italy
| | - Angelo G. Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo, Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Italy
| | - Lorenzo Cosmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria T. Costantino
- Allergy and Clinical Immunology Unit, Department of Medicine, “Carlo Poma” Hospital, Mantova, Italy
| | - Nunzio Crimi
- Division of Pneumology and Allergology, Policlinico, University of Catania, Italy
| | - Simona D’Alò
- Allergology Unit, AV3 ASUR Marche, Hospital Civitanova Marche, Macerata, Italy
| | - Maria D'Amato
- Respiratory Department, Division of Respiratory Diseases “Federico II” University, AO Dei Colli, Naples, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Alessandro Farsi
- SOS of Allergology and Clinical Immunology, Azienda USL Toscana Centro, Prato, Italy
| | - Elisabetta Favero
- Severe Asthma Multidisciplinary Outpatient Clinic, Vittorio Veneto Hospital, Treviso, Italy
| | - Maria P. Foschino Barbaro
- Section of Respiratory Diseases, Medical and Surgical Sciences Department, University of Foggia, Italy
| | - Gabriella Guarnieri
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Italy
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce & Carle, Cuneo, Italy
| | - Manuela Latorre
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Italy
| | | | - Carlo Lombardi
- Departmental Unit of Allergology and Pneumology, Hospital Institute Fondazione Poliambulanza, Brescia, Italy
| | - Luigi Macchia
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | | | - Francesco Menzella
- Pneumology Unit, Santa Maria Nuova Hospital, Azienda USL di Reggio Emilia IRCCS, Italy
| | - Manlio Milanese
- Pulmonology Unit, ASL2 Savonese, Pietra Ligure, Savona, Italy
| | | | - Paolo Montuschi
- Department of Pharmacology, Faculty of Medicine Catholic, University of the Sacred Heart Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eleonora Nucera
- Catholic University S. Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Parente
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Salerno, Italy
| | - Vincenzo Patella
- Allergology and Clinical Immunology Unit, Department of Medical Science, “Santa Maria Della Speranza” Hospital of Battipaglia, Salerno, Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, University Magna Graecia, Catanzaro, Italy
| | - Laura Pini
- Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili, Brescia, Italy
| | - Francesca Puggioni
- Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Luisa Ricciardi
- Allergy and Clinical Immunology Unit, University Hospital “G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Fabio L.M. Ricciardolo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Luca Richeldi
- Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Italy
| | - Erminia Ridolo
- Department of Medicine and Surgery, University of Parma, Italy
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin & AO Mauriziano, Turin, Italy
- Respiratory Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Pierachille Santus
- Department of Clinical and Biomedical Sciences, University of Milan, Respiratory Diseases, Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Nicola Scichilone
- Division of Respiratory Diseases, Department of Promoting Health, Maternal-Infant. Excellence and Internal and Specialized Medicine (Promise) G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Giuseppe Spadaro
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
| | - Andrea Vianello
- Division of Respiratory Pathophysiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Vittorio Viviano
- Allergology, Pneumology and Respiratory Department 42 PTA Biondo-Regional Center for Allergy Prevention and Anaphylactic Shock, Palermo, Italy
| | - Mona R. Yacoub
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria C. Zappa
- Pulmonology Department, Sandro Pertini Hospital, Rome, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - SANI (Severe Asthma Network Italy)
- Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
- Respiratory Unit and Adult Cystic Fibrosis Center, And Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Italy
- Department of Medicine, Allergy Unit Asthma Center, University of Verona, Italy
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Italy
- University of Insubria, ICS Maugeri, IRCCS, Varese, Italy
- Respiratory Rehabilitation, ASL3, Genoa, Italy
- Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Italy
- Allergy and Clinical Immunology, University of Turin & AO Mauriziano, Turin, Italy
- Respiratory Medicine, Department of Medical Sciences, University of Turin, Italy
- Department of Medical Sciences and Surgery, School and Chair of Allergology and Clinical Immunology, University of Foggia, Italy
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, Naples, Italy
- Deptartment of Experimental and Clinical Biomedical Sciences “Mario Serio”, Respiratory Unit, Careggi University Hospital, Florence, Italy
- Respiratory Medicine Section, Policlinico of Bari, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
- Allergy Unit, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Respiratory Unit, Presidio Ospedaliero of Pordenone, Italy
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo, Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Allergy and Clinical Immunology Unit, Department of Medicine, “Carlo Poma” Hospital, Mantova, Italy
- Division of Pneumology and Allergology, Policlinico, University of Catania, Italy
- Allergology Unit, AV3 ASUR Marche, Hospital Civitanova Marche, Macerata, Italy
- Respiratory Department, Division of Respiratory Diseases “Federico II” University, AO Dei Colli, Naples, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
- SOS of Allergology and Clinical Immunology, Azienda USL Toscana Centro, Prato, Italy
- Severe Asthma Multidisciplinary Outpatient Clinic, Vittorio Veneto Hospital, Treviso, Italy
- Section of Respiratory Diseases, Medical and Surgical Sciences Department, University of Foggia, Italy
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Italy
- Allergy and Pneumology Unit, A.O. S. Croce & Carle, Cuneo, Italy
- Department of Pneumology, Niguarda Hospital, Milan, Italy
- Departmental Unit of Allergology and Pneumology, Hospital Institute Fondazione Poliambulanza, Brescia, Italy
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
- Pneumology Unit, Santa Maria Nuova Hospital, Azienda USL di Reggio Emilia IRCCS, Italy
- Pulmonology Unit, ASL2 Savonese, Pietra Ligure, Savona, Italy
- UOC Allergology Department, Piacenza, Italy
- Department of Pharmacology, Faculty of Medicine Catholic, University of the Sacred Heart Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University S. Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Salerno, Italy
- Allergology and Clinical Immunology Unit, Department of Medical Science, “Santa Maria Della Speranza” Hospital of Battipaglia, Salerno, Italy
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, University Magna Graecia, Catanzaro, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili, Brescia, Italy
- Allergy and Clinical Immunology Unit, University Hospital “G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, Italy
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
- Department of Medicine and Surgery, University of Parma, Italy
- Department of Clinical and Biomedical Sciences, University of Milan, Respiratory Diseases, Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
- Division of Respiratory Diseases, Department of Promoting Health, Maternal-Infant. Excellence and Internal and Specialized Medicine (Promise) G. D'Alessandro, University of Palermo, Palermo, Italy
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
- Division of Respiratory Pathophysiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
- Allergology, Pneumology and Respiratory Department 42 PTA Biondo-Regional Center for Allergy Prevention and Anaphylactic Shock, Palermo, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Pulmonology Department, Sandro Pertini Hospital, Rome, Italy
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21
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Singh D, Virchow JC, Canonica GW, Vele A, Kots M, Georges G, Papi A. Extrafine triple therapy in patients with asthma and persistent airflow limitation. Eur Respir J 2020; 56:13993003.00476-2020. [PMID: 32430414 DOI: 10.1183/13993003.00476-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/21/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Johann Christian Virchow
- Universitätsmedizin Rostock, Zentrum für Innere Medizin, Abteilung für Pneumologie, Rostock, Germany
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy.,Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
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22
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Licari A, Ciprandi G, Marseglia GL, Silvestri M, Tosca MA, Anastasio E, Brambilla I, Caffarelli C, Castagnoli R, Chini L, Ciprandi R, De Vittori V, Duse M, Di Cicco ME, Indinnimeo L, Kantar A, Leone M, Marinelli G, Moschese V, Olcese R, Peroni DG, Pistorio A, Salmaso C, Zicari AM. Asthma in children and adolescents: the ControL'Asma project. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020002. [PMID: 33004772 PMCID: PMC8023065 DOI: 10.23750/abm.v91i11-s.10295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/23/2022]
Abstract
The control of asthma is the objective of asthma management. However, it is difficult to obtain in clinical practice. The Italian Society of Allergy and Clinical Immunology promoted the nationwide project "ControL'Asma" to investigate the real situation in a group of children and adolescents with asthma. The preliminary outcomes demonstrated that many asthmatic subjects do not achieve adequate asthma control. Moreover, asthma in Italian children and adolescents was usually more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled and partly controlled asthma affected about the half of subjects. However, this project suggested that the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.
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Affiliation(s)
- Amelia Licari
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Giorgio Ciprandi
- Department of Medicine, Allergy Clinic, Casa di Cura Villa Montallegro, Genoa, Italy.
| | - Gian Luigi Marseglia
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | | | | | - Elisa Anastasio
- Department of Medical and Surgical Sciences, Pediatrics Unit, University"Magna Graecia", Catanzaro, Italy; “ControL’Asma” Study Group.
| | - Ilaria Brambilla
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy; “ControL’Asma” Study Group.
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy; “ControL’Asma” Study Group.
| | - Riccardo Castagnoli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy; “ControL’Asma” Study Group.
| | - Loredana Chini
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy; “ControL’Asma” Study Group.
| | - Riccardo Ciprandi
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini-Ospedale Pediatrico, Genoa, Italy; “ControL’Asma” Study Group.
| | - Valentina De Vittori
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy; “ControL’Asma” Study Group.
| | - Marzia Duse
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy; “ControL’Asma” Study Group.
| | - Maria Elisa Di Cicco
- Pediatric Division, Department of Obstetrics, Gynecology and Pediatrics, St. Chiara University Hospital, Pisa, Italy; “ControL’Asma” Study Group.
| | - Luciana Indinnimeo
- Department of Pediatrics and NPI, University of Roma Sapienza, Rome, Italy; “ControL’Asma” Study Group.
| | - Ahmad Kantar
- Pediatric Cough and Asthma Center, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy; “ControL’Asma” Study Group.
| | - Maddalena Leone
- Maternal and Infantile Department of Pediatrics ASST Grande Ospedale Metropolitano Niguarda Milano, Italy; “ControL’Asma” Study Group.
| | - Guido Marinelli
- Pediatria, Università di Genova; “ControL’Asma” Study Group.
| | - Viviana Moschese
- Pediatric Allergology and Immunology Unit, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy; “ControL’Asma” Study Group.
| | - Roberta Olcese
- Pediatric Allergy Center, Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Diego G Peroni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; “ControL’Asma” Study Group.
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Claudia Salmaso
- Pediatric Allergy Center, Istituto Giannina Gaslini, Genoa, Italy; “ControL’Asma” Study Group.
| | - Anna Maria Zicari
- Department of Pediatrics, Policlinico Umberto I, Sapienza University, Rome, Italy; “ControL’Asma” Study Group.
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23
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Lee LA, Bailes Z, Barnes N, Boulet LP, Edwards D, Fowler A, Hanania NA, Kerstjens HAM, Kerwin E, Nathan R, Oppenheimer J, Papi A, Pascoe S, Brusselle G, Peachey G, Sule N, Tabberer M, Pavord ID. Efficacy and safety of once-daily single-inhaler triple therapy (FF/UMEC/VI) versus FF/VI in patients with inadequately controlled asthma (CAPTAIN): a double-blind, randomised, phase 3A trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:69-84. [PMID: 32918892 DOI: 10.1016/s2213-2600(20)30389-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite inhaled corticosteroid plus long-acting β2-agonist (ICS/LABA) therapy, 30-50% of patients with moderate or severe asthma remain inadequately controlled. We investigated the safety and efficacy of single-inhaler fluticasone furoate plus umeclidinium plus vilanterol (FF/UMEC/VI) compared with FF/VI. METHODS In this double-blind, randomised, parallel-group, phase 3A study (Clinical Study in Asthma Patients Receiving Triple Therapy in a Single Inhaler [CAPTAIN]), participants were recruited from 416 hospitals and primary care centres across 15 countries. Participants were eligible if they were aged 18 years or older, with inadequately controlled asthma (Asthma Control Questionnaire [ACQ]-6 score of ≥1·5) despite ICS/LABA, a documented health-care contact or a documented temporary change in asthma therapy for treatment of acute asthma symptoms in the year before screening, pre-bronchodilator FEV1 between 30% and less than 85% of predicted normal value, and reversibility (defined as an increase in FEV1 of ≥12% and ≥200 mL in the 20-60 min after four inhalations of albuterol or salbutamol) at screening. Participants were randomly assigned (1:1:1:1:1:1), via central based randomisation stratified by pre-study ICS dose at study entry, to once-daily FF/VI (100/25 μg or 200/25 μg) or FF/UMEC/VI (100/31·25/25 μg, 100/62·5/25 μg, 200/31·25/25 μg, or 200/62·5/25 μg) administered via Ellipta dry powder inhaler (Glaxo Operations UK, Hertfordshire, UK). Patients, investigators, and the funder were masked to treatment allocation. Endpoints assessed in the intention-to-treat population were change from baseline in clinic trough FEV1 at week 24 (primary) and annualised moderate and/or severe asthma exacerbation rate (key secondary). Other secondary endpoints were change from baseline in clinic FEV1 at 3 h post-dose, St George's Respiratory Questionnaire (SGRQ) total score, and ACQ-7 total score, all at week 24. Change from baseline in Evaluating Respiratory Symptoms in Asthma total score at weeks 21-24 was also a secondary endpoint but is not reported here. Exploratory analyses of biomarkers of type 2 airway inflammation on treatment response were also done. This study is registered with ClinicalTrials.gov, NCT02924688, and is now complete. FINDINGS Between Dec 16, 2016, and Aug 31, 2018, 5185 patients were screened and 2439 were recruited and randomly assigned to FF/VI (100/25 μg n=407; 200/25 μg n=406) or FF/UMEC/VI (100/31·25/25 μg n=405; 100/62·5/25 μg n=406; 200/31·25/25 μg n=404; 200/62·5/25 μg n=408), with three patients randomly assigned in error and not included in analyses. In the intention-to-treat population, 922 (38%) patients were men, the mean age was 53·2 years (SD 13·1) and body-mass index was 29·4 (6·6). Baseline demographics were generally similar across all treatment groups. The least squares mean improvement in FEV1 change from baseline for FF/UMEC/VI 100/62·5/25 μg versus FF/VI 100/25 μg was 110 mL (95% CI 66-153; p<0·0001) and for 200/62·5/25 μg versus 200/25 μg was 92 mL (49-135; p<0·0001). Adding UMEC 31·25 μg to FF/VI produced similar improvements (FF/UMEC/VI 100/31·25/25 μg vs FF/VI 100/25 μg: 96 mL [52-139; p<0·0001]; and 200/31·25/25 μg vs 200/25 μg: 82 mL [39-125; p=0·0002]). These results were supported by the analysis of clinic FEV1 at 3 h post-dose. Non-significant reductions in moderate and/or severe exacerbation rates were observed for FF/UMEC 62·5 μg/VI versus FF/VI (pooled analysis), with rates lower in FF 200 μg-containing versus FF 100 μg-containing treatment groups. All pooled treatment groups demonstrated mean improvements (decreases) in SGRQ total score at week 24 compared with baseline in excess of the minimal clinically important difference of 4 points; however, there were no differences between treatment groups. For mean change from baseline to week 24 in asthma control questionnaire-7 score, improvements (decreases) exceeding the minimal clinically important difference of 0·5 points were observed in all pooled treatment groups. Adding UMEC to FF/VI resulted in small, dose-related improvements compared with FF/VI (pooled analysis: FF/UMEC 31·25 μg/VI versus FF/VI, -0·06 (95% CI -0·12 to 0·01; p=0·094) FF/UMEC 62·5 μg/VI versus FF/VI, -0·09 (-0·16 to -0·02, p=0·0084). By contrast with adding UMEC, the effects of higher dose FF on clinic trough FEV1 and annualised moderate and/or severe exacerbation rate were increased in patients with higher baseline blood eosinophil count and exhaled nitric oxide. Occurrence of adverse events was similar across treatment groups (patients with at least one event ranged from 210 [52%] to 258 [63%]), with the most commonly reported adverse events being nasopharyngitis (51 [13%]-63 [15%]), headache (19 [5%]-36 [9%]), and upper respiratory tract infection (13 [3%]-24 [6%]). The incidence of serious adverse events was similar across all groups (range 18 [4%]-25 [6%)). Three deaths occurred, of which one was considered to be related to study drug (pulmonary embolism in a patient in the FF/UMEC/VI 100/31·25/25 μg group). INTERPRETATION In patients with uncontrolled moderate or severe asthma on ICS/LABA, adding UMEC improved lung function but did not lead to a significant reduction in moderate and/or severe exacerbations. For such patients, single-inhaler FF/UMEC/VI is an effective treatment option with a favourable risk-benefit profile. Higher dose FF primarily reduced the rate of exacerbations, particularly in patients with raised biomarkers of type 2 airway inflammation. Further confirmatory studies into the differentiating effect of type 2 inflammatory biomarkers on treatment outcomes in asthma are required to build on these exploratory findings and further guide clinical practice. FUNDING GSK.
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Affiliation(s)
| | - Zelie Bailes
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Neil Barnes
- GSK, Brentford, Middlesex, UK; Barts and the London School of Medicine and Dentistry, London, UK
| | | | - Dawn Edwards
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Huib A M Kerstjens
- University of Groningen and University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, Netherlands
| | - Edward Kerwin
- Crisor, Clinical Research Institute, Medford, OR, USA
| | - Robert Nathan
- Asthma & Allergy Associates, PC and Research Center, Colorado Springs, CO, USA
| | | | | | | | | | - Guy Peachey
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Neal Sule
- GlaxoSmithKline (GSK), Collegeville, PA, USA
| | | | - Ian D Pavord
- Nuffield Department of Medicine and Oxford Respiratory NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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24
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Asthma exacerbations and worsenings in patients aged 1-75 years with add-on tiotropium treatment. NPJ Prim Care Respir Med 2020; 30:38. [PMID: 32868782 PMCID: PMC7459309 DOI: 10.1038/s41533-020-00193-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 06/18/2020] [Indexed: 12/26/2022] Open
Abstract
This review explores the effect of tiotropium Respimat® add-on therapy on asthma exacerbations and worsenings, adverse events (AEs) related to exacerbations and symptoms and any effects on seasonality across the 10 UniTinA-asthma® clinical trials comprising over 6000 patients. When added on to inhaled corticosteroids ± additional therapies, tiotropium significantly reduced the risk of exacerbations and worsenings in adults with symptomatic severe asthma and provided a non-significant improvement in worsenings in adults with symptomatic moderate and mild asthma, which was significant for patients with moderate asthma receiving tiotropium 2.5 µg once daily vs. placebo. Trials in paediatric patients were not powered to assess exacerbations or worsenings, but when AEs related to asthma exacerbations and symptoms were grouped into a composite endpoint and pooled, tiotropium improved outcomes vs. placebo (rate ratio 0.76; 95% confidence interval 0.63, 0.93). The reduction in exacerbations with tiotropium is apparent across all patients during the observed seasonal peaks of these events.
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25
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Martin MJ, Beasley R, Harrison TW. Towards a personalised treatment approach for asthma attacks. Thorax 2020; 75:1119-1129. [PMID: 32839286 DOI: 10.1136/thoraxjnl-2020-214692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022]
Abstract
Asthma attacks (exacerbations) are common, accounting for over 90 000 UK hospital admissions per annum. They kill nearly 1500 people per year in the UK, have significant associated direct and indirect costs and lead to accelerated and permanent loss of lung function. The recognition of asthma as a heterogeneous condition with multiple phenotypes has revolutionised the approach to the long-term management of the condition, with greater emphasis on personalised treatment and the introduction of the treatable traits concept. In contrast asthma attacks are poorly defined and understood and our treatment approach consists of bronchodilators and systemic corticosteroids. This review aims to explore the current limitations in the description, assessment and management of asthma attacks. We will outline the risk factors for attacks, strategies to modify this risk and describe the recognised characteristics of attacks as a first step towards the development of an approach for phenotyping and personalising the treatment of these critically important events. By doing this, we hope to gradually improve asthma attack treatment and reduce the adverse effects associated with recurrent courses of corticosteroids.
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Affiliation(s)
- Matthew J Martin
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tim W Harrison
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
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26
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Kerwin E, Pascoe S, Bailes Z, Nathan R, Bernstein D, Dahl R, von Maltzahn R, Robbins K, Fowler A, Lee L. A phase IIb, randomised, parallel-group study: the efficacy, safety and tolerability of once-daily umeclidinium in patients with asthma receiving inhaled corticosteroids. Respir Res 2020; 21:148. [PMID: 32532275 PMCID: PMC7291639 DOI: 10.1186/s12931-020-01400-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/19/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients with asthma uncontrolled on inhaled corticosteroids may benefit from umeclidinium (UMEC), a long-acting muscarinic antagonist. METHODS This Phase IIb, double-blind study included patients with reversible, uncontrolled/partially-controlled asthma for ≥6 months, receiving ≥100 mcg/day fluticasone propionate (or equivalent) for ≥12 weeks. Following a 2-week run-in on open-label fluticasone furoate (FF) 100 mcg, patients were randomised (1:1:1) to receive UMEC 31.25 mcg, UMEC 62.5 mcg or placebo on top of FF 100 mcg once-daily for 24 weeks. As-needed salbutamol was provided. Primary and secondary endpoints were change from baseline in clinic trough forced expiratory volume in 1 s (FEV1) and clinic FEV1 3 h post-dose, respectively, at Week 24. Other endpoints included change from baseline in home daily spirometry (trough FEV1, evening FEV1, morning [pre-dose] and evening peak expiratory flow) over 24 weeks. Safety was assessed throughout the study. RESULTS The intent-to-treat population comprised 421 patients (UMEC 31.25 mcg: n =139, UMEC 62.5 mcg: n =139, placebo: n =143). UMEC 31.25 mcg and 62.5 mcg demonstrated significantly greater improvements from baseline in clinic trough FEV1 at Week 24 (difference [95% CI]: 0.176 L [0.092, 0.260; p<0.001] and 0.184 L [0.101, 0.268; p<0.001], respectively), clinic FEV1 3 h post-dose at Week 24 (0.190 L [0.100, 0.279; p<0.001] and 0.198 L [0.109, 0.287; p<0.001], respectively) and mean change from baseline in daily home spirometry over 24 weeks versus placebo. No new safety signals were identified. CONCLUSIONS UMEC is a highly effective bronchodilator that leads to improved lung function when administered as a single bronchodilator on top of FF in subjects with fully reversible, uncontrolled/partially-controlled moderate asthma. These data support a favourable benefit/risk profile for UMEC (31.25 mcg and 62.5 mcg). TRIAL REGISTRATION GSK study ID: 205832; Clinicaltrials.gov ID: NCT03012061.
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Affiliation(s)
- Edward Kerwin
- Crisor LLC Research, Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Zelie Bailes
- GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Robert Nathan
- Asthma & Allergy Associates, P.C. and Research Center, Colorado Springs, CO, USA
| | - David Bernstein
- Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Bernstein Clinical Research Center, Cincinnati, OH, USA
| | - Ronald Dahl
- GSK, 980 Great West Road, Brentford, Middlesex, UK
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Vitiello G, Maltagliati L, Rossi O. New perspectives in allergen specific immunotherapy driven by big trials with house dust mite sublingual SQ ® tablets. Clin Mol Allergy 2020; 18:10. [PMID: 32536827 PMCID: PMC7288442 DOI: 10.1186/s12948-020-00124-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/23/2020] [Indexed: 02/06/2023] Open
Abstract
House-dust mites (HDM) allergy is the prevailing condition in subjects allergic to inhalants. Clinical studies with HDM extracts—either subcutaneous (SCIT) or sublingual (SLIT) have long been characterized by small sample size, varying allergen doses, and poorly defined endpoints assessing disease severity. In the last decade, well-designed, randomized, controlled studies recruiting thousands of patients have been conducted with newly developed HDM sublingual tablets (SQ®-HDM tablets). This drug is easily dispersible in the oral cavity due to the patented Zydis® technology and its allergen composition is balanced in terms of group I and group II major mite allergen content, reflecting the equal contribution of the two components to HDM sensitization. HDM is the most common allergen associated with asthma. Clinical efficacy of the SQ® HDM SLIT-tablet in HDM allergic asthma has been evaluated in randomized, double-blind, placebo-controlled trials. Both endpoints related to “present” asthma control (inhaled corticosteroid—ICS) as well as endpoints related to “future” asthma control (occurrence of asthma exacerbations) were included in these studies, in agreement with GINA (Global Initiative for Asthma) guidelines. Based on the positive results of these studies, SQ®-HDM SLIT-tablets were approved Europe-wide as registered drug for treating moderate-to-severe allergic rhinitis with or without allergic asthma and not well controlled HDM allergic asthma, associated with allergic rhinitis of any severity. GINA guidelines in 2017 included SLIT-tablet-based immunotherapy as an “add-on” treatment for asthmatic patients sensitized to HDM; indeed, allergen immunotherapy (AIT) is considered to be a complementary treatment option that targets the immunological of allergic diseases, representing the only treatment potentially disease-modifier or, at least, with a long-term efficacy. The availability of a safe, standardized, registered treatment for HDM respiratory allergies is pivotal in the immunotherapy field, pushing it out of a century-long limbo of amatorial interest towards the full dignity deserved by the only casual treatment of respiratory allergies.
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Affiliation(s)
- Gianfranco Vitiello
- Experimental and Clinical Medicine Department, University of Firenze, Largo Brambilla 3, 50100 Florence, Italy
| | - Lucia Maltagliati
- Experimental and Clinical Medicine Department, University of Firenze, Largo Brambilla 3, 50100 Florence, Italy
| | - Oliviero Rossi
- SOD Immunoallergologia, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Nassikas N, Spangler K, Fann N, Nolte CG, Dolwick P, Spero TL, Sheffield P, Wellenius GA. Ozone-related asthma emergency department visits in the US in a warming climate. ENVIRONMENTAL RESEARCH 2020; 183:109206. [PMID: 32035409 PMCID: PMC7167359 DOI: 10.1016/j.envres.2020.109206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 06/10/2023]
Abstract
Ozone exposure is associated with higher risk of asthma-related emergency department visits. The meteorological conditions that govern ozone concentration are projected to be more favorable to ozone formation over much of the United States due to continued climate change, even as emissions of anthropogenic ozone precursors are expected to decrease by 2050. Our goal is to quantify the health benefits of a climate change mitigation scenario versus a "business-as-usual" scenario, defined by the United Nations Intergovernmental Panel on Climate Change Representative Concentration Pathways (RCPs) 4.5 and 8.5, respectively, using the health impact analytical program Benefits Mapping and Analysis Program - Community Edition (BenMAP - CE) to project the number of asthma ED visits in 2045-2055. We project an annual average of 3100 averted ozone-related asthma ED visits during the 2045-2055 period under RCP4.5 versus RCP8.5, with all other factors held constant, which translates to USD $1.7 million in averted costs annually. We identify counties with tens to hundreds of avoided ozone-related asthma ED visits under RCP4.5 versus RCP8.5. Overall, we project a heterogeneous distribution of ozone-related asthma ED visits at different spatial resolutions, specifically national, regional, and county levels, and a substantial net health and economic benefit of climate change mitigation.
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Affiliation(s)
- Nicholas Nassikas
- Department of Pulmonary, Critical Care, and Sleep Medicine, Brown University Alpert Medical School, Providence, RI, 02903, USA.
| | - Keith Spangler
- Department of Earth, Environmental, and Planetary Sciences, Brown University, Providence, RI, 02912, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, 02903, USA; Institute at Brown for Environment and Society, Brown University, Providence, RI, 02912, USA
| | - Neal Fann
- U.S. Environmental Protection Agency, Office of Air Quality Planning and Standards, Research Triangle Park, NC, 27709, USA
| | - Christopher G Nolte
- U.S. Environmental Protection Agency, Office of Research and Development, Research Triangle Park, NC, 27709, USA
| | - Patrick Dolwick
- U.S. Environmental Protection Agency, Office of Air Quality Planning and Standards, Research Triangle Park, NC, 27709, USA
| | - Tanya L Spero
- U.S. Environmental Protection Agency, Office of Research and Development, Research Triangle Park, NC, 27709, USA
| | - Perry Sheffield
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, NY, 10029, USA
| | - Gregory A Wellenius
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, 02903, USA
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Virchow JC, Kuna P, Paggiaro P, Papi A, Singh D, Corre S, Zuccaro F, Vele A, Kots M, Georges G, Petruzzelli S, Canonica GW. Single inhaler extrafine triple therapy in uncontrolled asthma (TRIMARAN and TRIGGER): two double-blind, parallel-group, randomised, controlled phase 3 trials. Lancet 2019; 394:1737-1749. [PMID: 31582314 DOI: 10.1016/s0140-6736(19)32215-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND To date, no studies have assessed the efficacy of single-inhaler triple therapy in asthma. Here we report on two studies that compared the single-inhaler extrafine combination of beclometasone dipropionate (BDP; inhaled corticosteroid), formoterol fumarate (FF; long-acting β2 agonist), and glycopyrronium (G; long-acting muscarinic antagonist) with the combination of BDP with FF. METHODS Two parallel-group, double-blind, randomised, active-controlled, phase 3 trials (Triple in Asthma With Uncontrolled Patients on Medium Strength of ICS + LABA [TRIMARAN] and Triple in Asthma High Strength Versus ICS/LABA HS and Tiotropium [TRIGGER]) recruited patients from 171 sites across 16 countries (TRIMARAN), and from 221 sites across 17 countries (TRIGGER). The sites were a mixture of secondary and tertiary care centres and specialised investigation units. Eligible patients were adults (aged 18-75 years) with uncontrolled asthma, a history of one or more exacerbations in the previous year, and previously treated with inhaled corticosteroid (TRIMARAN: medium dose; TRIGGER: high dose) plus a long-acting β2 agonist. Enrolled patients were initially treated with BDP/FF (TRIMARAN: 100 μg BDP and 6 μg FF; TRIGGER: 200 μg BDP and 6 μg FF) for 2 weeks, then randomly assigned to treatment using an interactive response technology system with a balanced block randomisation scheme stratified by country. Patients, investigators, site staff, and sponsor staff were masked to BDP/FF/G and BDP/FF assignment. In TRIMARAN, patients were randomly assigned (1:1) to 52 weeks of BDP/FF/G (100 μg BDP, 6 μg FF, and 10 μg G) or BDP/FF (100 μg BDP and 6 μg FF), two inhalations twice daily. In TRIGGER, patients were randomly assigned (2:2:1) to 52 weeks of BDP/FF/G (200 μg BDP, 6 μg FF, and 10 μg G) or BDP/FF (200 BDP and 6 μg FF), both two inhalations twice daily, or open-label BDP/FF (200 μg BDP and 6 μg FF) two inhalations twice daily plus tiotropium 2·5 μg two inhalations once daily. Coprimary endpoints for both trials (BDP/FF/G vs BDP/FF) were pre-dose forced expiratory volume in 1 s (FEV1) at week 26 and rate of moderate and severe exacerbations over 52 weeks. Safety was assessed in all patients who received at least one dose of study treatment. These trials were registered with ClinicalTrials.gov, NCT02676076 (TRIMARAN), NCT02676089 (TRIGGER). FINDINGS Between Feb 17, 2016, and May 17, 2018, 1155 patients in TRIMARAN were given BDP/FF/G (n=579) or BDP/FF (n=576). Between April 6, 2016, and May 28, 2018, 1437 patients in TRIGGER were given BDP/FF/G (n=573), BDP/FF (n=576), or BDP/FF plus tiotropium (n=288). Compared with the BDP/FF group, week 26 predose FEV1 improved in the BDP/FF/G group by 57 mL (95% CI 15-99; p=0·0080) in TRIMARAN and by 73 mL (26-120; p=0·0025) in TRIGGER, with reductions in the rate of moderate and severe exacerbations of 15% (rate ratio 0·85, 95% CI 0·73-0·99; p=0·033) in TRIMARAN and 12% (0·88, 0·75-1·03; p=0·11) in TRIGGER. Four patients had treatment-related serious adverse events, one in TRIMARAN in the BDP/FF/G group and three in TRIGGER-one in the BDP/FF/G and two in the BDP/FF group. Three patients in the BDP/FF/G group in TRIMARAN and two patients in TRIGGER-one in the BDP/FF/G group and one in the BDP/FF group-had adverse events leading to death. None of the deaths were considered as related to treatment. INTERPRETATION In uncontrolled asthma, addition of a long-acting muscarinic antagonist to inhaled corticosteroid plus long-acting β2-agonist therapy improves lung function and reduces exacerbations. FUNDING Chiesi Farmaceutici.
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Affiliation(s)
- Johann Christian Virchow
- Universitätsmedizin Rostock, Zentrum für Innere Medizin, Abteilung für Pneumologie, Rostock, Germany.
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Medical University of Łódź, Łódź, Poland
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology, and Critical Care, University of Pisa, Pisa, Italy
| | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Dave Singh
- Medicines Evaluation Unit, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sandrine Corre
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | | | - Andrea Vele
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | | | - Giorgio Walter Canonica
- Humanitas University and Research Hospital, Center of Personalized Medicine: Asthma and Allergy, Milan, Italy
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Virchow JC. Allergen immunotherapy (AIT) in asthma. Semin Immunol 2019; 46:101334. [PMID: 31711771 DOI: 10.1016/j.smim.2019.101334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 12/16/2022]
Abstract
Bronchial asthma remains one of the most common chronic diseases with a high degree of morbidity and still a considerable mortality with an increasing prevalence in many countries. Although remarkable progress has been made in the past decades in the medical treatment for asthma, curative or disease modifying approaches are still limited to allergen immunotherapy (AIT). Despite a plethora of potential immunological actions observed during AIT, the precise mechamisms that might exert beneficial effects especially in asthma remain unclear. Clinical studies in the past have suggested clinical benefits in symptom control and medication use with a small reduction in allergen-specific and non-specific bronchial hyperresponsiveness but these results were mainly derived from small, frequently suboptimally designed studies which were poorly comparable. Only recently have larger, dose ranging studies with well standardized allergens with patient relevant endpoints such as corticosteroid requirements for asthma control or the onset of exacerbations following inhaled corticosteroid (ICS) withdrawal corroborated the potential clinical effects of AIT in asthma, suggesting that it might replace some of the controller effects of ICS. In addition, newer, up-do-date designed studies support previous data that in patient populations at risk to develop asthma AIT might have a role in secondary prevention. Further studies on the long term effects as well as comparative studies are needed to further corroborate the role of AIT in the prevention and the control of asthma are needed.
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Affiliation(s)
- J Christian Virchow
- Departments of Pneumology / Intensive Care Medicine, Universitätsmedizin Rostock, Ernst-Heydemann Strasse 6, 18055 Rostock, Germany.
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Efficacy and Safety of HDM SLIT Tablet in Japanese Adults with Allergic Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:710-720.e14. [PMID: 31541768 DOI: 10.1016/j.jaip.2019.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND The standardized quality (SQ) house dust mite (HDM) sublingual immunotherapy (SLIT) tablet has demonstrated efficacy and safety for allergic asthma (AA) in European trials. OBJECTIVE To evaluate the efficacy and safety of SQ HDM SLIT tablet treatment for up to 19 months in Japanese adults with AA. METHODS In this randomized, double-blind, placebo-controlled trial, patients aged 18 to 64 years with AA were randomly assigned (1:1:1) to SQ HDM SLIT doses of 10,000 or 20,000 Japanese Allergy Unit or placebo. Subjects had Asthma Control Questionnaire score of 1.0 to 1.5 and daily inhaled corticosteroid use of 200 to 400 μg of fluticasone propionate at randomization. The primary end point was the time from randomization to the first asthma exacerbation as the inhaled corticosteroid dose was being reduced. RESULTS Of the 826 randomized subjects, 693 (84%) completed the trial. No statistically significant differences between the active groups and the placebo group were observed for the primary or any other efficacy end points. However, post hoc analysis indicated a significant difference between the 20,000 Japanese Allergy Unit and placebo groups among subjects who used a short-acting β2-agonist during the baseline period (hazard ratio, 0.70; 95% CI, 0.48-1.00; P = .04997). No deaths or anaphylactic reactions were reported. Most adverse events were mild to moderate in severity. CONCLUSIONS The trial demonstrated a favorable safety profile of the SQ HDM SLIT tablet in Japanese adult patients with AA. The treatment appeared to be efficacious in patients requiring rescue medication (ie, short-acting β2-agonist) at baseline in the efficacy assessment using asthma exacerbation during inhaled corticosteroid reduction (JapicCTI number 121847).
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Eriksson G, Nolte H, Ljørring C, Riis B, Virchow JC. Comparison of the novel CompEx asthma exacerbation endpoint to the ATS/ERS adapted moderate/severe asthma exacerbation definition used in the MITRA trial. Respir Med 2019; 153:1-2. [PMID: 31136926 DOI: 10.1016/j.rmed.2019.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Göran Eriksson
- Department of Respiratory Medicine and Allergology, Lund University Hospital, Lund, Sweden
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Backer V, Mastronarde J. Pharmacologic Strategies for Exercise-Induced Bronchospasm with a Focus on Athletes. Immunol Allergy Clin North Am 2019; 38:231-243. [PMID: 29631732 DOI: 10.1016/j.iac.2018.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is the transient narrowing of the airways during and after exercise that occurs in response to increased ventilation in susceptible individuals. It occurs across the age spectrum in patients with underlying asthma and can occur in athletes without baseline asthma. The inflammatory mechanisms underlying EIB in patients without asthma may be distinct from those underlying EIB in patients with asthma. This review summarizes mechanistic and clinical data that can guide the choice of chronic and acute pharmacologic therapies targeting control of EIB. Relevant regulations from the World Anti-Doping Agency are also discussed.
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Affiliation(s)
- Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, Copenhagen NV 2400, Denmark.
| | - John Mastronarde
- Department of Medical Education, Providence Portland Medical Center, Pulmonary/Critical Care Medicine, Oregon Health & Science University, 5050 Northeast Hoyt Avenue, Suite 540, Portland, OR 97213, USA
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Prieto L. Tablet-based sublingual immunotherapy for respiratory allergy. Allergol Immunopathol (Madr) 2017; 45 Suppl 1:30-35. [PMID: 29146015 DOI: 10.1016/j.aller.2017.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Allergic respiratory disease represents a significant and expanding health problem worldwide. The gold standard of therapeutic intervention is still grucocorticosteroids, although they are not effective in all patients and may cause side effects. Allergen Immunotherapy has been administrated as subcutaneous injections for treatment of allergic rhinoconjunctivitis and asthma and has been practiced for the past century. Sublingual immunotherapy (SLIT) tablets are now available for grass- or ragweed-induced rhinoconjunctivitis and will be available in Spain for house dust mite (HDM)-induced rhinoconjunctivitis and asthma in the next months. In this review, new developments in the field of tablet-based SLIT for respiratory allergy are summarized, with special emphasis on HDM-induced allergic rhinitis and asthma. SLIT tablets are the best-documented immunotherapy products on the market and represent a more patient-friendly concept because they can be self-administrated at home.
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Singh D. Evaluation of New Drugs for Asthma and COPD: Endpoints, Biomarkers and Clinical Trial Design. Handb Exp Pharmacol 2017; 237:243-264. [PMID: 27838852 DOI: 10.1007/164_2016_70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There remains a considerable need to develop novel therapies for patients with asthma and chronic obstructive pulmonary disease (COPD). The greatest challenge at the moment is measuring the effects of novel anti-inflammatory drugs, as these drugs often cause only small effects on lung function. Measurements that demonstrate the pharmacological and clinical effects of these drugs are needed. Furthermore, we now recognise that only subgroups of patients are likely to respond to these novel drugs, so using biomarkers to determine the clinical phenotype most suitable for such therapies is important. An endotype is a subtype of a (clinical) condition defined by a distinct pathophysiological mechanism. An endotype-driven approach may be more helpful in drug development, enabling drugs to be targeted specifically towards specific biological mechanisms rather than clinical characteristics. This requires the development of biomarkers to define endotypes and/or to measure drug effects. This newer approach should continue alongside efforts to optimise the measurement of clinical endpoints, including patient-reported outcome measurements, required by drug regulatory authorities.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, University Hospital of South Manchester Foundations Trust, Langley Building, Southmoor Road, Wythenshawe, Manchester, M23 9Q2, UK.
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A novel endpoint for exacerbations in asthma to accelerate clinical development: a post-hoc analysis of randomised controlled trials. THE LANCET RESPIRATORY MEDICINE 2017; 5:577-590. [PMID: 28583396 DOI: 10.1016/s2213-2600(17)30218-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Occurrence of severe asthma exacerbations are the cornerstone of the evaluation of asthma management, but severe asthma exacerbations are rare events. Therefore, trials that assess drug efficacy on exacerbations are done late in clinical development programmes. We aimed to establish an endpoint capturing clinically relevant deteriorations (diary events) that, when combined with severe exacerbations, create a composite outcome (CompEx). CompEx needs to strongly mirror results seen with the severe exacerbation-validated outcome, to allow the design of clinical trials of shorter duration and that include fewer patients than trials assessing severe exacerbations. METHODS Data from 12 asthma trials of 6 months or 12 months duration and, with standardised collection of exacerbations and diary card variables, were used to construct and test CompEx. The study populations had a mean age of 35-53 years, 59-69% were female, and had a mean FEV1 percentage of predicted normal of 63-84%. With data from five trials, we established a series of diary events based on peak expiratory flow (P), reliever use (R), symptoms (S), awakenings (A), and threshold values for change from baseline and slopes to assess trends. For the development phase, we evaluated different variable combinations and deterioration criteria to select the most robust algorithm to define a diary event for the composite outcome. We defined a composite outcome, CompEx, as first occurrence of a diary event or a severe exacerbation. We assessed the performance of CompEx in seven trials by comparing the event frequency, treatment effect (hazard ratio; HR), and the sample size needed for future trials for the CompEx versus episodes of severe exacerbations. FINDINGS CompEx (based on PRS) was the algorithm that best fulfilled our two-set criteria. When censored at 3 months, CompEx resulted in 2·8 times more events than severe exacerbations, and while preserving the treatment effect observed on severe exacerbations (CompEx over severe exacerbation average HR 1·01). The increased number of events, together with the sustained treatment effect, resulted in a large net gain in power, with a 67% mean reduction in the number of patients required in a drug trial for severe exacerbations. In six of seven comparisons tested, CompEx reduced the sample size needed by at least 50%. Validation of independent test populations confirmed the ability of CompEx to increase event frequencies, preserve treatment effect, and reduce the number of patients needed. INTERPRETATION CompEx is a composite outcome for evaluation of new asthma therapies. CompEx allows design of shorter trials that require fewer patients than studies of severe exacerbations, while preserving the ability to show a treatment effect compared with severe exacerbations. FUNDING AstraZeneca.
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